HIV epidemic and other crisis response in sub-Saharan Africa

Report
from International Labour Organization
Published on 30 Apr 2002
InFocus Programme on Crisis Response and Reconstruction
Working Paper 6
Desmond Cohen
Recovery and Reconstruction Department, Geneva, April 2002

PREFACE

The overall goal of the current ILO InFocus Programme on Crisis Response and Reconstruction is to develop the ILO coherent and rapid response to the different crises - natural disasters, armed conflicts, financial and economic downturns and difficult political and social transitions - focusing on areas of ILO comparative advantage. Knowledge development constitutes one of the Programmes four main pillars. The other three are timely needs assessment and programme formulation and implementation in the crisis-affected countries; advocacy at the international, regional and national levels on the employment and other socio-economic dimensions of crisis and the need to address them as an integral component of crisis prevention, resolution and post-crisis reintegration, reconstruction, and development processes; and capacity building of the ILO and its constituents to enhance their effective and active role in crisis response. The Programmes implementation is currently quite advanced in all four areas.

The present paper on HIV and other crisis response in sub-Saharan Africa is one of the outputs of the Programmes research work, undertaken with an external network of researchers from various universities and other research institutions around the world.

Desmond Cohen has provided a valuable analysis of the HIV/AIDS epidemic, showing how armed conflicts and other crises in the region are contributing to an escalation of the epidemic. Above all, he has indicated how the ILO crisis response work can integrate understanding of this interconnection.

The InFocus Programme on Crisis Response acknowledges the contribution of Janine Rodgers and Mike Shone to the commencement of the study, as well as that of Erik Lyby who reviewed the first draft with me. I am also grateful to the ILO Jobs for Africa Programme, especially Mpenga Kabundi, for providing funding for the exercise. The ILO Crisis Response Programme as well as the ILO/AIDS and Jobs for Africa Programme will do their best to ensure follow-up to the recommendations. We are also sure that others working on the different crises as well as on HIV/AIDS will find the analysis and recommendations useful for their work. We welcome feedback from readers and users of this working paper.

Eugenia Date-Bah
Director
InFocus Programme on Crisis Response and Reconstruction
International Labour Office
4, route des Morillons
CH-1211 Geneva 22
Switzerland

EXECUTIVE SUMMARY

The most recent estimate from UNAIDS (December 2001) is that there are presently 40 million people living with HIV globally. During 2001 new HIV infections were 5 million, of whom 1.8 million were women. Since the start of the epidemic in the 1980s, cumulatively some 20 million Africans have died from AIDS, and there are an estimated 28 million people in Africa living with the virus. Other countries in Southern Africa have now joined Botswana with HIV prevalence amongst adults in excess of 30 per cent. In the worst-affected countries, steep declines in life expectancy are occurring, and at the present time four countries in the region have life expectancies at birth of less than 40 years. Across sub-Saharan Africa, life expectancy is estimated now at only 47 years, compared with a non-AIDS projection of 66 years.

An epidemic on this scale has an effect on all aspects of life in the region and is increasingly seen as structurally changing the parameters of development in ways that are only now receiving the attention of the international community. It is increasingly clear that the HIV epidemic has its origins in conditions of poverty, gender inequality and patterns of development that intensify the mechanisms through which HIV transmission takes place. Simultaneously, the HIV epidemic, through its impact on development, exacerbates poverty and gender inequality and undermines the organizational capacity and human and social capital essential for development.

Amongst the factors that are driving the HIV epidemic in Africa are crises such as armed conflict, environmental degradation, and those caused by economic and social policy failures. Similarly, these crises tend to generate the conditions in which the epidemic thrives through the displacement of populations, intensification of poverty and destruction of productive capacity. There are clear bidirectional factors operating which together undermine development in Africa as well as in other regions.

