Memorandum submitted by the United Nations
World Food Programme
SAVING LIVES:
THE DEADLY
INTERSECTION OF
AIDS AND HUNGER
During the course of reading this, tens of people
will die from hunger (it is estimated that one person dies as
a result of a hunger-related problem every five seconds). Most
of the victims will be malnourished young children too weak to
fight off disease. Their deaths will occur quietly in dusty villages
in Malawi, the slums of Mumbai, the highlands of Peru. These deaths
will not make the news.
Hunger only captures the headlines at the height
of crises caused by politics and natural disasters—the war
in Iraq, the earthquake in Bam, drought and civil conflict in
Afghanistan. The fact is that only 8% of the deaths from hunger
occur in these types of dramatic food emergencies. It is not that
these operations are not critical—right now we face a complete
disruption in the food pipeline to the DPRK—but they are
usually well funded.
On average, 80% of the money donors give to
WFP is earmarked for these types of high profile operations. There
is no clearer confirmation of what people in the humanitarian
community call the CNN effect—money follows the media. If
there are no horrible images of skeletal babies, no food riots,
no mass exodus of starving people, the cameras are soon gone—and
so is the money.
Unfortunately, for over 800 million people,
the struggle to find enough food goes on off camera. Hunger and
malnutrition still claim more lives than AIDS, tuberculosis and
malaria combined.
Out of the 10 greatest threats to public health,
colleagues at WHO tell us that undernutrition is still number
one and deficiencies in micronutrients like iron, iodine and vitamin
A rank number eight. (WHO, 2002) One in four of the world's children
under five years old is underweight—168 million all told;
181 million are stunted from long-term undernutrition, and 51
million are wasted from short-term severe malnutrition. The life
of a child is lost every five seconds because we have failed to
end widespread hunger and malnutrition.
Much of the silent suffering from hunger today
is among millions of victims of AIDS and their families. AIDS
has added a new, more sinister element to the dynamics of hunger.
I have been asked to give an overview of global food issues and
then focus in on the lethal connection between the AIDS pandemic
and the growing incidence of chronic hunger in developing countries,
especially in Africa.
First, progress against poverty and hunger do
not necessarily go hand in hand
Globally, during the 1990s there was a 20% reduction
in the prevalence of poverty. That is remarkable progress, but
in many countries it was not accompanied by a corresponding decrease
in hunger and malnutrition. In fact, the latest FAO data show
that the number of people who are chronically hungry worldwide
is on the rise and in the second half of the 1990s there was actually
a net gain of 18 million in this group. There are few social indicators
where we are slipping back so badly. We clearly have the resources
to solve this problem and, ironically, many of the world's leaders
are at odds today—not about food shortages—but about
what to do with food surpluses.
Second, investments in both long-term agricultural
development and food aid have dropped sharply
Global food aid has dropped by more than a third
just since 1999. There is no doubt that the United States has
the best record in the world on food aid and Americans have been
extremely generous to WFP. But the trend is not encouraging. In
1999, the US donated roughly 9.5 million metric tons. By 2003
those figures had plummeted to 4.6 million metric tons—
more than a 50% drop.
Global food aid slipped from 15 million tons
in 1999 to 9.6 million last year, or a decline of roughly one-third,
but nearly all of that decline is attributable to the 5 million
ton cut by the United States.
Some European donors are prone to accusing the
US of using food aid for surplus disposal. But that accusation
does not stand up, simply because it costs so much to ship food
aid to developing countries and then distribute it that no one
in his right mind would dispose of surpluses that way.
Third, we can hardly expect to make progress on
hunger if overseas development assistance is directed to countries
that are relatively better off
Only about 25% of bilateral aid by OECD countries
is actually targeted to the least developed countries (LDCs).
Interestingly, the record for multilateral aid is only somewhat
better. Among UN agencies, only WFP and UNICEF exceeded 40% of
expenditures directed to LDCs in 2001. We need to target more
of our resources at the most desperate and vulnerable. If we are
serious about countering the rising number of hungry people, we
are going to have to start re-ordering priorities. (Report of
the Secretary-General on Comprehensive Statistical Data on Operational
Activities for Development for the Year 2001/E/2003/57).
