The Unwritten Sociology of HIV

Alex de Waal

  • Aids in the 21st Century: Disease and Globalisation by Tony Barnett and Alan Whiteside
    Palgrave, 416 pp, £52.50, June 2002, ISBN 1 4039 0005 1

The first anecdotal evidence that Aids-related illness and death were contributing to a crisis in African farming came in the mid-1980s; the first consultants’ reports and academic studies were completed by about 1990. But even the international agencies that sponsored these studies, including the Food and Agriculture Organisation and the Department for International Development, somehow ignored the findings when designing their assistance programmes. It is only now that rural development and food security programmes in Africa are beginning to take account of the implications of Aids.

A report published by the International Crisis Group (ICG) in 2001 compared the impact of HIV on Africa to that of a war. The prologue was written as a war reporter’s dispatch from Botswana. Eighty per cent of the country’s hospital beds were filled with casualties, 20 per cent of the national budget was devoted to war expenditure, the economy had contracted by 30 per cent, and young people had begun dying in such numbers that life expectancy had dropped to ‘medieval’ levels. But Botswana is not only not at war: it is Africa’s most prosperous nation. The figures refer to the probable impact of Aids a few years from now.

In sub-Saharan Africa, the war against Aids must be fought on terrain long since overrun by the enemy. Across the continent, 29.4 million people are estimated to be living with HIV or Aids, about 70 per cent of the global total. Of the five million new HIV infections and three million Aids deaths in 2001, the majority were in Africa. Fifteen years ago, life expectancy at birth in Southern Africa was in the sixties and creeping higher: it was commonly assumed that, over time, Africa would close the gap on Europe. Today, in Southern African countries life expectancy is plunging to the mid-forties and below, while in Europe and America it is predicted that within a few decades we may live to a hundred years or more.

HIV/Aids spreads unusually slowly for an unchecked epidemic. The graph of an epidemic in the acute stage is like a slanted ‘S’. From a single case, the number of people with the disease accelerates until it reaches a peak, whereupon a reverse slope follows, usually slower, with the epidemic declining or dying out altogether. Some epidemics, such as cholera or Sars, spread and peak rapidly, in weeks or at most months. With a short incubation period and a high fatality rate, they tend to burn themselves out before they spread too far. The most feared untreatable diseases, such as Ebola, which causes haemorrhagic fever and death within a few days, flare up in spectacular fashion and abate very quickly.

An HIV/Aids epidemic is very different. In the absence of effective treatment, it takes an average of eight to ten years for HIV infection to develop into full-blown Aids, leading to death. This gives the virus plenty of time to spread before the epidemic is recognised. Aids can also be mistaken for other diseases, and people who would like to avoid the shame of an incurable sexually-transmitted infection are all too willing not to believe they are HIV-positive. The stealth of the illness and the stigma it entails mean that, two decades into the global Aids pandemic, we are still climbing the slope of the ‘S’: the worst is still ahead.

A great deal is now known about the human immunodeficiency virus, with its multiple strains, frequent mutation and propensity to recombine in new and potentially more virulent forms. But this expertise has had little impact on the lives of the great majority of the 40 million people living with HIV and Aids in the poor countries of the world. Nor has it altered the course of the pandemic. In America and Europe, anti-retroviral therapy has commuted the death sentences of HIV sufferers, who now live with a chronic condition. In Africa, only 0.2 per cent of those living with HIV are currently on a clinically supervised course of ARV. This number is rising fast: the most hopeful sign for a long time. But despite their impact on the life expectancy of people with HIV and Aids, ARVs are merely a holding measure. HIV is still a few steps ahead of the international pharmaceutical industry. Drug resistant strains are a growing fear. Optimists maintain that a vaccine is perhaps a decade or so away; pessimists worry that no vaccine will ever be effective.

