This article appears in the February 2002 edition of the Catholic Medical Quarterly
HIV / AIDS The Global Perspective
The HIV/AIDS pandemic is a major developmental crisis which threatens the social and economic fabric and political stability of many nations on the continent of Africa. It threatens to undo all the developmental gains of the last 20-30 years. But although Sub-Saharan Africa is currently the worst affected region, it must be stressed that the problem is global, with 95% of new cases of HIV infection occurring in the developing world. AIDS is not just a health issue: it is fuelled by poverty: it is no coincidence that the countries most ravaged by the pandemic changing the face of Africa are the poorest
A total of 25.3 million African people are now living with the condition: millions of young adults have already died. There are now more than 12 million children orphaned by AIDS in sub-Saharan Africa, equivalent to the entire child population of the UK. It is estimated that by 2010, 43 million children will have been orphaned by AIDS world wide.
A whole generation will be growing up without parents. Villages are becoming ghost towns, local economies are crumbling. Many of these children are heads of households at the age of 10 years. Some have been orphaned 2-3 times as parents, aunts, uncles and grandparents died in succession. Recent experiences show that orphanages are not the best place for the development of these children. Rather, ways must be found for keeping them in the community, possibly by fostering. But many will end up on the streets, where they are open to exploitation, sexual and otherwise. In my years of work in refugee camps, orphans were never a problem, as traditional African culture will always look after them within the extended family. Now, however, we are witnessing the fragmentation of the family net work, with dire consequences.
Prevalence rates are highest in the region of Southern Africa. The impact is staggering. In health, many of the staff who were available to stem the progress of the pandemic have already died from HIV related illnesses. It is difficult to find replacements: when it is possible, there is a huge 'burnout� rate. The nursing profession is considered a high risk activity with low prestige and low pay. Bed occupancy rates vary between 50-80% due to HIV related illnesses. In education there are similar problems, since so many of the teachers have died and it is virtually impossible at present to replace them. At the same time children are being with drawn from school by surviving parents to care for sick relatives. This particularly applies to young girls. Again, as rural Africa survives on subsistence farming and small scale traders, the economic consequences are devastating. If one reviews the business sector, many middle to senior managers are dying. How is it possible to replace them? These victims have had years of training and experience. Couple all these factors with reduced inward investment in highly infected countries and regions, and the devastation becomes monumental.
The macro-economic front looks equally dispiriting. Developing countries are still having to pay back more on debt to Western countries than their expenditure on health budgets. The average health budget in sub-Saharan Africa is $7.00/per capita/per year. Structural adjustments consisting of austerity packages have been imposed on the developing world for the past two decades to ensure debt repayment. Such settlements always:
- Cut Health Budgets.
- Slash Education Budgets.
- Cause much unemployment and fuel a large migratory workforce.
- Cut food subsidies leading to increased malnutrition.
All these factors fan the pandemic. There are, however, signs of hope. Uganda, Thailand and Senegal have managed to keep the disease under control. Governments and community leaders - religious and secular - must lead the fight against stigma and denial. All sectors and levels of government and civil society must be mobilised. If prevention succeeds, the effects of the epidemic are reduced.
Conflict also exacerbates the pandemic. Rape, prostitution for survival, together with the HIV/AIDS prevalence rate in soldiers, estimated to be 90% in Zimbabwian soldiers, are features of this category. It also results in increased migration of populations and the particular living conditions in refugee camps, with resultant breakdown of norms and values governing sexual behaviour, contributing to an increased spread of the virus.
Women are more vulnerable for a variety of reasons - economic, social and physical. For every 10 African men infected, 12 - 13 women are infected.
The direct consequences of these factors are:-
- There is an 80% loss of income to each household.
- Life expectancies are now back to those in the 1960's.
- Child mortality rates have doubled in some countries.
- It is estimated that the GDP of Botswana will be 38% smaller In 2021, reversing a whole generation of developing gains.
