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Africa: HIV/AIDS and Failed Development
Africa: HIV/AIDS and Failed Development
Date distributed (ymd): 001031
APIC Document
+++++++++++++++++++++Document Profile+++++++++++++++++++++
Region: Continent-Wide
Issue Areas: +economy/development+ +security/peace+ +gender/women+
Summary Contents:
The posting contains an analysis of the two-way connection between
HIV/AIDS and failed development, adapted for APIC from a longer
paper produced for the United Nations Research Institute on Social
Development (UNRISD, Geneva) by Joe Collins and Bill Rau. Rau is an
independent consultant and member of the Board of Directors of the
Africa Policy Information Center. He has worked on development
issues for over 20 years and on policy issues relating to HIV/AIDS
for eight years. References have been removed in this version, but
are available in the longer paper, which will be available later
this year on the web site of the UNRISD (http://www.unrisd.org).
+++++++++++++++++end profile++++++++++++++++++++++++++++++
HIV/AIDS and Failed Development
Joe Collins and Bill Rau
HIV/AIDS continues to cut into the fabric of African households and
societies. It is not uncommon to hear that a quarter to a third of
the adult population in several African countries are HIV infected.
Against this reality of a rapidly spreading epidemic, some two
decades of prevention interventions have met with but limited
success. Whatever successes there might be are not to be lightly
dismissed. The reasons for those successes, however, are not well
understood and thus not readily applicable elsewhere. To date, most
prevention efforts have focused on increasing individual awareness
about risks of transmission and promoting individual risk reduction
through a variety of means.
Far less attention has been given to either understanding or
designing prevention programs in light of the social and economic
context in which individuals live. It is commonplace for HIV/AIDS
program managers to acknowledge poverty as a causative factor, but
to then say that "poverty" is beyond the scope of their programs.
Instead, top-down analyses and decisions about prevention have
shaped public health responses. While the urgency spawned by an
epidemic often requires quick decisions and implementation, and
while the HIV/AIDS epidemic is of urgent concern in many countries
and to many social groups, HIV/AIDS is now too pervasive and too
deeply embedded in society to be "managed" through top-down public
health approaches alone. Placing the epidemic within the context of
a set of development issues and drawing upon the resources and
experiences of local initiatives might at first appear to step back
from the urgency demanded by an epidemic; in fact, it is the only
effective response.
Poverty and HIV/AIDS
Poverty is a key factor in leading to behaviors that expose people
to risk of HIV infections. The United Nations Development Program,
for example, argues that poverty aggravates other factors that
heighten the susceptibility of women:
"A lack of control [by poor women] over the circumstances in which
the intercourse occurs may increase the frequency of intercourse
and lower the age at which sexual activity begins. A lack of access
to acceptable health services may leave infections and lesions
untreated. Malnutrition not only inhibits the production of mucus
but also slows the healing process and depresses the immune
system."
The relationship between poverty and HIV/AIDS is "bi-directional":
- Poverty is a factor in HIV transmission and exacerbating the
impact of HIV/AIDS.
- The experience of HIV/AIDS by individuals, households and even
communities that are poor can readily lead to an intensification of
poverty and even push some non-poor into poverty. Thus HIV/AIDS can
impoverish or further impoverish people in such a way as to
intensify the epidemic itself.
The extent of impoverishment in the world today is truly
staggering. According to an internationally adjusted standard of
absolute poverty, sub-Saharan Africa has four times as many poor
people as non-poor. 1.2 billion persons are forced to live on less
than one dollar a day. Poverty and gender are inextricably
intertwined. Women and girls are disproportionately represented
among the poor. Seventy percent of the world's poor are women. It
is poor women who are most susceptible to HIV infections, for
gender alone does not define risk.
When we call people "poor" we are in danger of forgetting that they
are made poor. Poor people are really impoverished people. They are
impoverished by inequitable socioeconomic structures on the
household level, on the village level, on the national level, and
on the international level of trade and commerce. This becomes
clear as we look at AIDS as one in a series of "shocks" experienced
by the majorities of people in developing countries.
Poverty, Migration and HIV
The epidemiological relationship between migration and HIV is well
established. A study in Senegal found that 27 percent of the men
who had previously traveled in other African countries and 11.3
percent of spouses of men who had migrated were infected with HIV.
