Global Policy Forum

By Charlene Smith

Noel Chikamba staggers across the red dust yard his wife swept only this morning, spittle forms at his lips as he raves loudly and incomprehensibly.

Aya, his wife, stops grinding corn and bites her lip watching him; he is skeletally thin, his eyes are glazed and protruding. The clothes that he refuses to allow her to wash are filthy. He is one of the 28 million people infected with HIV/AIDS in sub-Saharan Africa, and so is she. Noel's disease has progressed to AIDS-related dementia; she knows he will soon die.

"In my mind, he has already gone," she says, "I am now worried about the children," she waves her hand at four children under the age of 12. Her daughter, the eldest, is staggering under the load of a container of water she walked three miles to collect. Her 10-year-old son is pulling weeds from spindly crops of butternut and wild spinach.

The family is among 15 million starving people in sub-Saharan Africa. They are luckier than most because they still have some food. It is not enough, but they have neighbours who have nothing. Many reasons have been given for the present famine in southern Africa -- bad governance, high foreign debt, the failure of International Monetary Fund structural adjustment, wars, all the usual recipes for disaster, but too little has been written about what is possibly the primary ingredient in this catastrophe: the impact of AIDS/HIV on workforces, agriculture and individuals and the gross failure of most southern African governments to act in time to provide treatment to their people.

Perhaps this famine is the first widespread indicator of precisely how HIV/AIDS destroys communities and nations. It is an indictment too of a global community that has become focused on the politics of greed and is methodically turning off the capacity for nations of high infection to reform, heal their nations and redevelop.

Lori Bollinger of The Futures Group International notes that although total world trade has tripled in the last two decades, reaching almost US$13 billion by 2000, sub-Saharan Africa total trade increased by only 10 percent in the same period. "This is the result of many factors including weakening economic performance, decreases in commodity prices, war, famine and drought, yet HIV/AIDS has played and will continue to play a role, as sub-Saharan African contains approximately three quarters of the world's HIV+ population."

Wherever HIV/AIDS has gained a foothold in, it has thrown up a flag in every area of human rights abuse found in that community or nation. AIDS is possibly the ultimate warrior for social justice. When it manifested in the USA in the early 1980s it showed up in gay communities and was probably the motivator homosexuality needed to loudly and proudly step out of the closet. It manifested among drug users, and until methadone and clean needles programmes became widely available it threatened to storm through Europe and the USA, in the way it is through Russia and Iran now.

It showed up in blood banks: the rights of haemophiliacs and those who needed regular blood supplies had been ignored, controls have improved but more work needs to be done as recent contaminated blood scares in the US and Denmark have shown. In China, the major agent in the spread of HIV has been programmes where peasants give blood in return for money, the dirty needles used has seen the virus spread fast.

In Africa where the rights of women are scorned, and male sexual entitlement rules, and where the rights of children are honoured in noble sayings -- "it takes a village to raise a child" or "every child is my child" -- but ignored in practice, 55 percent more women are HIV infected than men and six times more girl children than boys.

In Nepal, HIV is throwing up flags on child trafficking. In South Africa it has caused huge debate, but not much action, around sexual violence (a woman is raped every 26 seconds). Across continents it is raising questions about migrant labour, and the conditions afforded truckers and sex workers.

Jenny Brown, district health officer in Barkley East a breathtakingly beautiful part of eastern South Africa says, "we hate the harvest season, because within a month of the seasonal workers moving in sexually transmitted illnesses increase. Within a few months we begin picking up increased TB and with it, we know, is HIV." However, in most clinics surrounding that area there are too few nurses, very few have electricity or running water -- nurses go to polluted rivers to collect water, and Mike Agenbag, the environmental officer in the same community, reports that the main river running through that area, the Tsolo, which serves around 250 000 people, is more polluted than the sewage ponds in the main village of Cala. Few clinics have more medical supplies than gentian violet, crepe bandages and paracetamol.

