If We Don’t Pay, They Will...
by: R.B.

R.B.
Human Geography
Fall 2006
December 10, 2006

If We Don’t Pay, They Will:
The HIV/AIDS Crisis in Sub-Saharan
Africa and the Burden of the Developed World

     HIV/AIDS is a complicated disease that has either broken or bent the theoretical rules that had in the past been set forth by epidemiological dogma. HIV is unique among infectious disease agents not in that it merely evades host defenses, but rather that it attacks them mercilessly. Nobody is immune to HIV, and people from all walks of life—rich and poor, young and old—have been infected with the insidious virus (Ghani and Boily 2003, 59). Efforts to control and prevent HIV/AIDS are worldwide, but so far, the majority of the successes in these programs have been in developed nations. The epidemic is most severe in sub-Saharan Africa, where not only is the disease taking a toll on family life, but is also unraveling the fragile fabric of their cultural and political infrastructures. Despite the control and prevention efforts in these countries, HIV/AIDS still spreads like wildfire across the savannah. The harsh truth is that these efforts cost a lot of money—in most cases, more money than the affected countries can afford without cutting other essential government services. The burden of helping to fund these programs with noble, albeit lofty, goals falls on the developed world, which must help in bigger and better ways than ever before.
     Sub-Saharan Africa has long borne the vast majority of HIV/AIDS cases worldwide. An AIDS vulnerability study published in 1992 by the Global AIDS Policy Coalition showed that out of 57 countries at high societal vulnerability of contracting HIV/AIDS, 34 of these countries were located in sub-Saharan Africa (Mann, Tarantola, and Netter 1992, 601). (In contrast, most post-industrial nations were classified as “low vulnerability” by the same study.) Current statistics by UNAIDS and the WHO have shown that 63% of all HIV-infected individuals in the world live in sub-Saharan Africa. In addition, while the prevalence of HIV/AIDS has declined in sub-Saharan Africa between 2004 and 2006 from 6.0% to 5.9%, this meager decrease in prevalence is unlikely to weaken the impact of HIV/AIDS on this region (UNAIDS/WHO 2006a, 3). The regional impact of HIV/AIDS is underscored by the number of deaths from the disease in sub-Saharan Africa: an astonishing (and frightening) 72% of all HIV/AIDS deaths globally take place there (10). The fact that the percentage of global HIV/AIDS mortality is larger than the percentage of global prevalence in sub-Saharan Africa should give us pause for thought. While it is no small feat that in some countries of sub-Saharan Africa there is a decline in HIV/AIDS prevalence, it speaks volumes that the bulk of the worldwide deaths from the disease occur in these same countries. This may hint at a deficiency in the treatment regimen of existing HIV/AIDS cases, which is not too surprising considering the wealth of the majority of these nations in sub-Saharan Africa. The prevalence of the disease is also a cause for concern. These two factors definitively establish the need for more effective HIV/AIDS control and prevention programs to be implemented and sustained.
     Strategies for combating HIV/AIDS fall into two major categories: control of existing cases, and prevention of future cases. Control strategies involve antiretroviral therapy and vaccine development. Antiretroviral therapy has been instrumental at improving the quality of life of HIV/AIDS patients by slowing the immune system deterioration caused by the disease, at least for those who can afford such a luxury. UNAIDS and the WHO have been pushing for increased use of antiretroviral therapy as a means of increasing the lifespan of those infected with HIV/AIDS—an initiative which has, as of 2005, been moderately successful in bringing antiretroviral therapy to 1.3 million people worldwide (UNAIDS/WHO 2006b, 4). However, this only represents a mere fraction of total HIV/AIDS cases worldwide. The need for a vaccine against HIV can be felt worldwide, especially in developing nations (Ghani and Boily 2003, 72). However, vaccine development is expensive and made complicated by the genetic diversity of HIV; it is not clear whether a vaccine against the clade of HIV prevalent in one part of the world would be cross-reactive against a clade in a different part of the world (Meade and Earickson 2000, 288). Control strategies are thus limited in execution, if not in scope. As Denis P. Burkett (1981) puts it:

Curative or therapeutic medicine can be likened to the stationing of an ambulance at the foot of a cliff to rescue casualties occasioned by people falling over the edge, and conveying them to efficient, but expensive, medical establishments. This service is necessary, but it is surely better to erect a fence round the top of the cliff. (149)

