New York Times, June 23, 2000- By DONALD G. McNEIL Jr.
PARIS, June 22 -- The global AIDS epidemic, long thought of as an urban phenomenon, is shifting strongly to rural areas in the third world, a report from Unaids and the Food and Agricultural Organization said today.
That shift has dire implications for people with the disease and the countries that are involved with the crisis. Although city dwellers can sometimes find social services to help them or can beg on the streets, a poor farm family often collapses when one adult is deathly ill.
"H.I.V. hits particularly young adults, and they are the core of the labor force, the keystone of the farm household," said Jacques du Guerny, an AIDS expert at the Food and Agricultural Organization.
When one family member cannot plow, weed or market and others have to cut their workloads to care for that person or have to sell the family ox or plow to buy medicine or pay for funerals, the farm may collapse. That in turn cuts food supply to city residents. Even if the family carries on, it may plant less or plant less labor-intensive and less nutritious crops, the report said.
The situation is particularly bad in Africa, where many countries have infection rates from 10 to 25 percent of adults; in India, with a low infection rate but more than four million cases; and in several Caribbean countries, including Haiti. Despite the wide publicity on AIDS deaths in the United States, Africa accounts for 83 percent of AIDS death, according to Unaids.
The disease spreads in rural areas in many ways. Particularly in southern Africa, rural people migrate to the cities or mines to look for work, become infected and return home once or twice a year. The disease also spreads along truck routes, where prostitution thrives, especially near borders where truckers can wait for days.
Rural poverty, too, creates vulnerability. In one example, Mr. du Guerny said, Cambodia farmers often go bankrupt in bad years and accept money from lenders who charge high interest rates. If the borrowers fall behind, Mr. du Guerny said, "traffickers come and say, 'Sell us your daughter, and we will help you repay the loan.' This creates tremendous vulnerability and risk of infection."
Preventive measures like sex education and condom distribution focus on cities and hardly exist in the countryside. Traditional customs that can spread the disease like the central African practice of "cleansing" a widow through sex with a relative of the dead husband are stronger in the countryside.
The report was released in Rome, the F.A.O. base. It had no worldwide estimate of urban-rural prevalence, and it noted that rural H.I.V. rates "are harder to measure and more prone to underreporting and misdiagnosis." Instead, the study reached its conclusion by compiling case studies. In one Indian state, Tamil Nadu, the rate is growing faster in the countryside than in cities. In rural Buhera, Zimbabwe, the rate among pregnant women who visitprenatal clinics is 50.8 percent, well above the national average.
The chief epidemiologist for Unaids, Bernhard Schwartländer, said that there were no worldwide figures for the urban-rural shift but that one rule was that the disease spread faster from cities to countrysides with well-developed roads and bridges.
"In Botswana, a small country with very good infrastructure and a lot of people living near the roads," Mr. Schwartländer said, "there's no difference in infection rates between urban and rural areas. But in Tanzania, where it's a day's walk to get to a trading area to sell your stuff, people only do that once or twice a month."