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"I'm a car washer," Vusi proudly told me. "But today I have not made enough to eat." This was why he was asking me for money, he said.

My journey to South Africa, where I met Vusi, was intended to teach me more about the international HIV/AIDS epidemic. Yet here I was spending time with Vusi, a young Zulu adolescent, at a local fast food restaurant called Wimpy's in Durban, where he lives. Vusi was quite cosmopolitan, reciting American city names and asking me where I was from. He wore a plain white T-shirt, shorts and sandals and had the tired yet hopeful look of someone who had worked a hard day, but still had the energy to talk and dream.

I couldn't help being moved by the economic situation Vusi and his friends faced. The country estimates a 49 percent national unemployment rate, down from last year's rate of 50 percent. In Port Elizabeth, a beautiful coastal tourist city, unemployment estimates are much higher, possibly reaching 90 percent.

Whenever there is systematic oppression, as was the case under apartheid, a country experiences repercussions for generations. Lack of education and literacy, distrust and misinformation all abound, creating a workforce ill-equipped to handle the demands of today's job market. I continually had to remind myself that democracy in South Africa was only nine years old. Nelson Mandela was elected president in 1994. Change takes time.

Not surprisingly, Vusi's career plight and my own interest in HIV/AIDS are intertwined. Abraham Maslow's Hierarchy of Needs states that basic physiological requirements such as food and water precede other necessary components to a healthy life. When someone is poor and unable to provide food for themselves and their family—as half of South Africans are—learning a new skill (e.g. HIV prevention) becomes less important, even if that skill could dramatically lengthen life. And for someone already infected, immunocompromised, and lacking access to highly active anti-retroviral therapy (HAART), malnutrition radically hastens death.

Luckily, though, I met people throughout South Africa dedicated to providing job skills, income, and proper nutrition to those affected by HIV/AIDS.

The Hillcrest AIDS Center is just outside Durban. One of Hillcrest's services involves 60 community health workers who find villagers either suspected of infection or affected by HIV/AIDS. The villagers are screened by a "sister" (roughly equivalent to a nurse practitioner in the United States) and then are eligible to receive food assistance, simple job skill training (such as craft-making) and available medical therapy. Transport to the closest hospital costs the average villager 40 Rand, which equals eight hours of work for someone lucky enough to have a minimum wage job. If a person has no income, paying that much to get access to Pfizer's donated diflucan for his or her thrush is too much to ask (thrush barely exists in the United States thanks to access to HAART—but people still die of thrush in South Africa). So Hillcrest does whatever it can to get medications and bring them to the villages. To further save villagers' hospital expenses, Hillcrest has plans for a respite care facility for those requiring overnight antibiotic therapy. Sometimes someone with HIV needs an antibiotic intravenous drip to live for a couple of years instead of dying in a few months. And when that someone is a mother, two or three more years is invaluable to her children's development and to community stability.

Even though hospitals can seem inaccessible to many of the poor surrounding Durban, there are hospitals that appear receptive to those with HIV/AIDS. One is called McCord Hospital, located in Durban. This facility boasts one X-ray suite, two operating rooms, a lab, and air-conditioning on certain floors. The staff was kind and considerate and the walls displayed signs affirming the hospital's dedication to those affected by HIV/AIDS. It also operated a counseling center called "Sinikithemba" which is Zulu for "hope" and is constructing a research center affiliated with the local university to increase research of the epidemic.

But the hospital can do only so much toward one's recovery, so it routinely helps people die. When someone gets "sick," the individual may or may not get tested for HIV. "What's the point?" is the answer some would give, due to lack of HAART. And having HIV/AIDS is grounds for losing one's job and social support. By the time someone enters McCord, the family has exhausted all homeopathic and clinic options available to a loved one. And so the nurses, doctors, and staff of the hospital help many people die. It was humbling to walk through the men's medical/surgical ward observing the skeletal bodies and glazed expressions of hopelessness and anxiety, realizing most of the patients had end-stage AIDS and would die soon.

We all know how devastating this disease is, with more than 40 million infected—5 million in South Africa alone. Yet providing medications or offering HIV/AIDS testing, counseling, or food seems insufficient to stave off the epidemic. Although South Africa now provides land ownership, job placement, education, electricity, and decent roads to black South Africans living in townships and informal settlements, much more needs to be done. Economics is as important as the epidemic. I wonder where Vusi will be in 10 years. Will he gain marketable skills at school? Will he expand his car washing business? Or will he become HIV positive during his adolescence just as an estimated 70 percent of his classmates in Durban will? As an American who recently heard President Bush promise $15 billion to the HIV/AIDS epidemic in sub-Saharan Africa, I will keep my eyes on the horizon both here and abroad, hoping it helps, for Vusi's sake.

Melissa deCardi is in her final year of the Family Nurse Practitioner Program, with an HIV/AIDS subspecialty, at the Columbia University School of Nursing. She visited South Africa for three weeks in January 2003.


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