US Aid to AIDS in Africa Author(s): Meredeth Turshen Source: Review of African Political Economy, No. 55, Democracy, Civil Society and NGOs (Nov., 1992), pp. 95-101 Published by: Taylor & Francis, Ltd. Stable URL: https://www.jstor.org/stable/4006076 Accessed: 16-07-2019 15:58 UTC REFERENCES Linked references are available on JSTOR for this article: https://www.jstor.org/stable/4006076?seq=1&cid=pdf-reference#references_tab_contents You may need to log in to JSTOR to access the linked references. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at https://about.jstor.org/terms Taylor & Francis, Ltd. is collaborating with JSTOR to digitize, preserve and extend access to Review of African Political Economy This content downloaded from 128.6.218.72 on Tue, 16 Jul 2019 15:58:47 UTC All use subject to https://about.jstor.org/terms Briefing: AIDS in Africa 95 which like AIDS suppresses the imgrated farming. 'Self-reliance is the goal, integrated farming is the means, mune system, is one of the most lethal and simplicity must be the way of life.' diseases in tropical Africa; it is the most common reason for hospitalization and the most frequent cause of This refusal of the model. Is it a death of children under five years old. strategy that could inspire also the African governments report 80 million peasant associations of Senegal? Bibliographic Note: cases of malaria annually. There are no continent-wide estimates of deaths from malaria, but in general case B Lecomte,(1986) Project Aid: Limitations and fatality rates exceed 10 per cent - that Alternatives, OECD, Paris; S Tilakaratna, 1989, means possibly 8 million Africans die 'Retrieval of Roots for Self-reliant development: some experiences from Thailand', WEP Workingfrom malaria each year. Like tubercuPaper no.49, ILO, Geneva. losis, another major cause of death in Africa, malaria is on the rise. An increase in the incidence of tuberculosis has been observed since 1985 in Burundi, Central African Republic, Kenya, Tanzania, Uganda, Zaire and Zimbabwe - all countries with a high Meredeth Turshen prevalence of HIV; 30 - 60 per cent of WIO estimates that 6 million Africans the additional cases are attributable to HIV infection. have been infected with the human US Aid to AIDS in Africa immunodeficiency virus (HIV) and that African children die of many other 1.16 million cases of AIDS had occurred among adults and children in sub-Sahadiseases. An estimated 250,000 infants ran Africa by 1991. These are cumulative die annually of neonatal tetanus, a figures for ten years, including cases and disease that has been preventable since deaths. AIDS is the only diseasefor which 1931 when a vaccine was developed. An estimated 1.2 million African chilcumulative figures are published; every other disease is reported annually and new dren under the age of five die each cases are separated from that year's death year of diarrhoeal diseases. WHO toll. Although I do not wish to minimize publishes numbers of AIDS cases but the problem of AIDS in Africa, one should not AIDS deaths. If one assumes a note that the effect of cumulative report- similar rate of deaths from AIDS in the United States and Africa (about 63% of ing is to amplify the problem. Americans with AIDS have died), then It is import to place AIDS in the some 94,000 African adults and chilcontext of other health problems in dren died of AIDS in 1990. AIDS is a Africa when determining types and new and growing health problem, one amounts of health assistance. WHO of the many health problems in Africa. publishes no death statistics for Africa, High levels of malnutrition debilitate only random data are available. Famand make Africans susceptible to speine and malnutrition are currently the cific causes of death, a phenomenon cause of most deaths in droughtknown as generalized susceptibility or stricken parts of Africa. An estimated non-specific mortality. Which disease 100,000 Somalis have died and 1.5 is written on the death certificate is million are at risk of death by starvaperhaps less important for aid policy tion in that one country alone. Malaria, makers than the fact that high levels of This content downloaded from 128.6.218.72 on Tue, 16 Jul 2019 15:58:47 UTC All use subject to https://about.jstor.org/terms 96 Review of African Political Economy sickness and death call for public health programmes that can deliver a broad range of preventive and curative health services in Africa. sexually transmitted diseases. USAID has not been integrating AIDS prevention into basic health services, favouring instead a vertical approach to AIDS control through family planning There are several problems with the programmes and clinics for the treatresponse of the US Agency for Internament of sexually transmitted diseases. tional Development (USAID) to AIDS in Africa. The main problem is that AIDS control, for example, might usefully be integrated in the Safe Motherhood Initiative. The vertical USAID is setting up single-purpose approach does not take into account programmes to prevent AIDS and that AIDS is a family disease, a disease AIDS alone. Yet AIDS is a syndrome of that affects the health of several family many opportunistic infections, not a members not seen in family planning