Examination of Witness (Questions 120
- 139)
TUESDAY 20 JUNE 2000
PROFESSOR ALAN
WHITESIDE
Mr Worthington
120. The most basic thing in the face of this
epidemic is: can the state hold together? Looking at the impact
of this on the public sector, when you go to Zambia and find out
they are losing more teachers through AIDS than they are possibly
able to train, can you take us through that area about the impact
on the public sector of the epidemic?
(Professor Whiteside) When one looks at the public
sector one is looking at a very peculiar set of problems. What
you are finding is that in Africa the public sector is generally
a sector which has been a very generous employer of people, and
basically it has got very generous employment conditions. What
AIDS is doing is, where in the past you would lose one or two
people per year in the ministry because of cancer, diabetes, kidney
failure or whatever, now you are looking at very large numbers
of people who are unable to function in the public service, and
are unable to be replaced in many instances. I think as a matter
of urgency we need to look at the effect the epidemic is having
on the state sector, on schooling, on the ability of the state
to actually function. Unfortunately, nobody has done this. I wish
I could come in and present you hard data, but I cannot. You have
referred to the Zambian paper and that is about all there is.
It tells us that in Zambia there are more teachers dying than
are being trained at the moment. The education sector is a particular
concern of mine because if you lose a teacher then that class
does not get taught. That class will not get taught until there
is a replacement teacher. The trouble with HIV is that it is different
from other causes of death because it is quite a long-term process.
At least with a death in a motor accident it is an event, and
once the event has happened you can put in place your contingency
plans. With HIV in the public sector you are constrained by the
terms and conditions of service, and you will keep somebody on
for six months on full pay, six months on half pay, and then you
may medically board them after another few months, so there is
a long-term process. I am not saying that is a bad thing, because
for many families that is the only source of support, but it does
have an effect on the state. We need to look at that as a matter
of urgency.
121. We need to look at it as a matter of urgency,
but the logic of what you are saying is that you are advocating
removing benefits and good conditions from sick people?
(Professor Whiteside) No, what I am advocating is
understanding what those conditions mean for the state funding,
for the state revenue and for the efficiency of the Civil Service.
What I may be advocating, and maybe this is the extent we have
to go to, is to say, "Okay, let's look at some sort of support
to central ministry finances, in order that they can employ more
people. Let's stop doing structural adjustment, and start looking
at not slimming down the Civil Service but expanding it, because
we are going to need those people".
122. The picture I see is of these states being
held back by an appallingly paid middle-class that has been destroyed
in sub-Saharan African states by lack of wages and lack of conditions
so that you do not attract the talent?
(Professor Whiteside) Absolutely, I think that is
correct.
123. For a moment you seemed to be saying that
we are wasting resources on sick people; we should put it into
other things. You are not saying that?
(Professor Whiteside) No, I am saying you need to
look at how you are using your resources, and you need to look
at the changing use of your resources, and you need to understand
that there are trade-offs. For every person you treat with HIV
and AIDS, according to the World Bank, you could educate ten primary
school children. At the country level we have to make choices;
at the international level we have to make choices; what I am
also saying is that I am appalled we have this whole concept of
slimming down civil services in African countries, making them
leaner and meaner, because by the time they are lean and mean
we have an AIDS epidemic eating in and we are losing people from
lean and mean civil services.
124. Is education the worst affected sector
in your view?
(Professor Whiteside) I think it is the most important
sector that has been affected, simply because it holds in charge
the next generation. Probably the worst affected sector is the
health sector. I think HIV levels are the same in the health sector
as in the general population. There is a whole question of morale
among health sector staff. It must be absolutely soul-destroying
to have to sit in a clinic in rural Kwazulu-Natal and watch people
die, and people you know. Probably the morale of the health sector
is the worst affected. On the education sector there is another
problem here we need to be aware of. First of all, the epidemic
is not impacting only on the Civil Service, it is impacting across
societies. What we are looking at is a situation where, if I am
running the Coca Cola plant in Swaziland and my industrial chemist
dies then I would probably go and look for a school chemistry
teacher in the first instance, pull them with higher wages, train
them up and use them rather than starting training again. Because
the education system trains people in a broad range of disciplines,
I suspect we are going to find them being lost to the private
sector and to other state sectors as well out of teaching. I would
put education at the top of my list where we need to respond.
