Of the many diseases and epidemics that dot human history, none have been as controversial as AIDS, and few have been as deadly. In the two decades since the HIV virus was first identified, AIDS has progressed from a disease of homosexual men and intravenous drug users that many people regarded as unimportant to one of the biggest global health concerns of the 21st century. “HIV/AIDS has succeeded in joining people around the world in a common consciousness of its threats and implications” (Barnett & Whiteside, 2003:4). This common consciousness has lead to widespread attention to and support for prevention and treatment initiatives. Through intensive education programs and public health campaigns, many developed nations have managed to curtail the spread of AIDS, but fear and cultural norms continue to fuel the rampant increase in AIDS infections in many developing countries, particularly in southern Africa.
No nation or population has been isolated from the effects of the global AIDS epidemic. AIDS now affects every continent except Antarctica, and millions of people continue to be infected each year. As of December 2004, more than 39 million people worldwide are currently living with HIV or AIDS, an estimated 2.2 million of them under the age of 15 (UNAIDS 2004). AIDS claimed 3.1 million lives in 2004, adding to the estimated death toll of 20 million victims worldwide since AIDS first appeared in 1981(Avert 2005). While the main methods of AIDS transmission were once male-to-male sexual contact and sharing needles, most new cases today are contracted through heterosexual sex, and women account for a growing number of cases. The rate of infection among women is increasing, particularly among older teens and young adults, and women currently account for almost half of all people living with AIDS. Transmission from mother to child during pregnancy, childbirth or breastfeeding is responsible for more than 600,000 new infections annually, a number than continues to grow as the number of women carrying the AIDS virus grows.
The effects this epidemic has on children around the world are as varied as they are tragic. Not only are millions of children all over the world dealing with HIV infections themselves, millions more are orphaned as AIDS claims one or both parents. At the end of 2003, the estimated number of children orphaned by AIDS reached 15 million. The majority of these children live in sub-Saharan Africa, where in some nations the majority of children have lost at least one parent to AIDS, but the problem is not confined to a single continent. In India, 2 million children have been orphaned, the highest total of any single nation. These orphans are made more vulnerable to AIDS infection themselves because of the poverty and powerlessness that comes from being left to fend for themselves in an impoverished nation. Young girls are at especially high risk, because many will turn to the sex trade as a way to earn a living or fall prey to older, more experienced men looking for a part-time companion.
Education has suffered in many regions as AIDS and HIV related illnesses have claimed high numbers of schoolteachers, and children, especially girls, are frequently forced to drop out of school to care for ailing parents or siblings. These effects combine to create a vicious cycle of ignorance that leaves an entire generation of already vulnerable children at an even more dramatically elevated risk by denying them the one thing that has proved effective in controlling the spread of AIDS: access to complete and accurate information about the disease. In some African nations, many people still have not heard of AIDS, even as it is killing their neighbors and family members. Misinformation about AIDS transmission and myths about cures are prevalent in many cultures, which only exacerbates the crisis. In nations that have adopted aggressive educational efforts, the results are universally positive, in developing countries as well as wealthier Western nations. Through an aggressive campaign of public education in the media and the schools and initiatives to encourage condom use among the nation’s large commercial sex industry, Thailand has managed to drastically reduce the rate of AIDS transmission (Kanabus & Fredriksson), and some African nations have realized similar modest successes.
The southern part of the African continent has been most dramatically affected by the AIDS epidemic. Despite civil wars and famines, AIDS remains the leading cause of death on a continent that contains only 10% of the world’s population, but 90% of all AIDS infected children (Maxwell). Zimbabwe is one of the nations dealing with the worst of this epidemic, which has touched every aspect of their society and led to a 40% decrease in life expectancy over the past decade.
