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AFRO-NETS> The Nation: AIDS and Poverty in Africa

The Nation: AIDS and Poverty in Africa

The Nation; May 21, 2001; Pg. 22

AIDS and Poverty in Africa: Prevention and treatment require a focus 
on overall health and development

By Eileen Stillwaggon

The decision by pharmaceutical companies to withdraw their patent 
suit in South Africa removed an important obstacle to access to anti-
retroviral treatment of HIV/AIDS in the developing world. Drug copi-
ers, such as Cipla Ltd. of India, have offered to provide a three-
drug combination for about $ 350 instead of the $ 10,000 to $ 15,000 
paid in the United States for one year's treatment at patent-
protected prices. Even at Cipla's price, however, treatment of 
HIV/AIDS raises serious questions of feasibility for very poor coun-

But treatment of people with HIV/AIDS is not only the compassionate 
solution, it is also cost-effective. The cost of not treating AIDS 
includes the burden of opportunistic infections in, and early death 
of, 25-35 percent of the work force in the next decade. The addi-
tional impact on the economy and society of a generation of 6-year-
olds raised by 11-year-olds cannot be adequately addressed in macro-
economic models of the cost of HIV/AIDS. Access to treatment is a ne-
cessity for Africa. 

What might be overlooked, however, as life-sustaining drugs become 
available, is the fact that prevention is still by far the more com-
passionate and more cost-effective answer. Prevention does not re-
place treatment, but it does reduce the number of people whose lives 
will depend on expensive drugs with significant side effects. The key 
to a good prevention program is understanding the dynamics of disease 
transmission. But most prevention programs have been extremely narrow 
in scope. International AIDS policy derives from an erroneous precon-
ception that the high rate of HIV transmission in Africa is primarily 
an issue of sexual behavior that can be addressed by behavior modifi-
cation. That policy has met with some success in the United States 
and other rich countries. In Africa and in similarly impoverished 
populations, however, biological factors that result from poverty 
play a determining role in the high rates of HIV transmission. Fail-
ure to recognize those biological factors and to integrate them into 
a model of transmission for poor populations has led to prevention 
strategies that have failed and to the perpetuation of racial stereo-

Sexual behavior is obviously an important factor in the transmission 
of sexually transmitted diseases. Education programs have been very 
successful in Uganda in reducing incidence (new cases) in recent 
years. But sexual behavior alone cannot explain HIV prevalence as 
high as 25 percent of the adult population in some African countries 
and less than 1 percent in the United States. The presumption that 
high rates of partner change explain the very high rates of HIV is 
generally not explicit. But it is the implicit assumption behind an 
AIDS-prevention policy that consists of behavior modification and 
condom provision, with some recent attention to sexually transmitted 
diseases (STDs). There has been very little analysis of the myriad 
factors that influence HIV transmission in a profoundly poor region. 

The question is straightforward: How is AIDS different in Africa? In-
stead of being addressed with mainstream methods of scientific in-
quiry, the AIDS-in-Africa debate was hijacked in the 1980s by an ex-
treme behavioralist explanation that transformed the question into: 
How are Africans different? So ingrained in Western thought is the 
notion of racial difference that the distortion of the question went 
unnoticed, and the behavioral approach has dominated both research 
and policy for more than a decade. 

The justification for a behavioral explanation of African AIDS was 
found not in careful empirical studies but in hypothetical arguments 
based on a powerful racial metaphor that portrays Africans as a spe-
cial case. The literature that formed the basis of AIDS policy is 
characterized by sweeping generalizations about an imagined pan-
African culture of sex as a commodity and fertility as a duty to 
one's ancestors. Unlike most scientific and social science work, the 
literature on African sexuality relies on suggestive language, dou-
ble-entendre and innuendo. It also resembles a pyramid scheme, since 
almost all works cite the same few anthropological studies of the 
1980s that designate Africa as the "domain of Homo Ancestralis," a 
hypothetical early stage of human development in which sexual rela-
tions were unencumbered by Eurasian patriarchy. The social science 
literature on "African sexuality" exhibits much lower standards of 
proof than would be required for publications on European or North 
American subjects. The momentum of Western stereotypes clothed in so-
cial science jargon compensates for the empirical weaknesses of the 
works. The use of species terminology in the designation of Africans 
as Homo Ancestralis is a metaphor that inescapably carries the intel-
lectual baggage of nineteenth-century racial science, which main-
tained that Africans were a genetically distinct species from Europe-
ans. The ease with which the image of hypersexualized Africans was 
incorporated into AIDS policy indicates the persistent force of this 
nineteenth-century racial view. The emphasis on racial difference is 
evident in the terminology used to describe multipartnered sex in Af-
rica and in the West. Africans are described as being polygamous, 
which lends an exotic air and marks Africans as the social "other," 
whereas Westerners simply have multiple partners. 

