AIDS in Africa

[2000] began with 24 million Africans infected with the virus. In the absence of a medical miracle, nearly all will die before 2010. Each day, 6,000 Africans die from AIDS. Each day, an additional 11,000 are infected.

By 1990, the sense of urgency about AIDS in wealthy nations had also started to dissipate. In the '90s it became clear we were not going to have a major heterosexual epidemic in the States, said Michael Merson, who would succeed Mann at the WHO program. AIDS was no longer a threat to the West.

Foege, the former [US federal Centers for Disease Control and Prevention] CDC director, now teaches at Emory University. He has a maxim for his public health students: Tie the needs of the poor with the fears of the rich. When the rich lose their fear, they are not willing to invest in the problems of the poor.

When Brown and Hall first proposed to study the phenomenon in 1987, they could not obtain CIA approval for use of personnel and computer modeling resources. Internal critics declared global AIDS an unfit subject of intelligence, or said the impact on U.S. interests would be benign.

Speaking of one military colleague at the National Intelligence Council, Brown said, His penetrating analysis was, Oh, it will be good, because Africa is overpopulated anyway. Others were saying, It may be big, but what are you going to do about it? Still others, Brown recalled, discounted the likelihood of damage to allied militaries. If officers began dying of the disease, they said, That boosts morale, because there’s more room for advancement.

Another security official, recalling those debates, said critics reasoned that Africa’s limitless pool of unemployed men left armies with plenty of reinforcements. If you have one 18-year-old with a Kalashnikov [rifle] and he dies, you find another 18-year-old, he said. The cold truth was that the impact on military stability was minimal.

AIDS policy is now a key world commodity—right up there with shiploads of computers, crude oil and wheat.

Oxfam believes that 39 of the world’s biggest drug companies are contributing to a gross breach of human rights in South Africa and has today called on the United Nations to investigate.

People concerned by globalisation frequently invoke the spectre of the growing might of corporations, which are seen as claiming ever greater chunks of influence in global policy setting. Rarely has this picture been drawn as clearly as in a recent court case in South Africa, in which the government of the country with more people living with HIV/AIDS than any other was locked into a fierce struggle with an industry doing everything possible to preserve its profits.

Happily, this David-and-Goliath story ended well when the 39 pharmaceutical companies suing the government decided to unconditionally drop their case against the Medicines and Related Substances Control Amendment Act, No. 90 of 1997, albeit after having tied it up in court for more than three years. Thus the final victory must be tempered by its high costs: during these three years, more than 400,000 South Africans have died of HIV/AIDS. Additionally, it is important to recognize that the legal victory alone will not automatically translate into improved care for people with HIV/AIDS; further steps are necessary before the hopes raised by this case—particularly for access to life-saving anti-retroviral medications—can be realized.

What might be overlooked, however, as life-sustaining drugs become available, is the fact that prevention is still by far the more compassionate and more cost-effective answer. Prevention does not replace treatment, but it does reduce the number of people whose lives will depend on expensive drugs with significant side effects.

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Attending to broader health concerns is not as expensive, or as hopeless, as it might seem. There are also serious weaknesses in a prevention plan that relies exclusively on provision of condoms, even with health education. It does not address women’s lack of power in sexual relationships, nor the irrelevance of condoms to most people after a few beers. Strengthening immune systems will help to protect people from some of the consequences of unsafe sex and from other infectious diseases as well. What it will take to prevent HIV transmission and to treat people with HIV/AIDS is no less, but no more, than what has been needed all along in sub-Saharan Africa and other poor regions. It would have been cheaper to provide the infrastructure, the nutrition, the education and the medicines before HIV/AIDS, but it is still a bargain calculated in both compassionate and cost-effective terms.

Although there are numerous factors in the spread of HIV/AIDS, it is largely recognised as a disease of poverty, hitting hardest where people are marginalised and suffering economic hardship. IMF designed Structural Adjustment Programmes (SAPs), adopted by debtor countries as a condition of debt relief, are hurting, not working. By pushing poor people even deeper into poverty, SAPs may be increasing their vulnerability to HIV infection, and reinforcing conditions where the scourge of HIV/AIDS can flourish.

Health status is influenced by socioeconomic factors as well as by the state of health care delivery systems. The policies prescribed by the World Bank and IMF have increased poverty in African countries and mandated cutbacks in the health sector. Combined, this has caused a massive deterioration in the continent’s health status.

The health care systems inherited by most African states after the colonial era were unevenly weighted toward privileged elites and urban centers. In the 1960s and 1970s, substantial progress was made in improving the reach of health care services in many African countries. Most African governments increased spending on the health sector during this period. They endeavored to extend primary health care and to emphasize the development of a public health system to redress the inequalities of the colonial era. The World Health Organization (WHO) emphasized the importance of primary healthcare at the historic Alma Ata Conference in 1978. The Declaration of Alma Ata focused on a community-based approach to health care and resolved that comprehensive health care was a basic right and a responsibility of government.