The combination of economic, social and political factors that contribute to the AIDS crisis in much of Africa are exemplified by the current conditions in Zimbabwe. A depressed, agrarian economy that relies heavily upon migrant workers and a large, active military have contributed to a thriving and lucrative commercial sex industry, as men who are away from their wives for long periods of time seek intimacy elsewhere. This widespread prostitution combined with a social hierarchy that restricts the ability of women to insist upon condom use has led to high rates of infection not only among sex workers and the men who patronize them, but also among the wives of these men. Almost one quarter of the adult population of Zimbabwe is HIV positive, and the infection rate among sex workers in the city of Harare was an alarming 86%, according to a 1995 study (Avert). Poverty, both a cause and a symptom of the AIDS epidemic, drives many poor girls and women into prostitution to support themselves. “The women I work with say they’d rather die of AIDS tomorrow than die of hunger today,” said Ann Waweru, Director of Voluntary Women’s Rehabilitation Centre in Kenya (Avert 2005). Widespread poverty also pulls many children out of schools and into whatever work they can find in order to help support their family, continuing a pattern of illiteracy that makes providing information about AIDS prevention to the public difficult. This need to leave school is often an immediate result of the loss of one or both parents to AIDS. And unlike most epidemics that kill the young, old, and sickly, AIDS claims most of its victims from among otherwise healthy adults in their prime wage earning years, further increasing the poverty of the nation. The country’s gross domestic product has declined for seven consecutive years, due to a combination of factors, including the dwindling productivity of an AIDS ravaged population. The failing economy and lack of opportunity has in turn led to the emigration of many skilled professionals, increasing already widespread shortages of the doctors, nurses and teachers desperately needed to help combat the AIDS crisis.
The social climate in Zimbabwe also contributes to ignorance about how AIDS is spread. Discussions about sexuality are taboo, particularly for girls, and women have little authority in their sexual relationships, which makes it impossible for those who do know how to protect themselves to insist upon using condoms. One study showed that 1 in 5 Zimbabwean girls did not know how to protect against AIDS (Smith, Furno & Stanton 2000). Many young women fall prey to “sugar daddies” who pay for food, clothing and education in return for sexual favors, and others are raped by men who believe the folklore that sex with a virgin will cure the disease. Misinformation about how the disease is contracted is rampant; the belief a person infected with HIV would exhibit visible symptoms is common, and abstinence is not widely associated with AIDS prevention (Bankole, Singh, Woog & Wulf 2004). In addition, a powerful stigma surrounds AIDS, based largely on misconceptions about how the disease is spread. This stigma discourages the people of Zimbabwe from getting tested and seeking what little treatment is available. Although it is traditional for extended family to take in orphaned children, AIDS orphans are often abandoned or left to their own devices either because of the fear that surrounds the AIDS virus or because the family is simply overwhelmed by all the distantly related orphans needing care, which has led to an explosion in orphanage populations, child-headed households and the number of children living on the streets.
Politics play a role in the AIDS crisis as well. As in much of Africa, the government of Zimbabwe failed to address AIDS at all in the early years of the epidemic. Controlled by a regime that is perceived as anti-Western and distrustful of outsiders, Zimbabwe has received little of the international aid that has provided some relief for other African nations. Allegations of government corruption have further hindered international aid efforts, as have government restrictions on the import of anti-HIV drugs (Avert 2005). Only about 3% of patients needing anti-retroviral medication in Zimbabwe are receiving them, and even basics such as clean syringes and antibiotics are frequently unavailable at the country’s clinics (Timberg 2005). Many international agencies are reluctant to donate money to relief efforts in a nation where the government cannot be trusted to ensure medication and other relief is distributed to the needy.
