What the last world Aids day 1st December 2012 was all about.
GETTING TO ZERO
- ZERO NEW HIV INFECTION
- ZERO AIDS RELATED DEATHS
- ZERO DISCRIMINATION
POVERTY AND HIV/AIDS IN SUB-SAHARAN AFRICA
Desmond Cohen
POVERTY AND HIV/AIDS IN SUB-SAHARAN
AFRICA
There are two bi-causal
relationships which need to be understood by those involved in policy and
programme development. These are:
- the relationship between poverty and HIV/AIDS -- which
includes the spatial and socio-economic distribution of HIV infection in
African populations, and consideration of poverty-related factors which
affect household and community coping capacities; and
- the relationship between HIV/AIDS and poverty --
understanding the processes through which the experience of HIV and AIDS
by households and communities leads to an intensification of
poverty.
To make sense of these relationships
there has to be an understanding of the complex socio-economic processes at
work in African societies, together with a conceptualisation of poverty which
is multi-dimensional. It follows that analysis of the issues has to
encapsulate:
- the gender dimensions of poverty -- in particular that
the poorest households are often female headed;
- the intergenerational aspects of poverty -- the
importance of seeing poverty as part of dynamic social, economic and
political processes;
- the qualitative as well as quantitative measures of
poverty -- giving appropriate weight to those aspects of poverty which
delineate and define capacities and contributions by individuals and
households to socio-economic and political processes, and how these are
changed by the epidemic; and
- the ways in which the HIV epidemic alters the complex
relationships between the poor and the wealthy -- through changes in
income and asset distributions brought about by the epidemic and through
an intensification of processes of social exclusion.
HIV PREVALENCE C THE EVIDENCE
Of the global total of 30 million
persons living with HIV in 1997 some two-thirds (21 million) are in sub-Saharan
Africa. Infection is concentrated in the socially and economically productive
groups aged 15-45, with slightly more women infected than men. There are significant
differences in the ages of infection of girls and boys with infection occurring
at younger ages for girls (with girls and young women in some countries
outnumbering boys and young men by factors of 5 or 6 in the age range 15-20).
It is estimated that 12 million persons have died from HIV-related illnesses
since the start of the epidemic worldwide, of whom approximately 9 million were
Africans. It follows that the cumulative affected population in Africa
taking into account spouses, children and elderly dependents must be of the
order of 150 million1.
This is a staggering proportion of the total population in sub-Saharan Africa -
more than one quarter of Africans are directly affected by the HIV epidemic.
Few people can remain unaffected in indirect ways, i.e. through the illness and
death of relatives and colleagues.
The levels of HIV prevalence in
parts of Africa are extremely high - in Southern Africa there are now many
countries with HIV infection rates in adults in the range of 20-25%. The gap
between rural and urban HIV rates -- previously substantial -- is now narrowing
rapidly in many countries. For some urban populations HIV is now as high as
40-50% -- rates of infection earlier considered wholly improbable. One
consequence of the high HIV infection rates among women is the increasing
number of children with HIV (through mother to child transmission). It is
estimated that there are presently some 8 million children in Africa who have
lost one or both parents to HIV-related illnesses, and that by 2010 these
numbers will have increased to some 40 million. In many countries the
proportion of children who have lost one or both parents will be as high as
20-25% by the end of the first decade of the new millennium. These trends have
direct implications for intergenerational poverty and impose immense challenges
for policy makers.
HIV infection is not confined to the
poorest even though the poor account absolutely for most of those infected in
Africa. There is limited evidence for a socio-economic gradient to HIV
infection, with rates higher as one moves through the educational and
socio-economic structure. It follows that the relationships between poverty and
HIV are far from simple and direct and more complex forces are at work than
just the effects of poverty alone. Indeed many of the non-poor in Africa have
adopted and pursued life styles which expose them to HIV infection, with all
the social and economic consequences that this entails. It follows that the
capacity of individuals and households to cope with HIV and AIDS will depend on
their initial endowment of assets - both human and financial. The poorest by
definition are least able to cope with the effects of HIV/AIDS so that there is
increasing immiseration for affected populations. Even the non-poor find their
resources diminished by their experience of infection (morbidity and death),
and there is increasing evidence in urban communities of an emerging class of
those recently impoverished by the epidemic.
The effects of HIV and AIDS are
reflected in the changes in Life Expectancy which is the best summary indicator
of the effects of HIV and AIDS on countries with high levels of HIV prevalence.