In neighboring villages where men had not migrated less than one
percent of the people were HIV positive. High HIV prevalence rates
in areas of high out-migration have been documented in Mexico,
Senegal, Ecuador, and in the south-east of Ghana. Rural communities
in West Africa known for out migration (mostly to the southern
areas of Cote d'Ivoire) such as the area of Tambacounda in Sengeal,
Sikasso in Mali, the district of Manya Krobo in Ghana, the area of
Mono in Benin and the Otukpo Local Government Area in Nigeria are
recording HIV infection rates two to three times that of the
national rates. Using 1993 data, a study of migrants in Kenya
concluded: "Independent of marital and cohabitation status, social
milieu, awareness of AIDS, and other crucial influences on sexual
behavior, male migrants between urban areas and female migrants
within rural areas are much more likely than non-migrant
counterparts to engage in sexual practices conducive to HIV
infection. In rural areas, migrants [returning] from urban places
are more likely than non-migrants to practice high-risk sex."
The risks of HIV/AIDS associated with migration are well known to
both men and women. Women in rural Tanzania a few weeks before
Christmas told researchers that they lived in fear of their
husbands coming home for Christmas since they thought they would be
"bringing AIDS." In some places female sex workers return, also
with some money and often HIV, and in search of a husband.
In a related way, sites of large construction projects have been
facilitated the spread of HIV. Most of the workers are single men
(unmarried or without their spouses). With their wages, usually
ready availability of liquor, and peer support, they induce women
into either short or longer-term sexual relations. Workers at the
Katse Dam construction site in Bokong, Lesotho, were found to have
seroprevalence rates nearly seven times as high as people in nearby
villages. In Mpumalanga, South Africa, HIV/AIDS and other STDs have
increased dramatically, "Thanks to a multi-million dollar infusion
of cash to develop the area." Infrastructure construction has not
only attracted large numbers of men, but with the wages they can
offer rural women and schoolgirls money, food, and clothing in
exchange for sexual favors.11 AIDS is but One in a Series of
"Shocks"
As a socioeconomic process, HIV/AIDS is just one more problem on
top of many others. Tanzanian social scientist Gabriel Rugalema
investigated the impact of AIDS in a village in the severely
affected northwestern part of his country. He wrote of people's
views of the epidemic:
"In general, they did not think of AIDS as something terribly new.
Rather, they saw it in the wider context of other crises predating
it. During and for a few years after World War II, the study area
was struck by famine partly due to drought and partly due to
rationing imposed by the British colonial government in Tanganyika.
... Most households had to dispose of their assets."
" In the early 1970s, drought led to widespread food shortages in
the area particularly in 1973-1974. This was a generalised hunger
throughout Tanzania and the situation was made worse by the world
oil price shock. . . . A few years later there was olushengo lwa
Amin (Amin's war), that is, the 1978-1979 war between Uganda and
Tanzania. Although the village is about 72 kilometers from the
border it not only received some of the displaced people from the
border villages but it suffered the economic disruption wrought by
the war. Much of the period from 1970 has been characterized by
poor national economic performance and consequently the decline of
the coffee crop in the area. The economic downturn has continued
with only brief hiatuses in some years."
The Shock of Economic Reform
The economic hardships faced by most Africans over the past two
decades (if not longer) came at a time when HIV/AIDS was emerging
and spreading. While a direct link between economic reform
programs, including structural adjustment programs, and the spread
of HIV/AIDS is difficult to draw, the conditions created by the
former definitely facilitated the latter. In general, structural
adjustment programs have links with the HIV/AIDS epidemic in
several ways. They often:
- Further undermined the rural economy, at the cost of livelihoods
and nutritional status; they also caused or intensified economic
recessions and led to increased poverty and class and gender
inequality.
- Fostered the development of transportation infrastructure to
support the heightened export orientation of the economy. Numerous
studies from countries in Africa and India document the sexual
networking and the high HIV prevalence along the truck routes.
- Increased labor migration and urbanization. Both of these
phenomena, as already emphasized, preceded structural adjustment
programs but increased with the emphasis on an export-oriented
growth.
