Memorandum submitted by Professor Alan
Whiteside
PREAMBLE
AIDS is without doubt the most serious threat
to development and stability in much of Africa today. It may have
similar consequences in parts of Asia and the transition economies
over the next few decades. In Africa the impact is inevitable
and, although prevention must remain a priority, planning for
impact is urgent and crucial. Despite this need little planning
for impact is being done in developing countries or, and perhaps
more worryingly, in the major donor agencies.
There are reasons for this lack of planning.
The most important is that the impact of AIDS is still evolving
and will take several decades to work through all its ramifications.
In countries where HIV has peaked (and Uganda is the only African
country where, on available evidence, this might be the case),
it still takes several more years for the AIDS cases to appear
and the people fall ill and die. The impact of this on households,
communities, society and children, especially orphans, will take
years to be felt. Thus the first difficulty in planning for impact
is that it can't be seen. The second is that the body of research
into impact is small and occasionally misdirected—for example
there have been attempts to look at household impact that ignore
the fact that the worst affected households will dissolve and
so are not there to be studied. Finally planning for impact requires
imagination and may involve reversing policies—for example
governments and donors may need to make social payments to destitute
families and individuals. Work in many African countries finds
that poverty and lack of basic food is the overarching problem
for families caring for people with AIDS.
This memorandum will focus on two items:
— the impact of AIDS on development
goals and governance; and
— what should be done by development
agencies.
1. The impact of HIV/AIDS on development and
governance
Writing about Africa a group of concerned World
Bank staff members noted. "HIV/AIDS has spread with ferocious
speed. All but unknown a generation ago, today it poses the foremost
and fastest growing threat to development in the region. By any
measure, and at all levels, its impact is simply staggering:
At the regional level, more than 11 million
Africans have already died, and another 22 million are now living
with HIV/AIDS. That is two-thirds of all the cases on earth.
At the national level, the 21 countries
with the highest HIV prevalence are all in Africa. In Zimbabwe
and Botswana, one in four adults is infected. In at least
10 other African countries, prevalence rates exceed 10 per cent.
At the individual level, the arithmetic
of risk is horrific. A child born in Zambia or Zimbabwe tonight
is more likely than not to die of AIDS. In many other African
countries, the lifetime risk of dying of AIDS is greater than
one in three.
This fire is spreading. AIDS already accounts
for 9 per cent of adult deaths from infectious disease in the
developing world. By 2020, that share will quadruple to more than
37 per cent.[1]
With India having the most infections of any country in the world
already, it is possible that the African experience will be repeated
in some Asian countries.
One of the most striking features of most of
the development goals—what they are, how they should be
achieved, and what indicators should be used,—is the degree
to which the HIV epidemic appears to be ignored. There is little
grasp of what AIDS means beyond the health sector. It is the contention
of the author that it has the potential to totally undermine development
in every sense of the word and undercut development goals.
The most obvious impact is the effect on life
expectancy. In the 1997 HDR the UNDP began considering HIV/AIDS
as an issue and incorporating it into their statistics (although
this is still not done for all countries). The impact of AIDS
on life expectancy, and consequently in terms of the Human Development
Index and ranking of countries is considerable (Table 1). But
these data reflect an AIDS epidemic that is still in the early
stages. Furthermore the life expectancy figures are at least two
years prior to the date of the report.
Table 1
THE CONSEQUENCES OF HIV/AIDS FOR LIFE EXPECTANCY[2],
THE HDI AND GLOBAL RANKING: EVIDENCE FROM SELECTED AFRICAN COUNTRIES
| | 1996
| 1997 |
1998 | 1999
|
| | HDI
| Life | HDI
| Life | HDI
| Life | HDI
| Life |
| | (rank)
| Exp | (rank)
| Exp | (rank)
| Exp | (rank)
| Exp |
| Botswana | 0.741
| 65.2 | 0.673
| 52.3 | 0.678
| 51.7 | 0.609
| 47.4 |
| | (71) |
| (97)
| | (97)
| | (122)
| |
| South Africa | 0.649
| 63.2 | 0.716
| 63.7 | 0.717
| 64.1 | 0.695
| 54.7 |
| | (100) |
| (90)
| | (89)
| | (101)
| |
| Zimbabwe | 53.4
| 53.4 | 0.513
| 49 | 0.507
| 48.9 | 0.560
| 44.1 |
| | (124) |
| (129)
| | (130)
| | (130)
| |
| Kenya | 0.473
| 55.5 | 0.463
| 53.6 | 0.463
| 53.8 | 0.519
| 52 |
| | (128) |
| (134) |
| (137) | |
(136) | |
| Zambia | 0.411
| 48.6 | 0.369
| 42.6 | 0.378
| 42.7 | 0.431
| 40.1 |
| | (136) |
| (143) |
| (146) |
| (151) |
|
| Uganda | 0.326
| 44.7 | 0.328
| 40.2 | 0.34
| 40.5 | 0.404
| 39.6 |
| | (155) |
| (159)
| | (160)
| | (158)
| |
Effectively life expectancy falls. The consequence is that
the HDI declines and countries drop down global rankings. The
impact of AIDS on the Human Poverty Index as is shown in Table
2, will be even larger because here the key is what percentage
of people live to age 40. (It might be argued that the absence
of life means all other indicators are irrelevant.)