The aims of this paper are threefold. Firstly, it attempts to identify the key concepts essential for understanding the HIV epidemic as a development issue, so that the epidemic is seen as a structural phenomenon which affects all aspects of development in Africa. Secondly, the paper reviews what is known about the interconnections between crises and the HIV epidemic, in order to better understand both the role of crises in respect of the HIV epidemic and the causal role of the epidemic on the conditions in which crises arise. Finally, in section 3 of the paper there is a review of the activities of the ILO Infocus Programme on Crisis Response and R,-construction, with the aim of identifying the processes whereby the HIV epidemic, seen primarily as a development problem, affects the work of the Programme. The discussion of the Programmes approach to crisis, and of empirical data, leads to the conclusion that HIV/AIDS needs to be fully integrated into the work of the Programme (and more generally within the ILO). Current approaches require review and modification if they are to be effective in addressing crisis conditions which are made even more intractable under the impact of HIV/AIDS. Suggestions are made as to how best to move forward, both generally with the integration of HIV/AIDS within the work of the Programme and in respect of changes to traditional ILO approaches to crisis, if they are to fully take into account the developmental and other effects of HIV/AIDS.

INTRODUCTION

It is now recognized, rather belatedly, that the HIV epidemic poses major threats not only to social development but more generally to national and international security. This is reflected in the Resolution of the UN Security Council in June 2000 and the clear statement on this issue that emanated from the UN Special Session on AIDS held in June 2001.1 Thus, the Declaration of Commitment on HIV/AIDS from the UN General Assembly Special Session on AIDS (UNGASS) affirmed the following:

Noting with grave concern that Africa, in particular sub-Saharan Africa, is currently the worst-affected region, where HIV/A1DS is considered a state of emergency which threatens development, social cohesion, political stability, food security and life expectancy and imposes a devastating economic burden... recognizing that poverty, underdevelopment and illiteracy are amongst the principal contributing factors to the spread of HIV/AIDS, and noting with grave concern that HIV/AIDS is compounding poverty and is now reversing or impeding development in many countries and should therefore be addressed in an integrated manner. ...Noting that armed conflicts and natural disasters also exacerbate the spread of the epidemic. (articles 8, 11 and 12)

The UNGASS went further than just describing the reality of the situation in sub-Saharan Africa and urged "all UN agencies, regional and international organizations, as well as NGOs involved with the provision and delivery of international assistance to countries and regions affected by conflicts, humanitarian crises or natural disasters, to incorporate as a matter of urgency HIV/AIDS prevention, care and awareness elements into their plans and programmes and provide HIV/AIDS awareness and training to their personnel" (article 76). The meeting also established specific targets in respect of the various provisions of the Declaration to be met by 2003 (articles 75, 77 and 78 at the Annex of this paper).

It is also worth noting at this point the UNGASS article that is of special relevance to the ILO (article 49) which reads as follows:

By 2005, strengthen the response to HIV/AIDS in the world of work by establishing and implementing prevention and care programmes in public, private and informal work sectors and take measures to provide a supportive workplace environment for people living with HIV/AIDS.

These global statements of concern about the implications of the HIV epidemic are to be welcomed in that they affirm a commitment to address the complex problems of AIDS. It is, however, going to prove much more difficult to achieve global objectives than it is to set out projected targets, for there continues to be clear evidence that the epidemic is generally not understood as a threat to international security and to social and economic development and that, even where high priority is given to issues of HIV/AIDS, there are great programmatic weaknesses in going forward with effective responses.

In section I of this paper, there is a review of the epidemiological situation in sub-Saharan Africa setting out some of the key features of the epidemic. This is followed by a brief analysis of various aspects of the epidemic that are intended to form a basis for understanding some of the key issues that need to be considered in designing and implementing policy and programme responses: issues of the systemic effects of HIV and AIDS; the impact on human capital; and the effects of AIDS on poverty. This is followed in section 2 by a review of the interaction of the HIV epidemic with crises, so as to establish in broad terms the most important relationships between structural variables. Finally, in section 3 the conclusions and insights into epidemic processes and effects are used in reviewing the generic ILO Programme on Crisis Response and Reconstruction with the intention of achieving integration of HIV and AIDS.