These data are remarkable for what they illustrate of the demographic impact of
the epidemic on African populations. In many countries adult mortality has
doubled and trebled over the past decade and this is directly attributable to
HIV and AIDS. What is now being experienced by these populations are levels of
Life Expectancy which were typical of the 1950s. This is not confined to those
living in poverty but nevertheless is concentrated on those living in poverty
who account absolutely for most of those who die from HIV-related illnesses.
These data reflect HIV infection which occurred in the late 1980s, and since
then in many countries HIV prevalence has intensified rather than diminished.
Thus the outlook for further declines in Life Expectancy is bleak indeed, both
in the aggregate and for those who are the poorest.
It is easier to understand some of
these complex issues if the bi-causal relationships are analysed through
partial analysis - specifically by segmenting the stages of the epidemic so as
to isolate some of the causal and consequential factors at work in the
processes of immiseration. These processes are well illustrated by the
different life-histories which are in the various boxes -- selected precisely
because they illustrate some of the important dynamic forces at work. But what
needs also to be kept in mind are the aggregative effects of the HIV epidemic,
for it will not only impoverish individuals and communities but will also erode
the capacity of the socio-economic system through losses of human resources.
Poverty and HIV Infection
The characteristics of the poor are
well known as also are some of the causal factors at work which contribute to a
"culture of poverty" - the fact that the children of the poor often
become the poor of succeeding generations. Poverty is associated with weak
endowments of human and financial resources, such as low levels of education
with associated low levels of literacy and few marketable skills, generally
poor health status and low labour productivity as a result. An aspect of the
poor health status of the poor is the existence amongst many Africans of
undiagnosed and untreated STDs which is now recognised as a very significant
co-factor in the transmission of HIV. Poor households typically have few if any
financial or other assets and are often politically and socially marginalised.
These conditions of social exclusion increase the problems of reaching these
populations through programmes aimed at changing sexual and other
behaviours.
It is not at all surprising in these
circumstances that the poor adopt behaviours which expose them to HIV
infection. It is not simply that IEC activities are unlikely to reach the poor
(which is too often the case) but that such messages are often irrelevant and
inoperable given the reality of their lives. Even if the poor understood what
they are being urged to do it is rarely the case that they have either the
incentive or the resources to adopt the recommended behaviours. Indeed to take
the long-view in sexual or other behaviours is antithetical to the condition of
being poor. For the poor it is the here and now that matters, and policies and
programmes that recommend deferral of gratification will, and do, fall on deaf
ears.
Even more fundamental to the
condition of poverty is social and political exclusion. So HIV-specific
programmes are neglectful of the interests of the poor and are rarely if ever
related to their needs, and also unfortunately are other non-HIV related
programme activities -- such as those relating to agriculture and credit. More
generally it is the absence of effective programmes aimed at sustainable
livelihoods which limit the possibilities of changing the socio-economic
conditions of the poor. But unless the reality of the lives of the poor are changed
they will persist with behaviours which expose them to HIV infection (and all
the consequences of this for themselves and their families).
Two examples of this state of
affairs will perhaps suffice to indicate how poverty leads to outcomes which expose
the poor to HIV. Firstly, poverty -- especially rural poverty, and the absence
of access to sustainable livelihoods, are factors in labour mobility which
itself contributes to the conditions in which HIV transmission occurs. Mobile
populations, which often consist of large numbers of young men and women, are
isolated from traditional cultural and social networks and in the new
conditions they will often engage in risky sexual behaviours, with obvious
consequences in terms of HIV infection. Secondly, many of the poorest are women
who often head the poorest of households in Africa. Inevitably such women will
often engage in commercial sexual transactions, sometimes as CSW but more often
on an occasional basis, as survival strategies for themselves and their
dependents. The effects of these behaviours on HIV infection in women are only
too evident, and in part account for the much higher infection rates in young
women who are increasingly unable to sustain themselves by other work in either
the formal or informal sectors.
There are increasing numbers of
children infected with HIV through perinatal transmission (from mother to
child). This reflects the large numbers of pregnant women who are HIV positive.
Perinatal transmission is largely preventable through appropriate access to
drugs (AZT) but these drugs and the necessary infrastructure for their delivery
are more or less unattainable for most African women. Limitation of access to
AZT is not confined to the poor although they account absolutely for most of
the women who have the greatest need.
