SAR, Vol 11, No 4, July 1996
LIBERALIZING AIDS IN AFRICA:
THE WORLD BANK ROLE
BY COLLEEN O'MANIQUE
Based at Toronto's York University, Colleen O'Manique has done extensive work and research on the issue of AIDS in Uganda.
"Get AIDS and see the World." This rather caustic comment came from one of the participants at the International Conference on AIDS in Paris in 1990, a reflection on the epidemic of conferences that accompanied the global spread of HIV. Needless to say, very few in the global conference circuit that this most recent pandemic has created are African. According to the 1994 report AIDS in the World, 90 percent of global resources for AIDS prevention are concentrated in North America and Europe, areas representing 20 percent of the global population and 16 percent of HIV-infected people. Sub-saharan Africa's share, with 10 percent of the world's population and 66 percent of infections, is only 2.8 percent.
Still, AIDS programmes and projects have mushroomed on the African continent in line with the steady growth of the global AIDS industry. Many grassroots organizations are attempting to mitigate the devastating impact that AIDS deaths are having in their communities. But the majority of interventions remain externally- funded and donor-driven. Moreover, although general health care expenditure either remained static or declined throughout the continent in line with fiscal restructuring, funding for AIDS-specific programmes continued to climb.
The World Health Organization's Global Program on AIDS (WHO/GPA) led the global institutional response from 1986. The WHO/GPA was the principle coordinating and funding mechanism for countries receiving bilateral and multilateral development assistance for AIDS control and prevention. Recently, however, the program was reorganized to integrate other UN-sponsored initiatives more closely with those of the WHO.
In January of 1996, UN AIDS officially became operational, combining WHO's programme with those of UNICEF, UNESCO, UNDP and the World Bank. The reorganization is meant, in the words of new Director Dr. Peter Piot, . . . "to make UN AIDS a more efficient, client friendly programme . . . an informal global alliance bound by a common commitment to challenging AIDS" ( AIDS and Society Bulletin, July/August 1995 p.9). UN AIDS came out of a growing concern within the UN system that WHO's approach was too narrowly medical and technicist to deal adequately with the emerging impacts and consequences of the various AIDS epidemics.
Within UN AIDS, the WHO is expected to remain central to country-level programming, but the UNDP takes over the official coordinating role. Needless to say, the World Bank is the strongest financial power. Corresponding to the Bank's recent interest in social policy, its influence in shaping the response to AIDS is potentially quite significant.
Thus far, the evidence suggests that the World Bank's response to AIDS fits firmly into the neoliberal canon, which valorizes the individual, privatization, neo-charity, and cost-recovery, all the while ignoring the social and political contexts fuelling the particular epidemics in Africa.
So, how is one to understand the dimensions of this epidemic and what can we expect from the World Bank in this new "client friendly" alliance?
AIDS in Africa
The past decade saw AIDS grow to epidemic and tragic proportions in Sub-saharan Africa. Although levels of HIV infection were consistently higher in central and east Africa, today no African region remains untouched and each year countries with previously low rates report increasing incidence of seroprevalence. According to the Department of Health in South Africa, 7.6 percent of sexually active adults were HIV positive at the end of 1994, up from 4.5 percent at the beginning of the year. Surveys carried out in the rest of the southern African region reveal similarly significant rises.
Although other health conditions remain statistically more important in Africa, to the extent that deaths from other communicable infectious diseases, parasitic diseases and malnutrition still outnumber those from AIDS, rising levels of HIV infection pose problems unique to the virus. AIDS disproportionately affects the most productive sector of the population. The most obvious consequences include rising dependency ratios, productivity losses in agriculture and industry, and the loss of people with critical talents and rare skills.
HIV infection aggravates other infectious diseases as the number of people with weak immunity climbs. Less than a decade ago, tuberculosis was considered a stable, endemic health problem; today, in association with the HIV/AIDS pandemic, tuberculosis is resurgent. The interaction of the two suggests a view of a future with rapidly worsening epidemics, each intensifying the other.