That, by the way, is where DFID is doing very good work. There
they are getting an A+ on my report card.
Chairman
125. Are there any lessons to be learned from
Uganda, which seems to have tackled this HIV/AIDS problem rather
earlier than South Africa, and the disease is arguably most advanced
there? Is there any evidence of the effect of AIDS on the public
sector in Uganda?
(Professor Whiteside) I am not actually aware of any,
I have to say. That is something which I really ought to look
at. I think we certainly have seen demographic effects. We have
certainly seen effects on population pyramids, and that is hard
evidence I have seen from Uganda, but the other sectors I have
not seen. One of the really ironic things is, the poorer you are
the harder it is to find the impact. There is so little interchange
between the state and the citizens. In a society like Mozambique
a person sitting out in Tete Province might not interact with
the state at all. He may not seek health care, he may not have
children in school, he may not use the road so there is no interaction.
Whereas in a country like South Africa, or Zimbabwe, where there
is that social contract between the state and the citizenry we
are running into a serious problem.
Mr Worthington
126. I want to move on to look at the impacts
on family structures and, in doing that, to really look at the
psychology and sociology which is around here. If I can use a
parallel with the fall in family size—it was said that occurred
when infant mortality rates fell very considerably; and people
saw it necessary to have a large family in order to ensure they
were looked after themselves in their pensionable years. I am
trying to imagine what is happening to the psychology in African
families about moving towards smaller families. What is the impact
of AIDS on that movement? Are they saying, "We now have to
have larger families to make sure that some survive?" Have
you done any research, has anyone done any research on that?
(Professor Whiteside) There is no research on that
I am aware of. There has been one study in rural Tanzania by a
gentleman called Gabriel Rugalema where he looked at how families
cope. There is certainly no evidence that families are changing
the structure or the size in response to the epidemic. In fact,
if anything I think there is a growing feeling of absolute despair
and dismay in many African communities as they watch mortality
go up. Of course, in parenthesis, one might like to realise it
is not just the young that are orphaned, it is also the elderly
because they are losing the people who would care for them in
states where there is no social security system. In fact, they
are having to care for the orphaned grandchildren now at the very
time of life when they are least able to do so.
127. Can we move into the issue of orphans.
Both states and village people are going to have to think about
this and how they cope. What has your view been of how this need
to adjust is developing? What should be the response of ourselves,
or states, and what is the mixture of responsibilities between
the state and individuals?
(Professor Whiteside) There is a myth that the African
extended family absorbs the orphans that are left. I think the
problem is that the very few studies that have been done of the
impact on households have missed one glaringly obvious fact, and
that is the worst affected households have disappeared. You cannot
measure what is not there. Households which have collapsed, where
the children are living under the bushes (and there are those
households) are not being measured. If anything, we are tending
to under-estimate the scale of the problem. The idea that the
household can cope is not the case. One of the whole emphases,
particularly in Southern African countries with rapid urbanisation,
has been towards a more nuclear family. In a setting where you
are living in a township house, it is not designed for an extended
family, so we have some serious, serious problems there. What
should be done? For me the priority is the orphans and the education
of the children, because I think without them we do not have a
state, we do not have a society. What we have got to do is start
finding imaginative ways to provide care and support to children
and to the communities in which they are lodged. I think this
is going to involve doing some things which development people
do not like doing, like transferring money; like accepting that
maybe 10 per cent is going to be syphoned off to buy a truck or
two to build houses, but the 90 per cent will reach those communities.
I really am of the opinion that we need to be moving towards some
sort of support for households and communities to take care of
children in distress; and I would not include just AIDS orphans
or just orphans either, I think we need to expand it. If you do
any form of discrimination in favour of orphans then you are creating
a problem just as much as if you do nothing.