We also know a lot about how to prevent HIV transmission. In Africa, HIV is transmitted overwhelmingly by unprotected heterosexual sex. Recent claims that unsterilised needles are chiefly to blame fail to explain why HIV prevalence correlates so closely with risky sexual activity, and why rates are close to zero in pre-teen children and the elderly, age groups that receive their fair share of injections. The condom can do most to slow the spread of the virus. Unfortunately, the task of persuading men and women to buy and use condoms is not simple. One problem has been the havoc created by pathological moralists, for whom the enemy is sex itself. But public health planners have also been poorly served by a medical establishment that has undervalued the social epidemiology of HIV. Finding out what works and what doesn’t has been a hit-and-miss affair, largely a matter for community health workers, individual researchers and health planners, many of them driven to despair by the onslaught of the illness, and by their lack of allies in the struggle against it.

Nonetheless, health planners and voluntary organisations have a sense of what to do, and are now calling for the measures they have already taken on their own initiative to be brought into the mainstream and taken account of in aid programmes and government policy. The ICG’s image of mobilisation as if for war remains pertinent. For twenty years, there has been any amount of ad hoccery and incrementalism, skirmishing with the menace rather than mounting a co-ordinated counter-offensive, while the invading force has penetrated deeper. So far, however, most heads of state have failed to make Aids the chief priority, not just for their health service, but for every government institution.

Globally, HIV/Aids has taken a course largely unaffected by attempts to stop it. As the pandemic has spread to India, China and the former Soviet Union, it has become clear that we are seeing the beginning of a worldwide phenomenon. The numbers infected in these countries may soon surpass those in Africa. Meanwhile, HIV prevalence levels have reached and stayed at hitherto unimagined heights: in Swaziland and Botswana, almost 40 per cent of adults are living with the virus, in Zimbabwe only marginally fewer. We know very little about what happens to a society when a substantial proportion of its adults die in the prime of life. As a rule of thumb, a given HIV prevalence level means that about twice that number of adults will succumb to Aids in their lifetimes. The 25 per cent prevalence in South Africa translates into a 50-50 likelihood that a teenager today will develop Aids.

History suggests that demographic adversities rarely come singly. The Black Death – the calamity that most readily invites comparison with Aids – followed on the heels of the worst famine of the Middle Ages and was in turn succeeded by a century of population decline. The late 19th-century famines that overwhelmed India, China and much of Africa came in rapid succession, each giving rise to epidemics. In all cases, including the period of the Black Death, war and brigandage took their toll. It would be unusual if the HIV/Aids pandemic were not to bring demographic consequences of a comparable scale in its wake. One threat is the resurgence of tuberculosis, much of it drug-resistant, partly sparked by Aids but now generating its own momentum. The spiral of impoverishment and hunger in Southern Africa may also result in a mounting death toll from famine. We are simply not prepared for disasters of this magnitude and complexity.

Tony Barnett and Alan Whiteside have been saying as much for the best part of two decades. AIDS in the 21st Century is their review of the social science of Aids, of the reasons for the pandemic, and of what it may entail. It is already the foundation text for postgraduate courses in Aids and development, Aids and politics, and so on – courses which will necessarily multiply in the coming years. It is also the best reference book for those who are – or should be – grappling with the implications of Aids in development planning, business and public affairs.

Barnett and Whiteside provide a simple graph that summarises both the distressing inevitability of the next decade of the pandemic, and the uncertainty about what will happen after that. In terms of HIV prevalence, Southern Africa is, perhaps, nearing the top of the S curve. A line representing Aids deaths follows, showing the eight to ten-year time lag. HIV rates may be high and rising, but deaths from Aids remain temporarily low. We can predict with grim precision that without massive provision of ARV treatment, today’s HIV rates will translate into an avalanche of early deaths in just under a decade.