As governments consider ways to strengthen their
support for humanitarian aid around the world, three changes in
the funding process could be considered:
(1) Provide multi-year funding, not single-year
funding. WFP needs more predictable funding to help vulnerable
families. It is extremely difficult for us to plan and respond
effectively when we do not know our funding level each year.
(2) Address chronic hunger—not just
emergencies. We appreciate every penny we get for emergency aid—whether
it's for the people of Iraq, southern Africa or Afghanistan—but
we can't forget families who live in countries where there is
no immediate "emergency". Their hunger is just as painful.
(3) Provide funds to buy the full package
of assistance needed by hungry, poor people—food, water,
medicine and shelter. Funding these elements together addresses
the full extent of the challenges that vulnerable families face
everyday.
We are in danger of falling even farther behind
in the battle to end hunger unless we come to grips with the interaction
between hunger and the AIDS epidemic in the developing world.
We tend to see AIDS through the lens of our own experience here
in the developed world, while the economic and sociological dynamics
are very different in Mozambique, Cambodia, or Zimbabwe.
The AIDS coverage in the media focuses heavily
on the on demand for anti-retroviral drugs, but if you were to
go out and talk to families in southern Africa, the hardest hit
region, you would get a very different picture. These people talk
about food.
Peter Piot, head of UNAIDS, often relates a
story about one of his first visits to Africa: "I was in
Malawi and I met with a group of women living with HIV. As I always
do, I asked them what their highest priority was. Their answer
was clear and unanimous: food. Not care, not drugs for treatment,
not relief from stigma, but food."
Is that so surprising? Colleagues at FAO calculate
that seven million farmers have been lost to AIDS in Africa alone,
the continent with the worst food security problems in the world.
Eight out of 10 farmers in Africa are women, mostly subsistence
farmers, and women are disproportionately affected by the disease.
Ending AIDS is not a battle we will win with
medicine alone— we need proper nutrition, education, clean
water. We need integrated packages of assistance or we run the
risk of tossing our money away.
Besides money, we need a lot of creativity.
In the news reports about the recent Mars missions, the enthusiastic
NASA team coined a new term the "work-around"—as
in "when we find a problem on the way, we look for a work-around
to get past it". While the term might not pass muster as
the best English, it does capture a spirit of innovation and flexibility,
a spirit we surely need in the battle against AIDS.
AIDS and hunger interact. They feed off one
another. Why is food such a big issue for the families affected
by them?
— First, the disease is seriously undermining
food production. With millions fewer farmers working, there is
less food. Weakened HIV-positive farmers who can still work are
not as productive and less capable of earning off-farm income
as well. As farmers earn less, they cannot afford fertilizers
and other farm inputs. Harvests dwindle further and they enter
a downward spiral, selling what assets they have and sliding into
abject poverty. Soon enough, their families go hungry.
— Then there is the nutritional dimension.
Malnourished bodies are more prone to disease, including AIDS.
People who are both HIV positive and malnourished are especially
susceptible to opportunistic infections, most notably tuberculosis.
— Hungry people are also more vulnerable
to exploitation. Prostitution is especially rampant in poor communities
where people simply do not know where they will get their next
meal. Poverty-stricken families look the other way as uneducated
girls earn money in one of the few ways they can.
There is a vicious cycle at work here. Poverty
increases vulnerability to HIV infection. AIDS increases the risks
of poverty. But for communities seeking to find their way out
of the cycle the way forward is anything but clear. For one thing,
the stigma of AIDS discourages testing and we usually do not know
who is HIV positive and who is not. So successful interventions
must often target whole communities where we know the disease
is taking its heaviest toll.
There are three specific ways WFP and our NGO
and government partners can intervene to help:
First, we must do everything that we can do
TODAY to meet the needs of the orphans and vulnerable children—in
particular those in the most affected communities.