128. What will it mean in terms of the developed
community, are we going to look at residential child care?
(Professor Whiteside) No, that is the last thing I
would do. I think that would be tremendously detrimental. What
I would suggest, and I have put this forward in South Africa,
is maybe we should look at providing some sort of grant for surrogate
mothers; identify responsible people in the community, perhaps
through the churches, and say to them, "Okay, what we would
like you to do, we have identified these children who are still
in their households perhaps with sick parents or no parents, and
we would like you to take responsibility for those. Here is a
grant which will cover the cost of caring for the children. Here
is a little bit extra for your time. Now you become the surrogate
mother". That is the one route I think one could take. At
the same time I think the state, through the municipalities or
through the town councils, whatever, is going to have to recognise
that those households no longer have an income and cannot pay
the tariff for the water, the rates for the house, the rent for
the house, or the cost of the electricity in settings where you
have those things. We now have to have some sort of reserve, contingency
money, to ensure we can keep those people in a house and recognise
they are not going to pay for the basic services which they are
going to get. It has to be through partnerships.
129. It is difficult to see how you set up a
one purpose welfare state with child benefit payments for one
cause—AIDS?
(Professor Whiteside) We would not.
130. You are talking about huge change.
(Professor Whiteside) I talk about children in distress
generally. I would extend it far beyond AIDS orphans. I would
extend it to children who are in distress because of adult death.
We are talking about quite a considerable change. We are also
talking about partnerships which have not been there before. It
would be a partnership between the municipality, the Ministry
of Welfare, the church group (if that is who you decide), the
NGOs whom you may charge with actually dealing with the money.
It would be a partnership with the local police forces as well
to make sure there is some sort of monitoring of some of the things
which go on.
Mr Robathan
131. If this was a small problem I could accept
what you say, but actually this is a huge problem as we have identified.
If you are going to start saying to the people, "You will
be exempt from municipal tax etc", do you not think you will
find there is a major problem with the entire breakdown in the
way in which the state is funded?
(Professor Whiteside) I do not think we have a choice,
frankly. I think we either have to be imaginative and look at
some of these options. I am not giving you the blueprint. I am
just giving you some thoughts which we have been developing over
the last year or on things that you might do. Obviously one is
not saying we are going to say to people, "You don't pay
rates because you are taking care of an orphan", but what
we might say is, "Here's a small package so you are not out
of pocket for taking care of this person". That will be immeasurably
cheaper than putting that person in an institution. That is the
sort of thing I am talking about. It requires imagination and
is building a social contract between the state and the community,
and that in turn will have a preventative effect on the AIDS epidemic.
Mr Colman
132. I was a bit surprised that you were talking
about the NGOs being the ones who should administer the money.
I would have thought, rather like happens in the UK, this is very
much a central local government function. I attended the Commonwealth
Local Government Forum which took place at the same time as CHOGM
in Durban last year and certainly social services were being discussed
as a natural function for local government to be involved in.
Why do you feel that local government cannot be trusted with administering
such a proposed policy and why would NGOs be involved?
(Professor Whiteside) I do not think it is axiomatic
that local government would not be trusted or that NGOs would
be involved. I think it would be specific to every setting. In
South Africa we have just developed quite a major tool kit/manual
for local government so we are looking at this issue. It may be
that the local government would like to devolve some of these
functions on to NGOs. In other settings there may not be a local
government that can do this. Here one would look at countries
like Mozambique. It is not a one size fits all solution. We have
to look at the peculiar circumstances for each country.
Barbara Follett
133. Apart from the obvious example, what political
leadership is there in sub-Saharan Africa to spearhead a response
to HIV/AIDS? What is being done to remove the stigma from those
with HIV and protect their human rights?
(Professor Whiteside) What is the obvious example
you see?
134. I was getting myself into trouble there.
I was going to talk about President Mbeki and what he had said,
which might be questionable in terms of leadership.