single disease; and WHO has shown programmes or sexually transmitted over the years that single-purpose disease clinics. programmes are wasteful of scarce resources and undermine competing USAID's assistance to the surveillance health programmes. WHO has also of sexually transmitted diseases is part shown that prevention and treatment of the evaluation of intervention need to be combined if disease control programmes are to be effective. USAID projects to reduce the spread of HIV, rather than for the treatment or cure of gives little assistance for treatment, disease. The surveillance of sexually even of associated infections such as transmitted diseases serves as a proxy tuberculosis, although African women are pleading for help in caring for the for changes in HIV incidence, since few if any projects are able to demonsick. Another problem is that political strate a direct effect on HIV transmisrather than public health criteria of sion. need appear to guide the setting of targets for priority assistance. A fourth Second, although contaminated blood problem is that little of the money is known as a highly efficient mode of allocated actually goes to Africans; transmitting HIV (over 90% efficiency most of it is distributed in the US to as opposed to 0.1-1% efficiency of various non-governmental and private sexual transmission), USAID gives voluntary organisations. little assistance to protecting blood supplies other than the development An Analysis of Project Aid of new rapid screening tests for use in emergency rooms. The main recipients USAID is giving little assistance to of transfusions are anaemic children African health services beyond the and women treated for spontaneous or training of some health workers, and self-induced interruption of pregnancy that training is single-purpose; for and complications of childbirth. example, laboratory technicians are Women and children, you will recall, training to recognise only sexually account for more than 60% of Africans transmitted diseases (including AIDS), with AIDS. USAID recommends, in despite the plethora of opportunistic Cameroon and elsewhere, that blood infections associated with AIDS that need diagnosis and treatment. At the transfusions be reduced to a minimum. Evidently there is little confivery least, laboratories should be able dence that blood supplies can be made to screen for tuberculosis as well as This content downloaded from 128.6.218.72 on Tue, 16 Jul 2019 15:58:47 UTC All use subject to https://about.jstor.org/terms Briefing: AIDS in Africa 97 safe. Nor is there support for research on sources of blood supplies in African countries. Third, having decided that intrave- nous drug use plays only a minimal role in HIV transmission in Africa, USAID says little about contaminated needles and syringes in medical settings. Disposable needles, which were first introduced in Africa in the 1970s, are systematically reused in medical practice, although they cannot be steri- lized. USAID's response is not, in tional opportunities are restricted, especially for girls, in which there are few job opportunities for young men, and even few for uneducated women, in which couples are frequently separated when men migrate in search of work, the sale of sexual services is likely to be common, blurring the line between infidelity and prostitution. The outcome of this strategy of targeting prostitutes is that USAID unwit- tingly supports the victimisation of women. Instead of receiving consola- prevailing conditions of scarcity, to tion, praise, and the assistance they supply conventional reusable syringes need, women are being blamed for the and autoclaves for sterilization, but spread of AIDS in Africa. African rather to support research on a prefilled women are already suffering the brunt injection device that holds a single of the AIDS epidemic, both as the dose of vaccine or medication in a nonmajority of the afflicted population reusable syringe with an attached and as caretakers of both sick relations needle, and a device that allows only one filling of a syringe designed to be disposable. Scarce foreign exchange will be needed to import these devices. Fourth, USAID's main preventive strat- egy is to persuade sexually active adults to use condoms. USAID encourages governments to target prosti- tutes and their clients in these efforts. This approach relies on the classic and their children. Now they are being stigmatized as prostitutes, blamed for transmitting HIV to their clients, for having 'unprotected' sex, for getting pregnant, and for passing HIV to their infants. An underlying problem is the use of target groups in planning research and intervention projects. Categories such as prostitute, intravenous drug use, public health responses to sexually and homosexual mislead health policy transmitted diseases - education, conmakers by suggesting that transmistact tracing and condom distribution. sion modes differ from group to There are two problems with this group. Recent ethnographic research approach in the African setting. One, reveals the collapse of all these categothese responses have little relevance to ries in the field: not only female and the majority of African women at risk male prostitutes, and