At the present time, HIV/AIDS as such has had little part in the design and implementation of the Programmes activities. This in part reflects the scale of the task already facing the Programme in responding to the different structural crises in Africa and in part arises from the decision of the ILO to establish a special unit to address HIV/AIDS in the world of work. This paper is itself a recognition by the Programme that HIV/AIDS affects significantly the crisis-related activities of the ILO, thus making it essential that response processes be reviewed so as to ensure relevance and effectiveness. It is readily agreed by all that HIV/AIDS often has its origins in conditions of crisis and is in turn exacerbated by the social, economic and political effects of crisis.

1. UNDERSTANDING AND RESPONDING TO STRUCTURAL CONDITIONS

1.1 The epidemiological situation

According to UNAIDS (December 2001) there are presently 40 million people living with HIV globally. During 2001 new HIV infections globally were 5 million, of whom 1.8 million were women. As UNAIDS noted in its Report, "AIDS has become the most devastating disease humankind has ever faced."2

AIDS is estimated to have killed 2.3 million Africans in 2001, and since the start of the epidemic in the 1980s cumulatively some 20 million people have died. There were an estimated 3.4 million new infections in 2001, which means that there are presently 28.1 million Africans living with the virus. Several other countries in Southern Africa have now joined Botswana with HIV prevalence rates in excess of 30 per cent. Indeed, within countries there are cities with even higher rates of HIV prevalence amongst adults, some in excess of 50 per cent.

In most countries, there are continuing urban/rural differentials in rates of HIV in the population, but even with lower rates of HIV, most of those infected are in the rural population. The other striking feature of the epidemic which has persisted over time is that more women are infected than men and that women typically become infected at much earlier ages than men (with consequent greater losses of healthy Scars of life). In the worst-affected countries, there is a steep loss in life expectancy, and four countries now have life expectancies at birth of less than 40 years. Across sub-Saharan Africa, life expectancy is estimated now at only 47 years, compared with a non-AIDS projection of 66 years. There are presently an estimated 12 million children who have lost their mother or both parents to the epidemic, and this appalling number of orphaned children is projected to more than double over the next ten years.

A simple calculation will demonstrate how pervasive the epidemic is within sub-Saharan Africa. As we have seen, an estimated 20 million people have died since the start of the epidemic. A further 28 million are presently living with the virus, and most of them will die within the next ten years. This means that some 50 million people will die from HIV-related illnesses, including AIDS, before the end of the present decade. If it is assumed that about five people within the immediate family are affected for every African who dies, then some 250 million are closely affected. To this number needs to be added those less directly affected such as extended families, colleagues at work, close friends in faith and other communities - perhaps doubling the number of those directly affected to give a total of some 500 million.

Such simple calculations demonstrate the scale of the impact of the epidemic in sub-Saharan Africa, suggesting that most of the population is affected. The epidemic has effects on social, political and economic life not witnessed previously, so that all developmental activities, including those relating to security at national, regional and international levels, have to explicitly address the implications of what is evolving as a huge humanitarian disaster. The epidemic undermines development and thus further deepens the conditions in which HIV transmission thrives. Simultaneously, the capacity of families, communities and nations to cope with the complex social, political and economic consequences is reduced. The HIV epidemic is flourishing in a region that has witnessed continuous crises over the past 50 years from a multitude of causes ranging from conflict to natural disaster, and countries are becoming increasingly impoverished. These conditions are exacerbated in many countries by policy responses that often worsen the underlying conditions in which people live.

1.2 Responding systemically

What is often missing from the discussion of the HIV epidemic is an understanding of a country complex economic, social and political system, with the result that policy and programmes are based too often on a partial analysis that misses the interdependence. The key fact to understand is that the parts are interconnected within a system, and it therefore requires complex analysis and needs to take account of the ways that the parts interact and interconnect. Therefore the analysis needs to be dynamic rather than static, so that policies have to consider not only the impact effect of HIV on development but also the longer-term effects on the interdependent parts of the system.