(Professor Whiteside) I think there is an obvious
example of leadership, and that is President Museveni. Coming
back to an earlier questions, what are the lessons from Uganda:
I think the main lesson we can learn from Uganda is leadership
at every level, but leadership from the top to start with because
that makes the whole thing respectable and makes it possible to
have leadership all the way down. What is being done in terms
of leadership. I have to say, I am hugely disappointed by the
lack of leadership we are seeing. When we look at a problem like
HIV and AIDS I think there are three stages in our response. I
think that we, working in the HIV and AIDS community (and I am
sure there are people behind me in that community), have made
two very serious mistakes. The first mistake we made was to go
out and say, "There is a problem". We went out and said,
"AIDS is a problem". Eventually people were convinced
there was a problem called AIDS, but what we had not done was
shown them that it was a general problem, and one which they needed
to take on board. Then we get to the second stage in terms of
what we have done, and we have made everyone convinced that it
was our problem. We did it in such a way that they did not see
what they could do about it. We had everyone convinced that there
was a problem, that it was their problem, but they did not know
what to do with it. That is the paralysing result. People cannot
see where to go. With a problem on this scale it is very easy
to get to that point. It is rather like global warming. We all
know the climate is changing. What are we doing about it? I take
my tin cans down to the recycling plant religiously but that is
about it. We have that effect in terms of AIDS. We just paralyse
people. We now need to get to the third stage, which is: there
is a problem; it is our problem; and this is what we are going
to do about it. That is the point we need to get to with leadership,
to show that they do not have to stand there like rabbits transfixed
in the headlights, watching for the train coming down the track.
There is something they can do, and it does not have to be done
by a group of people parachuting in from Washington, London or
Paris.
135. Do you think much has been done to remove
the stigma from HIV/AIDS in South Africa, or in other parts of
sub-Saharan Africa?
(Professor Whiteside) I think there are one or two
places where it has been addressed and addressed successfully.
I think Uganda is the one example of a place. It can never be
normal for someone to be living with HIV and AIDS, but it is,
to some extent, accepted. In South Africa, no, absolutely not.
The stigma involved in admitting you are HIV positive is huge.
It is terrible, because there are growing numbers of people who
are living with HIV and AIDS and who are unable to admit to it.
In one provincial parliamentary grouping there was a person who
was admitted to hospital living with HIV and AIDS. A friend of
mine from an NGO was called in to counsel that person, and the
hospital administrator said, "This member of the provincial
cabinet said he did not want to see anyone from government because
then they would know he was HIV positive". That is the scale
of the problem we are looking at.
136. My daughter lives in South Africa (and
I spent a great deal of my life living there) and recently her
domestic was raped. This is a woman who has had three sexual partners
in her 37 years of life. As part of the test after the rape she
had an HIV test. She was found to be positive. Two weeks had not
elapsed since the rape so it was not from the rape. This is a
very respectable churchgoing woman in deep, deep shock at what
has happened to her. What has shocked my daughter has been the
lack of back-up that this woman has received. The back-up has
come because my daughter has hassled. There has been no counselling
or help, and the stigma has been huge on this totally respectable
and probably almost blameless woman, who is now trying to adjust
to life with this disease. Therefore, I agree with what you are
saying and I think the scale of the problem is huge. To turn to
the economy, obviously this will have an effect on GDP. Are there
any points on the scale where infection would have more of an
effect on GDP? Is there some point where it meets on the graph
where it definitely would have an effect on GDP?
(Professor Whiteside) You are asking an economist
this. As you probably know, economists have successfully predicted
27 of the last nine recessions, so I am not quite certain how
to answer this! I think there are a number of bench-marks, and
at these points you start to get seriously worried. I think the
first one is when 5 per cent of the antenatal clinic attenders
are infected; because I think at that point you are probably on
that exponential stage of the curve. I think the next one is probably
10 per cent because then you are not succeeding in slowing it,
and it is then going to go the way it is going to go. The World
Bank has done some modelling on this. Basically what they are
saying is that HIV has the potential to slow economic growth down.