child prostitutes who are school girls and married of both sexes, use drugs and perform women and do not control their sexuanal intercourse, but also female and ality. They are not in a position to male tourists sample drugs and sex on impose the use of condoms on their holidays, though they were not on sex partners. Second, many of the women or drug tours and may not have left marked as prostitutes are not full-time home with that intention. commercial sex workers. In societies in which marriage is nearly universal, in Fifth, USAID is channelling funds which poverty is extensive and living through US-based non-profit and volstandards are low, in which educauntary organisations, rather than as- This content downloaded from 128.6.218.72 on Tue, 16 Jul 2019 15:58:47 UTC All use subject to https://about.jstor.org/terms 98 Review of African Political Economy sisting governments and health services directly. The disbursement of funds through US organisations may create a few jobs for Americans and markets for American products, but it does not further the original purpose of foreign aid, which as I understand it, is to help people in distress to recover their productive abilities. USAID targets specific countries for priority assistance on criteria other than public health need. Priority recipients are political allies such as Kenya and Zaire, or countries such as Ghana that are show-cases for the monetary policies of the International Monetary Fund or, in the case of Cameroon, which has reported fewer than 500 cases of AIDS to WHO, the country of origin of the WHO Regional Director for Africa. Finally, USAID assistance in the cat- of third world development, and the scientific issues appear to be limited to specific experiments in the control of AIDS, which may have application in the United States. The macro-economic issues are not confined to Africa; they include balance of payments deficits and the inability of third world countries to repay bank loans. In response to these problems, USAID supports IMF and World Bank structural adjustment programmes, which comprise a set of economic reforms that includes currency devaluation, export promotion, import reduction, and the curtailment of government expenditure. Their goal is the repayment of outstanding debts. Since 1980, IMF and World Bank balance of payments loans have sup- ported economic reform programmes in some 40 African countries; the minimum condition for these loans is the adoption of specific policies that egory 'health care financing' revolves shape the economic reforms. In addiaround financial planning, which will probably be of interest to the multina- tion to an auction system to determine exchange rates, the IMF and the World tional pharmaceutical industry. AsBank require increased domestic cursistance is currently directed to the rency prices for exports, price liberalidevelopment of a cost model that zation, and increased incentives to the countries can use to plan transfusion private sector; both agencies treat the services; the object is to implement food production sector as a 'virtual cost recovery programmes - in other words, fees for blood transfusions and "residual" in the programmes of most for HIV testing. There is no evidence ofcountries producing agricultural crops for export.' donations to help defray the costs of treating people with AIDS or with the Rising levels of unemployment and bread riots are but two indicators of the social damage these reforms have incurred. UNICEF has documented The Underlying Policy the impact of structural adjustment on Objectives health and health services. Currency devaluation reduces individual and The type of assistance the US government is providing to Africa seems to be government spending power for purchases of life-sustaining necessities determined by policy considerations (food, water, shelter), as well as health as much as by science, medicine, or care. Export promotion increases workpublic health. The policy consideraloads, which fall especially heavily on tions concern macro-economic issues curable diseases of concomitant epidemics such as tuberculosis. This content downloaded from 128.6.218.72 on Tue, 16 Jul 2019 15:58:47 UTC All use subject to https://about.jstor.org/terms Briefing: AIDS in Africa 99 Africa's women farmers, affecting their An Alternative Health Policy health and that of their children. Import reduction, especially in combination with currency devaluation, af- fects the flow of medical and pharmaceutical supplies and equipment into the many African countries that do not produce their own. The curtailment of government expenditure has more seriously affected health, education and welfare than other services. The IMF and the World Bank are encouraging several African govern- ments - for example, Kenya and Ghana - to charge for health services, a burden that falls disproportionately on the poor. The net result is a decline in both health status and health care in Africa. In the words of an editorial in the Lancet, 'there is mounting evidence The portrayal of AIDS as a sexually transmitted disease, not only exposes women to victimization, but also justifies a health assistance policy limited to health education and condom distribution, combined