The Coming Plague (85 page)
Authors: Laurie Garrett
With concern mounting about the Thirdworldization that AIDS might bring upon Africa, Peter Plot teamed up with Mead Over to do a systematic analysis of the relative cost of HIV compared to other, better-understood diseases. After carefully computing the per capita burden in terms of productive healthy years of life lost, Piot and Over concluded that the direct costs of treating HIV disease, even in the absence of AZT and other expensive drugs widely available in North America and Western Europe, far outstripped those of any other common ailment in Africa.
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The impact was already being felt keenly in some sub-Saharan countries. Malawi's entire health care system, for example, was in genuine peril of collapse under the burden of HIV, and the nation's public health leadership in 1990 issued desperate pleas to WHO, the World Bank, U.S. AID, and other Western organizations for funds.
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Even as Africa's leaders began to absorb the dire economic implications of the WHO and World Bank AIDS studies, critics were emerging who charged that the well-intended analyses grossly underestimated the epidemic's impact. For example, nurse Eunice Muringo Kiereini, a Kenyan woman who chaired the WHO Regional Nursing/Midwifery Task Force, claimed that the studies failed to consider the special economic roles women and children played in African economies. Ever since the beginning of Africa's mass urbanization it was the continent's young men who left the farms and villages in favor of jobs in the cities. Few village women had the option of abandoning their traditional lifestyles. As a result, in many parts of Africa villages were populated by females of all ages, male children, and elderly men, many of whom were too feeble to work. Young men would return to their wives and children periodically, but their lives were elsewhere.
So it was the women and children of Africa who maintained the continent's agricultural economies, Kiereini said.
“Women are hit the hardest by the international structural injustices prevailing in the Third World,” Kiereini explained.
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“The majority of countries in Africa are dependent for foreign earnings on the export of one or two agricultural products such as cocoa, tea, coffee, etc. Trade in these products is grossly imbalanced in the favour of the rich countries. Prices are so low and unstable and the market is controlled by foreign interests. A country in this situation sinks even deeper into poverty.
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“The majority of countries in Africa are dependent for foreign earnings on the export of one or two agricultural products such as cocoa, tea, coffee, etc. Trade in these products is grossly imbalanced in the favour of the rich countries. Prices are so low and unstable and the market is controlled by foreign interests. A country in this situation sinks even deeper into poverty.
“It is true to say that women and children who provide 80%â90% of the labour force earn extremely low income at the end of the day. The little money they are paid is controlled fully by men. Consequently, women and
children are trapped in the vicious cycle of structural poverty. In this kind of situation there is little or no money available to meet the basic needs of the family.”
children are trapped in the vicious cycle of structural poverty. In this kind of situation there is little or no money available to meet the basic needs of the family.”
Though in some parts of Africa women were less valuable than local livestockâas evidenced by prevailing bride-prices and dowriesâit was they who raised the continent's futures: its crops and children. When husbands contracted HIV in the cities and passed the virus on to their wives during periodic return visits to the villages, AIDS appeared in rural areas that were completely lacking in health care and social support systems. The affected women continued to plow the soil with their hand hoes, lugging babies on their backs, until their AIDS-devastated bodies collapsed. And with each female death Africa's agricultural productivity declined another, barely perceptible notch. The cumulative burden of these declines, Kiereini warned, could, by the year 2000, be more desperate for some countries than their losses of professional elites. The demise of Africa's female agricultural workers could, she warned, lead to acute food shortages.
Even uninfected, healthy African women were being forced out of productive roles in agricultural sectors by the AIDS epidemic. In most African societies, both traditionally and under modern codified law, women had virtually no basic rights. They were, legally, their husband's property, as surely as were his cows or goats.
If the husband died, his property reverted not to the wife but to his relatives. The crops that the widow had tilled became a new source of prosperity for the in-laws. The widow and children, now landless, often lacking even changes of clothing, had to find a means of survival.
In the short run the village and overall societal economies experienced little if any impact from this process because the in-laws continued to harvest crops. But as the epidemic expanded, and even those in-laws were infected, Africa faced the creation of an unprecedented rural underclass of desperately impoverished, often starving women and children. Further, it was obvious that eventually the cumulative load of deprived widows would exceed the available labor force of in-law inheritors, causing declines in crop production.