The increased burden of disease places immense pressure on public health facilities and undermines familial and community coping strategies. In many countries AIDS is expected to reverse the gains made in child survival and life expectancy. HIV epidemics in Africa will hence have devastating long-term social, economic and political consequences unique to the continent.
The public health response to AIDS in Africa evolved in a context of massive debt crises and draconian adjustment and restructuring programs, which included the withdrawal of the state from the social spheres, privatization, and opening up national economies to global market forces. In this regard, AIDS policy was formulated within a social and political context which circumscribed policy choices.
But the problem goes deeper. AIDS policy in African countries increasingly reflects the broader neo-liberal agenda that accompanies the current global order. Within the emerging neoliberal consensus, individuals and families must become "empowered" at the local level to protect themselves from infection and to cope with the multiple effects of the epidemic. Added to the itinerary of AIDS control programmes are income generation for women, women's legal education, programmes targeted at orphans (school fees relief, income generation, support for extended families), and other interventions aimed at mitigating the social and economic impact of the epidemic, or at "empowering" people and communities to do so for themselves.
The World Bank AIDS agenda
These ideas are clearly articulated in the 1993 World Development Report Investing in Health, which marked the beginning of the World Bank's hijacking of the global health agenda away from WHO. Global AIDS policy is no exception. One of the five main clusters of public health care interventions elaborated in the report is an AIDS prevention program and educational program targeting "high risk" groups, which includes the regulation and control of sources of blood transmission as well as community treatment of the sick through low-cost protocols.
Consistent with the health policy proposed by the World Bank's Investing in Health, AIDS policy is being brought into line with the neo-liberal ideology that ascribes health mainly to the private domain, with the public sector responsible only for the most minimal cluster of vertical, cost-effective interventions targeted at the poor, or with regard to AIDS, at "high risk" groups. The "private sphere" consists of three very different social actors; the individual and the family (and here, women are singled out as important health promoters and caregivers), charities and NGOs, and private businesses.
The global multisectoral strategy arrived at a moment when the factors augmenting HIV spread are further exacerbated by globalization, these factors themselves linked to the policies of multilateral institutions such as the IMF and the World Bank. The Bank, however, relinquishes any responsibility for its own role in the process. The October 1995 article "Bank Rattled by Claim that Policies spread HIV" in AIDS Analysis Africa documents the Bank's response to a report which analyzed the role of structural adjustment programs in promoting conditions that facilitate the spread of HIV.
The World Bank responded that such claims were "unscientific" and a "bad joke." To quote World Bank health economist Phillip Musgrove: "We accept that economic development helps spread AIDS, that is true of almost any disease . . . It sounds clever to say that development should be tailored to take account of this, but no-one really knows how to do that. People talk about promoting local development, but that means taking the economy back 50 years" (p.15).
Nevertheless, the authors of the report, Peter Lurie, Robert Lowe and Percy Hintzen, join a growing number of critics analyzing the relationship between structural adjustment and rising levels of HIV infection. Such factors as increased labour migration and the separation of households, the high demand for family labour in the face of declining incomes, the growing vulnerability of women, who, faced with limited options, engage in transactional sex in order to feed their families or meet school fees; these are the social and economic realities with which individuals live and make "choices" concerning sexual behaviour. Although most commonly understood as a disease provoked by high levels of "promiscuity," the conditions that augment the spread of HIV in Sub-saharan Africa are no different than those that fuel other diseases. Underlying "biological" and "behavioral" factors are unequal gender relations, shrinking rural subsistence economies, increased migration and urbanization, instability and civil war.
The World Bank spelled out its response to AIDS clearly in its AIDS Assessment and Planning Study of Tanzania. This study identified the "most promising" options as (1) the establishment of a comprehensive STD/HIV prevention and control program to decrease the risk of HIV infection for those with treatable STDs; (2) active condom promotion for both disease prevention and family planning; (3) IEC (Information, Education, Communication) Messages specifically targeted to different audiences to change behaviour; (4) the reduction of the need for blood transfusions; (5) the treatment of AIDS at primary facilities and at home rather than at hospitals to realize significant cost savings. In addition, these more general policies are recommended: intensifying public expenditure review and control, with a view to raising allocations to the health sector through reductions elsewhere, while also reducing inefficiencies within the health system; pursuing economic reform vigorously, so that the full growth potential of the economy can be realized; seeking increased external funds, through donors and commercial investors, to compensate for reduced domestic savings caused by AIDS.