Barnett and Whiteside explain in some detail the conditions that have made it possible for this pandemic to sweep through Southern and East Africa, and why it now threatens other parts of the world. Each epidemic is different. In China, a leading cause has been contaminated needles and the practice of selling blood. In Russia and Ukraine, the highest rates are among injecting drug-users, above all the prison popul-ation. In many countries, sex workers and their clients are the highest risk group. But once HIV enters the general population – a 5 per cent rate among adults is conventionally defined as the threshold – a generalised heterosexual epidemic is likely to ensue, as it has in Southern Africa.

How can it be stopped? To date, most projections for the course of the pandemic have been based on intervention and the extent to which it might improve the situation. In Africa, increasing awareness, overcoming stigma and denial, and changing sexual practices – typically by promoting abstinence, being faithful and using condoms, the ‘ABC’ – will, it is hoped and expected, reduce the incidence of HIV. Making ARV treatment cheaper and more easily available will give those infected a longer life.

This hasn’t yet happened. There are very few countries in which the reality has proved better than planners’ forecasts (or hopes) – Brazil is one, Uganda another. Yet the assumption that changing sexual behaviour and providing treatment will be both feasible and effective continues to drive policy, and has made it possible to ignore the wider impact of Aids. In the same way that many individuals who are confronted with the disease – in themselves, their colleagues, or friends and family – go into denial, so have policymakers. Dealing with this comprehensive threat to the social and economic foundations of large parts of the world demands collaboration between different academic disciplines and different policymaking fiefdoms. Too many institutions have an interest in continuing with business as usual.

What if prevention and treatment continue to have only a marginal effect? What might the ‘wider impact’ look like? This is Barnett and Whiteside’s chief concern. The most striking legacy of the pandemic is the number of children orphaned. In Africa, about 55 per cent of infected adults are women, who are also on average infected at a lower age than men – six to ten years younger. When one marriage partner dies of Aids, it is probable that the other also has the disease. The progress of the pandemic therefore promises, with distressing certainty, a huge number of orphans. The increase in orphans in Southern Africa closely follows the curve of Aids deaths. This legacy is long-lasting. In Uganda, the one African country in which the epidemic has clearly passed its acute stage and where HIV prevalence has fallen from a peak of 20 per cent in 1991 to perhaps 5 per cent today, the number of orphaned children is only now reaching its height.

The ‘wider impact’ could equally well be defined in terms of poverty, with repercussions for nutrition, literacy and child survival. For a number of reasons, economists are not the best people to measure the impact of the disease. Early studies that tried to link HIV prevalence and economic performance found little evidence for a relationship. This is unsurprising, given that the epidemic had yet to translate into heightened death rates, and in view of the many other shocks to which poor and vulnerable African countries are subject. But even as the epidemic has matured, and the econometric tools have been sharpened, serious problems remain. Some are methodological. For example, in most attempts to account for growth, human capital – usually correlated to the level of education – seems to contribute relatively little, while a majority of African countries are diagnosed as suffering from an excess of available labour. It follows that the loss of a substantial proportion of the workforce can easily be made good, and insofar as ‘excess’ labour is being lost, GDP per capita may actually rise. The World Bank presented a version of this argument as recently as 1999. But it has become clear that labour force losses – including, crucially, the contribution of women to the domestic economy and child-rearing – are not only a human disaster, but an economic one. Skills, experience and networks are being lost. Workers’ morale is suffering. Labour is being diverted to care for the sick and for orphaned children.

Today’s consensus among economists is that a 10 per cent prevalence will cut GDP growth by 0.4 per cent (thus South Africa’s 25 per cent will cost 1 per cent). This is bad, but well within the range of adverse effects that the finance ministers of poor countries are accustomed to. Droughts, collapses in the price of coffee or cotton, oil price hikes or wars can do worse things to an economy over a short period of time. By the same token, debt relief, improved market access or more favourable aid relations can do more to improve a country’s performance in a year than any major commitment of time and resources to the business of turning round this intractable epidemic. No wonder that HIV/Aids has yet to rise to the top of the agenda of African finance ministers, or their counterparts in Washington, London or Paris. Over time, however, a relentless year on year handicap of 1 per cent makes it almost impossible for African countries to reach the UN’s target of halving poverty by 2015. In chapters dealing with orphans, agriculture, the private sector and the economy, Barnett and Whiteside pull together the increasing evidence that HIV/Aids is undermining all the main resources of social and economic development.

