HIV/AIDS IS EXACERBATED BY POOR HEALTH
SYSTEMS
13. Of the estimated global total of 34.3 million
people who at the end of 1999 were living with HIV/AIDS, 24.5
million of them were in sub-Saharan Africa. A further 5.6 million
were in South and South East Asia, where the epidemic is at an
earlier stage. The cumulative total of those orphaned by HIV/AIDS[7]
was 13.2 million, 12.1 million of them in sub-Saharan Africa.
2.2 million of the 2.8 million AIDS-related deaths in 1999 were
in sub-Saharan Africa. The prevalence rate for sub-Saharan Africa
in 1999 was 8.57 per cent, compared to a global prevalence rate
of 1.07 per cent. GDP per capita in sub-Saharan Africa in 1998
was US$ 1,607, whilst that of OECD countries was US$ 20,357. That
sub-Saharan Africa figure masks some appalling country rates —
Botswana at 35.8 per cent, Zimbabwe at 25.06 per cent and South
Africa at 19.94 per cent, for example. Furthermore, certain regions
and towns within these countries will have much higher prevalence
rates. Prevalence is much worse in these poorer countries than
in, say, Western Europe, where it is 0.23 per cent. The contrast
between Western Europe and sub-Saharan Africa is significant.
In both regions the epidemic began in the late 1970s/early 1980s.
14. Not only is prevalence much worse in sub-Saharan
Africa than in Western Europe — AIDS-related deaths are
also far greater. In 2000 there were 540,000 adults and children
living with HIV/AIDS in Western Europe, and 7,000 AIDS deaths,
a ratio of about 77 to 1. In sub-Saharan Africa there were 25.3
million living with HIV/AIDS and 2.4 million AIDS deaths, a ratio
of about 10.5 to 1. Although a crude measure, for epidemics of
similar duration the discrepancy in the numbers of deaths is telling.
One reason for the difference is the use of anti-retroviral therapy
(ART) in Western Europe, itself a medication unavailable to sub-Saharan
Africa because of costs. Even before the use of ART, however,
death rates in Western Europe were going down as expertise grew
in how to "manage" HIV/AIDS. The use of drugs to treat
opportunistic infections was resulting in healthier and longer
lives for HIV-positive people. Again, in sub-Saharan Africa there
is no health service with the funds to afford such drugs or the
capacity to dispense them.
15. It is clear then that poverty plays a crucial
part in a population's vulnerability to infection and capacity
to live with the disease. Clare Short said that "there are
special features of life where people are desperately poor. For
example, [HIV/AIDS] spreads massively faster where there are untreated
sexually transmitted diseases (STDs) and in populations where
there has never been or is very little availability of antibiotics.
That is highly linked to poverty and people's immune systems are
weaker when they are badly fed and in poor health ... There is
no doubt that the speed of spread and the degrees of suffering
are made massively worse by poverty".[8]
The link between STDs and HIV/AIDS is partly behavioural —
unprotected sexual intercourse exposes a person to both. But it
is also biological. In particular, untreated genital herpes appears
to be an entry point for HIV/AIDS. The lack of access to STD treatment
in many parts of the developing world (and untreated STDs are
much more prevalent in developing countries) is thus a significant
factor in the spread of HIV/AIDS.
16. The failure to treat STDs, and its impact on
the spread of HIV/AIDS, is merely one example of the wider fact
that the poor in developing countries do not have access to primary
health care, nor to sexual and reproductive health services. This
has an impact both on the spread of HIV and also on the care of
those who are HIV-positive.
17. HIV/AIDS, however, is not the only communicable
disease devastating the developing world. An anecdote from a Committee
visit makes the point. In 2000 the Committee visited South Africa
and it was there that we heard a great deal about the impact of
HIV/AIDS on social and economic development. At a meeting with
a local community group in KwaZulu Natal, Members asked some of
the group what they were doing to protect themselves against HIV/AIDS.
Why, came the response, are we always asked about HIV/AIDS? Why
aren't we asked about malaria? Doesn't anyone care about that?
18. The point is a good one. An examination of the
WHO statistics for 1999 reveals that HIV/AIDS accounted for 4.8
per cent of deaths in 1999 (about 2.7 million people). Tuberculosis,
however, accounted for 3 per cent of deaths (about 1.7 million
people) and malaria for 1.9 per cent (about 1.1 million). Given
the concentration of TB and malarial epidemics it is quite possibly
the case that in certain areas TB and malaria are claiming as
many if not more lives than HIV/AIDS. If we turn to diarrhoeal
diseases we see that they account for 4 per cent (2.2 million),
nearly as many deaths as were caused by AIDS. Is not the problem
a more general one — the poor health of poor people? Why
put such a stress on HIV/AIDS?
19. There is certainly a wrong way to go about highlighting
the crisis of HIV/AIDS. Professor Alan Whiteside warned against
an exclusively AIDS-specific approach, "I think there is
a real problem with going into a country and saying AIDS is a
problem. The World Bank, I believe, is currently falling into
that trap, but if you go in and say, 'AIDS is a problem', the
country is going to turn round to you and say, 'If you see it's
a problem, you solve it'".[9]
We discuss in more detail later the response of the World Bank
and other donors to the epidemic. It is true that we should not
"hype" HIV/AIDS to the exclusion of other diseases and
the poverty which is such a contributory factor to the poor health
of the developing world. To do so is simply to export our rich
country preoccupation with one of the few diseases about which
we still feel vulnerable. It is easy to see how such an approach
can be resented by countries which have been struggling for years
with poverty and where even diarrhoea claims millions.
20. The point has already been made that the fight
against HIV/AIDS must be part of the larger fight against poverty.
As poverty declines, so eventually will HIV/AIDS. The epidemic
must also be seen in the context of the need for better health
services in the developing world and the need for a more effective
response to all communicable diseases. Recent work by the European
Commission and the G7 have linked HIV/AIDS with TB and malaria
in a single communicable disease strategy. This is commendable
and necessary. All these diseases are diseases of poverty. The
relief of poverty and the provision of health care for the poor
will have a fundamental impact on all three diseases.
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