”Clearly, AIDS is no longer just a health problem. It is a developmental crisis with potentially
ominous consequences for Africa and the world.”[1]
Context:
As
a region, Sub-Saharan Africa (SSA) is characterized by having the greatest
infectious disease burden, the weakest public health infrastructure, highest
birth rates, lowest annual income, poorest economic outlook, highest illiteracy
rates, largest number of displaced persons, poorly trained and equipped
militaries, and a history of corrupt
governments.[2] If this were not enough, Human
Immunodeficiency Virus (HIV)[*],
an emerging infectious disease, made its début
in SSA in the early 1980s and has been
wreaking havoc on this region’s population ever since.
Currently
SSA sports some alarming statistics: 72% of the world’s HIV infections in only
10% of the world’s population and 80% of the
world’s HIV-positive women. For comparison, SSA adults
are 30 times more likely to be infected than those in Brazil or India, and 300
times more likely to be infected than adults in China. The impact of this devastating disease on SSA, may most likely be the coup de grǎce
for these fragile biosocial, economical, and
governmental systems that are struggling to
make there way in the world and demand
exploration and hopefully further elucidation.
The
risk of this pandemic to regional and global stability breaks the traditional notions of security based on territorial
sovereignty and integrity.[3] Examining the region as a whole adequately
contextualizes the global problem but does not provide the granularity needed
for comprehending the myriad of socio-economic factors contributing to the
epidemic. This can only be done when the
region is explored on a country-by-country basis. For the purposes
of this essay we examine the HIV epidemic in three West Africa countries:
Nigeria, Ghana, and Senegal in greater detail.
Background:
Just five years ago the International Labor
Office in Geneva described an “AIDS belt” across East and Central Africa with an
approximate 10% prevalence rate, reporting relatively
few cases in West, southern, and northern Africa.[4] In 2004, many countries in Africa’s southern
cone have adult prevalence rates exceeding
25%, and there is very little hope that West
Africa will not follow this trend.
HIV/AIDS
is much more then a health problem. The
loss of people during the most productive
years of their lives will certainly affect individual countries overall
prosperities and capabilities throughout
SSA. The macroeconomic impact of these early deaths is difficult to assess due
to varied mechanisms by which AIDS will impact the overall economic performance. AIDS deaths lead directly to a reduction in
the number of prime workers available.
Less experienced and educated workers
replacing those who have died, could potentially
lead to lower productivity. A shortage of workers leads to higher wages
and increased migration, which leads to higher domestic production costs and
loss of international competitiveness.
Reduced savings because of greater health care expenditure and a loss of
worker incomes can generate a significant drop in capital accumulation savings.[5]
The
high numbers of HIV infected military members may increase instability of the
region in the coming years. Militaries
of SSA typically do not test for HIV with any regularity, if at all, and depend
on United Nations (UN) peacekeeping missions to financially support their
militaries. The movement of highly
infected soldiers has contributed to the pandemic, and in the near future
countries partaking in UN sponsored activities will be required to test and
remove infected military members from peacekeeping missions. For many of the SSA nations that are already
politically unstable, even the perception of a weakened military can make them
susceptible to an internal coup d’etat or possible enemy attack.
GHANA
Ghana is well endowed with natural
resources, has roughly twice the per capita output of the poorer countries in
West Africa, and remains heavily dependent on international financial and
technical assistance. The economy
revolves around subsistence agriculture, which accounts for 36% of the Gross
Domestic Product (GDP), and employs 60% of the work force. In 1992 approximately 31% of the population
subsisted below the poverty line.[6][†]
Human Cost: In 2003, Ghana’s estimated population was 20.5 million
with a median age of 19.8 and a life expectancy of 56 years. The first case of HIV was reported in Ghana
in March of 1986. In 2001 the number
of adult Ghanaians living with HIV/AIDS was estimated to be 360,000 (3%), 70%
of those are female, and with an additional ~ 28,000 deaths due to
HIV/AIDS. In 2004, the Ministry of
Health in Ghana estimates the number of orphans, due to death of parent(s) to
AIDS, to be 200,000.[‡]
Questions:
1. Given the
experience of other SSA countries, why do you think Ghana’s HIV/AIDS rate is
much lower comparably, and where do you see prevalence rates going in the next
5 years?