with HIV testing as a means of monitoring the spread of infection. The inadequacy of this approach is shown in the US where there has been a resurgence of tuberculosis linked to the spread of HIV with inner city public hospitals collapsing under the burden of caring for AIDS patients. The policy failure in Africa, where fiscal austerity programmes have cut deeply into government budgets for health, education and welfare services, is even more grave. of deteriorating welfare conditions - e.g. as measured by infant mortality, nutritional status, and educational enrolment - throughout Africa', and 'the AIDS could usefully be conceived of as an environmental disease in Africa. A broad environmental approach would quality of health services overall has address the underlying determinants of the spread of HIV - the economic structures that create the need to migrate in search of work and in the process destroy the social and familial networks that protect people from some types of disease experience. Although African women do not advocate a return to traditional institutions of patriarchal domination, they do recognise the failure of alternative networks in urban areas to protect young girls, in particular, from the sexual exploitation that is the stigma of deteriorated . . . ' Rather than use the AIDS epidemic as an opportunity to redress the underfinancing of African health services, USAID would seem to be pursuing its long-desired programme goal of population control. The agency insists on the nature of AIDS as a sexually transmitted disease, it focuses almost exclusively on the heterosexual transmission of AIDS in Africa, and it emphasizes condom use to prevent HIV transmission. Of course, condoms also prevent conception. Although USAID projects a 30 to 50 per cent increase in child mortality as a result of the epidemic, it expects the population growth rate to decline by only 1 per cent, because total fertility is so high in Africa. USAID concludes that this is not the time to diminish family planning efforts, but instead such efforts could be redoubled. AIDS. The formulation of AIDS as an environmental disease would entail a different health policy, one that calls for an investment in the prevention and treatment of common infections, in- cluding tuberculosis, sexually transmitted diseases, and malaria. Because women and children account for more than 60% of people with AIDS in This content downloaded from 128.6.218.72 on Tue, 16 Jul 2019 15:58:47 UTC All use subject to https://about.jstor.org/terms 100 Review of African Political Economy Africa, priority should be accorded to caring for them, taking their social as well as their physical health needs into consideration. Treatment implies an investment in African health services, along the lines advocated by WHO and UNICEF in the primary health oped more than 50 years ago. Aid dollars are needed to rebuild African health services that deteriorated during a decade of neglect and are now being called upon more than ever to cope with the myriad infections associated with AIDS. care programme. Recognition that AIDS is an environmental disease would also call for new solutions to malnutrition that address the entire food system, beginning with issues of landlessness, and not limited to improved distribution and increased consumption of food. Because AIDS is still primarily an urban disease, an environmental approach would entail plans to accom- modate rural-urban migration, which has increased under the pressure of austerity measures and structural adjustment programmes and caused African cities to grow at the rapid rate of 6% per year. Good urban planning encompasses housing, water supply, sanitation and transportation needs, as well as health care. An environmentally oriented AIDS policy would re-examine certain development strategies that are proving detrimental to women's health. For example, the tourist industry, sponsored by national governments and encouraged by international agencies as a solution to slow economic development, has (in some cases, intentionally) promoted prostitution. USAID needs to turn away from the search for a quick technological fix to the AIDS problem in Africa. Putting foreign aid dollars into the development of a vaccine is not likely to help Africans, who still suffer from diseases such as neonatal tetanus and tuberculosis for which vaccines were devel- Bibliographic Note AIDS & Society: International Research and Policy Bulletin 1990, 1 (4):19; AIDSTECH/Family Health International, 1990, Semi-Annual Report, I October 1989 - 31 March 1990, Durham, North Carolina; E M Ankrah, 'AIDS and the Social Side of Health, Social Science & Medicine, 1991, 32 (9):967-980; M T Bassett and M Mhloyi, 'Women and AIDS in Zimbabwe: The Making of an Epidemic', InternationalJournal of Health Services, 1991, 21(1):143-156; A S Benenson (ed), 1990, Control of Communicable Diseases in Man, APHA, 15th edition, Washington, DC. K Carovano, 'More than Mothers and Whores: Redefining the AIDS Prevention Needs of Women, International Journal of Health Services, 1991, 21 (1):131-142; P Chaulet, 'La lutte antituberculeuse dans le monde: strategies et actions sur le terrain', Alger, 1991, mimeo; G A Cornia, R Jolly