Examination of Witnesses (Questions 420
- 439)
TUESDAY 11 JULY 2000
MR JACQUES
DU GUERNY
420. Can you say a little bit more about that.
(Mr du Guerny) The issue of impregnation is important
in many African countries because the number of children, the
fact that women are fertile, is important for their status. Traditionally,
a woman's status was, to some extent, related to the number of
children she could produce; and for a man it was also important
to show that he could produce many children. Of course, any barrier
method comes into conflict with this.
Barbara Follett
421. I would like to ask you what role, if any,
the traditional healers, the so-called witch doctors, might play
in raising people's awareness of HIV/AIDS or, in fact, making
people's awareness of it less clear.
(Mr du Guerny) This is a very interesting issue because
there were some studies in francophone Africa a few years ago,
which tended to show that AIDS has put into question so-called
western or modern medicine —" doctors with the white
blouse and the hospital kind of set-up —" which is
one of the symbols of the modernisation process. It is urban based.
It is knowledge based, etcetera. Of course, this had created problems
for traditional medicine and those who practised it. The failure
of modern medicine in the field of AIDS to cure that, has been
seen by some of the traditional healers as an opportunity to reassert
themselves, particularly because, of course, they have a more
holistic approach, which is directly understandable in their communities
and to the people they deal with. It is not something which is
foreign and incomprehensible like western or modern medicine can
be. So they are much more attuned to the needs of the local communities
and are able to provide much more psychological support, even
through rituals and things like that. Even if they do not, from
a scientific perspective, provide any demonstrable result, they
still provide comfort and support to the family and to the sick
person. This is an area where, of course, modern medicine is often
weak. It is very instrumental. We can give you your injection
and your pills and this is it. Any sort of relation, which is
supposed to exist in theory, often in practice does not happen.
However, besides this, there are probably many opportunities to
co-operate, a bit like in family planning programmes. There was
a debate, many years ago, about what to do about traditional midwives:
whether one would enter into conflict with them or not. The strategy
which was decided in many family planning programmes, often in
South East Asia, was to co-opt, to bring in the traditional midwives
by giving them training, so as to make allies out of them and
have barefoot agents. It is possible that some kind of development
like this could be done.
422. Has anything like this been done with the
traditional healers in HIV/AIDS?
(Mr du Guerny) Frankly speaking, I am not aware of
this kind of development. One point I would like to stress is
that traditional medicine is not cost-free. This is often not
sufficiently recognised. The traditional healers may not be paid
in cash but through forms of sacrificing animals, offerings, etcetera.
It can amount to significant cost. So one of the burdens on the
family is that there are medical and care costs, even if there
is no modern medicine involved.
Chairman
423. Can we explore the relationship between
the urban areas and the rural areas, which you do in your paper:
the prevalence of HIV/AIDS in urban areas and rural areas.[1]
Do we have any reliable information that you can quote in comparison?
Is the prevalence thought to be greater in urban areas or less
than in rural areas? What do we know about it?
(Mr du Guerny) As a general rule, the
prevalence is higher in urban areas. Often in rural areas, especially
a few years ago, it was very low. But it is increasing in rural
areas. In some cases like rural areas, which are sometimes on
borders, or borders between countries' crossing points where there
are market activities, things like that, there can be very high
rates of prevalence; or in some of the mining areas; so these
are special cases. However, generally the prevalence is higher
in urban areas. It is increasing in rural areas but the problem
is that as the urban areas represent roughly 30 to 35 per cent
of the total population, even lower rates of prevalence in rural
areas can have a much larger impact on the total numbers and,
therefore, on the national level. This is one of the reasons why
the rates for the national levels have appeared to increase rapidly,
because first the urban areas had quite high levels, but when
it is 30 per cent of the national level it still remains much
lower; but as it moves up into the rural areas, then the national
level moves up faster.
424. I understand. That is the way statistics
work. Given this difference between the urban and rural areas,
should prevention strategies in rural areas be planned and implemented
differently from those in urban areas?
(Mr du Guerny) One of the difficulties with these
epidemics is that is why I often use the term pandemic, which
is the sum total of all the epidemics and interface —"
because it is not just one epidemic. For example, you can have
one epidemic, which is linked to the fisher folk communities.
You can have an epidemic which is linked to "pastoralists".
You can have a plantation economy epidemic, etcetera. They can
all have their own specific characteristics and their own dynamics.
Therefore, it is extremely important to develop strategies, which
are tailored to each of these specific epidemics. One of the problems
now is that one has tended to view rural populations in rural
areas as sort of homogeneous, and tended to have blanket approaches.