Worse yet, one of the few survival options left to widowsâperhaps the only way they could feed their childrenâwas prostitution. So, impoverished by AIDS, the woman would be forced into a life that virtually guaranteed that she, too, would die of the disease.
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By 1991 the gender ratio of AIDS in Africa was shifting, reflecting higher infection rates among women. For example, researchers from the University of California at San Francisco studied nineteen- to thirty-seven-year-old women in Kigali, Rwanda. A third of the randomly sampled women were HIV-positive. Even among women previously thought to be at very low risk for HIV because they were monogamous throughout their lives, the infection rate was 20 percent. The same group also showed that many women in Rwanda were dying of AIDS but not being counted in national statistics
because their symptoms didn't fit with the male-based WHO definition of the disease. The researchers suggested that the true extent of AIDS in African women might be two to three times the diagnosed numbers.
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because their symptoms didn't fit with the male-based WHO definition of the disease. The researchers suggested that the true extent of AIDS in African women might be two to three times the diagnosed numbers.
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Josef Decosas, of Canada's International Development Agency, argued that the continent's women were caught in “an epidemiologic and demographic trap” from which they could not be freed without greater social equity. Decosas contended that any hope of slowing Africa's devastating epidemic before it brought financial ruin to much of the continent was inextricably tied to improvement in the status of Africa's women.
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Researchers at the UN's Food and Agriculture Organization, based in Rome, tried to calculate the impact AIDS would have on African agricultural production. Their best estimate was that Africa's overall labor forceâpredominantly womenâwould be reduced by 25 percent by 2010.
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Another factor compounding estimates of the socioeconomic costs of AIDS was the epidemic's continuing geographic expansion. Though every political leader on the continent knew by 1989â90 what caused the disease and which social measures might prevent its spread, agonizingly few took steps to warn their populaces prior to HIV's full-scale emergence in their midst. South Africa, for example, was spared significant HIV emergence until the late 1980s. There is no evidence that the virus existed in the country prior to 1986, and for the first three years it was almost exclusively a disease of gay white men who had traveled in Europe and North America.
By 1989, however, HIV was emerging in South Africa's black population. The microbe found advantages in apartheid policies regarding migrant labor: men from throughout the country, as well as nearby Swaziland, Mozambique, and Malawi, were granted work permits for jobs in the gold and diamond mines, but were not allowed to bring their wives and children. Living in squalid barracks, the men frequented brothels in the mining towns whenever possible. Each prostitute became an AIDS amplifier.
By 1991 local experts were estimating that as many as 400,000 black South Africans, mostly men, might be HIV-positive. Given that black infection rates were thought to be near zero two years earlier, this represented explosive growth.
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Similarly, Ethiopia, which had long been spared the AIDS scourge, witnessed a phenomenal explosion of cases in 1991â93. As late as 1986 the country had no evidence that HIV had emerged within its borders. In February of that year the first AIDS case was diagnosed in Addis Ababa. By 1992 local experts estimated that more than 800,000 Ethiopians were infected, with the highest rates of infectionânearly 15 percentâseen among military personnel.
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Roy Anderson and his team at Imperial College in London predicted that AIDS in fifty-three African nationsâincluding several north of the Saharaâ“would reverse the size of population growth rates over timescales of a few to many decades.”
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In other words, even though African countries had some of the highest
population growth rates in the world, the epidemic was likely to outstrip that explosion and some countries might eventually experience negative population growth.
population growth rates in the world, the epidemic was likely to outstrip that explosion and some countries might eventually experience negative population growth.
The World Bank predicted two immediate consequences of AIDS in hard-hit African areas: a radical slowdown of national GDPs and tremendous competition for scarce health care resources.
The latter was already occurring, prompting fears that secondary and tertiary disease epidemics would emerge in the wake of AIDS because countries would no longer have the resources to control other bacterial, viral, and parasitic microbes. Given that HIV/AIDS monopolized less than 1 percent of the continent's meager health budgets prior to 1984, the trend toward resource absorption by the AIDS epidemic was disturbing.