2. The HIV rates in
women are very high compared to Senegal where male infection rates exceed women
by 1.3:1. What do you see a much higher
rate in women in Ghana?
Economic Impact: Economically speaking what makes HIV/AIDS so important to
national development is that it virtually affects the development effort in all
sectors. In the health sector the cost
of AIDS will have a major impact on the allocation of health resources. Treatment with antiretroviral drugs for
infection with HIV indicates an annual cost of ~ 45 million Cedis ($5,120 US)
per patient. Treating opportunistic
infections for AIDS ranges between 36,308 –380,350 Cedis ($5.19 – 54.34 US) per
episode of illness.[7] Raw health care costs are minuscule compared
to the loss of people from the labor force due to AIDS illnesses and
death. With 60% of the work force
earning their living from subsistence and commercial agriculture, decimation in
the labor force will result in local malnutrition and substantial decreases in
available agriculture exports.
Question:
1. It appears that
unless the current HIV trend is reversed, Ghana will experience a labor
shortage in the coming years. What
propositions have been developed to address these eventualities?
Social Cost: The increase of orphans due to AIDS deaths puts additional
strain on families and social systems.
The care of orphaned children falls to orphanages, extended family
members, an adolescent member of the family taking over as head of household,
or finds children relegated to living on the streets. This is especially difficult in major urban
centers where traditional family structures are not as strong as in the
countryside. Many orphans will never
receive adequate health care and schooling.
As far as societal implications there will also be a long-term burden on
social services responsible for providing orphanages, health care, and schools
fees. Skilled workers and professionals
are precious commodities in all countries, and substantial losses will add an
additionally strain to not only their respective fields but also on education
systems suffering from the same shortfall.
Questions:
1. The impact of
HIV/AIDS cases in teachers will reduce their availability to the educational
sector and result in a general shortage of qualified instructors. This shortage will be repeated many times
over in other skilled and professional occupations as well. Since education is the lynchpin for renewal
of these valuable resources, does the government of Ghana have a plan for
filling this void?
2. School enrollment
and attendance is currently declining with the postulated cause is said to be,
the rising infection rates among the youth or families requiring children to
stay at home to care for sick family members.
How are these issues addressed in the current policies?
3. Socio-cultural
factors such as stigma and denial make the care and support for people living
with HIV/AIDS by family members and healthcare workers a daunting
challenge. Do you have programs that
address these issues?
Military Preparedness: Evidence derived from the southern African countries where
this epidemic has had more time to mature, shows military HIV prevalence rates
generally run two to three times higher than the population at large. With 20 to 50% of the Ghanaian military
expected to become HIV positive over the next 2 to 5 years, it is reasonable to
expect a tremendous degradation in combat readiness. In addition, there is concern over the
increasing loss of high-ranking military officers and the impact this will have
on the internal stability of the military.
Questions:
1.
Given that military members in SSA experience 2-3 times higher HIV rates
then the general public, do you anticipate instituting any new criteria for new
and current military members?
2.
How would you view a UN mandate requiring only HIV negative soldiers
being allowed to participate in peacekeeping missions?
Security Factor (Stability): In January 2001, for the first time since transition to
democracy almost a decade earlier, a new government took over in Ghana. The sad nature of Ghana’s economic problems
continue into 2004 with a 30 to 50% inflation rate, high levels of poverty,
worsening income distribution, lack of consistent growth, rising urban
unemployment, and overwhelming debt. The
most significant policy issue is how to achieve macroeconomic stabilization in
the shortest possible time without compromising steady long-tem growth?[8]
Question:
1. Given the gravity
of problems facing Ghana over the next five years, how would you characterize
the impact of HIV on Ghana’s ability to make progress?