- Mandated cutbacks in spending on health care and other social
services. At the beginning of the 1990s, when resources were
urgently needed for HIV/AIDS prevention programs, the average
annual per capita expenditure on health by African governments was
a mere US $2. In many countries, most notably in sub-Saharan
Africa, nothing could have been more inappropriate than decreasing
access to health services, given the already very high rates of
untreated STDs and non-specific bacterial and vaginal infections,
a now recognized leading factor in the spread of HIV infection.
Cutbacks in funding for public clinics reportedly also encouraged
the reuse of disposable syringes, potentially contributing to HIV
transmission.
The Shock of Gender
We have already discussed some of the links between gender
inequalities and HIV/AIDS susceptibility and vulnerability. Here we
place a sample of the linkages in the context of structural shocks.
- Breakdown of household regimes and attendant securities: Decades
of changes in economic activity and gender relations have placed
women in increasingly difficult situations. HIV/AIDS has
accelerated the process and made "normal" sexual relations very
risky. Although poorly documented, the range and depth of women's
responsibilities have increased during the era of AIDS. More active
care-giving for sick and dying relatives has been added to the
existing work load. Children (girls first) have been withdrawn from
school, both to save on costs and to add to labor within the
household. Thus, HIV/AIDS is facilitating a further and fairly
rapid differentiation along gender lines.
- Loss of livelihood: Whether women received remittances from men
working away from home, received "allowances", or earned income
themselves, AIDS made the availability of cash more problematic. In
Malawi, women and men have increasingly taken on work on farms of
larger and/or wealthier farmers in order to earn income or in-kind
payments, often neglecting production on their own holdings.
- Loss of assets: Again, although poorly documented, fairly
substantial investments in medical care occur among many households
affected by HIV/AIDS. These costs are dis- investments to the
family and survivors. Household food security is often affected in
negative ways. In many parts of Africa, women lose all or most of
the household assets after the death of a husband.
- Survival sex: Low incomes, dis-investment, constrained cash flow
all place economic pressures on women. Anecdotal evidence and some
studies indicate that these pressures push a number of women into
situations where sex is coerced in exchange for small cash or
in-kind payments. Along the Thailand-Burma border, many of the sex
workers are young women, caught up in the "green harvest" in which
their work is a means to repay loans made to their families by
money lenders who recruit young women for the sex industry. Most of
the young women return home HIV-positive.
Taken together, these and existing education, employment, legal,
and other structural biases facing women, add to the shocks that
have disrupted social institutions over the past decades.
Militarism and Armed Conflict
Wars and civil violence have contributed to situations of increased
susceptibility. Epidemiologic data is usually lacking in many of
the areas of prolonged warfare or civil violence. Thus, data from
the early 1990s continues to be cited to describe the HIV/AIDS
situation in Congo. It is worth noting, however, that literally all
the countries of Eastern and Southern Africa have been engaged in
or have experienced repercussions from wars or major civil violence
since the mid-1970s. It is in these regions of Africa that the
epidemic is most severe.
Warfare presents major opportunity costs for Third World countries.
Resources flow to arms and equipment purchases, military salaries,
replacement costs, and hundreds of other large and small
expenditures. Arguably, these resources in the mid and late 1980s
could have been going for desperately need improved access to
health care, especially STD treatment and other forms of HIV
prevention. In many countries military expenditures in the 1990s
(and today) divert needed resources from health care (including
support for home health care) as the epidemic means sharply
increased needs. Zimbabwe, for example, in 1999 was spending about
70 times on its military presence in Congo as on HIV/AIDS
prevention.
Displaced and refugee populations numbering in the hundreds of
thousands (and more) have had their lives disrupted by military
actions. During the 1994 genocide in Rwanda, "'virtually every
adult woman or girl past puberty who was spared from massacre by
the militias had been raped' --along with many younger children."
As many as 5,000 Rwandese women have had children as a result of
being raped. Many of these children have been abandoned. Life in
refugee camps often is precarious for women and girls. For example,
a high incidence of rape was reported among Somali refugees in
Kenya in 1993. Given the high prevalence of HIV/AIDS among soldiers
and the violence of rape, clearly rape has become a mode of
transmission of HIV.