Revisualizing the development effects of HIV as being systemic is the first step towards more realistic analysis and thus the basis for more effective policies and programmes. What this entails has been explored elsewhere by the author, but several examples will indicate what is required in thinking systemically about the epidemic.3

  • In reviewing the prospects for commercial agriculture in Zimbabwe, where the effects of HIV and AIDS are severe, it is evident that the real problems are not the replacement of unskilled labour. In a country where unemployment is high, there is in general little difficulty in finding replacement labour, although there will inevitably be a loss of specific knowledge due to labour losses. The major problem has its origins in human and organizational capacity losses in those supplying services to commercial farms, where skilled and managerial labour is scarce and expensive to replace. It is thus the discontinuity and higher costs with respect to the supply of inputs from other sectors that are the primary cause of the problems facing commercial agriculture. This is not to argue that internal effects on enterprises will be unimportant, but they are likely to be secondary. Paradoxically, therefore, the more an enterprise is integrated with the market system with respect to inputs, then the more vulnerable it becomes to the effects of HIV on human capital.

  • One of the most important sectors in all countries is that of transport which plays a critical role in respect of market integration. Now the transport sector also plays an important role in the transmission of HIV, given the fact that labour migration and labour mobility have been important in the spread of infection in populations. This can be seen most evidently in Botswana which has the highest recorded global prevalence of HIV and where there is relatively little difference in rates of HIV between rural and urban/perrurban populations. The incidence of HIV infection, and its general distribution in Botswana, seem to a significant degree to have been assisted by the existence of a functioning transport network that positively encourages the mobility of labour. Workers in the transport sector in many countries also exhibit high rates of HIV infection - this seems to be especially the case in respect of drivers, road maintenance staff at all skill levels, and those involved in servicing transport equipment. This is a key sector that is crucial for the smooth finctioning of the economic system, but which again paradoxically the more efficient it is the more it plays a role in the transmission of HIV. It is also one which is very vulnerable to disruption because of losses in human capital and organizational dysfunctionality due to the impact of HIV and thus will have generalized consequences for the country as a whole.

  • Most countries and many development agencies have, as objectives, the eradication of poverty and the achievement of sustainable livelihoods. Now it is evident that the HIV epidemic threatens the achievement of these policy aims through its effects on the level and distribution of poverty. There is increasing empirical data that confirm the hypothesis that those affected by HIV and AIDS will experience greater poverty and that countries will display increasing levels of income and wealth inequality. Poverty is, of course, multidimensional and will manifest itself in different forms of deprivation, including higher levels of food insecurity, rising unemployment, a worsening of housing conditions and reduced consumption of key products and services. This is often associated with stigmatization and discrimination of those infected and affected, including the children of families that have experienced HIV and AIDS. In several African countries one aspect that has been documented is reduced school enrolment of children in families affected by AIDS, thereby having long-term consequences for development which are impossible to predict. There is thus a series of effects caused by HIV/AIDS that require complex and integrated policies and programmes if they are to be effective. These also have to address the inter-generational impacts of HIV, since the children of those affected are likely also to experience poverty and deprivation generally and so become the next cohort of those who fail to practice behaviours that protect them from HIV infection.
What is required is a radical shift in the conceptualization of the HIV epidemic that focuses on the interdependence of social and economic relationships at all levels - country, community and family. It means developing much more complex analytical models that are based on a deeper understanding of the relationships. The simplistic models of how to achieve behaviour changes that concentrate on changing the individual instead need to focus on the role which community and group values and norms play in the determination of sexual and drug using behaviours. More generally, what are needed are policies and programmes that address the epidemic and yet reflect a comprehensive understanding of the issues. These must reflect an understanding of the systemic factors that determine both the causes and the consequences of the epidemic. Unless responses address the underlying structural conditions that determine the processes of HIV transmission, such as poverty, gender and patterns of social and economic development, they will achieve little in the long term. In the same way, if responses to the impact of the epidemic on a society and economy must also reflect the complex interactions that are operating if they are to be effective.

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Footnotes

1 Declaration of Commitment on HIV/AIDS, UNGASS, 25-27 June 2001.

2 AIDS epidemic update, WHO[UNAIDS, December 2001.

3 Desmond Cohen: Responding to the socio-economic impact of the HIV epidemic in sub-Saharan Africa: Why a systems approach is needed, Working Paper, UNDP, 1999.