The Problem of AIDS in Africa
HIV first emerged in Africa during the early 1970’s but did not garner much concern or attention until around the early 1990s when global health care communities and agencies became alarmed at the explosion in the incidence rate of infected individuals and as well, the related mortality rates that rapidly followed. Due to a high illiteracy prevalent in these countries, the efforts of local agencies in the health sector to educate inhabitants on the topic of AIDS failed miserably. Governmental officials took a passive stance and were persistent in their denials that the disease existed counter-arguing instead that AIDS was but a mere fiction, a fabrication on the part of global organizations to interfere with the politics and governing of its countries.
The combined illiteracy of locals and ineffectual or non-existent efforts of most African governments to intervene have contributed to the ease with which AIDS have continue its trajectory of infection throughout much of Africa. The disease progressed swiftly throughout the 52 countries of its mother continent to infect mothers and fathers, sons and daughters and, sisters and brothers. Tracking its way easily through the pathways of illiteracy, ineffectual health system, poverty and poor governmental intervention, AIDS infected (and killed) hundreds of thousands of the African population within a relatively short timeline.
AIDS IN AFRICA: A POLITICAL ECONOMY
Much blame has been cast on African people for the global spread of AIDS in much the same way as gays and homosexual individuals were and still are blamed for its emergence in the Western hemisphere of the world.
The earliest verified HIV case was diagnosed on 1959 in Kinhshasa, Congo; African blood samples before this time were essentially free of the virus. Similar to influenza and rabies, AIDS is a disease that is transmitted from animals to humans; the closest relatives of HIV are SIVs which are viruses carried by apes and monkeys. HIV-1 is a strain of HIV that most resembles a chimpanzee SIV, which is commonly found in rain forests of coastal West Africa. HIV-2, a milder West African virus, is nearly identical to a monkey SIV. These viruses have lived in their natural hosts for millions of years and don't make them sick. The currently favored idea of how the viruses jumped into humans is that people hunted chimps and monkeys for meat, and cut themselves while butchering (Williams).
Up until the late 19th century, most Africans were farmers and lived in rural villages. In colonial Africa, forced labor was the rule. For example, copper mines in Katanga (Congo) rounded up Africans from Zambia, Rwanda, Angola and Mozambique to work in their underground mines and millions more were drafted by colonial armies during both world wars. During the 1930's, the French built a railroad through coastal West Africa, drafting (once again) hundreds of thousands of African laborers from distant locations and marching them through the rain forest under appalling conditions of near-starvation. According to one theory, it is here that Africans first were exposed to SIVs, as workers made desperate by starvation had to hunt apes as foods.
Since the emergence of the first AIDS-diagnosed case, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that at the end of year 2003, over 20 million people worldwide had died of AIDS with Africa, having the highest percentage of deaths. At present, about 42 million people are infected with the virus HIV; of this estimate, 70 per cent of the world’s HIV-positive people live south of the Sahara desert that is, in Africa (Guest).
The 13th International AIDS Conference, held in Africa in 2000, described an unreal and unimaginable ‘natural’ genocide of Africans. Reports estimated that approximately fifteen million Africans have already died and that thirty-four million are HIV-infected, including 25 million in sub-Saharan Africa. In addition, it is estimated that HIV/AIDS will kill 67% of teenagers in some African countries. It was found that women are twice as likely as men to become infected and it was predicted that over thirty million African children will become orphans by year 2010 with life expectancies dropping from 70 years to 30 in some countries.
An extremely high ratio of 1:3 adults (defined as being between the ages of 15 to 49) is said to be infected with Botswana being the hardest hit country having over 38 percent of its adult population infected (Guest).
While these numbers are staggeringly high, more alarming are claims by international health organizations such as the UNAIDS and WHO that declare that these estimates may in fact, be below the real and actual figures. Some (African) countries gather no data regarding HIV/AIDS prevalence while others may simply extrapolate national statistics from alternate sources of data such as surveys of HIV prevalence amongst pregnant women antenatal clinics.
There are few cases of diagnosed HIV/AIDS due to a socio-cultural stigmatization of the disease; as a result, doctors are encouraged to either ‘mis’-diagnose AIDS-infected patients with other types of illnesses or to put alternative causes of death on patients’ death certificates. Studies revealed that Africans are sensitive about the topic of sexual relations outside marriage. Since AIDS is a sexually transmitted disease, the identification of a person as carrier or patient is often taken as an indication of promiscuity, despite the awareness that the disease can be transmitted in other ways. It is not uncommon for doctors to write up patients’ death as being caused by tuberculosis or pneumonia thereby contributing to a ‘silencing’ of the disease; author Vinh-kim Nguyen, in his article on Ties That Might Heal (Nguyen) attest to this phenomenon of denying and renouncing the existence of AIDS on the part of African societies and in so doing, create a ‘silent epidemic.’