The number of orphans in sub-Saharan Africa
is huge, growing and likely to continue to grow. By 2010, some
20 million children will have lost one or both of their parents
to AIDS.
Combined with other causes—including war
and other diseases-the total number of orphans is an almost incomprehensible
40 million young people. That may seem a large burden for the
world to bear. The real burden is borne by the families and communities
on the frontline of the epidemic. And by the children themselves.
In addition to their deep psychological loss,
orphans between 10 and 15 years old are subject to higher rates
of malnutrition, physical and sexual abuse, and exposure to HIV.
And they are much less likely than children whose parents are
alive and well to go to school or get health care.
These are brutal facts. But one even more jolting
is that as bad off as orphans are, many children whose parents
are sick with AIDS can be even worse off. They must watch their
parents die, grow poor as the household income dwindles, and deal
with the trauma of rejection as neighbours—even some family
members—shun them.
These kids are the ones who shoulder the real
burden of the pandemic. They are the main financiers of the international
response to this global problem. And they are financing it by
mortgaging their own childhoods and future to take on the responsibilities
of nursing ill parents and earning money for their families' survival.
AIDS has turned children into parents—especially in Africa.
It is not so unusual to see a 10 or 12-year old raising siblings
without the guidance of an adult.
Once orphaned, millions of children are shifted
from household to household—and sometimes from household
to the street. It is the elderly of Africa, especially women,
whose backs are further bent under the weight of providing these
children with food, shelter and—in the very best of circumstances—a
school uniform and fees so they can resume their education.
Food aid has an important role to play in helping
families and communities in supporting orphans and vulnerable
children. For example, we use food aid to:
— directly feed children in shelters
and centres;
— support vocational training programmes;
— make sure that foster parents—including
grandmothers who are sometimes looking after a dozen of their
grandchildren—can feed them all; and
— bolster the family larder with take
home rations so kids can be kids and go to school instead of working
the fields or running off to the nearest city.
Right now, we are only scratching the surface.
We can do so much more.
Second, we must do everything we can to help
children in the most affected communities and countries enroll
in school—and attend regularly.
There is such strong agreement that education
is our most immediate hope for addressing this epidemic.
When it comes to HIV prevention, it's been called
the "education vaccine". And it's not just HIV prevention
education, as important as that is. It's much more powerful than
that—the skills and social norms that we learn in a safe
and nurturing school environment. It can shape who we are, how
we relate to others, and what we are able to do with our lives—for
ourselves and others.
Helping children to attend school longer—especially
girls—has a proven record for interrupting the spread of
HIV. The longer a girl attends school the more knowledgeable she
becomes. Knowledge is power and it's that personal power that
enables young people to manage the circumstances around them better
and to judge the actions of others better. This translates into
positive and healthy behaviours that last a lifetime.
Food aid has an important role to play in strengthening
schools, particularly in those communities most affected by AIDS.
— We know that providing one nutritious
meal a day at school can improve enrolment, attendance and academic
performance—we have seen enrolment increases of up to 300%
in schools that provide meals.
— We know that where school-feeding
programmes involve the community, schools become platforms for
AIDS awareness and HIV prevention, health and nutrition education,
agriculture and skills training programmes.
— And we know that providing take-home
rations to the most vulnerable children can offset the family's
cost of sending them to school—a major issue in families
where the breadwinner has AIDS.
School feeding programmes both mitigate the
nutritional impact the current epidemic has directly or indirectly
on children and also helps reduce their vulnerability to HIV infection
in the future through education. It stands out as one of the few
interventions which can be effectively targeted to communities
with high HIV rates—and scaled up rapidly.
Knowing what we do about the benefits, active
support should be given to extend school feeding to every school
in every community currently most affected by the epidemic.
Third and finally, we must do everything we
can to use food and nutritional assistance to maximise the benefits
of therapeutic drug interventions for AIDS and related conditions.