The fence to which he refers is, of course, meant to prevent the tragedy from occurring in the first place. Thus, focus on the establishment of preventive frameworks and strategies should occur in order to minimize risk of HIV/AIDS contraction in the future.
     HIV/AIDS prevention strategies are thus of paramount importance for the control effort. While these strategies are bound to be expensive—perhaps even more expensive than control strategies—they will help to prevent new cases of HIV/AIDS in the future, and thus are representative of a large investment in the future: if the transmission rate can be slowed significantly in the near future, that will reduce the need for therapeutic control in the long-term, which in turn translates into savings of the money that would have been spent on therapeutics. Slutkin (1992) states that “in most developing country programmes, emphasis must be made on strategies and interventions for preventing HIV infection by sexual transmission,” and, furthermore, that “the care and support of persons with HIV infection with AIDS and their families is also very important, but a major challenge of the 1990s will be to keep as much programme attention as possible on the prevention agenda” (5). Prevention strategies include public education about HIV/AIDS as a disease itself and about behavior changes that will limit the spread of the disease such as safer sex practices, condom usage, early HIV/AIDS diagnosis, et cetera (Ghani and Boily 2003, 71-72; Slutkin 1992, 5). At the beginning of the epidemic, public education about AIDS was “energetic, extensive, and often expensive” (Wellings 1992, 287), which would have had a more significant impact if HIV/AIDS were an immunologically “normal” disease. However, more recently, AIDS is viewed as a chronic, as opposed to an acute, problem which requires sustained prevention efforts to combat the disease effectively, especially in the absence of a vaccine or cure (287). Countries that have had the most success with sustained prevention efforts to keep pace with the spread of HIV/AIDS have certain advantages over other countries where the efforts initially trailed off after the initial outbreak of the disease. These advantages include an active mass media, an informed and unified (as to advice on how the disease should be prevented) collection of interest groups, and a more centralized and concerted effort to provide one definitive source of information and resources regarding combating HIV/AIDS (289; Shannon, Pyle, and Bashshur 1991, 60). Of course, all of these things are more likely to be found in Western, post-industrial countries with a high degree of political stability. In addition to lacking these advantages, many efforts towards public education are rebuffed by already-established cultural institutions, e.g. the Church (Gould 1993, 56). Meeting these challenges head on will be a difficult and expensive task.
     Compounding these challenges is the socially-destructive impact of HIV/AIDS on the demography and economic development of sub-Saharan African nations, which are massively threatening, especially in comparison to the developed nations in the world (Prewitt 1988, cited in Shannon, Pyle, and Bashshur 1991, 59). Life expectancy at birth is declining in sub-Saharan Africa (Gregson 2003, 90), and for every 10 adult males that have HIV/AIDS in that region, 14 adult females have it (UNAIDS/WHO 2006a, 5). Females are the primary child-rearers in sub-Saharan Africa, and many orphans—or worse, many childhood HIV/AIDS patients due to mother-to-child transmission—are created in this environment (Gregson 2003, 91). Bess Keller reports that “the family is often the only social safety net that can keep children in school”; this puts an enormous strain on the education system as an alternative child-rearing system as well as a vehicle for HIV/AIDS education, especially since the “crisis of HIV/AIDS…has more to do with people in schools than physicians in hospitals” (Keller 2005, 115-116). However, school quality has been declining in sub-Saharan Africa due to economic constraints (115). Where should the money to revitalize the educational system, and to revamp the HIV/AIDS prevention strategies in sub-Saharan Africa?
     While this money should be completely domestically generated, the reality of the situation is that many of the countries most severely afflicted with widespread HIV/AIDS prevalence and mortality are economically ill-equipped to dedicate all of the necessary funds for prevention programs. In fact, according to 1991 statistics, five of the countries in sub-Saharan Africa are among the 42 poorest nations in the world (Shannon, Pyle, and Bashshur 1991, 66), with the vast majority of the rest being definitively third-world. According to UNAIDS and the WHO, the amount of funding used for the control and prevention of HIV/AIDS globally increased annually on average US$1.7 billion between 2001 and 2004, and reached US$8.3 billion in 2005 (UNAIDS/WHO 2006b, 4). Moreover, sub-Saharan African countries (and to a lesser extent, other countries) showed significantly increased domestic public funding spent on HIV/AIDS programs, with US$2.5 billion of the US$8.3 billion spent on HIV/AIDS programs being generated domestically (4). Despite this increase, HIV/AIDS programs are still under-funded and HIV/AIDS still continues to spread at a steady pace. The need to sustain these programs over the long run, combined with the steadily increasing prevalence rates, underscore the dire need for more funding globally, but also with respect to sub-Saharan Africa.
     The Rev. Gary Gunderson—the director of the interfaith health program at Emory University—has said, “The response already made to AIDS [by Africans] is quite unprecedented. What has not changed is our response [in the developed world]: We’re acting as we’ve always acted, which is with relatively low-grade charity” (Keller 2005, 117). This is a call to arms for the developed world to fight HIV/AIDS with its vast and extensive financial armory; it is through our aid that ultimately the spread of HIV/AIDS will slow to a more manageable pace, and from there, sub-Saharan countries can take over. This is more than simply a humanitarian effort, but also an effort that will ultimately help these African countries develop economically. In an increasingly globalized world, wealthy nations cannot just stand idly by while other nations buckle under the stress of HIV/AIDS, especially when wealthy nations are ultimately dependent on other nations for their livelihoods. Thinking about HIV/AIDS in this altruistic fashion may seem selfish, even anti-humanitarian to an extent, but these are terms that policy-makers, diplomats, and economists—the political elite—can understand. If we think about it in this way, maybe there will be more of a push to help sub-Saharan countries in resolving their plight. It is a win-win situation. After all, if we don’t pay for it, they will—with their lives.


Works Cited

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