SENEGAL
Senegal's economy, fourth
largest in Western Africa, follows Nigeria, Ghana, and Côte d'Ivoire. The agricultural sector contributes one-fifth
of the GDP and supports 75% of the working population. Approximately 12% of the land is currently
arable. The marine fishing industry is
the leading exporter followed by groundnuts, phosphate, and iron ore
products. Senegal maintains a long
history of military participation in international peacekeeping operations.
Human Cost: According to 2003 data the
population is estimated to be 10.5 million; median age 17.8 years and life
expectance at birth 56 years. The first
case of HIV was identified in 1986. In
2001 approximately 27,000 (0.5%) adults were HIV positive and there were 2,500
deaths. Reports indicate that the sex
ratio for HIV infection is 1.3:1 (9 males for 7 females),[9]
unlike Ghana, which identified 80% of infections, were in women. The major religion is Islamic with 94% of the
population practicing this faith.
Questions:
1.
Given the experience of other SSA countries, why do you think Senegal’s
HIV/AIDS rate has remained comparably low and where do you see prevalence rates
heading in the next 5 years?
2. Senegal has seen more HIV cases in men then
in women. For example, Ghana has seen
80% of the cases are in women. What
explanation(s) would you provide to illuminate this finding?
3. How does your
approach to the HIV/AIDS issues fit into your general public health policy?
Economic Impact: The economic effects of AIDS will be initially felt by
individuals and their families and ripple outwardly to agriculture, then
businesses, and finally the macro-economy.
This being the case the agricultural economy, which employs 74% of the
economically active population, will be hit first and hardest. AIDS will affect the health sector in at
least two ways: first in the number of AIDS patients seeking medical treatment,
and second, from the financial impact of treating these patients.[10] In 1997, the Ministry of Health decided to
introduce triple cocktail therapy beginning in 1998. While the cost of this therapy is typically ~
600,000 Communaute Financiere Africaine (CFA)
($1,000 US) per month, the government negotiated a price of 362,000 CFA ($603
US) per month. It is unclear if this
program continues and if and when these drugs are offered to all newly
identified HIV positive people but if the program has continued, the present
approximate cost is $1.5 (US) million per month.[11]
Question:
1. The costs
associated with HIV diagnosis and AIDS treatment is expensive. Senegal is one of the few SSA countries that
has able to offer this treatment. How
many people have you enrolled in this program and do you anticipate continuing
the program?
Social Cost: The United States Agency for International Development (USAID) has singled out Senegal for its positive results in HIV
prevention over the last two decades, attributing their success to early active
governmental support into aggressive prevention programs. The mode of HIV transmission in Senegal is
mainly heterosexual. Senegal’s Muslim
majority (94%) and Catholic minority have been generally supportive of
government programs, where in most countries these religious groups typically
condemn those infected with HIV.
Question:
1. How did the
religious authorities react to the epidemic?
Military Preparedness: Senegal has ~ 16,500 military personnel including
security forces. The military requires
testing for all military members participating in selected deployments. New recruits and those applying for
promotions are tested as well.
Questions:
1. When mandatory
testing identifies an HIV positive military member, is the member allowed to
stay in the military? What treatment is
available? Are family members tested as well?
2. When soldiers
return from extended deployments is there a follow-up testing program?
3. How would you view
a UN mandate requiring only HIV negative soldiers be allow participation in
peacekeeping missions?
Security Factor (Stability): In January 1994, Senegal undertook numerous economic
reform initiatives with the support of the international donor community. This reform began with a 50% devaluation of
Senegal's currency, the CFA franc. In
addition, government price controls and subsidies have been steadily dismantled
since. This brought a real growth
in GDP of 5.6% in 1996 and 4.7% in 1997 after a sluggish economic growth in
previous years. With an external debt of
$2,495 (US) million, and its economic reform program on track, Senegal
qualified for the multilateral debt relief initiative for heavily indebted poor
countries (HIPC). Progress on structural
reforms is on track, but the pace of reforms remains slow as delays occured in
implementing a number of measures on the privatization program, good governance
issues, and the promotion of private sector activity. However, macroeconomic indicators show that
Senegal turned in a respectable performance in meeting International Monetary
Fund targets in 2000 with an annual GDP growth increased of 5.7%, as compared
to 5.1% in 1999. Inflation was reported
to be 0.7%, compared to 0.8% in 1999, and the current account deficit
(excluding transfers) was held at less than 6% of GDP.[12]
Question:
1.