Agriculture in the region is collapsing as migrant worker husbands come home, infect their wives who run small farms, and in time both die, leaving a growing number of child-headed households. Bernadette Chimosuro, a longtime AIDS worker in Masvingo, Zimbabwe describes what happens to the orphans (she has adopted 16 herself and teaches the running of small scale agricultural programmes because healthy eating is essential to stave off fullblown AIDS). "I'll give you a typical example of one child. Her parents died. The water was cut off because the bill had not been paid. They ran out of food. She left school and tried to find a job. She could not. An older man began paying for things in return for sex. She became infected, she died, now the next child is doing the same trying to care for her siblings."

South Africa's Kwa Zulu Natal province has a large peasant base in small agricultural communities, or large commercial farms. It has 300,000 orphans, very few of whom are cared for by government or communities. The Enhancing Care Initiative of the University of Natal was awarded a R720 million grant (£1 = R15) from the UN Global Fund in April. It had submitted a project proposal that would have given nevirapine to prevent HIV transmission to babies (MTCT) and would have put mothers, and later fathers on antiretroviral therapy to prolong their lives and reduce the orphan population. It would have extended triple therapy (HAART) to the 400,000 employed people in KZN who may have needed it to extend their lives and combat productivity and job losses due to death. Government blocked the grant and is presently attempting to ban nevirapine, the cheapest and most commonly used drug to prevent MTCT.

What is happening with so many parents dying is that fewer and fewer children, those that are not infected, attend school, which imperils the long term economic and stability prospects of nations. Alan Whiteside of Health Economics and HIV/AIDS Research Division at the University of Natal reports that school enrolment is dropping. "By 2002 enrolment was about 275,000 well below the approximately 370,000 in 1998." He said lower enrolment was either a factor of children dying in infancy or not being born (SA experiences the death of 7,000 babies a month due to AIDS according to the SA Paediatricians Association) or, "they are alive and not attending school because their caregivers cannot afford the school fees, book fees and uniforms; the children's labour is needed at home; there is no-one to send them to school; or they feel stigmatised."

In Zimbabwe, commercial farmers funded and ran an extensive network of rural clinics, AIDS hospices and care for AIDS orphans. Those networks have collapsed as that government continues a three year campaign against white commercial farmers. On August 8, 2,900 white farmers were expelled from their farms by government -- despite an estimated 6 million Zimbabweans facing starvation. Sixteen farmers who continued planting and farming after June 24 were arrested.

In Swaziland where 230 000 people are starving, that government announced on August 2 that it was buying a R250 million luxury jet for Swaziland's King Mswati III. Prime Minister, Sibusiso Dlamini arranged to buy the plane at a price five times the country's national deficit. Dlamini said the jet was needed to help the king attract foreign investment and international aid. However, it is not just poor governance in parts of sub-Saharan Africa that is leading to unprecedented death.

UNAIDS, in its recent Report on the Global HIV/AIDS Epidemic, says that:

failure to control AIDS is an index of inequitable development and poor governance. Income inequality, gender inequality, labour migration, conflict and refugee movement all promote the spread of HIV.

More than a billion of the world's 6 billion people cannot fulfil their basic needs for food, water, sanitation, health care, housing and education ... Greater access to high-income countries' markets, debt relief and more development aid will go a long way towards enabling countries to reduce poverty. High-income countries spent more than US$300 billion in 2001 on agricultural subsidies -- roughly equivalent to the combined domestic product of all sub-Saharan Africa. AIDS represents a long and devastating tale of exclusion for millions of people, with or without HIV infection.

Despite the pious soundbites of world leaders, they are simply not interested in confronting an epidemic that is cutting a swathe through southern Africa now, but by next year will begin to see Asian nations take over as areas of highest HIV infection. UNAIDS estimates that 850,000 Chinese were living with HIV/AIDS in 2001, "with reported HIV infections having risen more than 67 percent in the first six months of 2001."

HIV is knocking on the door everywhere -- it is only the foolish that sleep on, hoping it will go away.

