The New Geography of HIV/AIDS
By Gezahegne Bekele, PhD
Addis Tribune- July 5, 2002
It has been over twenty years since AIDS emerged as a disease. The world has learnt a lot about the disease since then. Most of all, we have learned that the disease is humankinds' biggest plague ever and capable of ruining countries and their social systems, freezing the development aspirations of already slow-growing economies, and escalating the misery of the poor and marginalized segments of society.
The numerical dimension of AIDS is sad and dramatic. By the end of 2000, 21.8 million people around the world have died of AIDS; 4.3 million of the dead were children. Nearly twice that many - 40 million - are now living with HIV, the virus that causes AIDS. Most of these are likely to die over the next decade or so because, the disease stands to kill more people in the future than it has killed in the past, because of the new geography of the disease. The pandemic now has set siege to poverty-stricken third world nations as they account for most of the new victims of the disease. In 2001, 5 million people were newly infected with HIV. This in itself is disconcerting; except that the estimated number of newly infected adults and children in
Africa reached 3.4 million. There are now 16 countries in Africa in which more than one-tenth of the adult population age
15-49 is infected with HIV. In countries of the southern zone of the continent, at least one adult in five is living with the virus. In
Botswana, a shocking 35.8% of adults are now infected with HIV, while in South Africa, 19.9% are infected, up from 12.9% just two years ago. In Ethiopia, one in ten adults are infected and sadly the figure may actually be higher since cultural inhibitions, stigma, shortage of testing facilities, and poor data collection methods are likely to understate the problem.
A common lesson from our experience with AIDS in the last quarter century, is that the less aggressive our response to its prevalence, the more expensive and devastating the consequence of the disease. The eventual human and economic costs of the epidemic are dependent on the adequacy and appropriateness of our response at critical times against the epidemic. There is a correlation of slow reaction to the disease and subsequent high human and economic costs that occurs because as the rate of HIV infection in the general population rises, the chances of encountering an infected partner becomes higher. Consequently, even the same patterns of sexual risk result in more new infection. Put differently, past prevention failures eventually turn into current needs for care.
Another lesson is that the disease may be global but prevention methods are not. Consequently, understanding the factors that make the explosion of the epidemic possible in the new geography of HIV/AIDS, e.g. African nations, is essential in stemming the effects of the pandemic. The relative success of medical management of HIV/AIDS in more developed nations is a function of their apparent local conditions. The success of medical therapies in the west is dependent of the ease with which information can be disseminated, surveillance and monitoring can be implemented, resources are amassed, and expertise in treatments developed. The new geography of HIV/AIDS barely has the factors and facilities that were instrumental in producing significant reductions in the prevalence of and mortality from the pandemic. Consequently, adoption of proven beneficial practices from more developed nations may not be effective due to the disparity in local conditions. At the very least, similar efforts as in the west may not produce similar success in the new geography of the pandemic. This does not imply, that useful therapies should not be tried in the new geography, but that their wholesale introduction may promise far less and that in the new geography of the pandemic, HIV/AIDS is a poverty and development issue. As a result, the most effective HIV/AIDS "vaccine" is sustained, equitable development that lifts its people out of poverty, disease and underdevelopment this is especially true where (e.g. Africa) giving palliative care and treating opportunistic infections in a typical case costs almost three time the average per capita income and when the cost of treatment for one AIDS case for a year is equal to sending ten children to primary school for a year.
South African President Thabo Mbeki came under heavy criticism last year when he suggested that AIDS is not a problem for
President Mbeki was accused of sowing confusion over AIDS when, in fact, all he did was insist that AIDS was linked to poverty. What he said in his speech to the 13th International AIDS Conference in Durban was the following: "I heard stories being told about malaria, tuberculosis, hepatitis B, HIV/AIDS and other diseases. As I listened even longer to this tale of human woe, I heard the name recur with frightening frequency - Africa, Africa. In the end, I came to the conclusion that as Africans, we are confronted by a health crisis of enormous proportions. One of the consequences of this crisis is the deeply disturbing phenomenon of the collapse of immune systems among millions of our people, such that their bodies have no natural defense against attack by many viruses and bacteria. As I listened and heard the whole story told about our own country, it seemed to me that we could not blame everything on a single virus. What I heard was that extreme poverty is the world's biggest killer and the greatest cause of ill health and suffering across the globe. The world's biggest killer and the greatest cause of ill health and suffering across the globe, including south Africa, is extreme poverty." Somehow it is difficult to be confused with what he actually said. Far from that, he was actually dwelling on the reality of the new geography of HIV/AIDS. Although HIV/AIDS may be the greatest plague that the world has ever known, poverty and underdevelopment cannot be ignored as Africa's fundamental margins of the global economy and caused a virtual collapse over the past four decades. The systemic crises that confronts the continent, at the very least, played a hand in delaying appropriate response to the HIV/AIDS pandemic. It also is partially to blame for the under development and in some cases collapse of Africa's public health delivery systems as well as for the social dislocation and unrest. Africa's poverty and underdevelopment provide the ideal conditions for the spread of ill health, diseases, death and epidemics. So long as HIV/AIDS and poverty together drive a vicious circle, attributing the explosion of the AIDS epidemic just to sexual behavior is not consistent with the realities of life in the new geography. Instead, the explosion of the pandemic is closely related to failures in economic, political, and social settings, both national and international. AIDS is not merely another infectious disease; it flourishes in and reinforces conditions of poverty, oppression, urban migration and social violence. As a result, countries that are poorer or more unequal are the hardest hit by the epidemic. This vicious synergy between HIV/AIDS and poverty is best manifested in the world's poorest region- Africa.
The new geography of HIV/AIDS demands a new understanding of the complex interactions of poverty and HIV/AIDS. This new understanding must include the exercise of caution when advocating for methods borrowed from experiences elsewhere.
Unfortunately, the caution also extends to drug therapies that may give relief to suffering patients. The global response should recognize the complexity of the pandemic in poverty-stricken nations. Most of all, the global response should seek alternatives to attempts to employ measures that showed success in the developed world only after decades of intensive education, extensive organzation of care centers, highly selective, and closely monitored clinical trials. The new and growing international awareness of the dimensions of the pandemic in the new geography of HIV/AIDS, particularly Africa, should be welcomed though it arrived twenty years too late and after millions have been victimized by death and misery. The global response should not over-promise its therapeutic marvels, especially, to fragile, under-served, and under-resourced masses in the new geography of HIV/AIDS. No doubt, quick success in arresting the epidemic is vital to the salvation of Africa and others in the new geography of HIV/AIDS, the therapies required to achieve it may not, however, be the same ones tried in well-appointed settings of the developed world. The new geography of HIV/AIDS has immense needs for health care delivery infrastructure, safely nets to the sick and their families, extensive surveillance and monitoring facilities and general economic progress. In many ways, the developed world managed to escape this list of synergy of ills. Consequently, the success in the developed world of arresting the epidemic may be due to the presence of the capabilities that the new geography of HIV/AIDS so desperately lacks. Africa and others of the new geography of HIV/AIDS have these needs but their greatest need is economic and political
progress that uplifts the poor so that they can contribute to their health and security.