A related problem is the
transmission of HIV through breast milk where there is now clear evidence that
significant numbers of babies are infected by this route. This is avoidable and
poverty is a clear factor in access to the methods for prevention of
transmission to babies through breast milk. To prevent transmission through
breast milk requires the ability to buy baby formula and access to clean water,
plus an understanding of why these changes in practise are needed. Neither
clean water nor the income for purchasing formula are available to the poor, so
they are unable because of their poverty to adopt a form of prevention known to
be successful as a means of limiting HIV transmission. This problem is
resolvable through relatively inexpensive programme activities backed up by
community mobilisation to ensure support to families. There are, therefore, no
good reasons why action in this area are not being undertaken by governments,
NGOs and donors.
Individuals, families and
communities are impoverished by their experience of HIV and AIDS in ways that
are typical for long drawn-out and terminal illnesses. It is a feature of HIV
infection that it clusters in families with often both parents HIV positive
(who in time experience morbidity and mortality). There is thus enormous strain
on the capacity of families to cope with psycho-social and economic
consequences of illness, such that many families experience great distress and
often disintegrate as social and economic units. This experience is well
reflected by the testimony of Lucy (see Box) who has seen her expectations as a
mother and grandmother completely overturned by HIV/AIDS. Integral to her
experience is the disappearance of traditional support processes for the
elderly who can no longer anticipate being supported by their children. Instead
the old are taking on burdens of care for children under conditions of
increasing personal impoverishment and with associated living and other problems
for both generations.
|
By the time my sons
became ill with AIDS, one of my daughters-in-law had already died of
tuberculosis, and the other had become mentally sick. So I was the closest
person to my sons. I had to resume the role of a mother caring for her sick
children. I was the only one who could ensure that their physical and
emotional needs are met. It was very touching having to nurse my sons again
and watching them bed-ridden and deteriorating day by day. My heart shrunk
whenever I thought of caring for my grandchildren after the death of their
fathers. Their sickness had started encroaching on the savings I had made for
my own welfare in old age. It was very painful watching them die. When I was
a young girl of 17 getting married, I never dreamed that someday I would see
three of my sons die.
My sons left behind 6 orphans, and now I am once again a mother to children
ranging in age from 8 to 15. Two of my grandchildren were also HIV infected.
One has already died, and one is still living at age 8, though she has
started falling sick. I am taking care of them alone because in our culture,
it is the family of the father who must care for orphans. This is a great
challenge having to look after young children again after counting myself
among those who had graduated from the responsibility of being a
mother.
Before my sons became ill, I had hoped that my role as a grandmother would be
to care for my grandchildren occasionally during school holidays, but now I
am alone in caring for them. In the old days, children were not exposed to so
many outside influences, but now Uganda society has changed so much. I find
that some of the tactics I used to instill discipline in my own children no
longer yield the desired response from my grandchildren. I find the children
less respectful and undisciplined in spite of my effort. I feel so sad that I
have gone back to the beginning and I have to struggle to get resources to
ensure that their basic needs are met, such as school fees, medical care,
clothing and other needs. Lucy
|
Poor families have a reduced
capacity to deal with the effects of morbidity and mortality than do richer
ones for very obvious reasons. These include the absence of savings and other
assets which can cushion the impact of illness and death. The poor are already
on the margins of survival and thus are also unable to deal with the consequent
health and other costs. These include the costs of drugs when available to
treat opportunistic infections, transport costs to health centres, reduced
household productivity through illness and diversion of labour to caring roles,
losses of employment through illness and job discrimination, funeral and
related costs, and so on. In the longer term such poor households never recover
even their initial level of living as their capacity is reduced through the
losses of productive family members through death and through migration, and
through the sales of any productive assets they once possessed. A true process
of immiseration is now observable in many parts of Africa.
An important aspect of the coping
experience of those infected and affected by HIV and directly related to
poverty is the survival time from initial HIV infection to death in Africa. HIV
infected persons in Africa live for a shorter time after initial infection than
in developed countries, and this is not simply related to access to new
anti-retroviral treatments (although this is now an important factor in the
differential experience of rich and poor countries). Even prior to the
availability of ARV in rich countries the evidence was that HIV infected
persons in Africa had a survival time from infection to death of approximately
5-7 years, about half that in developed countries. The explanation is complex
but is to a significant degree related to the poverty of most of those infected
with HIV in Africa.