As more and more
people become infected with HIV in SSA, and given the success of Senegal in
providing HIV infected persons with education and treatment, is there any
concern that people from these countries will come to Senegal seeking treatment
for HIV/AIDS? And if this is a concern,
how do you plan to address this?
NIGERIA
The most populous country in
Africa, Nigeria accounts for approximately one-fourth of West Africa's
people. Although less than 25% of
Nigerians are urban dwellers, at least 24 cities have populations of more than
100,000. <small>Nigeria
is Africa's leading oil producer. Following nearly 16 years of
military rule, a new constitution was adopted in 1999 and a peaceful transition
to civilian government was completed.
The current president faces the daunting task of rebuilding a
petroleum-based economy whose revenues have been squandered through corruption
and mismanagement, and institutionalizing democracy. In addition, the administration must defuse
longstanding ethnic and religious tensions if it is to build a sound foundation
for economic growth and political stability.
Despite some irregularities, the April 2003 elections marked the first
civilian transfer of power in Nigeria's history. </small><small>Nigeria's economy is highly dependent on the
capital-intensive oil industry, which contributes ~ 95% of export earnings and
75% of government revenue. The bulk of
the population is engaged in agriculture, which contributes about 30% of GDP. By 2000 Nigeria's per capita income had
plunged to about one-quarter of its mid-1970s high. </small>
Human Cost: In
2003 Nigeria’s estimated population was 134 million with a median age of 18 years and a life
expectancy at birth of 51 years. The
first case of HIV in Nigeria was identified in 1986. In 2001, the number
of adult Nigerians living with HIV/AIDS was estimated to be 3.5 million (5.8%)
with approximately 170,000 deaths. In
2003, the United States Agency for International Development estimated 1
million orphaned children were living in Nigeria due to AIDS. Several factors have contributed to the rapid
spread of HIV in Nigeria: sexual networking practices such as polygamy, a high
prevalence of untreated sexually transmitted diseases, low condom use, low
social status of women, stigmatization, and a denial of HIV infection.[13]
Question:
1.
Compared to other SSA countries, why do you think Nigeria’s HIV/AIDS
rate is much lower comparably and where do you see prevalence rates going in
the next 5 years?
Economic Impact: Data on the economic impact are
limited but a recently developed United Nations model has predicted that the
impact on economic growth is potentially larger in Nigeria than the overall SSA
average. Using this model the cost of
HIV/AIDS to the country would be $2-3 (US) per capita or approximately 0.8% of
the GDP. This model developed by the
United Nations Program for HIV/AIDS shows how increasing mortality rates have
led to a discontinuity in education with many pupils losing or having a change
of their teachers. The potential impact
on sectors such as agriculture, households, and firms show an increase in costs
and expenditures particularly labor costs, reductions in savings, and shifting
productivity patterns.[14] The USAID allocated $14.5 (US) million for
HIV/AIDS activities in 2002 and $24.6 (US) million in 2003.[15]
Question:
1.It appears that unless the current
HIV trend is reversed, Nigeria will experience a labor shortage in the coming
years. What propositions have been
developed to address these realities?
Social Cost: The Nigerian society is characterized by rivalry and
tension between regions and ethno-religious groups. The variety of customs, languages, and
traditions among Nigeria's 250 ethnic groups gives the country a rich
diversity. The dominant ethnic group in
the northern two-thirds of the country is the Hausa-Fulani, most of whom are
Muslim. HIV/AIDS having already taken
hold in the general population has placed family breadwinners, as well as key
leaders in government and industry at substantial risk. Through their loss the country’s economy
faces potential devastation. The spread
of HIV/AIDS is believed to be via heterosexual activities.