and F Stewart, 1987, Adjustment with a Human Face: Protecting the Vulnerable and Promoting Growth, Oxford: Clarendon Press; H V Fineberg, 1988, 'Education to Prevent AIDS: Prospects and Obstacles', Science 239:592-596; Jeffrey R Harris, 1990, statement to the 33rd annual meeting of the African Studies Association, Baltimore, MD, panel on 'AIDS: Current State of the Epidemic and Treatments'; Don Kaseje, 1989, 'Le paludisme', Mortalite et societe en Afrique au sud du Sahara, Paris: Presses Universitaires de France. J Loxley, 1990, 'Structural Adjustment in Africa: Reflections on Ghana and Zambia', ROAPE 47:827; G Merritt, W Lyerly and J Thomas, 1988, 'The HIV/AIDS Pandemic in Africa: Issues of Donor Strategy' in AIDS in Africa: The Social and Policy Impact edited by N Miller and R C Rockwell, 115129, Lewiston, NY, The Edwin Mellen Press; M Navarro, 'Epidemic Changes All at Inner-City Medical Center', New York Times, 11 November 1991; T Quinn, 1990, statement to 33rd annual meeting of the African Studies Association, Baltimore, MD, panel on 'AIDS: Current State of the Epidemic and Treatments'; E Rosenthal, 'Doctors Warn of a Looming TB Threat', New York Times, 16 November 1991; J D Snyder and M H Merson, 1982, 'The magnitude of the global problem of acute diarrhoeal disease: a review of active surveillance data', WHO Bulletin 60 (4) and 'Structural Adjustment and Health in Africa', 1990, Lancet 335:885-886. This content downloaded from 128.6.218.72 on Tue, 16 Jul 2019 15:58:47 UTC All use subject to https://about.jstor.org/terms Briefing: Angolan Elections 101 C F Turner, H G Miller & L E Moses (eds) 1989, 1. The Movimento Popular de AIDS: Sexual Behavior and Intravenous Drug Use, Libertaqao de Angola (MPLA) Washington, DC: National Academy Press; elections for the National Assembly USAID, 1991, Statement of Richard A Cobb, Deputy Assistant Administrator, Bureau for and narrowly missed winning the Africa, Agency for International Development Presidency. They had nothing to gain on Aid and the HIV/AIDS Pandemic in Africa, and much to lose from a return to war. Subcommittee on Africa, Committee on Foreign Affairs, US House of Representatives, There is evidence to suggest that the Washington, DC, 6 November 1991; USAID, won the resumption of hostilities took MPLA 1990,HIVInfection and AIDS:A Report to Congress on the USAID Program for Prevention and Control, off-guard allowing UNITA to make Washington, DC; USAID, nd, Building rapid gains. Western military observPartnerships to Stop AIDS, Washington, DC; F ers confirmed that of the two forces, Vachon, J P Coulaud & C Katlama, 1985, the MPLA's Forqas Armadas Pupulares 'Epidemiologie actuelle du syndrome d'immunodeficit acquis en dehors des groupes de Liberta~ao de Angola (FAPLA) a risque', La Presse Medicale 14(38):1949-1950; appeared less prepared for hostilities WHO, 1988, Proposed Programme Budget for the Financial Period 1990-1991, Geneva: World Health Organization; WHO, 1992, 'Update: AIDS Cases Reported to Surveillance, Forecasting and Impact Assessment Unit (SFI), Office of Research (RES), Global Programme on AIDS, 1 April 1992, Geneva. Angola: Free and Fair Elections! and generally more eager for demobilisation. This too appeared to be the verdict of the Angolan people; they voted for the MPLA not because of their record of economic management (which is generally regarded as weak even taking the disruptions of war into account) but for their promise to deliver a consensual government of reconciliation. Patrick Smith 2. Interviews with officials indicate there was genuine incredulity in the Instead of a national celebration to UNITA camp that they had lost the mark the significant achievement of elections: they had been told themthe 29 and 30 September 1992 multiselves and they had been told by their party elections, Angola has been erstwhile foreign backers in Washingplunged into a new period of armed ton and Pretoria that they would win. confrontation. Once the Unaio NacionalEven Savimbi appeared to believe his para Independencia Total de Angola own propaganda. Rather than attempt (UNITA) had refused to accept the to reconcile their membership to elecelection result and its key leadership toral defeat, the bulk of information left Luanda for Huambo (its base in the emanating from the UNITA radio Central Highlands) the stage was set station was highly inflammatory. There for a resumption of the civil war. All had been little attempt to reconcile that was absent in the hostilities folUNITA's Forqas Armadas de lowing the polls was a formal declaraLibertagao de Angola (FALA) to detion of war. In the confused pattern of mobilisation given the poor state of the events following the elections, any economy. The reaction of the FALA attempt to apportion blame for the troops, put in context, is also underbreakdown of the political process is standable; from all the information far from an exact science; but some keythey received from their leadership, developments elucidate the issues there was little economic future for around the resumption of major hosthem under a MPLA-dominated gov- tilities: ernment. This content downloaded from 128.6.218.72 on Tue, 16 Jul 2019 15:58:47 UTC All use subject to https://about.jstor.org/terms