We are watching the decimation and fragmentation of families.
My purpose is to present HIV/AIDS from a wider perspective than a purely medical point of view. The problems are multi- faceted and multi-layered. It is not just a health issue but a global challenge involving an increasingly large slice of the world's population. Its components include the future development of these people and confronting the social and economic problems arising from it.
While it is true to assert that there is a strong behavioural element to the disease, the main factor that makes people vulnerable is poverty. The large, global, political, economic and social forces which reinforce poverty must be challenged.
A vaccine will not solve the problem in countries where health services are almost non-existent; neither will cost price access to retroviral drugs.
Despite the spread of the pandemic, aid levels to Africa have been falling dramatically - by almost half between 1995 and 1999. Although 25.3 million people are currently infected with HIV in sub Saharan Africa, funding from ten major donors for HIV/AIDS related projects reached a mere $202 million in 1998 a little over half the annual budget of Guy�s and St. Thomas� Hospitals in London.
An immediate commitment of $10 billion annually is needed now to provide food, basic health care and vital preventative strategies across the region. At a UN Conference in July, at which I attended, Kofi Annan asked for $10 billion for a health fund for HIV/AIDS, TB, and Malaria - the world's biggest killers. To date $1.4 billion has been pledged by rich Western nations. Currently too much aid is donor-driven by western governments insensitive to real needs on the ground. The increases in aid must be matched by policies driven by local people and organisations.
What then are the main determinants in the pandemic? Can they be altered?
- Poverty with the breakdown of the health services and the educational sector, and with decrease in economic activity and resultant unemployment, the major factor. It also leads to migration of workers in search of jobs which increases the rate of partner change and to the rise and distribution of virus subtypes. Its alleviation lies firmly with international agencies and national governments.
- The differing cultures among the various groups in the area lead to many practices which may tend to spread the infection. Perhaps the only way such behaviour can change is by knowledge and education. Young children and adolescents should be taught life skills and not simply in formed about HIV/AIDS alone. Leaders at all levels from the President of the country to the village leader, and preachers in the pulpit should be encouraged to present the knowledge. One of the most important points is to aim at increasing the age of first sexual intercourse and decreasing the number of sexual partners.
- Sexually transmitted diseases are a potent source of spread of the virus and must be energetically treated. Voluntary testing should be encouraged.
- The strong message from the Church of abstinence before marriage and fidelity within marriage must be widely and vigorously pursued. The question of the use of condoms has to be faced but they are not a solution to the problem. The causes are far more complex: the problems are rooted in poverty. Unless this is tackled head on there will be very little impact on the disease.
- The Spiritual Dimension. Church communities will become a natural source of community based palliative care. Millions of AIDS orphans will require an engaged material and spiritual response from Christian communities both in the developing and the developed world. The Gospel message of compassion, acceptance, love and hope are the most vital elements in any response.
The Catholic Church joined the struggle against AIDS back in the early 1980s when the epidemic first emerged from the shadows. Church mission hospitals and clinics, which already provided a substantial proportion of health care in sub Saharan Africa, were at the forefront. By the mid 90s the number of sick and dying people had increased drastically. Now the Churches are activating their worshipping communities to tackle the local needs of sufferers and their families and orphans.
To summarise We need more untied aid - in the UK we are still a very far cry from the 0.7% GDP we pledged more than 30 years ago. We need to drop the debt - and the inhuman austerity packages which are drawn up by the IMF/World Bank to repay the loan, which leaves the health care/educational systems in many of these countries in ruins. We need fairer trading rules and regulations.
Finally leadership in developing countries must be held accountable. The Jubilee 2000 initiative has shown that if people are given the facts they can hold their governments to account.
Based on a talk given at the Guild�s Annual Symposium, Manchester 2001.
Dr. Carole Collins has worked widely in refugee camps in Africa and has been a consultant to Oxfam and Christian Aid.