I do not think this will be possible in the future if one wants
to have an impact but, of course, this makes it much more difficult
and expensive. Dealing with the rural areas, one has to take into
account the cultural patterns and things like that. They can be
different according to the people we are dealing with. Fishing
communities often work in a rather different way from sedentary,
agricultural, etcetera. In semi-arid zones there is a lot of population
movement —" much more than South East Asia, the central
plain of Thailand or wherever. Therefore, one has to adjust these
strategies because in some cases one will have to emphasise much
more the rural/urban migrant; and in other cases one will have
to emphasise how the farm household works. To make effective strategies
does require rather good knowledge of various populations we are
dealing with, but also knowledge of the meeting points between
these populations. That is like what happens at festivals, temple
fairs, things like that. This is why we always feel that holistic
strategies are necessary because one cannot just approach it in
a simplistic way. That does not work. This is because it is linked
to human behaviour and human behaviour is such a complex and diversified
area.
425. Do you conclude, therefore, that HIV/AIDS
programmes, both in their design and expenditure, are inadequately
targeted on rural communities and the diversity of the rural communities
you have described?
(Mr du Guerny) I certainly think so, yes. There have
been a number of efforts but they tend to be small-scale like
NGOs, etcetera. They have very limited access and resources. Up
to now there has been a tendency to focus more on urban areas.
We need to balance it more because since urban and rural areas
are so interlinked, it does not make sense just to work on one
side. One has to think carefully in each case about how and where
one distributes one's effort.
Chairman: The "how" is important.
I am going to ask Barbara Follett to lead us on the impact on
farm households.
Barbara Follett
426. I am interested to know to what extent
the shock of HIV/AIDS on rural households differs from other shocks
which might hit those households and be equally impoverishing.
For example, deaths due to malaria, TB or war.
(Mr du Guerny) In Africa, often when one dies of AIDS,
in fact, one dies of TB or of malaria. Because it suppresses your
immune system one dies of something else. TB is one of the leading
causes in such a case. Now war: Of course, war is a total disaster,
so it is a bit difficult to classify or rank such a disaster.
One of the problems is that there is often no discrete separation.
One thing tends to lead to another. Just like if you go back to
medieval Europe, famine, pestilence and war were often mingled
together. In some cases this is the thing in Africa. It is certain
that various conflicts, which are there, are creating the conditions
for future epidemics. That is something which has to be kept in
mind. One can see this in a country like Rwanda or Ethiopia. We
are now seeing increases in the levels of AIDS. At the farm household,
the problem is the resilience of the system. This depends very
much in what kind of farming system it is located. For example,
if there are rather regular abundant rains, one can be more sure
of producing the minimum quantity of agricultural products. In
the Sahel area or more northern Kenya, which are semi-arid areas,
where rain is much more uncertain, then one tends to become vulnerable.
Among the farm households, of course, the wealthier ones are less
vulnerable. They have more resilience. When a member of the household
is sick it is possible to hire casual labour, whereas in a poor
household this is not possible. On the contrary, if they were
hoping to be hired out as casual labour, it does not work any
more. This is where poverty comes in. At the farm household level,
where there is very little margin for security, then anything
which happens can be a disaster. Now the problem with AIDS is
that it takes a long time. A sudden death is more easily absorbed
as a shock because these systems are traditionally more used to
it. It is protracted disease which stops people earning income
and they require expenditure. That is one of the very insidious
aspects of AIDS. Also, in these very traditional communities,
when they are in the beginning phases of disease, since they can
be quite common diseases, they do not associate it with what is
really going to happen. So they will make all the investments
necessary to try to get care, etcetera. In poor households, one
of the problems also is the time which is taken up in care and
things like that. Since basically these households' main assets
are often their labour, anything which is deducted from that can
have quite a serious impact.
Mr Rowe
427. In rich developed countries the opportunity
to bring holdings together has actually been seized with readiness
—" I assume it depends very much where you are in the
world —" but where families can no longer run their
plot, is there a move to amalgamate them with others, or do they
simply fall into disuse as we saw in Rwanda?
(Mr du Guerny) This is where the land tenure systems
come into play. If you have a system of private property, then
there could be consolidation. But, for example, in a lot of Africa,
they are community-based systems of land tenure. Therefore, theoretically
it is the ancestors who own the land. It is handed out to a lot
of families, according to their size and requirements. So your
issue then does not work in such a context. But also there is
another point. As I mentioned, the epidemic is concentrated more
in certain areas than in others. In a community, on which it has
impacted quite severely, the wealthier farmers would also be affected.
Therefore, they would not necessarily be in a position to buy
the land, which would be for sale. So everybody is hit and the
question of winners and losers is not quite the same.