The Shock of Disillusionment
Many of the shocks have been reviewed at aggregate levels. Less
evidence exists on what might be called sub-shocks, the
repercussions of larger changes. For example, agricultural
marketing reforms produced a ripple effect of shocks for
market-oriented small-scale farmers:
Reductions and delays or cutoffs in credit � Delays in supply of
hybrid seeds and fertilizers; Disruptions in agricultural extension
and veterinary advice; Delays in collection of crops; Crop losses
for lack of storage; Delays in payment for crops. One observer
notes: "Farmers have struggled on a daily basis to overcome the
combined shocks of cattle disease, years of drought, and marketing
reforms. The onslaught of HIV/AIDS has further impaired household
responsiveness as it cuts into available labour and household
resources." To cope with these shocks small-scale/low asset farmers
sold their own labor to other farmers, working for low wages or
in-kind payments during peak labor periods and not infrequently
contributing to further impoverishment.
For young people, these shocks added to the real or perceived
insecurity and low returns from agriculture. The sense that they
could improve their material well-being from rural enterprises was
further eroded. At the same time, the long-established patterns of
migration to employment centers were failing to provide as much
opportunity for some employment as in the past. Schooling became
less of an assurance of advancement. These structural shocks
affected the expectations, hopes, and commitments to work within
the prevailing economy in the 1980s and 1990s. The system was not
working for many young people who increasingly turned to
alternatives forms of income generation and/or social support.
Paul Richards makes this point about young men in Sierra Leone,
some of whom have been involved in the war there and in neighboring
countries since the late 1980s. Young men from Burkina Faso, Sierra
Leone and other West African countries found opportunities
constricted by economic crises in labor absorbing countries (Cote
d'Ivoire and Nigeria). Young people were blocked from economic
opportunity in their home areas (where very limited opportunities
existed) and through the migrant labor system. The shocks that ran
through the system included: Loss of income, Loss of self-respect
and confidence, Rejection as "marginal" and unemployed (i.e. street
people, thieves, beggars).
Overall, the shocks of disillusionment and social rejection made
the long-term prospects of dying from AIDS far less compelling than
the immediate needs for food or companionship and social acceptance
in a military unit. Richards writes: "HIV/AIDS cuts short the
normal life expectation, and already [c. 1999] young people in
Tanzania make it clear that they have to work with the space they
will get. Life has to lived to the full but perhaps over 30-40
years rather than a normal three score years and ten." A study of
young people in central Ghana uncovered similar attitudes that may
not be fully generalizable but definitely reflective of the
situations in which many young people find themselves. "Such
attitudes to death in the era of AIDS point to apparent
misunderstanding or lack of motivation for behavioural change in
the existing socioeconomic circumstances." In other words, the
attitude can be expressed as: "Why change my sexual behavior when
I see little hope for improvements in life's opportunities." It
seems that such attitudes are not statements of fatalism, but of
disillusionment and realism.
In sum, quick, dramatic, prolonged and stressful shocks have shaped
the environment in which HIV/AIDS has found fertile ground. Several
of the shocks noted here are a direct outcome of development
paradigms pursued by international donor agencies. Other shocks
reflect deep structural factors (some social and cultural, others
political and economic) that have made many societies and specific
groups within society especially vulnerable to conditions conducive
to HIV transmission. The HIV/AIDS epidemic is one more disaster
visited upon impoverished people. The epidemic calls into question
what in so many countries and international arenas has been called
"development" as well as the means used to achieve it. As Dr.
Roland Msiska, a senior policymaker in Zambia in relation to
HIV/AIDS, has stated: "Is HIV a symptom of development gone wrong?
If the answer is yes then we need to tackle the disease
'development,' as we deal with the symptom "HIV."
It follows, then, that the ways "development" have been practiced
over the past several decades are not appropriate, either for the
well-being of most African people or for containing the HIV/AIDS
epidemic. Most international development institutions (including
USAID) continue to pursue development models that do not address
the needs or interests of most population groups, but money
continues to be awarded to these organizations. Alternatives do
exist, especially in the experiences of smaller, community-based
groups, advocacy NGOs, and select development and women's groups.
Those alternatives are explored further in the full paper.
This material is produced and distributed by the
Africa Policy Information Center (APIC). APIC provides
accessible information and analysis in order to promote U.S.
and international policies toward Africa that advance economic,
political and social justice and the full spectrum of human rights.
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