APPENDIX 8
Memorandum submitted by CDC Group plc
Having spoken to you recently regarding the
inquiry into the impact of HIV/AIDS on developing countries social
and economic development, I thought I would put together some
of my own thoughts on this issue. I must emphasise that these
are my own personal opinions and do not necessarily reflect the
approach of CDC Capital Partners.
I currently work in the Business Principles
Group within CDC Capital Partners as the Occupational Health and
Safety Specialist. The link between occupational health care and
primary health care within our investee companies has led to me
becoming more and more involved in the social and welfare aspects
of particularly the managed businesses. Over the last three years,
I have travelled widely in Africa and the Pacific Rim, and have
spent a considerable amount of time visiting the clinics and hospitals
that we run for our employees' use and, in many cases, for the
community at large. Typically during a year, I will travel to
Uganda, Côte d'Ivoire, Tanzania, Malawi, Zambia, Zimbabwe,
South Africa, Swaziland, Papua New Guinea and Solomon Islands.
Over the last year or so CDC has tried to get handle on the magnitude
of the general disease problem within our areas of influence.
We have set up a disease monitoring scheme, which reveals that
our directly controlled clinics administered over 467,000 treatments
to our employees and their dependants—bearing in mind that
we only employ around 43,000 people. The burden on the business
is clear. In the Pacific, each clinic visit costs the company
around $1.20, without taking into account lost production and
other indirect costs.
We (as in CDC Capital Partners majority holdings)
do not make a distinction between HIV-related disease and other
diseases—we find it impossible, inappropriate, undesirable
or all three. It is only one of the many chronic diseases affecting
people living in developing countries, but it is undoubtedly a
massive problem now and will become more so in the future.
HIV is a disease affecting the immune systems
of humans. It gradually reduces the body's ability to respond
to infections or attacks by pathogens and once AIDS has developed
in an individual then he or she becomes very susceptible to life-threatening
opportunist infections. HIV is spread most commonly in developing
countries through sexual contact. Infected women will, in approximately
one-third of cases, transmit the disease to their babies. HIV
can also spread to babies through the breast milk of their infected
mothers. The prevalence of HIV in Africa alone is leading to an
infection rate of around 13,000 people per day. However, throughout
the world there is a level of ignorance about the disease and
its causes that is astounding. Senior figures in multi-national
organisations often have little grasp of the risks and of the
way the disease is transmitted. In extreme cases, this can led
to totally biased, unrealistic views that can have major negative
impacts on investment decisions. At the opposite end of the labour
spectrum, many people in Southern Africa are convinced that HIV/AIDS
was part of a plot by the apartheid government to keep birth rates
down. As I mention later in this paper, the key to defeating the
disease is in removing this ignorance.
The number of infected people is difficult to
quantify properly because of the lack of reliable data, and because
of the stigma attached to the disease and its sufferers. Mass
HIV testing of the general population would raise all sorts of
moral and ethical questions on confidentiality, reporting, anonymity,
further treatment, and a whole range of other issues. Rates of
infection are generally gleaned from presentations at clinics
by pregnant females, or though screening of commercial sex workers.
The results that are gained are subjected to modelling techniques
that give a grasp of the magnitude of the problem. On the ground,
clinic officers and nurses are loathe to classify any individual
as suffering from an HIV-related disease. Our own disease records
do not show any significant proportion of people presenting at
the clinics with HIV-related illness. However, when asked, the
clinic officers will shake their heads and say that they can identify
those people suffering from HIV/AIDS simply by the patient's appearance.
There is undoubtedly a connection between the number of recorded
TB and pneumonia cases and the level of HIV infection in the general
population.