The high rate of infected cases didn’t happen overnight but its spread was insidiously invisible. African governments have done much too little, much too late. Most lacked monetary resources and the political will to improve sex education in schools or to hand out condoms. Efforts to provide health care have been insufficient; there are never enough clinics, nurses or drugs. The lack of political will to intervene manifested in the attitudes of most African governments who persisted in their claim that AIDS did not really exist. Eight years after the appearance and diagnosis of the first AIDS case in Africa, then Deputy Thabo Mbeki finally addressed the issue of AIDS in Africa. In 1998, he declared, ‘For too long we have closed our eyes as a nation, hoping the truth was not so real. For many years, we have allowed the HIV virus to spread, and at a rate in our country which is one of the fastest in the world.’
Many Africans still do not know the facts of AIDS; such lack of knowledge cannot be blamed solely on ignorance. Many miss out on safe sex messages simply because they did not received enough schooling to be able to read leaflets or newspapers and the majority can ill afford a television or radio. Even in places where most people have heard of AIDS, it’s rarely talked or discussed about and in situations when it is vocalized, AIDS is spoken of in euphemisms like ‘this thing.’ As typical of human nature, there’s an attitude of immortality and invincibleness but in Africa, where endemic poverty exists, such concerns of HIV/AIDS fatality takes second (if not, lower) place to strategies for day-to-day living and survival. In Africa where poverty is rife, the issue of death and fatality surrounding AIDS evoked little anxiety and fear apprehension.
There is little doubt that AIDS will impact on African’s lives to make the poor, poorer.
This in turn will affect the economies of households. AIDS rarely affect a single individual in African households; AIDS kills people at their productive peak, and often more than one person in the same family. Young children, especially girls, drop out of school to take over the role of breadwinner when one (or both) of their parents sicken and die. Health care and funeral costs drive these financially strapped households into further poverty, seducing the newly assigned breadwinner to undertake dangerous jobs at risk for HIV infection thus, sustaining this vicious circle of cyclical infection.
PATTERNS OF SEXUAL NETWORKING
The dispersion of any sexually transmitted disease is a culturally sensitive issue within any society because its cause is typically associated with a certain ‘perceived’ degree of either promiscuity or of unsafe and risky sexual practices and AIDS is no exception. For example, when one hears of a person infected with HIV, at best, one usually think of that person being infected because of unsafe sexual practices. Rarely does one claim, ‘Oh he/she must have had a contaminated blood transfusion.’ Unfortunately, these attitudes and beliefs are more often than not, grounded in truth because inherently, a disease such as AIDS are frequently transmitted via (unprotected) sexual relations.
In Africa, patterns of sexual networking is complex with many factors underscoring the population’s attitudes and behavior regarding sexuality. A 2002 UNAIDS study conducted on African cohorts revealed that Africans tend to start having sex younger compared with cohorts in other countries and that African girls become sexually active at a much younger age than boys Kuate-Defo). The report alludes to issues of multiple partners, an overlapping of relationships and extra-marital relations as adding to the increased risk for HIV infections where in areas such as rural Kenya the number of pre-marital partners for men was nine and for women, three.
In Africa, there is more sexual contact between people of different generations; there is a misplaced and misguided notion that young adolescent girls are less likely to be HIV-infected and as such, they are sought as sexual partners by older and middle-aged men who offer lavish gifts and monetary compensation. In a continent reputed to be the poorest, with the lowest gross national product and per capita income (Williams), many girls either give in by necessity or succumb by desire. By the time these girls marry, they are already infected with the virus and unknowingly infect their husbands (who engage in extra-marital sex) also pass the virus on to his younger mistresses.
In Europe and North America the relatively low prevalence of heterosexual transmission after a decade of HIV epidemic is still under maintained and dispersion is also relatively under control.
Patterns of sexual networking alone did not exacerbated the spread of AIDS in Africa. The continent’s high poverty has certainly accelerated its proliferation across its 52 countries from rural Kenya to metropolitan Burkina Faso. The majority of Africans do not have the monetary means to protect themselves; many cannot afford condoms or antibiotics to treat other kinds of STDs which are frequently common in Africa. An important AIDS-related implication of this is that a person’s risk for HIV increases significantly if they have a genital discharge or ulcers; genital discharge and ulcers create open sores and inflamed mucosal surfaces that enables the virus to enter the body more easily.