Elements in the
survival-time-differential of Africans which are undoubtedly important include
the inability to purchase relatively inexpensive drugs to deal with HIV
opportunistic infections (such as TB and diarrhea), poor basic health and
nutrition, limited psycho-social support and generally poor quality care both
in hospital and home settings. These factors are all remedial through programme
activities which can be provided at relatively low cost by the state and NGOs,
although they remain well beyond the capacity of poor households to provide for
themselves. Once provided they will extend and enhance the lives of those
infected and will permit them to support both themselves and their families.
Central to these processes are often
conditions of isolation and discrimination such that traditional forms of
social support for the poor and the sick become inoperable. Societies
characterised by random events such as illness and death have developed mechanisms
of social support -- traditional safety nets for those impoverished by disease
and crop failure. What appears to be happening is that traditional systems of
support are themselves in decline for structural reasons and are not being
replaced by state mechanisms. At the same time the clustering of poverty caused
by HIV, which concentrates spatially and in certain communities, places demands
on disintegrating social support systems to which they cannot respond.
Furthermore because HIV and AIDS are viewed in many communities as the outcome
of reprehensible behaviour there is often an unwillingness both to seek help by
those affected and negative responses often by those able to provide
assistance. A dual process has emerged which is the antithesis of what is
required if the poor are to deal with the social and economic costs of HIV and
AIDS.
Intergenerational Impacts of HIV
These intergenerational effects of
HIV and AIDS are the longest lasting of all and relate to the mechanisms
whereby the epidemic intensifies poverty and leads to its persistence. They are
those processes which generate over time a culture of poverty -- not created by
the HIV epidemic but undoubtedly strengthened by the direct and indirect
effects of the epidemic on social and economic development. They arise in part
from the effects of the epidemic on human and institutional capacity where
losses occur because of erosion of human resources. It follows that poverty
reduction strategies will be increasingly ineffective in the face of an intensifying
HIV epidemic which undermines sustainable development. Thus reducing poverty
through sustainable development has become an even greater challenge than
hitherto for countries in Africa.
It is possible to disaggregate the
effects of the epidemic so as to perceive what is going on at the levels of
families and communities. These will have their effects over many years and
unlike the coping strategies noted above are longer term in their consequences.
It is instructive to consider Kevina's story (see Box) in order to understand
the processes at work for all of the elements necessary for poverty to persist
over time are revealed by what she writes. These experiences are now being
repeated a million fold by other children throughout Africa, children who represent
the future -- who are the future for the continent.
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My names are Kevina Lubowa. I am
14 years old. I have 4 brothers and 3 sisters younger than me. I come from
Uganda. I am studying in Primary six. I have come here to say something about
AIDS and its problems.
AIDS means acquired immune-deficiency syndrome. It's a terrible disease. It
killed both my mother and father in 1992. It killed all brothers and sisters
of my father. It has killed many men and women in Uganda.
Some houses have been closed. But our house was not closed because my father
and mother left me with four brothers and two sisters. I look after them. I
also look after my grandfather who lives near us, because his wife died and
nobody was there to look after him. He is 84 years old. He lost his wife in
1992. The grandfather does not see. He has eye problems. It is me who looks
after the family.
From school, I go to bring water from the well. I take a jerrican on my head.
I tell my brothers and sisters to go in the bush and collect firewood.
Sometimes, when we don't have fire, we go and get it from our neighbours. We
cook potatoes, matooke, pumpkins and casava. But my brothers do not want
cassava; they want only matooke. Our banana plantation is now a forest. We
dig in our plantation on holidays and on Saturday. Our food is not enough.
Some days we don't get food. We eat cassava with boiled water as sauce. We
don't have money to buy sugar or tea leaves.
In the evening I make up beds for my young sisters and brothers. Every week
we cut grass to use as our mattresses. We all sleep together and cover
ourselves with blankets. Sometimes we sleep in the corner of the house
because our house is leaking. Our blankets get wet and we put them near the
fire or in the sun to dry.
There is the problem of disease. We get sick and go to the dispensary. At the
dispensary they want money but we don't have the money. They give only
tablets. We foot from home to the dispensary. You cannot stop a car because
they also want money. Old women help us and give us leaves and mululuza to
chew. This helps to get rid of fever.
Because I am a girl people think I am weak. So they come home and steal our
cassava and fire wood. Because I am a girl even when I see them I can do
nothing. Some people in the village are not friends. They shout at us, they
don't give us advice; we don't have any one to call father or mother; we feel
sad when we see other children laughing with their father and mother. In
short, this is how I find life.