According to commitments made at the UN Special Assembly on HIV/AIDS last year, signatory nations have to have in place, by 2003, "strategies, policies and programmes that identify and begin to address those factors that make individuals particularly vulnerable to HIV infection, including underdevelopment, economic insecurity, poverty, lack of empowerment of women, lack of education, social exclusion, illiteracy, discrimination, lack of information and/or commodities for self-protection, all types of sexual exploitation of women, girls and boys including for commercial reasons." At the 14th International AIDS Conference in Barcelona in July it became clear that most were nowhere near meeting these modest goals.

And the Global Fund to combat tuberculosis, malaria and HIV/AIDS which needs to spend $10 billion a year to effectively fight these international scourges, has thus far raised only $2.8 billion. It appears to have pathetically little chance of reaching its stated goals -- or controlling, never mind eradicating, these diseases.

The owner of a major racehorse stud farm asks: "Could you come and speak to my workers about HIV/AIDS, they're dying like flies." For the previous three months, she says, she and the owners of three neighbouring stud farms in the midlands of Kwa Zulu Natal have lost 180 workers. "My father-in-law has a farm in northern Kwa Zulu Natal and he says people are dying so fast that many families can no longer afford coffins and are wrapping and burying them."

She said she was being crippled by the high costs of training new workers and said the amount of death within their ranks was demoralising existing employees.

UNAIDS says that studies in Thailand and Tanzania show that the financial burden of death can be far greater than that of illness, and in Botswana "per capita household income for the poorest quarter of households is expect to fall by 13 per cent, while every income earner in this category can expect to take on four more dependants as a result of HIV/AIDS."

The editor of a major Sunday newspaper shakes his head over brunch, "my stepfather farms in the Northern province, and in the local village the butcher closed his shop and re-opened it as a mortuary, he says he makes more money."

On Saturdays and Sundays there are traffic jams outside Avalon Cemetery in Soweto as cars, buses and hearses queue to get in. By 2004 that cemetery will be full. Down the road in Ennerdale at the paupers' cemetery coffins are piled three deep in graves.

Research by Steven Forsythe of The Futures Group International says that in a sugar mill in South Africa, 26 per cent of all tested workers were infected with HIV. Infected workers incurred, on average, 55 additional days of sick leave during the last two years of their life. One study in Kenya on a sugar estate found that 25 per cent of the estate's workforce was infected with HIV.

UNAIDS notes that a study of three countries, Burkina Faso, Rwanda and Uganda has calculated that AIDS will not only reverse efforts to reduce poverty, but will increase the percentage of people living in extreme poverty from 45 percent in 2000 to 51 percent in 2015. In the Free State of South Africa, it says, households used up, "on average, 21 months of savings to pay for medical expenses and funerals."

Not only are people using up their savings, breadwinners are often the first to die and people aged 16 to 29 who would most often be relied on in Africa to take up the burden of care and work -- those young people in that age group are the most heavily infected, and are likely to be ill or dying too. Many elderly people have become HIV-infected washing the bodies of their ill children and grandchildren who lose control of their bowels in the late stages of the disease. The South African government has enacted laws to ban plastic supermarket bags in an environmentally friendly move that fails to acknowledge that the bags are coveted in poor communities to use instead of unaffordable gloves when handling final-stages AIDS patients who often lie covered in theire own faeces or menstrual blood unless washed.

The impact on food security is intense. Tanzanian research showed that food consumption dropped 15 per cent after the death of an adult. UNAIDS says:

the prospect of widespread food shortages and hunger is real. Some 20 per cent of rural families in Burkina Faso are estimated to have reduced their agricultural work or even abandoned their farms because of HIV/AIDS. In Ethiopia, AIDS-affected households were found to spend between 11.6 and 16.4 hours per week performing agricultural work, compared with a mean of 33.6 hours for non-AIDS-affected households.