Questions:
1.
The impact of HIV/AIDS cases in teachers will reduce
their availability to the educational sector and result in a general shortage
of qualified instructors. This shortage
will be repeated many times over in other skilled and professional occupations
as well. Since education is the lynchpin
for the renewal of these valuable resources, does the government of Nigeria
have a plan for filling this void?
2.
School enrollment and attendance are currently
declining, and the postulated cause is said to be rising infection rates among
the youth or families, requiring children to stay at home to care for sick
family members. How are these issues
being addressed in the current policies?
3.
Socio-cultural factors such as stigma and denial make
the care and support for people living with HIV/AIDS by family members and
healthcare workers a daunting challenge.
Do you have programs that address these issues?
Military Preparedness: Nigerian
military leaders are resistant to initiating greater transparency and
accountability in managing the country's multibillion-dollar oil earnings, and
these propensities continue to limit economic growth and prevent an agreement
with the International Monetary Fund (IMF) and bilateral creditors on debt
relief. There are approximately
76,000 active duty personnel in Nigeria’s three service branches. The Nigerian Army, the largest of the
services, has about 60,000 personnel deployed in two mechanized infantry
divisions. The military has demonstrated
its capability and willingness to mobilize, deploy, and sustain battalions in
support of peacekeeping operations in Liberia, Yugoslavia, Angola, Rwanda,
Somalia, and Sierra Leone. The Nigerian
Armed Forces Program on HIV/AIDS Control (AFPAC) has coordinated HIV/AIDS
activities for the Nigerian Army, Navy, and Air Force since 1987. The U.S. Government has been the primary
international donor to AFPAC. Since
2000, the project has targeted increased awareness of HIV/AIDS and sexually
transmitted infections, increased availability of condoms, and has mitigated
the impact of HIV/AIDS through home based care and support of people living
with HIV/AIDS.[16] The Nigerian government plans to provide free
antiretroviral drugs to HIV positive soldiers from the consignment of about
$3.7 (US) million worth of generic antiretroviral drugs it recently purchased
from India at a subsidized price.[17] The Nigeria military is not routinely tested
for HIV.
Questions:
1.
The Armed Forces represent a large and important segment of the Nigerian
population whose occupation puts them at increased risk of sexually transmitted
infections such as HIV/AIDS. Given the
experiences of other SSA militaries do you have policies in place or anticipate
instituting any new testing criteria for new or current military members?
2.
How would you view a UN mandate to require only HIV negative soldiers be
allowed to participate in peace keeping missions?
Security Factor (Stability): Nigeria's official
foreign debt is about $28.5 (US) billion of which approximately 75% is owed to
Paris Club countries. A substantial
portion of this debt is interest and payment in arrears. In August 2000 the International Monetary
Fund (IMF) and Nigeria signed a one-year Stand-by Arrangement (SBA) leading to
a December debt rescheduling agreement Nigeria and its Paris Club
creditors. By August 2001, despite
continued dialogue with the IMF, Nigeria had been unable to implement many of
the SBA conditions and as of September 2001, only a few of Nigeria's creditor
governments had signed bilateral rescheduling agreements. Any long-term debt relief will require strong
and sustained economic reforms over a number of years. Along with the endemic malaise of Nigeria's
non-oil sectors, the economy continues to witness massive growth of
"informal sector" economic activities, estimated by some to be as
high as 75% of the total economy.
However, the largely subsistence agricultural sector has failed to keep
pace with the rapid population growth and Nigeria, once a large net exporter of
food, must now import food. Nigeria
launched an ambitious development program to create a large industrial sector
to lessen its dependence on oil and agriculture but nonetheless, massive
external debts combined with political instability, corruption, and poor
macroeconomic management have hampered its implementation. Inflation, which
had fallen to 0% in April 2000, reached 14.5% by year-end and 18.7% in August
2001.[18] Although the government 's anti-corruption
campaign has thus far been disappointing, progress in injecting transparency
and accountability into economic decision-making is notable.