Poverty creates financial constraints and limitations that forces poor people to undertake dangerous jobs (Nguyen). Many African women, having little choice and no employment opportunities, resort to prostitution. The risk for HIV infection increases in situation where clients will offer more money for unprotected sex; in most cases, the women will habitually agree. Numerous studies found that African women’s survival strategies were largely dependent on the exchange of sexual favors (Turshen). In some countries such as Mozambique and Malawis, evidence suggests that war and poverty have a gender-specific effect; many men who have died during the war leave their wives behind to head the households. Many have lost most of their wealth and/or primary source of income (i.e. husbands) and find themselves unable to provide for the households (which usually includes children, husband’s parents, unemployed brother…) and thus, participate in the growing economy of prostitution in order to create much needed income.
In Western cultures, the prevention of AIDS infection has been more effective due to various factors: individuals are more educated and literate, people have more knowledge, better access to health and economic resources, better employment, a higher standard of living, and so forth. In addition, Western culture is predicated on a model of equalitarian relations where women have as much, if not, equal rights as their male counterparts. Decades ago, it was the man who took care of ‘protecting’ both himself and his partner in terms of contraceptive methods and disease prevention. In modern times, women now take care of these concerns; it is no longer uncommon for Western women to purchase condoms and demand that their partners use them otherwise forgo sexual relations. In Africa, this is not the case for women; the weight of customs makes it difficult and almost impossible for many African women to insist that their boyfriends or husbands use them. African women have little bodily autonomy. In fact, African women have little autonomy at all since the majority of them are greatly dependent on their husbands, fathers, brothers or other male counterpart for financial subsistence and survival.
There are a number of cultural practices that have aided in the proliferating spread of AIDS. In some areas, men are bounded by kinship obligations to marry and provide for their deceased brother’s widow. If the man’s death was caused by AIDS, the extension of sexual relations from his widow to his brother who in turn also engage in sexual relations with his own wife, will pass the virus from one infected person to the next.
Other cultural practices include male circumcisions with unsterilised razors and blades and to rites of male passage and bonding where ritual scars are cuts on people’s cheeks. In recent years, there has been an increase in child rape in South Africa attributed to the myth that a man can rid himself of HIV by sleeping with a virgin.
SUBORDINATE POSITIONS OF WOMEN
Sexism kills, just as surely as--and combined with--racism. In Africa, traditional oppression of women has meshed with new, profit-driven forms of oppression. In southern Africa, married women often don't dare ask their husbands to wear condoms, and are pressured by relatives to stay unprotected for maximum fertility. Husbands are expected to have many sex partners while their wives are expected to be monogamous. This subordinate position of African women is ruled by the primary fact that most African women are dependent on their husbands to provide financial support for them; African women are bounded to this type of relationship as long as she continues to depend on her husband’s economic support. African women are forced to endure the polygamous relationship of her husband so long as they require his financial contribution (Turshen). This economic dependence compounds women’s dependency on men and influence women’s ability to request or negotiate safer sexual practices (Bujra & Baylies).
Women’s vulnerability to HIV and their sexual and reproductive health status are centrally related to life within the context of a patriarchal society. The dominance of men pervades every aspect of African women’s lives: family, society, religion, the law and institutions all negatively affect women’s ability to be assertive and protect herself. Most women in African communities accept that their husbands or partners have other sexual partners, and because of a lack of education and skills women have been forced to become and remain “sexual slaves” to their men.
Another factor that facilitated the spread of AIDS is Africa’s endless wars and political uprisings. Soldiers are regularly employed in large part due to the continual political wars and as such, enjoy regular pay allowing them greater opportunity to buy sex. Wars – with its inevitable underpinnings of violence – carries acts of violence, with rape being a common occurrence. Lieutenant General John Koech, deputy chief of the Kenyan general staff declared that “between 50-60% of beds at the Forces memorial Hospital in Nairobi were now occupied by AIDS/HIV sufferers.” (BBC News) In 2000, the civil war in the democratic republic of Congo involved at least 14 separate armies and rebel factions of which almost half were estimated to be HIV-positive. The devastation that these wars produce are double-edged; deaths and rapes are a highly-visible source of devastation but not so visible nor evident, is the propagation of the virus from the HIV-infected soldiers to their unwilling recipients.
The lack of employment opportunities affect both men and women in Africa; while women prostitute themselves to supplement their livelihood, African men are forced to leave their homes and families for an inordinate amount of time and travel far to work in gold mines or as truck drivers. Such prolonged displacements tend to destabilize sexual relationships and helps spread the virus; many miners are separated by their wives for extended periods of time and may sleep with prostitutes to alleviate their sense of loneliness, for companionship or simply, for physical comfort (Crush & James). African mineworkers lead isolated, alienated and often violent lives. They are cut off from the broader society and their families working in an industry that demands a lot from them but yet give back so little (Crush & Williams). The life of the migrant mineworker is frequently an abrasive one in which the stresses of a dangerous and taxing job are exacerbated by the alienation of living away from home and family. These strains have a negative effect on the health of the migrant worker; several studies have revealed a positive correlation between psychological strains, social strains, and job stress. Other health outcomes produced by theses various stressors include: high blood pressure, diabetes, cardiovascular diseases, and the development of peptic ulceration.