A great deal of work has been done in trying
to quantify exactly the size of the HIV/AIDS problem. This is
often not helpful—we know that there is a major catastrophe
underway, and that it will roll on for years to come. UNAIDS and
other funded studies initially projected that the infection rates
would fall away after 2010 leading to a gradual decline in the
incidence of the disease. Alan Lopez from the WHO in his publication
The Global Burden of Disease indicates that new evidence
indicates infection rates will continue to rise, decimating populations
as they fall prey to AIDS well into the 2020s and beyond. Prevention
of the disease will not, in my opinion, be countered by vaccination
or other medical methods. The transmission rates may be reduced
but the disease will not be eradicated. The sheer size of the
increase in the population to be treated in Africa alone would
outstrip the application of any foreseeable intervention methods.
What we all need to realise is that a life expectancy of 42 years
or less for the population of a country is not acceptable in the
21st century. The death rates from HIV/AIDS-related illnesses
will continue to rise to the point where in many projections,
the population growth will go into decline. The response to many
of the questions on your paper are encapsulated in that bald statement—morale,
investment, government wealth, development targets, productivity,
mortality, drugs costs, and human rights in general will all be
adversely affected for the next 20 years and beyond.
Health education programmes are run by many
governments and NGOs, but there is a certain amount of resentment
amongst people especially to those schemes funded by bodies from
outside their own borders. Mass communication of information in
developing countries is not as simple as it is in the richer nations
of the world. Television, radio, and newspaper campaigns do not
reach the people who "need to know". This is all part
of the divide between the "haves" i.e. us, and the "have
nots" i.e. them. We tend to apply our complicated standards
to a situation that cannot cope with them. What is the point of
a TV campaign, such as is run by MTV, that reaches over a billion
people on a regular basis, but in the wrong parts of the world?
The great majority of the people who need to know and understand
about the risks associated with unsafe sexual practices do not
have running water, let alone power or the resources to buy TV
receivers and radios. Their main concern is in growing enough
food to survive, and to perhaps buy a few "luxury goods".
The most effective method of communicating the problem to the
masses is through the traditional peer group educators. The CHEP
scheme in Zambia is a prime example of how this is done. CHEP,
or the Copperbelt Health Education Programme, encourages local
people to use their skills to act in plays or dance groups. They
get the message across to the people in a way that is entertaining,
but which contains very serious messages not only about HIV/AIDS,
but also about cholera, STDs and parasitic infestations. The training
of new educators is cascaded out to the population—in theory
this means that there should be a wide coverage in a short time.
As is the case with many other aspects of this epidemic however,
funds are limited and so the effectiveness of the campaigns is
restricted by lack of resources. Companies can contribute in this
field, but their influence tends to be regional, if not just local.
Most companies distribute, or make available, free or very cheap
condoms to the workforce. Dispensers are being placed in easily
accessible positions such as toilets, workshops, beer halls and
other social centres. However, supplying these things does not
guarantee that they will be used. There is a major cultural hurdle
to overcome regarding the use of condoms, let alone other methods
of family planning. Men are very likely to insist that a condom
is not used resulting in the risks of transmission of HIV and
other STDs being vastly increased, along with the chances of pregnancy.
Women are reportedly often intimidated into having unprotected
sex. The prevalence of sexually transmitted disease also leads
to a massive increase in the likelihood of HIV transmission between
partners because of the presence of wounds on the genitalia. Women
are more likely to attend the health education sessions than men
and there is generally a perception that men do not take a sufficient
interest in the prevention of disease. People generally appear
to acknowledge that HIV/AIDS exists but many are either in denial,
don't care, or feel that the disease is something that is being
touted by the developed world as a reason for less sex so that
the population in the developing world is kept under control.
This view may appear jaundiced, but in many ways is perfectly
understandable.