Barbara Follett
428. Just to continue with what you were saying,
when people become ill, do they make any changes in their agricultural
arrangements? For example, do they move to crops that are less
time and labour consuming? Do they make adjustments in their lives?
(Mr du Guerny) Certainly. That is one of the first
things we noted when we did these surveys of agriculture. They
tended to abandon the more intensive crops like coffee, for example.
They also tended to drop the cultivation of fields which took
more time because they were more distant. This goes back to the
previous question. One of the important things would be to look
into how land is distributed, even under a communal system, so
as to save time in going to the field and coming back. They do
tend to retrench to subsistence crops, cassava and things like
that. Therefore, this has an impact on the nutrition of the family.
On the one hand, there is less cash with which to buy possibly
other foods. They also revert to less nutritious foods because
they are generally easier to produce. Like cassava they require
less work. One also has to take into account what is happening
to other household members at the same time. We do not have that
information but we suspect that there are interesting and important
effects. Is it the husband who is sick first? Is it the wife who
is sick first? Things like that. Because of the division of labour,
this would have differential impacts. It is something which would
be worthwhile looking into. For example, the wife also tends to
look after the homestead and the garden and things like that.
If she falls sick that could be abandoned. That is an important
part of what goes into the pot. Whereas if the husband abandons
looking after the coffee, then it is the cash variable which is
affected; the cash which was available to buy other food. These
kinds of things should be looked into but we have not had the
opportunity yet.
Mr Worthington
429. You have been partly answering the question
that I was going to ask. What about the impacts on girls and boys
of the deaths in families? What is it doing to their lives, as
they grow up, in terms of access to education or what is seen
as the division of labour within the family? Have you any ideas
on that?
(Mr du Guerny) We have a certain amount of information
on that. The impact is on the function of the gender roles. The
division of tasks and on whom the family is ready to invest, more
or less. The impact, of course, is different for boys and girls.
One of the major impacts is that women, in general, have to do
the caring functions. Therefore, the daughters will be brought
into this in order to support the mother. This can mean that they
might drop out of school. They also will have to help the mother
more in the house with cooking and things like that. There is
that impact. If we are dealing with a pastoral society, there
the boys play a significant role in looking after herds. The sickness
of the father would then put this onus on them. One thing is that
children, both boys and girls, tend to drop out of school. Also,
they tend to become less good farmers because the transmission
of knowledge is done through working with the parents. Therefore,
this process can be interrupted and they can be less skilful or
knowledgeable in the tasks they have to carry out. This is one
of the serious consequences for the future: that, basically, the
various epidemics mortgage the future of these children. One could
very well see that instead of having a development process, not
only would development be stopped but a reverse process might
be happening because the children could be less educated, less
skilful than their parents.
430. Could I ask about migration and migrant
labour. First of all, we are talking about sub-Saharan Africa,
so it is a huge area. How significant is migrant labour to rural
life on a general basis, or is it just in some locations that
it is significant?
(Mr du Guerny) Migration is extremely important in
Africa. These populations are extremely mobile, particularly in
western Africa, all the north/south migration from this Sahel
zone towards the coastal areas and the plantations into the more
humid zones. That has been going on for a long time and is well
entrenched. There are ethnic groups like the Mossi in Burkina
Faso where you can have more people outside a country than inside
at any one time. The migration is, for example, so entrenched
a way of life that it is part of becoming an adult for boys. It
is a ritual. In east Africa the situation is a bit diverse because
it is more rural-urban than inter country, although recently with
political changes there has been a lot of international movement.
But in West Africa it has been transboundary, which also creates
complications, because you cannot then have a national programme
or a national response when you have to deal with all these mobile
populations. It requires co-ordination between the countries if
they want to be effective.
431. Could you see an impact on the traditions
of migration already occurring because of HIV?
(Mr du Guerny) The changing flows or patterns?
432. Changing flows. The obvious one that you
point out in your paper is that a major part of village income
comes in migrant labour. Men have to return home because they
can no longer work. Then the burden falls on the poor community.
You point that out. I wonder if there are changes occurring because
of this taking out a large part of the active population who will
be migrant.
(Mr du Guerny) Agriculture is at the bottom of the
scale. Therefore, when there are gaps in the urban labour market,
this will always be like a pump. It will absorb the people from
rural areas. So the urban gaps will tend to be filled, particularly
if they are more-or-less unskilled labour. But then there is nobody
there at the rural end. This is why you can have changing age
structures in certain rural communities; where you have relatively
many more elderly and children in the population than you used
to.
Chairman
433. What is the impact of HIV/AIDS on casual
and landless labour? We understand that in some areas there are
pools of landless labour who would be hired normally by a landed
family and that possibly, because of the reduction in prosperity,
the casual labourer is no longer hired. Therefore, this reduces
their capacity to earn their living.