Apart from the stresses of underground mining (i.e. tough working conditions – combination of excessive heat, noise, humidity that causes discomfort, anxiety and fear) and of labour and human relations (i.e. lack of respect from seniors, little or no prospect of promotion, threat of retrenchment, boredom, sense of exploitation, unfair compensation), mineworkers have the added experience of social stress. The industry of mining often appeals to migrants who have no schooling background and thus represent one of the few employment opportunities open to them. In addition, in African countries, the issue of kinship relations place a great financial burden on the migrant miner to provide monetary support to not only his immediate family (i.e. wife and children) but also other members of the household (e.g. his parents, an unmarried sister, an unemployed brother and their children).
With the removal of influx control laws, thousands of African men and families have moved away from the impoverishment of rural areas to seek a better life in and near the urban centres; the bitter reality for many Africans is that there is no better life because too few jobs existed. In addition, the government’s policy adoption of a free market approach to housing translated to an abolishment of state-owned housing which in turn, meant that people fleeing rural poverty had no housing available to them.
The result is an emergence of huge squatter communities throughout the country marked by excessive overcrowding, a lack of sanitation, poor nutrition and hunger resulting in a high level of disease outbreaks. Migrant labour and family separation, combined with high levels of background infections have facilitated the transmission and progression of HIV. A study of HIV in KwaZulu/Natal in 1990 revealed that among people within the 15-44 year age group, those who were most mobile (defined as having moved once in the previous year) had nearly three times the incidence of HIV infection compared with their more stable counterparts.
Current AIDS awareness and prevention campaigns in Africa target men and women with messages of safer-sex – such as the use of condoms, monogamy, non-penetrative sex, reduction in number of partners, celibacy, and treatment of STDs - seldom, are successful. An important reason attributable to the failure of such AIDS prevention campaigns is that such campaigns are predicated on the assumption that all is equal between partners in sexual interactions but rarely it this the case.
Cultural explanations and perceptions of illness, disease and well-being – as understood by local communities – must also be factored in. Both are crucial in the sense that individuals’ views, attitudes and socio-economic reality will determine their behaviors in terms of a model of preventative health as opposed to a simplistic health model of treatment and compliance. In regards to AIDS, a model of preventative health is required to ensure that the disease be contained and to avoid a historical repeat of an epidemic population wipeout as that of the Bubonic Plague which killed over 25 million people in Europe within five years only. A health model of treatment and compliance should not be the focus and goal regarding AIDS intervention in Africa insofar that there exist no present vaccine and cure for the virus. A model of health treatment is ineffective, unproductive and without medical rationale if it discounts socio-economic factors such as poverty and structural and gender inequalities.
If interventions around are to be effective, they must address the factors which drive the epidemic. Such factors are deep-seated and intransigent, embedded in the very political, cultural and economic context which define the behavioral responses towards such intervention programmes.
Baylies, Carolyn and Janet M. Jujra. 1999. “ Solidarity and Stress: Gender and Local Mobilization in Tanzania and Zambia.” In Families and Communities Responding to AIDS, ed. Aggleton, Peter, Graham Hart and Peter Davies, eds. 35-52. New York: UCL Press.
Chapman, Rachel, Julie Cliff and Rosa Marlene Manjate. 2000. “ Lovers, Hookers, and Wives: Unbraiding the Social Contradictions of Urban Mozambican Women’s Sexual and Economic Lives.” In African Women’s Health, ed. Meredeth, Turshen, 49-68. Trenton: Africa World’s Press, Inc.
Crush, Jonathon and James, Wilmont, eds. 1995. Crossing Boundaries: Mine Migrancy In A Democratic South Africa. Ottawa: International development Research Centre.
Guest, Emma. 2003. Children of AIDS: Africa’s Orphan Crisis. London: Pluto Press.
Kuate-Defo, Barthélémy. 1998. Sexuality and Reproductive Health During Adolescence in Africa. Ottawa: University of Ottawa Press.
Nguyen, Vinh-Kim. “Ties That Might Heal: testimonials, Solidarity and Antiretrovirals in West Africa.” An Introduction To Medical Anthropology: Selected Readings, ed. Sandra Hyde, 403-437.
Williams, Olufemi A. 1991. AIDS: An African Perspective. Boca Raton: CRC Press.