I find it particularly disheartening that the
cost of the anti-retroviral treatments available in the developed
countries is orders of magnitude higher than the annual income
of a family in Africa. Treatment costs of $6,000 to $11,000 per
individual, per year are not uncommon in the US and Europe. How
can we reconcile that with a daily wage (if a person is in work)
of around $1 per day? The majority of the victims are subsistence
farmers or their families with no outside income. Can we expect
the drugs companies, employers, and governments to pick up a rising
bill that would be increasing at the rate of $150 million per
week? I also get the feeling that if an effective cheap vaccination
or treatment is developed by one of the multi-national researchers,
the last place it would be used would be Africa or India. However,
one of the most positive initiatives has been the development
of Nevirapine, one of the anti-retroviral family. If this is given
to pregnant women during and after labour then the likelihood
of the disease being transmitted to the baby is reduced by, I
believe, 30 per cent. The cost of this intervention is reported,
as being between $3 and $5 per treatment, but it still has not
spread widely to health providers.
As far as industry and companies in the developing
world are concerned, it is difficult to form an opinion on how
they are commonly approaching the HIV/AIDS epidemic. Where the
business is largely agriculturally-based, for example, in tea
or coffee plantations, or other labour intensive industries, it
is often very difficult for the company to grasp a true picture
of the scale of the problem. Many companies use large number of
unskilled, illiterate workers who are brought in for relatively
short periods and who are then returned to their villages which
may be considerable distances away. This gives rise to other aspects
of the epidemic that companies actually contribute to. By bringing
a mix of people into one central location, the disease can spread
within the temporary community. Members of that temporary community
become infected and then return to their homes where the disease
is spread further. Succession planning and retraining of replacement
workers is built into organisations but really only at the level
of lower to middle management and clerical staff—mainly
because the attrition rate is becoming more visible in this small
population. Other aspects to consider are the costs of medical
care for a person who has HIV and who will at some stage develop
AIDS. Does the company need insurance to cover this? What happens
regarding pension schemes? Is the company entitled to test an
individual who they suspect of being infected and what would they
do with the information if they had it? What testing methods can
be used—saliva tests are non-invasive but cost money? This
latter point returns to the medical confidentiality issue. Many
of the CDC Capital Partners majority investments have chronic
disease policies in place that address these issues on paper,
but putting them into practice involves a great deal of soul-searching
on the part of company management.
The effects of HIV/AIDS on the economies of
countries where large sectors of the population are affected are
essentially two-pronged. At government level, the burden placed
on health care provision and the cost of drugs and treatment facilities
is high. At the level of the victims, the onset of the disease
leads to a less effective individual. That individual is less
able to carry out daily tasks such as water collection and other
work because of the gradually debilitating nature of the disease.
Once full-blown AIDS arises then the infected person becomes a
burden to their family and the general community, as well as to
the medical services, as they become less and less able to provide
for themselves and their households. If the victim is the main
bread-winner within a family, and that family is housed in a company
scheme, then once the victim finally succumbs to the disease the
family will no longer be able to live in that accommodation. They
either return to their distant relations or squat near the larger
conurbations.
I feel that in general the world has developed
an "out of sight, out of mind" approach to the level
of HIV/AIDS infection in developing countries. The disease still
has a huge stigma attached to it in the west—it is something
that drug-users and homosexuals get, not "normal" people.
We have to get over that before we are likely to make any real
progress in raising awareness here, while in the worst affected
countries the resources are so limited that the effectiveness
of the intervention and education schemes is also severely strapped.
Huge amounts of money are being pumped into finding a cure for
this disease—if 10 per cent of that was diverted to education
in developing counties it would be a far more positive use of
the money. How about a levy on drugs companies for HIV/AIDS education
in the developing world?
I feel strongly that the west is "rearranging
the deck chairs on the Titanic" as far as this is concerned.
There are many good words or more proposals to go out and measure
the size of the problem—that isn't what is needed. If you
want to get a grasp on the magnitude of the situation, take a
drive from Entebbe airport to the Uganda capital Kampala. You'll
get to the coffin-making area where there are dozens of carpenters
making a living from the deaths of many thousands. And too many
of those coffins are very small . . .
I hope you find this of use. As I said at the
beginning it is my perspective, but if you have any other queries,
please contact me.
Duncan Wall
Business Principles Unit, CDC Group plc
May 2000
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