But other orphans have the same life. They don't have blankets; they don't
eat meat; they don't have sugar; they sleep in huts.. Some go to eat at the
neighbors or they get one meal a day. At school, life is good. The teacher
calls us orphans, but I don't want that name. Even other children don't want
that name. We think we are animals.
My friends, I am concluding by saying that the life of an orphan in Uganda is
bad. Some people want us to work as their house girls and house boys. Now we
want good food, blankets, education and many other things. We also want to
live in good houses. So orphans need help. We need to grow and to be proud
and happy people.
Let me stop here. Thank you very much. Merci beaucoup.
Kevina
|
Kevina's story contains all of the
essential elements that contribute to intergenerational poverty. Children are
left isolated who have lost both parents and access to most forms of social
support. The mechanisms for socialisation of children no longer operate, so
that systems for acculturisation do not function and the children become
alienated from their community. It is the beginning of the process of
alienation and anomie which have socially destructive outcomes for children and
their communities, and ultimately for society.
There are also the direct effects of
what has happened to the children which are material and damaging to their
futures. Poor nutrition leads to poor health which is an important cause of low
labour productivity and thus the persistence of low incomes for the poor. Poor
and damp housing is a major factor in causing illnesses such as TB which is
itself exacerbated by the HIV epidemic (where there is now a dual epidemic
underway in Africa). These children will continue to experience poor health
status over their lifetimes with all kinds of social and economic consequences
for them and their families.
The children's chances of escaping
from their poverty depends on access to resources which are self evidently
missing. These include access to education which is the primary mechanism that
the poor have for social mobility. But education is one thing that these
children will not have access to in accordance with their abilities -- most
evidently in the case of girl children. A generation is thus emerging with poor
health status, few skills (not even those necessary for rural development), low
levels of literacy and numeracy, little or no access to financial and other
real assets (where their property and other rights will often have been
infringed), and who have been deprived of normal processes of socialisation and
social inclusion. Indeed they will face additional social exclusion because
they come from families who have experienced AIDS.
These children display, in other
words, all those characteristics typical of the poor and the disadvantaged.
They are in effect the next generation of the poor, and are the outcome of
ongoing structural processes which are being intensified by the HIV epidemic
currently affecting so many Africans of all social classes and all ages. They
also represent both the future and the challenge for sustained development in
Africa. If their educational, health, housing and other psycho-social needs are
not addressed through specific policies and programmes then it is difficult to
see how national development objectives can possibly be achieved. Just as
important is the fact that large numbers of children growing up in poverty will
adopt precisely those behaviours which lead to HIV infection. They will in
effect become the next cohort of the HIV infected; a state of affairs which will
permit the epidemic to continue and intensify.
The HIV epidemic has its origins in
African poverty and unless and until poverty is reduced there will be little
progress either with reducing transmission of the virus or an enhanced capacity
to cope with its socio-economic consequences. It follows that sustained human
development is essential for any effective response to the epidemic in Africa.
A conclusion that has yet to permeate approaches to the epidemic not only in
Africa but more or less everywhere. While the HIV epidemic makes sustained
human development more and more unattainable, and actually adds to poverty, it
also destroys the human resource capacities essential for an effective
response.
Herein lies the problem: how to
achieve the sustainable development essential for an effective response to the
epidemic under conditions where the epidemic is destructive of the capacities
essential for the response. Simple answers to this problem do not exist,
but at least recognition of its existence is a step towards its solution. The
next step has to be the development of policies and programmes that address the
inter-relationships between poverty and development and to actually put in
place those activities that can make a difference for development outcomes.
Central to these activities are programmes that address poverty today so as to
facilitate future socio-economic development tomorrow. For unless the
intergenerational effects of HIV are addressed now then it is optimistic in the
extreme to assume that Africa will become a pole of development in succeeding
decades.
Endnotes
1. 21 million
currently infected with HIV plus 9 million persons who have died from
HIV-related illnesses times a factor of 5 to take account of those directly
affected.
BIOGRAPHICAL NOTE
Desmond Cohen is an economist with university
teaching experience in Africa, Canada, the UK and the USA. Formerly he was a
Governor and Associate Fellow at the Institute of Development Studies,
University of Sussex in the United Kingdom and until 1990, he was Dean of the
School of Social Sciences. He has both research and applied macro-economic
policy experience in a number of African and Asian countries. Previously he was
an adviser to the British Treasury on international financial policy. In
1997-98 he was Director of the HIV and Development Programme (UNDP), and
currently he is Senior Adviser on HIV and Development.