This response reflects, or at the very least is consistent with, the broader neo-liberal political agenda to the extent that, apart from a few vertical, technicist interventions such as condom distribution and STD treatment, people with AIDS are left to fend for themselves until the "full growth potential" of the economy can be realized. The burden of the multiple impacts of AIDS falls on "local communities" (read women) who are to be "empowered" to "cope better" through "community-based strategies" and "coping mechanisms." The radical discourse of primary health care has been appropriated by the major institutions. This is not what the international health community had in mind two decades earlier when, in 1978 at Alma Ata, Kazakhastan, WHO and its member states committed to a holistic vision of primary health care that encompased socio-economic transformation and devolution of power to local communities.
In neo-liberal discourse, "empowerment" and "self-reliance" mean that communities fend for themselves - the function of the state reduced merely to overseeing or monitoring the activities of donors and private charities. In the context of increased dependency ratios, AIDS-related productivity losses, shifting demographics and cutbacks in health and social services, prospects for the "realization of the full potential of the economy" through vigorous economic reform seem rather grim, caring for AIDS patients at home somewhat ill-conceived.
The policy response fits nicely into the World Bank global agenda. The factors that fuel the spread of HIV are not considered proper targets for intervention. Instead, policies and projects are designed to treat the effects (biological, social, economic) of AIDS, and more importantly to "empower people" to better cope with the outcome of HIV-related deaths or protect themselves from infection. The World Bank understanding of "African AIDS" is largely a depoliticized articulation to the extent that it fails to acknowledge the vested interests that underlie the current global order, an order that deeply shapes the pattern of spread of HIV, and disease in general.
At the same time it is profoundly political, further entrenching its social and moral agenda on the African continent. Asa Cristina Laurell and Oliva López Arellano's comments on the World Bank's vision for health ring true: ". . . what is really at stake is the determination of whose health is profitable for investment and, eventually, the power of decision over who should live and who should die."
DID YOU KNOW? FACTS ABOUT AIDS/HIV AND TB
Results of a 1992 AIDS testing of almost 400 teachers and government officials found that 42 percent were HIV-positive.
According to 1994 statistics, there were 125,000 people with HIV out of a total population of 1.4 million.
Ninety thousand cases of tuberculosis were reported in 1995 and 3,000 people were expected to die from the disease in that year.
In 1989 the TB notification rate among coloureds in South Africa was 548 per 100,000. By 1993 it had reached 670 per 100,000 and by 1994 it was 726.
Among Africans, the TB notification rate in 1994 was 180 per 100,000. In 1989 it had been 198 per 100,000.
Among Asians it was 43 per 100,000 in 1994 and among whites it was 17 per 100,000.
For the overall population, the TB notification rate in 1994 was 205 per 100, 000. In 1989 it was 211 per 100,000, so not much progress was made during those five years.
Dr Brian Williams, director of the Epidemiology Research Unit of the Medical Research Council, says South Africa may have the highest rate of TB in the world.
In late 1993, 30 percent of TB patients in Johannesburg hospitals were HIV-positive.
One in every five women visiting ante-natal clinics is HIV infected.
In KwaZulu-Natal and Mpumalanga, 14.4 percent of the residents are infected, compared to a national average of 7.57 percent.
The number of new TB cases rose from 6,002 in 1988 to 6,925 in 1989. The number then shot up to 8,987 in 1990, 12,130 in 1991, 15,237 in 1992, 20,125 in 1993, and 23,959 in 1994.
AIDS is the leading killer of children under five in the country.
If current projections hold, ont-third of children in Zimbabwe will be orphaned by the year 2010.
Data courtesy of Africa Information Afrique (AIA) Information on AIA can be obtained by emailing firstname.lastname@example.org
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