In Malawi, death rates among employees of the Ministry of Agriculture and Irrigation have doubled, almost entirely due to HIV/AIDS. In Namibia studies have shown that agricultural extension workers spend one tenth of their time attending funerals. And because most farming in Africa is done by women while men seek better paying work in the cities, and because women are the most HIV infected people on the continent -- some antenatal clinics in Kwa Zulu Natal, South Africa pick up rates of 55 percent to 60 percent infection, sex workers in Carletonville near Johannesburg have 72 percent rates of infection, 31 percent of women in Lesotho are believed to be infected and rates of 40 per cent are monitored in Botswana ante-natal clinics -- it means that famine becomes an obvious and longlasting legacy of HIV/AIDS.

Statistics from Food Harvest last year showed that women produce 60 to 80 per cent of the food in most developing countries and this percentage is growing. In sub-Saharan Africa and the Caribbean, women provide 80 per cent of staple foods, and in Asia they perform 90 per cent of the work in rice fields. The World Bank estimates that educating women could increase farm yields by 22 per cent. In Kenya, as an example, a national information campaign targeted at women increased maize yields 28 per cent, beans 80 per cent, and potatoes 84 per cent.

The Food and Agricultural Organisation warned in 2001 that AIDS had killed 7 million agricultural workers since 1985 and would kill an estimated further 16 million by 2020. It said then, "this is already severely affecting household food security," but about as much attention was paid to that as to the June, FAO summit on famine in Rome which was characterised by complete uninterest by the developed world. But it is not only farmers and labourers who are dying, people directing agricultural policy are succumbing. Kenya's Ministry of Agriculture reported last year that 58 percent of all staff deaths are due to AIDS and in Malawi's Ministry of Agriculture at least 16 per cent of the staff are living with HIV/AIDS.

What is needed are not donations of food other than temporary relief measures. UNAIDS calls for a more equitable global investment and trade flows system, as well as, higher levels of Official Development Assistance in support of poverty reduction strategies and improvement of social services. Since 1990, official development assistance provided to the 28 countries with the highest adult HIV prevalence rates (more than 4 per cent) have fallen by a third.

Tony Barnett of the School of Development Studies, University of East Anglia writing in AIDS and Economics, July 2002, says that HIV/AIDS is a harbinger of the global public health crisis. "Epidemics such as HIV/AIDS ... need to be related to other events, changes in political regime, new ideas, global warming, the global distribution of power. We cannot deal with these events in isolation from one another."

But simple projects work too. There are too few small scale agricultural projects taking place in sub-Saharan Africa. In Ohrigstad in the north of South Africa I was shown a large community centre with adjacent weed-covered fields and empty pig and chicken runs. A while before a large grant was received from a European donor for an agricultural project, the chicken and pig runs were built and stocked, farms ploughed, seeds planted. But no advice was given on irrigation, no-one was tasked with ensuring the community would plant, reap, and plant again -- and so the chickens and pigs were eaten, the first crops eaten too and weeds allowed to take over. There is an assumption that if you give peasants land they will plough and sow, there is an assumption that farming is inherent in peasants -- it is a fallacious assumption.

With an excessive focus on antiretrovirals the world has forgotten that for HIV/AIDS to be effectively combated and full blown AIDS to be delayed nothing is more effective than good nutrition. In sub-Saharan Africa people are dying sooner than they should because they simply lack enough food to eat, and advice on nutrition. The continent is awash in latex condoms, but too little food. Those already malnourished contract the virus easier, too.

And home-based care which began in Zambia and is now in use around the world not only relieves the burden on hospitals but unites communities in caring for each other when people are ill or dying, it ensures that orphans are not rejected but are integrated into communities and it enables communal lifesaving and income generating projects, such as subsistence farming to be successfully undertaken.

Famine in southern Africa now is an early warning call of what can be expected globally as HIV/AIDS intensifies its spread -- at present 40 million people are infected, in 2004, 100 million people will be infected globally according to the World Health Organisation. And as the world gathers at the Summit on Sustainable Development in Johannesburg it is worth reflecting again on our global interdependency. AIDS has no eyes, it doesn't just target the poor, it doesn't just target Africans, it is moving silently and quickly and demands new international thinking on poverty, human rights, access to food and healthcare, this virus is not just about health.

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