The World Bank estimated in 1991 that HIV/AIDS commanded more than 4 percent of Tanzania's health budget, even with fewer than 10 percent of all AIDS cases receiving hospital attention. But the situation was worse elsewhere: AIDS was eating up 7 percent of Malawi's health budget, 9 percent of Rwanda's, 10 percent of Burundi's, and an astonishing 55 percent of the Ugandan health budget.
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In early 1991 physicians in Zambia predicted that HIV/AIDS would soon overtake malaria, becoming the number one illness requiring hospitalization in the country.
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A month later physicians in Lusaka reported that HIV/ AIDS had, indeed, overtaken malaria and accounted for the use of 80 percent of the city's hospital beds. Barclays Bank complained of radically increased rates of absenteeism due to employee attendance at AIDS funerals and personal sick days. By 1992 in Lusaka, bus companies were requiring several days' advance notice for booking transport to funerals, due to backlogs. And copper production, Zambia's and Zaire's primary sources of foreign exchange, was slowly declining due to lost labor and AIDS illnesses. In 1990 the countries produced 800,000 tons of copper for export; by 1993 that was down to 600,000. Life insurance companies in Zimbabwe and South Africa faced bankruptcy as AIDS-related claims mounted. Coffee production declined by 5 percent in Uganda's hard-hit Rakai District between 1991 and 1993. Large-scale tobacco farmers in Zimbabwe took to distributing condoms to their workers in hopes of preventing a labor crisis.
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A month later physicians in Lusaka reported that HIV/ AIDS had, indeed, overtaken malaria and accounted for the use of 80 percent of the city's hospital beds. Barclays Bank complained of radically increased rates of absenteeism due to employee attendance at AIDS funerals and personal sick days. By 1992 in Lusaka, bus companies were requiring several days' advance notice for booking transport to funerals, due to backlogs. And copper production, Zambia's and Zaire's primary sources of foreign exchange, was slowly declining due to lost labor and AIDS illnesses. In 1990 the countries produced 800,000 tons of copper for export; by 1993 that was down to 600,000. Life insurance companies in Zimbabwe and South Africa faced bankruptcy as AIDS-related claims mounted. Coffee production declined by 5 percent in Uganda's hard-hit Rakai District between 1991 and 1993. Large-scale tobacco farmers in Zimbabwe took to distributing condoms to their workers in hopes of preventing a labor crisis.
The U.S. Census Bureau assisted counterpart African agencies in trying to count the population impact of AIDS. In early 1994 the agency announced that infant and child mortality was 15 percent higher in Zambia than had been the case in 1984. Since infant mortality rates were used worldwide as a gauge of development, the finding meant that Zambia's overall status represented a reversion to pre-1980 levels of development. Similar findings were made for Malawi and Uganda.
Following his dispute with WHO Director-General Nakajima, Mann joined the faculty of the Harvard School of Public Health in Boston and founded the Global AIDS Policy Coalition. Together with former GPA colleagues Tom Netter and Daniel Tarantola, Mann organized yet another
analysis of the scope and future of the AIDS pandemic. The Coalition's estimates, which were based on the Delphi Survey technique,
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were far grimmer than those promulgated by WHO.
analysis of the scope and future of the AIDS pandemic. The Coalition's estimates, which were based on the Delphi Survey technique,
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were far grimmer than those promulgated by WHO.
By 1992, they estimated, 12.9 million people worldwide had been infected with HIV, 2.7 million of whom had already developed AIDS.
By the year 2000 a minimum of 38 million people would have been infected with HIV, according to the Global AIDS Policy Coalition, but “a more realistic projection is that this figure will be higher, perhaps up to 110 million.”
In that scenario, 25 million people would have died of AIDS between 1980 and 2000.
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Anderson's group in London predicted a terrifying future for those African societies in which HIV had already, by 1990, become endemic to the general population. Barring development of a vaccine or effective means of controlling further spread of the microbe, HIV infection rates would exceed 80 percent of the sexually active population within forty-five years of the emergence of the virus in a given African society. Following that model, if HIV emerged around the Lake Victoria region, for example, during the period of hostilities between Uganda and Tanzania (1977â79), eight out of every ten adults living in the area in 2020 would either have AIDS, have already succumbed to the disease, or be HIV-positive.
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