JULY 13, 1994
ABIDJAN, Ivory Coast (AP) -- Working in Rwanda, Dr. Sergio Improta amputated seven limbs a day, rebuilt a smashed jaw, plucked maggots from gangrenous wounds and tried but failed to save a man with a machete gash so deep his brain was exposed.
He drew the line at blood transfusions.
"Too much AIDS," said the Italian physician, who was in Rwanda in May for the relief group Doctors Without Borders.
Long before its ethnic hatreds erupted in vast slaughter, Rwanda was known as one of the world's most heavily AIDS-infected countries. Now, after an orgy of bloodletting and rape and the rovings of millions of refugees, few experts doubt the plague has spread.
Doctors who have worked in internecine war zones in Rwanda, Liberia, Angola, Uganda and Somalia believe such conflicts have contributed to the spread of AIDS in Africa over the two decades the disease has engulfed the continent and encircled the world.
Even without scientific studies on the link between war and AIDS, international health experts say it's obvious the disease flourishes when conflict disrupts millions of lives.
"The list (of reasons) is almost limitless," said Dr. G.L. Monekosso, the World Health Organization's director for Africa. "This is a major problem. It is not mentioned among the injuries of war."
Among the reasons war and AIDS are a deadly mix:
-- Refugees: Exposure risks climb when different population groups mingle in mass refugee movements. Some doctors also believe sexual activity increases in refugee camps, where thousands live amid crowded, squalid conditions.
-- Soldiers: Invading soldiers routinely rape women in conquered territory, and medical relief workers say the arrival of peacekeeping armies brings an increase in consensual sexual activity with locals.
-- Blood transfusions: Health services typically break down in regions engulfed in conflict. People are wounded, blood screening is often impossible, and doctors must make choices. Sometimes, when a patient's life is at risk, they gamble that blood for transfusion is not infected.
-- Wounds: In Rwanda, tens of thousands of people were killed or wounded with flailing machetes, making it inevitable that single machetes were drenched with the blood of several people at a time.
Uganda, which borders northern Rwanda, is often cited as the world's worst AIDS situation; it has the largest number of documented AIDS cases on the continent -- 43,875.
"It's a historical fact that AIDS spread into Uganda at the time of the civil war there," Monekosso said. "The Rwanda situation is worrying because so much has happened in the last few months.
"You have wounded people bleeding, being hit with the same sharp objects," he said. "One in 10 people bleeding could be infected."
In its July 1 report, WHO estimated 4 million people have been diagnosed with AIDS since the disease began surfacing in the 1970s, with 67 percent of the cases in Africa. Of the 16 million people infected with HIV, the virus that causes the disease, WHO estimates at least 10 million live in Africa below the Sahara Desert -- the poorest and least stable region in the world.
"In principle, there's no doubt conflict and civil war makes the AIDS situation worse," said Dr. Michael Merson, head of WHO's Global Program on AIDS in Geneva.
"We've been concerned about the mass movements of people in Rwanda," he said. "It's tempting to blame soldiers or troops, but they're really only part of a complex equation."
Adding to the concern is the sense among some victims of war that AIDS prevention is pointless when bullets are flying, food is scarce and more immediate diseases such as dysentery and cholera are raging out of control.
"You can't sell them on the idea of preventing something they may get in five or six years, because their first need is to survive today," said Ronald Van Dijk, health officer for the U.N. Children's Fund in Liberia.
Nobody really knows what long-term legacy will emerge from Rwanda's tumult. Dr. Mambu-Ma-Disu expects it to be devastating.
The physician was WHO's director in Rwanda when the ethnic bloodbath began April 6. She fled three days later.
Rwanda was grappling with a refugee crisis even before the genocidal killings began because of its 4-year civil war and similiar ethnic tensions in neighboring Burundi.
In the past year, she said, 70,000 refugees from mostly rural, farming areas had congregated at a camp about 10 miles outside Kigali. In the capital city, roughly one-third of all people tested carried the AIDS virus.
Rape and promiscuity in the camp and steady traffic between the AIDS-ridden capital and the camp likely accelerated the spread of the disease, she said.
"It was not only a theory, it was reality," she said. "People were exposed.
"The other factor is all these soldiers running all over the country," she added. "These soldiers will have to return to their communities, and nobody knows what they will be bringing back."
Toward the end of her tour in Rwanda, Mambu-Ma-Disu said it was increasingly difficult to find clean blood to treat the wounded. She said WHO plans to send a shipment of rapid-test HIV kits, already used in war-riven regions of Bosnia-Herzegovina.
She has little doubt that wounded Rwandans are getting tainted blood.
"Even if there's a 30 percent chance the blood is positive (for the AIDS virus)," she said, "if somebody needs a transfusion to live, I don't know if you can just let them die."
Munah Sarweh, a 37-year-old prostitute in Monrovia, Liberia, longs for the time before civil war swallowed the country, before it was awash in wandering refugees and rapacious soldiers, before she began dying of AIDS.
"We had food, doctors and all other things in the prewar days," she said.
Once, she said, she could be choosy about her customers. But when the country and its economy collapsed, she found herself sleeping with "soldiers, drivers, anyone who would bargain fair."
She sadly pondered the pain and distress of having AIDS and said, "It's not a good thing to flirt with one's body."
In four years of civil war, more than 150,000 people have died, more than half the population of 2.2 million has been displaced, and thousands of soldiers from other West African nations have been posted there as peacekeepers.
Doctors have only anecdotal evidence but believe the war has dramatically accelerated the spread of AIDS.
Of the last 28 AIDS cases diagnosed in Monrovia, the capital, 22 have been Liberians returning from other countries; the rest were from Guinea, Ghana and Sierra Leone, said Dr. Moses Galakapai of the Health Ministry.
Despite a precarious peace agreement, factional fighting, banditry and rape still rage in the outlands. In recent weeks, Liberian newspapers have reported that armed bandits have been invading homes throughout Liberia's Bong County, killing the men and raping the women.
"We have to believe there are many cases out there in the midst of conflicts," Galakapai said.
Myrtle Gibson, an activist in Monrovia for women's and children's rights, said she met a 14-year-old girl in northwestern Liberia who'd been raped by 10 rebel soldiers the night before.
"The chances of her contracting AIDS were extremely high," she said.
It's no secret that officers in the Nigerian-led intervention force keep an army of Liberian girlfriends, or that the collapse of the economy has encouraged prostitution, said Ronald Van Dijk, a health officer with the U.N. Children's Fund.
Major hospitals in Monrovia screen blood for the AIDS virus, but Van Dijk said doctors in outlying areas often must play the odds.
"You can sacrifice a person now, or do the transfusion and risk AIDS," he said. "At least you have added some years to their life."
Taking a similar gamble, but for far different reasons, is Nigerian soldier Sunday Ayorede, 49, one of thousands of foreign peacekeepers in Liberia.
"I cannot stop having sex because somebody in the West says there is some deadly thing called AIDS," he said. "Sex was made to enjoy, and my girlfriends feel good having me."