These efforts undertaken by African governments after independence were quite successful....

While the progress across the African continent was uneven, it was significant, not only because of its positive effects on the health of African populations. It also illustrated a commitment by African leaders to the principle of building and developing their health care systems.

With the economic crisis of the 1980s, much of Africa’s economic and social progress over the previous two decades began to come undone. As African governments became clients of the World Bank and IMF, they forfeited control over their domestic spending priorities. The loan conditions of these institutions forced contraction in government spending on health and other social services....

The relationship between poverty and ill-health is well established. The economic austerity policies attached to World Bank and IMF loans led to intensified poverty in many African countries in the 1980s and 1990s. This increased the vulnerability of African populations to the spread of diseases and to other health problems....

The deepening poverty across the continent has created fertile ground for the spread of infectious diseases. Declining living conditions and reduced access to basic services have led to decreased health status. In Africa today, almost half of the population lacks access to safe water and adequate sanitation services. As immune systems have become weakened, the susceptibility of Africa’s people to infectious diseases has greatly increased....

Even as government spending on health was cut back, the amounts being paid by African governments to foreign creditors continued to increase. By the 1990s, most African countries were spending more repaying foreign debts than on health or education for their people. Health care services in African countries disintegrated, while desperately needed resources were siphoned off by foreign creditors. It was estimated in 1997 that sub-Saharan African governments were transferring to Northern creditors four times what they were spending on the health of their people. In 1998, Senegal spent five times as much repaying foreign debts as on health. Across Africa, debt repayments compete directly with spending on Africa’s health care services.

The erosion of Africa’s health care infrastructure has left many countries unable to cope with the impact of HIV/AIDS and other diseases. Efforts to address the health crisis have been undermined by the lack of available resources and the breakdown in health care delivery systems. The privatization of basic health care has further impeded the response to the health crisis....

The World Bank has recommended several forms of privatization in the health sector.... Throughout Africa, the privatization of health care has reduced access to necessary services. The introduction of market principles into health care delivery has transformed health care from a public service to a private commodity. The outcome has been the denial of access to the poor, who cannot afford to pay for private care.... For example ... user fees have actually succeeded in driving the poor away from health care [while] the promotion of insurance schemes as a means to defray the costs of private health care ... is inherently flawed in the African context. Less than 10% of Africa’s labor force is employed in the formal job sector.

Beyond the issue of affordability, private health care is also inappropriate in responding to Africa’s particular health needs. When infectious diseases constitute the greatest challenge to health in Africa, public health services are essential. Private health care cannot make the necessary interventions at the community level. Private care is less effective at prevention, and is less able to cope with epidemic situations. Successfully responding to the spread of HIV/AIDS and other diseases in Africa requires strong public health care services.

The privatization of health care in Africa has created a two-tier system which reinforces economic and social inequalities. As health care has become an expensive privilege, the poor have been unable to pay for essential services. The result has been reduced access and increased rates of illness and mortality. Despite these devastating consequences, the World Bank and IMF have continued to push for the privatization of public health services.

The World Bank has also increased its funding for health, and for HIV/AIDS programs in particular. While the shift in focus towards prioritizing social development and poverty eradication is welcome, fundamental problems remain. New lending for health and education can achieve little when the debt burden of most African countries is already unsustainable. Debt cancellation should be the first step in enabling African countries to tackle their social development challenges. Additional resources to support health and education programs should be conceived as public investment, not new loans. The new spin on the World Bank and IMF priorities fails to change the basic agenda and operations of these institutions. Indeed, it appears to be largely an exercise in public relations. The conditions attached to World Bank and IMF loans still reflect the same orientation prescribed over the past two decades. The recent moves towards promoting poverty reduction have actually permitted these institutions to increase the scope of their loan conditions to include social sector reforms and governance aspects. This allows an even greater intrusion into the domestic policies of African countries. It is highly inappropriate that external creditors should have such control over the priorities of African governments. And it is disingenuous for such creditors to proclaim concern with poverty reduction when they continue to drain desperately needed resources from the poorest countries....

The free market fundamentalism of the World Bank and IMF has had a disastrous impact on Africa’s health. The all-out pursuit of market-led growth has undermined health and health care in African countries. It has forced governments to sacrifice social needs to meet macroeconomic goals.

This approach to development is fundamentally flawed. The failure to prioritize public health denies its significance in promoting long-term economic growth. As the WHO Commission on Macroeconomics and Health recently concluded, health is more than an outcome of development, it is a crucial means to achieving development.