What does it mean for all these to start crumbling at once? Barnett and Whiteside give us a simplified but valuable idea by proposing four categories of epidemic, according to whether the society in question is rich or poor, and has a high or low degree of social cohesion. A rich, socially cohesive society will have a slow-onset epidemic that is relatively easily controlled. This is the case in Europe and North America (except for the growing heterosexual epidemic in deprived inner cities). A poor, socially cohesive society has a slow-onset epidemic that reaches a higher level, but is also kept below the 5 per cent threshold. This is the case in Bangladesh, for instance. A poor society with low social cohesion develops a generalised epidemic, and a rich society with low social cohesion does the same, only faster. South Africa and its neighbours fall into the latter category. The stark inequalities in those societies, and corollaries such as migrant labour and the sexual exploitation of young women, help explain the pace at which HIV has spread through them.

When Barnett and Whiteside apply this model to Uganda, they derive an interesting explanation for a much lauded ‘success story’. With the ending of the civil war in most of the country in 1986, Uganda moved from ‘poor/low social cohesion’ to ‘poor/ high social cohesion’ (while also becoming somewhat less poor). After 1986, more children (especially girls) went to school, farm incomes rose, local government was re-established – and the average age at which girls started having sex rose, while men appear to have had fewer partners. This hypothesis does not discount the more conventional explanations for Uganda’s success: the vigorous approach on the part of its leadership and the encouragement of NGO activities. But it helps explain why other governments, even when they begin to focus their policies and programmes on the illness, are proving less successful.

Yet if Barnett and Whiteside’s model is good, it follows that Uganda’s story can also operate in reverse. Were a poor but stable country to become divided by conflict or social collapse, its epidemic could take a different path. The wider impact of Aids – impoverishment or famine, giving rise to migration, for example – might itself throw the switch. A rural food crisis could bring thousands of young women and men to the cities, the women compelled to sell their bodies for survival, the men turning to crime. This would in turn raise HIV transmission. Widespread hunger could also accelerate the progress of HIV to Aids, raising the death toll. Wider impacts of this kind could interact, further deepening poverty and exacerbating conflict. While they might not be dramatic in the short term, such potential increases in HIV and Aids point to the real possibility that the pandemic may feed on itself. That is a frightening prospect.

Meeting the immense, long-term implications of Aids – including treatment and care, and the extension of prevention programmes – demands not only more money from rich countries, but a new way of dealing with Africa. At the moment, the focus is simply on how much money is pledged for the immediate future, but the funding of treatment will have little impact unless there is also a major investment in preventing famine, encouraging social cohesion, expanding basic education and a host of other such measures. Certainly the Europeans should match Bush’s pledge of $15 billion, made on the eve of the Evian summit; but the US will have to be at least as generous as European governments across the spectrum of assistance to Africa. While Aids funding remains a humanitarian add-on to other business, it cannot achieve its goal.

In the meantime, we still need a proper body of research about the ways in which Aids transforms societies. According to traditional patterns of life expectancy, a child who reaches adulthood might expect to live a further four or five decades. This forty or fifty years of adult life is the unexamined foundation of much of our economic and social life, and of our economics. On it is based the further expectation of handing on assets and skills to one’s children and living to be a grandparent. It is the basis for calibrating the returns on higher education as well as, say, the length of prison sentences, the cost of housing or the length of mortgages. It sustains the complex world of institutions which require people with prolonged personal experience to staff them. We are only beginning to understand what happens to a society in which these assumptions no longer hold good.