There are many international agencies dedicated to helping to deal with the AIDS crisis in Africa and around the world. AIDS is the only disease to have an entire United Nations agency devoted to its study, treatment and prevention. UNAIDS is an umbrella agency that operates in cooperation with the World Health Organization, UNICEF, the World Food Programme, the World Bank and other international organizations to coordinate AIDS relief efforts around the world. Other U.S. and international relief also take part in efforts to control the AIDS epidemic. Collectively and individually, these organizations provide assistance in the form of medical personnel, anti-retroviral drugs such as AZT, food, money and other supplies. Many of the more successful education and prevention campaigns have involved UNAIDS or other organizations working in conjunction with the governments of effected nations to create strategies to reach as many people as possible. Microsoft founder Bill Gates pledged $150 million from his philanthropic foundation to researching an AIDS vaccine and $50 million to an AIDS treatment program in Botswana, which is providing medication to thousands of AIDS infected patients. Pressure from international activist groups led to the availability of generic drugs at dramatically lower prices then their patented alternatives, and these less expensive drugs have greatly increased the number of patients able to receive treatment.
“To fight the plague on a global scale, we need a massive international campaign able to pressure political and economic power holders to take AIDS seriously and to sustain such commitment until the pandemic is brought under control” (Irwin & Miller 2002). The beginnings of this international campaign have come together in recent years, but much more is needed to overcome the many issues that complicate the AIDS crisis in Africa and other developing nations. Relief agencies are charged with walking a fine line between respecting native cultures and changing high-risk behaviors that are often intimately tied to that culture. To make a meaningful difference in the spread of the AIDS epidemic will take some cultural changes in how the people of these nations regard marriage, contraception and the rights of women. Prevention efforts must address many issues simultaneously. Encouraging and enabling poor children to stay in school and eliminating the school fees that are still levied in some areas, and therefore increasing literacy levels among at risk populations is a crucial step in facilitating the spread of information, because an illiterate populace will not receive the full benefit of educational campaigns. Teaching the risks inherent in traditional beliefs about polygamy and infidelity as being natural for men and making contraception an attractive alternative, as Botswana did with a series of suggestive condom advertisements, would begin to lessen the problem of traveling men bringing AIDS home to their wives, but developing new industries and lessening the number of workers living far from their families would provide a more permanent solution. The role of religious relief organizations is a topic that should be considered carefully; while some religious efforts are providing valuable assistance, others are spreading misinformation contradictory to the goals of other relief agencies and discouraging the use of potentially lifesaving condoms. Education itself is the most valuable prevention tool; expanding efforts to educate the population about AIDS transmission methods and enacting campaigns to secure more equitable rights for women who want to protect themselves and their children from this disease should be the focus of prevention efforts.
Treatment efforts face an entirely different set of challenges. Limited resources and the stigma of seeking treatment make the AIDS infected population in many countries difficult to reach. Education can reduce the stigma of AIDS somewhat, but for it to be addressed effectively, the message should come from within. Prominent African leaders, including Nelson Mandela and Zimbabwe’s president Robert Mugabe, have publicly announced that they have lost family member to the AIDS epidemic, in hopes of lessening the stigma that surrounds the disease. These efforts by recognized and respected members of Africa communities will likely do more to ease the stigma of AIDS than any outside efforts. Preventing mother to child transmission should be a primary focus of treatment efforts, because such transmission is highly preventable using relatively few resources. Implementing this would require increased outreach and testing programs targeted at women in the early stages of pregnancy. Testing services should be made accessible to as much of the population as possible, and those who test positive should have access to information and counseling on not spreading the disease further even in the absence of available medications, but providing these services would require more medical professionals than are currently available for the task. A recent proposal by the Institute of Medicine suggested forming a global health corps that would provide a modest salary or forgive student loans for professionals willing to work in areas facing health crises like the AIDS epidemic. Such a program would open up the option of working overseas to young doctors who otherwise could not afford it, establish a network of professionals that could oversee the use of relief resources independent of local governments, and provide much needed assistance to nations struggling with a shortage of native professionals. As any or all of these steps come into practice, though, relief agencies must remember that above all else, the goal of international assistance should be to encourage changes in society that create an atmosphere in which the people of Africa and other undeveloped nations are empowered to protect themselves against this deadly disease.
Tony Barnett & Allen Whiteside, 2003 AIDS in the 21st Century: Disease & Globalization
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