By the almost exclusive emphasis on behavior modification, AIDS re-
search and policy for sub-Saharan Africa implicitly incorporate the 
assumption that behavior explains the differences in HIV prevalence 
between African countries and rich countries without examining its 
implausible conclusions. How much sex are we talking about that would 
produce, in the absence of other factors, prevalence of HIV in Bot-
swana that is over fifty times that of the United States, eighty 
times that of France and 1,000 times that of Cuba? It was not until 
1999 that the central tenet was tested; a study published by UNAIDS 
showed no correlation between rates of sexual behavior and prevalence 
of HIV. 

There are significant levels of unprotected multipartnered sex in the 
United States and Europe, as evidenced by serious epidemics of other 
STDs, such as herpes-2 and chlamydia. In spite of the level of unpro-
tected sex, there has not been a heterosexual epidemic of AIDS in the 
rich countries. Among otherwise healthy, well-nourished people in in-
dustrialized countries, heterosexual transmission of HIV is rela-
tively rare--about one in 1,000 contacts between an HIV-positive fe-
male and an HIV-negative male, and about one in 300 contacts between 
an HIV-positive male and an HIV-negative female. 

Since the African epidemic is heterosexual, it is clearly different 
from that of the West, a fact that was noticed by South African 
President Thabo Mbeki. He had the temerity, as some Western scien-
tists viewed it, to ask how conditions of poverty in Africa affect 
the development of HIV/AIDS. It was a very conventional epidemiologi-
cal question, well within the bounds of standard research. His ques-
tion was treated, however, as heresy by at least a vocal minority of 
mainstream scientists, who seemed to regard any inquiry as beyond his 
prerogative. Spurned by the mainstream, Mbeki turned to scientists on 
the fringe of AIDS research who were eager for an audience. South Af-
rica lost valuable time in addressing the AIDS crisis as the govern-
ment vacillated and explored dead ends. 

Mbeki's question, however -- how does poverty influence AIDS in Af-
rica? -- is neither inappropriate nor unscientific. The environment 
in which any infection is transmitted in poor countries is very dif-
ferent from that of the United States and Europe and is strongly in-
fluenced by poverty, malnutrition, bad water and poor access to pre-
ventive and curative care. The standard epidemiological approach to 
understanding disease is characterized by Louis Pasteur's comment: 
"The microbe is nothing, the terrain everything." In other words, 
pre-existing health conditions play a key role in susceptibility to 
disease. We should expect HIV/AIDS to develop differently in rich and 
poor countries, just as do tuberculosis, pneumonia, measles and 
nearly all other infectious diseases. 

Ironically, mainstream biological science has the answers to Mbeki's 
questions, but the specialized and conservative nature of biomedical 
research inhibits any one scientist from coming forth with the solu-
tion, or perhaps even acknowledging it. Most social science has 
failed to incorporate biomedical data into its analysis, in spite of 
the obvious fact that HIV and AIDS are biological conditions. What 
has been missing is an interdisciplinary approach that incorporates 
biological and social data into an analysis of the social context of 
HIV disease in Africa. 

Sex tends to be distracting, for researchers as much as for the gen-
eral public. The sexual transmission of HIV diverted attention from 
the broader epidemiological environment in which a heterosexual epi-
demic developed in sub-Saharan Africa. Both rich and poor countries 
are characterized by high rates of unprotected multipartnered sexual 
activity. Populations in poverty are also characterized by malnutri-
tion, parasite infection and lack of access to medical care and anti-
biotics for bacterial STDs, which are important co-factors for trans-
mission of HIV. To acknowledge the synergistic relationship among 
malnutrition, parasite infestation and infectious disease is not to 
say that AIDS itself is a nutritional disease. Nor does it deny that 
HIV is sexually transmitted in Africa and causes AIDS. It merely sub-
jects STDs, including HIV/AIDS, to the same methodology employed in 
the study of other infectious diseases, however transmitted. 

Even a brief survey of economic conditions in sub-Saharan Africa in 
the years in which the AIDS epidemic began reveals an extremely 
compromised health environment. From 1970 to 1997, sub-Saharan Africa 
was the only world region to experience a decrease in food produc-
tion, calorie supply and protein supply per capita. In ten countries 
(including Zimbabwe, Kenya, Uganda, Zambia and Malawi), protein sup-
ply fell by more than 15 percent. Eighteen of the nineteen famines 
worldwide from 1975 to 1998 were in Africa, and 30 percent of the to-
tal population of the region was malnourished. Refugees from internal 
and external conflicts crowded into unsanitary camps where food ra-
tions were deficient in necessary nutrients. Sub-Saharan Africa is 
not the only region in which malnutrition is associated with 
HIV/AIDS. Among all low- and middle-income countries, HIV prevalence 
is strongly correlated with falling protein consumption, falling 
calorie consumption, unequal distribution of national income and, to 
a lesser extent, labor migration. Almost all of sub-Saharan Africa is 
tropical, with a very high prevalence of parasite infection, includ-
ing malaria, schistosomiasis and various intestinal and skin ail-

There is a large body of mainstream biomedical literature that docu-
ments the mechanisms by which malnutrition and parasite infection un-
dermine the body's specific and non-specific immune response. Pro-
tein-energy malnutrition (general calorie deficit) and specific mi-
cronutrient deficiencies, such as vitamin-A deficiency, weaken every 
part of the body's immune system, including the skin and mucous mem-
branes, which are particularly important in protecting from STDs, in-
cluding HIV. Parasite infestation plays a dual role in suppressing 
immune response. It aggravates malnutrition by robbing the body of 
essential nutrients and increasing calorie demand. Moreover, the 
presence of parasites chronically triggers the immune system, impair-
ing its ability to fight infection from other pathogens. 