Table 2
CHANGING LIFE EXPECTANCY AND THE EFFECT OF AIDS
| Country | Life Expectancy[3]
| Human Poverty Index
|
| | 1960
| 1970 | 1997
| 1998 | 1999
|
| Botswana | 46.5
| 51.6 | 47.4
| 27.0 | 27.5
|
| South Africa | 49.0
| 52.8 | 54.7
| — | 19.1
|
| Zimbabwe | 45.3
| 50.3 | 44.1
| 25.2 | 29.2
|
| Kenya | 44.7
| 49.7 | 52.0
| 27.1 | 28.2
|
| Zambia | 41.6
| 46.3 | 40.1
| 36.9 | 38.4
|
| Uganda | 43.0
| 46.3 | 39.6
| 42.1 | 40.6
|
One of the most significant features of AIDS given the IDT
of "reducing by one half the proportion of people living
in extreme poverty by 2015" is its link with poverty and
the fact that it pushes households and individuals into a downward
cycle.
The links between AIDS and poverty may be reinforced because:
— AIDS tends to be clustered in nations and households.
— it is possible that poor households are worse
affected by HIV.
— the nature of the disease means that the infected
person will experience periods of illness which increase in severity,
frequency and duration until they die. For the household this
is a disaster because productive capacity (including income earning)
at the very time when there is increased demand for resources.
— HIV infection invariably ends in illness and death,
unlike most other diseases.
— the age of AIDS infected persons means that there
is a massive increase in orphaning.
It is also the contention of this memorandum that AIDS can
have far reaching effects on political stability and issues of
democracy and governance (DG). (This is an area where USAID has
been leading thought and discussion). The impact of increased
morbidity and mortality among prime age adults and young children
is:
— loss of people in their 30s and 40s: people who
keep the wheels of commerce and the state turning, and provide
the next generation of leaders;
— the depletion of national human capital. The people
who die will have had resources invested in them—they will
have completed their education and training and be gaining experience.
Their death means this investment is lost;
— increased orphaning. Orphans represent a long-term
threat to stability and development unless there are imaginative
efforts to address the problem;
— potential instability as middle ranking army officers,
police and other security forces face increased illness and death;
— social instability if there is not a clear political
leadership. Evidence suggests that in societies facing economic
crisis and lack of clear political leadership the presence of
AIDS with its associated stigma may cause instability. The citizens
are aware of the increase in illness and death, the stigma associated
with it; and the lack of leadership leads to blame and anomie
in the society;
— human rights may be infringed, and this response
to the epidemic may even be entrenched through the legal system,
through actions such as making AIDS notifiable;
— government inefficiency may result. The reason
is that government tends to have generous conditions of employment
and be less flexible. Thus people who fall ill will have extended
periods of sick leave during which their posts will not be filled
and their work not done; and
— economic stagnation may result with the cost of
production going up and productivity declining.
2. What should be done by development agencies
The key points to be noted are:
— there are no simple, quick and technical solutions
to the epidemic;
— AIDS has to be seen as more than a health sector
issue, a multi-sectoral response is needed but people need to
understand what is meant by multi-sectoral;
— there is a need to identify key issues and respond
in ways that may go contrary to accepted development practise.
For example cash transfers might be needed to support the poorest
families and orphans, and governments may need technical assistance
in order to keep functioning;
— we need to ask what effect will AIDS have on indicators
and why does no one appear to be thinking about this?
— what are the links between HIV and poverty, and
what more needs to be done on this?
AIDS cannot be wished away. The full impact is still to be
felt, but what is certain is that we have to respond now.
Alan Whiteside is the Director, Health Economics and HIV/AIDS
Research Division, University of Natal, South Africa, an Associate
Researcher, Liverpool School of Tropical Medicine (DFID HIV/AIDS
Work Programme), Liverpool and an Overseas Development Group Fellow
of the University of East Anglia.
Professor Alan Whiteside
June 2000
1
A Memo issued on 2 June 1999 to World Bank staff and supporters
announcing the new AIDS in Africa initiative: "A wildfire
is raging across Africa". Back
2
The 1996 report has 1993 data, 1997 Report 1994 data, the 1998
Report 1995 data but the 1996 has 1997 data. Back
3
1960 and 1970 data from UNDP 1998 HDR, 1997 data from UNDP 1999
HDR. Back
|
