On the eve of the genocide of 1994, antenatal prevalence in the Rwandan countryside – ‘in the hills’, as they said in Kigali – remained less than 5 per cent. In rural Burundi it was even lower.13 The contrast with the relatively equal urban–rural prevalence that will be seen in Central Africa is difficult to explain in small countries with excellent transport systems, dense rural populations, and large income differentials between town and country. The towns did spread infection to their rural environs. A study in the Butare region in 1989–91 showed no association between HIV prevalence among rural women and the frequency with which they visited the town, but a significant association if their regular partner visited it daily.14 Yet these were small towns. The largest, Kigali, had only 220,000 inhabitants in 1986, only some 3 per cent of Rwanda’s population. They had no industry to attract the long-staying migrant workers who were probably most responsible for spreading infection to Central African villages. Whatever the reason, Aids in Rwanda and Burundi began and remained until the mid 1990s essentially an urban disease.
The contrast elsewhere in the Lake Victoria region was remarkable. In the lakeshore districts of Masaka and Rakai in south-western Uganda and the Kagera region of north-western Tanzania, Africa experienced its first rural-based Aids epidemic, a product of a prosperous peasant society at a moment of profound crisis. In East Africa during the 1970s the post-independence order was beginning to unravel. General Amin seized power in Uganda in 1971, precipitating eight years of violence and a magendo economy of illegality and self-help until the Tanzanian invasion overthrew him in 1979. Tanzania, although politically more stable, suffered severe economic decline as a result of the socialist strategy adopted in 1967, a decline accentuating Kagera’s long-standing problems of isolation, land scarcity, and agricultural decay. In Kenya, too, the prosperous era of Jomo Kenyatta gave way from 1978 to growing stringency and corruption under Daniel arap Moi.
HIV penetrated first into the borderland between Uganda and Tanzania west of Lake Victoria. Some have believed that the virus had been present in Uganda since the late 1950s or 1960s, pointing especially to occasional cases of the aggressive form of Kaposi’s sarcoma later found in some Aids patients. This is possible, but aggressive Kaposi’s sarcoma was a consequence of immune suppression rather than necessarily of HIV; nobody at the time noticed any change in the epidemiology of the disease, as they did in the early 1980s, and no stored blood from the region prior to the late 1970s has shown HIV antibodies.15 Without stronger evidence it seems more in accord with the continental pattern of the epidemic to think that Aids first appeared on the Uganda–Tanzania border in the late 1970s and HIV a few years earlier.
Its arrival cannot now be identified exactly. According to Uganda’s chief epidemiologist, symptoms later characteristic of Aids were first reported late in 1982,
when several businessmen died at Kasensero, an isolated small fishing village on Lake Victoria. This small town was also known for smuggling and illicit trade, and when these deaths occurred fellow traders shrugged it off as witchcraft. Others thought it was natural justice against those who had cheated. The only common characteristic the victims had was that they were all young and sexually active and stayed away from home for several days chasing wealth and presumably using it generously for their recreation and merriment.16
Across the border in Tanzania the first three Aids cases in Kagera region entered hospital in 1983. Retrospectively, however, medical workers believed that they had seen earlier cases. Kitovu Mission Hospital in Masaka district of Uganda was later said to have recorded 84 during 1982 alone. An African doctor in Rakai district believed that his uncle had died of the disease in 1980. The leading expatriate specialist later thought he had seen the corpses of Aids victims in Kampala in 1979 or 1980. Taken as a whole, the evidence suggests that HIV entered the region during the 1970s and became epidemic in the early 1980s.17
Local people called the new disease ‘Slim’ because wasting was commonly its most visible symptom. ‘In the first six months,’ Dr Anthony Lwegaba reported from Rakai in 1984,
the patient experiences general malaise, and on-and-off ‘fevers’. For which he may be treated ‘self’ or otherwise with Aspirin, chloroquine and chloramphenicol etc. In due course, the patient develops gradual loss of appetite.
II. In the next six months, diarrhoea appears on-and-off. There is gradual weight loss and the patient is pale. Most patients at this point in time will rely on traditional healers, as the disease to many is attributed to witchcraft.
III. After one year, the patient develops a skin disease . . . which is very itchy. Apparently it is all over the body. The skin becomes ugly with hyperpigmented scars. There may be a cough usually dry but other times productive.
IV. Earlier on after a year, the patient may be so weak that even when taken to hospital (not much can be done due to late reporting), goes into chronicity and death.18
Like the local people, Lwegaba blamed Slim on the young fishermen and smugglers who had flocked to the lakeshore to exploit the Nile perch fisheries and the magendo economy. ‘Since perch-fishing began,’ an investigator noted,
temporary fishing camps of grass huts and sheds have grown up seasonally on the lakeshore, with predominantly male populations. Male labour relies, for food, drink and sexual services, on cafés, teashops, and bars, largely run by women. Each camp is associated with particular farming communities, which may be at a distance of up to 15 kilometres from the shore.19
It was probably in these fishing camps and neighbouring villages that partner exchange reached the frequency required to raise HIV to the epidemic levels elsewhere found only in the urban environments of Kinshasa or Kigali. Fifteen years later researchers studied such a fishing community in Masaka district. Its men had on average one new sexual partner every twelve days. Some 41 per cent of their partners were regular and 59 per cent casual; 85 per cent were contacts within the village, 8 per cent in other fishing villages, and 6 per cent in the nearby trading town. The village women, in turn, had 90 per cent of their sexual contacts with other villagers and 42 per cent with casual, paying clients. Such promiscuity was highly localised, so that HIV prevalence in different parishes of the district in the mid 1990s was to range from 4 per cent to 20 per cent. ‘It is our mating patterns that are finishing us off,’ a researcher was told.20
Although this epidemic began in the countryside, the difficulty of transmitting HIV makes it likely that it would have died away if it had not been carried to more open sexual networks in trading centres, the capital, and eventually the entire East African region. The researchers in Masaka found surprisingly little sexual exchange between village and town, but they did find that sexual activity varied enormously between individuals.21 It was perhaps hyperactive and mobile individuals who transmitted HIV to the main-road trading centres where it next flourished. In the Kagera region, for example, the virus appears to have been carried from border trading posts to inland commercial centres like Kamachumu, long a focus of coffee marketing and politics. Thence it spread to the regional capital, Bukoba. By 1987 prevalence among those aged 15–24 was 24.2 per cent in Bukoba town (reaching 42 per cent in its lowest-status section) and 10 per cent in the neighbouring Bukoba and Muleba rural districts.22 Once the virus was established in trading towns, workers carried it back to hitherto unaffected villages. In the Kagera village studied by Gabriel Rugalema, for example, Aids was introduced in 1987 by ‘a woman with an unstable marriage who worked part-time as a commercial sex worker in Rwamishenye (a suburb of Bukoba town). She came back to the village after she had been weakened by infections and died a few weeks later.’ Another 18 women and 41 men died there during the next nine years:
A majority of the men