(Mr du Guerny) When you look at it from a systems
perspective, every group tries to pass on the costs to somebody
else. Therefore, it tends to be the weakest in the society who
have nobody else to whom they can pass on the cost, who end up
by bearing the brunt because the others will try to find some
other way. So the poorest might not find opportunities for casual
labour in some cases. However, we do not really know what the
situation is. We would need to look into this more carefully but
these are rather difficult surveys to do, because particularly
if you are landless they are difficult populations to identify
and to survey. So the landlessness question might eventually turn
out to be more important in other regions than in Africa, because
landlessness is also linked to the land tenure systems. Therefore,
it might be something which was more important in India, for example,
and parts of South East Asia. That, to my knowledge, has not been
looked into yet.
434. One other perverse reaction, it seems to
me, that might take place, is that you would get a population
increase because most human societies, faced with a large number
of deaths among their working population, will seek to increase
the number of children that they have if they can possibly do
that. This is certainly a feature of periods after large wars
in Europe; and I had the impression in Malawi, when we went there,
that the reaction of the rural poor to the reduction in the number
of children surviving into adult ages was to increase their fertility.
(Mr du Guerny) The recuperation phenomenon after wars
is well known. We have observed it also in Rwanda, where I am
told that women even share the men, since men are in short supply;
so women tend to share the men available in certain rural areas.
However, in the case of AIDS, I am not sure this can happen. This
is for one simple reason because the young women get infected
at young ages, 15 plus, so they tend to fall sick and die before
they can complete what would be the normal fertility history.
One would have to do simulation models to work that out really.
Mr Colman
435. I have a related question and perhaps it
comes in here. You talk about the women sharing the men that are
available. Is there a major legal or discriminatory problem which
is faced by women who have lost adult male household members to
HIV/AIDS? And is the problem one of lack of legal rights or protection,
or rights of enforcement?
(Mr du Guerny) Many countries have passed laws to
protect women's rights but the problem is often, particularly
in rural areas, that they are not necessarily enforced, or they
come into conflict with customary laws. Therefore, the customary
laws tend to be enforced instead. Sometimes there are also misunderstandings
like, as I mentioned, the land belonging, in fact, to the ancestors.
Therefore, neither the husband nor the wife is, in a western sense,
the owner of the land. The land reverts back to the ancestors
and de facto a woman is deprived of any right of access.
That is a very important issue and something which should be looked
into, how to protect the surviving widows. However, one has to
be aware that often this would be only a temporary measure because
many of these widows would themselves die after a few years. So
the strategy there and the concern would be to have a kind of
holding operation in order to protect the children's interest
as much as possible. If the widow is going to die afterwards —"
we do not know, of course, the widow may not die afterwards —"
then the key thing is what happens to the children. One should,
for example, review perhaps some of the education policies and
strategies in order to try and give the children marketable skills
at younger ages than is done presently in case disasters happen.
I think this whole issue of protection of the widow's rights is
something which sometimes should not exist in theory but does
exist in practice.
436. Are we looking at polygamy becoming the
norm perhaps through this or is this an informal arrangement?
(Mr du Guerny) No, no. Many of these societies are
still polygamous so that is why the issue if a wife dies is not
the same for the husband in a polygamous case because there are
already other wives or it is easier for the husband to remarry.
But in the case of the widows this is different, whether they
are or are not in a polygamous relationship, they do not have
the same kind of fallback position that their husbands do.
437. You are saying that the land rights go
to the nearest male relative rather than on to the wife?
(Mr du Guerny) Yes, because it can belong to the male
clan. So this is where, for example, the well known levirate system
with widow cleansing exists which originally was conceived as
a kind of social security in order to look after the widow but
in the age of AIDS it is a disaster. There you can see how societies
try to adjust their norms because now instead of the husband's
brother remarrying the widow, they will try to find a young boy,
for example, so that there are no sexual relations in order to
avoid this kind of thing because the other wives in the polygamous
set-up often are aware of the risk and are very much afraid then
of AIDS entering into their family through this practice.
Mr Rowe
438. You said something very interesting I thought,
that we may need to look again at our education programmes.
(Mr du Guerny) Yes.
439. Do you get the impression that all the
multitude of NGOs and the World Health Organisation and the United
Nations operations and so on have really taken seriously the impact
of AIDS on the planning of their strategies or do you get the
impression that they are really trying to persevere with the strategies
they had before?
(Mr du Guerny) I figure it is difficult to generalise
but one thing needs to be made clear, when you talk about the
UN system, WHO or FAO etc, we answer to the requests and instructions
of the Member States.
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