Question:
1.
Given the gravity of problems facing Nigeria over the next five years,
how would you characterize the direct impact of HIV on Nigeria’s ability to
continue to make progress?
[*] HIV disease is
characterized by a gradual deterioration of immune function. Most notably,
crucial immune cells called CD4+ T cells are disabled and killed during the
typical course of infection. These
cells, sometimes called "T-helper cells," play a central role in the
immune response, signaling other cells in the immune system to perform their
special functions. A healthy, uninfected
person usually has 800 to 1,200 CD4+ T cells per cubic millimeter (mm3) of
blood. During HIV infection, the number
of these cells in a person's blood progressively declines. When a person's CD4+ T cell count falls below
200/mm3, he or she becomes particularly vulnerable to the opportunistic
infections and cancers that typify.
Acquired Immunodeficiency Syndrome (AIDS), the end stage of HIV
disease. People with AIDS often suffer
infections of the lungs, intestinal tract, brain, eyes and other organs as well
as debilitating weight loss, diarrhea, neurologic conditions and cancers such
as Kaposi's sarcoma and certain types of lymphomas. Most scientists think that
HIV causes AIDS by directly inducing the death of CD4+ T cells or interfering
with their normal function, and by triggering other events that weaken a
person's immune function. For example,
the network of signaling molecules that normally regulates a person's immune
response is disrupted during HIV disease, impairing a person's ability to fight
other infections. The HIV-mediated
destruction of the lymph nodes and related immunologic organs also plays a
major role in causing the immunosuppression seen in people with AIDS.
Written in 2004
Written in 2004
[†]
Country and human facts and figures for all three countries studied here are
all taken from the CIA Fact Book, 2004 edition or United States State
Department on-line country profiles.
[‡] An
AIDS orphan is a child under 15 who has lost either mother or both parents to
AIDS.
REFERENCES
[1] Platform on
action on HIV/AIDS in the context of the world of work in Africa, 88th
Session, ILO, May 2000
[2]
Jennifer Brower and Peter Chalk, The Global Threat of New and Reemerging
Infectious Diseases. Rand Publishing, Pittsburgh, PA, 2003, p 42
[3]
Jennifer Brower and Peter Chalk, The Global Threat of New and Reemerging
Infectious Diseases. Rand Publishing, Pittsburgh, PA, 2003, p 42
[4]
Africa Development Forum 2000, Addis Ababa, Ethiopia, 3-7 December 2000 p 2
[5]
HIV/AIDS in Ghana, National AIDS/STI Control Programme Disease Control Unit,
Ministry of Health, Ghana. 3rd Edition; December 2001, p 40
[6]
CIA world Fact Book, 2003 edition
[7]
HIV/AIDS in Ghana, National AIDS/STI Control Programme Disease Control Unit,
Ministry of Health, Ghana. 3rd Edition; December 2001, p 40)
[8]
Ernest Aryeetey, Macroeconomic Stability, Growth and Poverty Reduction in
Ghana, Second Workshop: The Research Agenda, Cornell University, October 2001,
p 4
[9]
Mandiaye Loume, 2nd Global TB/HIV working Group Meeting, Durban,
June 2002
[10]
Lori Bollinger, Stover J. and Diop I, The Economic Impact of AIDS in Senegal,
The Futures Group International, The Centre for Development and Population
Activities, September 1999.
[11]
Diop, I., Unpublished data, taken from a Consultant Report, 1999
[13]
United States AID Brief
[15]
Country Profile, United States Agency for International Development, Bureau for
Global Health, July 2003.
[16] The United States Diplomatic Mission to
Nigeria, March 2004
[17]
Abiodun Raufu Lagos, Nigeria promises free antiretroviral drugs to HIV
positive soldiers, BMJ 2002;324:870 ( 13 April 2004)
[18]
Economic Commission for Africa, 2002