Poverty not only creates the biological conditions for greater sus-
ceptibility to infectious diseases, it also limits the options for 
treating disease. Infection with other STDs is an important co-factor 
for transmission of HIV; genital ulcer diseases in particular, such 
as chancroid, provide an entry point for HIV. Such painful bacterial 
STDs are relatively uncommon in rich countries because of the avail-
ability of antibiotics. In Africa, South Asia and Latin America, how-
ever, even when poor people have access to healthcare, the clinics 
may have no antibiotics to treat bacterial STDs that act as co-
factors for AIDS. These are among the conditions we have to consider 
in poor countries, and they are standard variables in epidemiology. 

Treating African AIDS as a special case caused by a hypersexualized 
culture obviously reinforces racist stereotypes and pessimism over 
Africa's future. It also pushes AIDS policy to an almost exclusive 
reliance on behavior modification and condom use and away from gen-
eral health and nutrition, and it gives us little preparation for 
similar epidemics that are now incubating in South Asia and Latin 
America. Some parts of India already have substantial epidemics; one 
out of every nine HIV-positive people in the world is Indian. Nascent 
or concentrated epidemics throughout Latin America, in combination 
with deteriorating economic conditions, produce conditions as propi-
tious to HIV as those in Africa ten years ago. By 1997, after several 
years of high unemployment, the prevalence of HIV in Buenos Aires was 
already what it had been in Zambia ten years earlier. At least a 
quarter of Latin Americans and Caribbeans cannot obtain 80 percent of 
their minimum calorie requirement even if they were to spend their 
entire income on food, and almost half the population of the region 
lives in poverty. 

Social conditions in Latin America aggravate the population's vulner-
ability to HIV/AIDS. As in Southern Africa, highly concentrated land 
ownership forces millions of workers to migrate for work, internally 
or internationally, increasing risk of HIV and other STDs through new 
sexual liaisons, including prostitution. Forty million children in 
Latin America live on the street; they eat from garbage cans, and 
many of them sell sex to survive. Sex tourism has shifted from Asia 
to the Americas, with children as the primary targets of an Internet-
based industry. Considering the extent of poverty and the immunologi-
cal effects of that deprivation, an AIDS epidemic of African magni-
tude is possible in parts of Latin America. Throughout the region, 
the preponderance of new cases has shifted from upper to lower income 
and from men to women and children. Based on the demographics of 
those recently infected, Latin American AIDS is already "African-

The policy implications of understanding the broader causes of the 
AIDS epidemic in Africa are reason for both optimism and pessimism. 
Reducing HIV transmission requires health education, availability of 
condoms and also a broad assault on malnutrition, diarrheal diseases 
and parasitic diseases, including malaria and schistosomiasis. To 
treat those already infected will require upgrading the health ser-
vices infrastructure and expanding health education. The steps that 
are necessary for both prevention and treatment of HIV/AIDS are the 
same as for addressing the other health and development needs of poor 

Identifying those needs is relatively easy, but they have not been 
adequately addressed in the past--not by the governments of poor 
countries or by their bilateral and multilateral aid partners. Even 
that dismal acknowledgment, however, should be balanced by a recogni-
tion of how relatively inexpensive some solutions are. Vitamin A sup-
plementation sufficient to prevent blindness and other deficiency 
diseases for one person for an entire year costs less than one con-
dom. A year's supplementation with vitamin A, iron and iodine costs 
less than ten condoms. To fortify the food supply with iron to pre-
vent anemia and increase disease resistance and work capacity costs 
about 20 cents per person per year. Attending to broader health con-
cerns is not as expensive, or as hopeless, as it might seem. There 
are also serious weaknesses in a prevention plan that relies exclu-
sively on provision of condoms, even with health education. It does 
not address women's lack of power in sexual relationships, nor the 
irrelevance of condoms to most people after a few beers. Strengthen-
ing immune systems will help to protect people from some of the con-
sequences of unsafe sex and from other infectious diseases as well. 
What it will take to prevent HIV transmission and to treat people 
with HIV/AIDS is no less, but no more, than what has been needed all 
along in sub-Saharan Africa and other poor regions. It would have 
been cheaper to provide the infrastructure, the nutrition, the educa-
tion and the medicines before HIV/AIDS, but it is still a bargain 
calculated in both compassionate and cost-effective terms. 

Eileen Stillwaggon, who has worked in Tanzania, Zimbabwe, Argentina 
and Ecuador, teaches economics at Gettysburg College.

She is the author of Stunted Lives, Stagnant Economies: Poverty, Dis-
ease, and Underdevelopment (Rutgers) and several recent articles on 
the biology and social context of HIV/AIDS in Africa and Latin Amer-

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