Anti-retroviral drugs can work wonders. So can
medications to treat the most common opportunistic infection,
tuberculosis. In hard hit communities, these drugs can help put
sick people back on their feet again so that they are better able
to provide for themselves and their families.
Food and nutrition programmes have a vital support
role to play here. AIDS is no different from any other disease
when it comes to one basic fact—our bodies need good nutrition
to fight off infection, regain strength and live productively.
Good nutrition can help to make AIDS and TB
drugs work their miracles. Especially in symptomatic periods where
caloric requirements are greater and capacities to work compromised,
food and nutritional support can make a critical difference. For
a number of years in countries like Cambodia, Lesotho and Uganda,
WFP has successfully used food rations as an incentive to keep
TB patients coming back for the full course of drug treatment
which is critical in preventing mutations that cause everyone
concern, even here in the United States.
There is no worse choice than that which faces
so many parents with AIDS—do we spend what we have to feed
our children today or to pay for the drug therapies we need to
stay alive for them tomorrow? Though there is much more to be
done, the international community has gone a long way towards
helping these families. The World Health Organization, UNAIDS,
the world's pharmaceutical companies, private foundations, activist
and governments are working together to reduce the cost of AIDS
drugs.
But now, after having taken the bold leap to invest
in helping the poorest gain access to life-extending AIDS drugs,
can any of us think of a worse decision than not taking the relatively
modest steps required to get the most out of those investments:
— to help ensure adequate nutrition
for those receiving ARVs to strengthen their bodies as they fight
the disease, and
— to help ensure the food-security
of their families while they are regaining their own strength.
For many, anti-retroviral drugs will come too
late or not at all. Even under the most hopeful scenarios, millions
of people won't have access to them. This concerns poor people
who live in poor communities with no clean water source and no
health clinic. Rural communities and poor subsistence farmers
may well be last in line once ARV therapies are more widely available
and that will have a clear economic impact on agriculture.
When it comes to humanitarian aid, governments
don't lead, they follow. And that is surely the case in the struggle
against AIDs and hunger in Africa. Already there are thousands
of community and faith-based organisations out there working in
the greatest humanitarian tradition, seeking to ease the suffering.
They are the ones coming up with the NASA style "work-arounds"
.One example:
There is a small orphanage near Lusaka called
the Children's New Life Centre run by an NGO that cares for 30
orphaned and abused children. One of those children is Henry Mwamba,
a seven year old who is rather small and frail for his age. Henry
lost both his parents to AIDS. He is himself HIV positive—and
what is worse—everyone in his neighbourhood in Lusaka knew
it.
When his mother and father died, Henry went
to live with his aunt, but ignorance and fear left him more alone
than before. His aunt took Henry in but beat, abused and isolated
him. He was kept away from the other children for fear he would
infect them. He only ate if there was food left over—often
not at all. Quickly he became severely malnourished, leaving him
easier prey to the diseases that ravage the lives of people with
HIV.
Maybe the toughest part of Henry's life was
not the hunger and illness, but the isolation. Henry's aunt would
only touch him with plastic gloves. Perhaps the greatest pain
for a child is to feel different and alone, beyond the reach of
love and the touch of someone who cares. As we grow, when we are
confronted with life's struggles, we can almost always imagine
something brighter, happier. Children like Henry have a hard time
doing that. Their imaginations have nothing positive to shape
their dreams, nothing to create a sense of hope.
Because of this small NGO and WFP food, Henry
is no longer malnourished, sick and alone. He is doing better
resisting infections and he is in school where he has made new
friends. Until ARVs reach the Henry's of the world—and even
when they do—food will be the first line of defence against
AIDS. Until we find a cure, the best we can do is buy time and
food aid can help us do that.
If we do not do more about AIDS now we will
soon be guilty of genocide. Not a genocide spurred by hate—a
genocide of neglect. Much of a generation will be lost in southern
Africa and the toll will be heavy in south-east Asia. This is
the greatest humanitarian challenge of our time.
Several background papers have also been submitted
by the World Food Programme. These have not been printed.
March 2004
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