The way they look at it happening is through diversion of resources
to savings. The reason that is important is because that is not
going into investment for production. The second one is through
the loss of skilled people. I think we are making something of
a mistake, in that we are not understanding the totality of the
society, politics and economics and how they interact. I have
just completed a book with somebody you will probably know called
Clem Sunter. Clem and I when we were writing the book speculated
about doing a correlation between South African firms' listing
on the London Stock Exchange and HIV prevalence levels; and then
we decided, no, that would be very naughty because it is rather
like looking at penguins and sales of ice cream in the United
Kingdom — there is no correlation. There is not a correlation,
and I would like that in the record! I suspect that HIV does have
an impact on the ability of a country's economy to operate, on
investment perceptions and whether or not people are going to
be there. I know there are many people in countries like Zambia,
Zimbabwe and Swaziland, who are looking at the epidemic and saying,
"What is this going to mean?" It may mean government
inefficiency. It will mean less in the way of savings that you
can access. I think that the circular effects of the epidemic
is one we have not unpacked. That is one area where some donor
actually needs to start saying, "Let's look at what HIV and
AIDS means to societies in terms of how we interact, not just
in economic terms".
137. It will obviously have an impact on government
tax revenues at some point?
(Professor Whiteside) Absolutely.
138. Do you think South Africa is going to be
worse hit than other sub-Saharan African countries, or not?
(Professor Whiteside) I think the other thing which
is quite an important point to make is that none of this is written
in stone. The fact that we are sitting here talking about this
means we can change the way things are going to happen. That is
what this Committee is about, I feel—looking into the future
and saying, "These are the choices, let's try and choose
different roads". To come back and try and answer the question:
I think, yes, it has the potential to be worst affected because
the citizenry of South Africa has, understandably and quite rightly,
a greater expectation of what they can get from the state and
what they are going to give to the stage. So we have more of a
social contact there. From that point of view, it could be worse.
Also healthcare and education are available and people are entitled
to that. They will make demands, so from that point of view the
impact could be worse. On the other hand, we have far more resources
to deal with this. We are a country that has come through years
of apartheid, and we have seen several miracles happen. Maybe
we can do something about it. We have to hope and pray for that.
Chairman: That leads us directly to what
is happening in the private sector.
Mr Colman
139. I look forward to seeing the work that
you have been doing with Clem Sunter and being more direct, rather
than listings on the UK Stock Exchange. Is there any evidence
that HIV/AIDS is affecting company profits in South Africa and
in other areas that you know about and is there any evidence to
date of the impact of HIV/AIDs on foreign investment and on domestic
savings? In a sense, you have answered the second part by saying
that there is a propensity to save more. What effect has there
been on company profits that you have been able to track, and
how has that affected foreign investment?
(Professor Whiteside) Let me answer with a case study.
In South Africa there is a company called the Joshua Doore Group—their
stores include Bradlows, Russells, Score, Electric Express—and
in 1998 they carried out a study that looked at issues around
HIV/AIDS and they asked whether AIDS would affect their operations.
They said that it would. They said that the prevalence of HIV
is currently 15 per cent and that it will rise to 27 per cent
among customers by 2015. They said that they expected there to
be a demographic impact, "resulting in an 18 per cent decline
in customers by 2015 in all provinces bar the Western Cape".
They also expect a 14 per cent decline in customers by 2010 in
Swaziland, Lesotho and Botswana. They said that the "consumption
patterns will change as disposable income is reallocated"
and that they needed to reposition themselves. They took decisions
including "that of remaining within its core competencies
and strengthening its market position; that of leveraging its
existing infrastructure to cater for other customer needs; and
that of diversifying geographically away from the HIV/AIDS epidemic".
As a result, it has expanded into Eastern Europe and is opening
shops in Czechoslovakia and Poland. That is what a perceptive
company in South Africa has done. Yes, I believe that it will
affect company profits. I believe that it has to. I believe that
companies are caught between a rock and a hard place as they look
at the impact on their operations and how they treat their employees
in terms of benefits. I do not know quite how they will resolve
some of the conflicts with which they are faced.
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