The socio-economic impact of HIV/AIDS in Zimbabwe

Know your HIV status
Know your HIV status (Wikimedia Commons)

In 1999, UNAIDS released a report on the socio-economic impact of the epidemic in Africa. The report confirms what researchers had suspected for several years: AIDS is exacerbating poverty and stunting development throughout the continent. The pandemic is wiping out much of the progress made in recent decades. Zimbabwe is on of the hardest hit countries in the continent.

Original broadcast: November 30, 1999

Transcript

Radio Netherlands, the Dutch International Service, presents “A Good Life” with Ginger da Silva.

I think it’s probably high time that we stopped talking about an epidemic because AIDS is endemic. It will be with us for another generation, no matter what we do.

Hello,as the AIDS epidemic continues to spread, the human, social and economic costs are also mounting, particularly in the continent hardest hit by the pandemic, Africa. The statistics are staggering: 22 million Africans are currently living with HIV or AIDS. 7 out 10 people newly infected with HIV live in sub-Saharan Africa. AIDS has now become the leading cause of death on the continent. Earlier this week, UNAIDS, the joint United Nations program on HIV/AIDS, released a report on the socio-economic impact of the epidemic in Africa. The report confirms what researchers had suspected for several years:  AIDS is exacerbating poverty and stunting development throughout the continent. The pandemic is wiping out much of the progress made in recent decades. Eric Beauchemin recently spent three weeks in Zimbabwe, one of the countries most heavily affected by the epidemic, and he looked at the socio-economic impact of the disease.

EB: You have the forms here for the purchase of a grave. Can we go through and see how many of thse people died of AIDS or AIDS-related causes? OK, let’s start counting: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 12, 13, 14, 15, 16, 17 burial orders for people who died of AIDS, only to count these few for this month. EB: These are all of AIDS. Definitely all AIDS.

Funeral parlours are one of the few businesses in Zimbabwe that have been booming since the advent of AIDS in the 1980s. In the western city of Bulawayo, there were two funeral parlours a decade ago. Now, there are 18. Every week in Zimbabwe, 2500 people die of AIDS. The majority are between the ages of 18 and 49, the most productive people in society. Some sectors are being hit harder than others.

Transport in itself is being viewed as a spreader of AIDS, unfortunately, because of the job content. Particularly drivers, mechanics that go out and repair vehicles, they leave home and their home environment for anything up to three weeks at a time.

David Howe is the chairman of the National Employment Council for the Transport Operating Industry in Zimbabwe.

During that period, they are away from their wives and girlfriends, and unfortunately we have commercial sex workers operating along truck routes. Where they do stop at night, their vehicles become their home, and they utilize that for sexual activities. There’s one particular route between Harare and a place called Nyamapanda, which is on the border of Mozambique. We found groups of commercial sex workers actually working between various truck stops, say for example there’s a common truck stop just outside of Harare, about 80 kilometres away. They would work between Harare and this common truck stop, and they would find their next client thereafter. So they could be – put in inverted commas – servicing as many as four or five drivers a day, and this is seven days a week. They don’t have off days.

The transport operating industry estimates that HIV rates among drivers are between 50 and 75%. That’s two to three times as high as among the general population. But the cost of AIDS to the transport sector is relatively low in purely economic terms. Drivers in Zimbabwe are unskilled and since unemployment rates exceed 50%, the transport  sector can easily and quickly replace the staff it loses. Other sectors are far more vulnerable.

Mining is one of the key sectors in the Zimbabwean economy. HIV rates are lower than in the transport sector, but the epidemic is taking its toll, says Doug Verden, the senior executive of the Chamber of Mines of Zimbabwe.

One of the issues of importance from the economic standpoint more than anything else is the question of extra training. You probably appreciate: it takes a long time to train a miner or mining personnel because of the difficulties involved, especially in Zimbabwe where we are not particularly capital oriented. It’s mainly labour orientation. It takes time to train people to get them to the required standard, and we do have problems whereby people after a number of years of training and have reached their peak of their prowess, if you like, then unfortunately contract HIV/AIDS and they fade away. And this is becoming a problem because it’s not so much the money, although that is one of the matters involved, but it’s the time factor. It takes a long time to train, for example, an overseer miner. It takes a long time to train a mine captain, and if these guys are passing away, you have the training problems of trying to replace them with skilled and experienced people.

More and more companies in the mining sector and other industries that require highly-skilled labour are trying to compensate for the rising death toll. Over-training or shadow training is becoming increasingly essential to survival. If a mining company, for example, needs 10 electricians, it’s likely to train 13 or 14 people because 3 or 4 will probably pass away before the end of their course. Companies are also using other approaches  to factor in AIDS, says Dr. Rene Loewenson, the director of the Training and Resource Support Centre, a non-profit organisation.

They’re also using more multi-skilling approaches and building a wider band of skills within companies. They’ve got much more intense in-service programmes taking place so that they use existing skills to have skills transfer within companies. There’s examples of cooperation within an industrial sector, of attachments with companies that have skills from companies which don’t. So there’s many, many innovative ways taking place within which companies are trying to rebuild skills. One projection that was done said that the skills training costs were going to multiply fivefold. But I think we are also looking at a change in the production system globally, and Zimbabwe is not escaping from that. Global competition is demanding that companies shift to more skills development. And so I think skills training would have been a development of high investment anyway in Zimbabwe. I think AIDS is adding to the cost of that.

Nowhere perhaps have the mounting costs of AIDS been as visible as in the insurance sector. Joe Martin Harvey works for one of Zimbabwe’s biggest insurance companies, South Hampton.

The insurance industry in Zimbabwe maintains statistics of AIDS claims. In the last few years, we’ve seen a rate of about 60% of  the claims being due to AIDS-related illnesses. That is quite a high figure, obviously, and it does not seem to be coming down. EB: But if you say that 60% of the claims that you are receiving now are AIDS-related, this must be heavily affecting your company. Yes, it does affect all the companies quite heavily. What we’ve done on the one hand is to set aside some money for the extra mortality which we anticipate. It does mean of course that the profitability of life insurance has been reduced as a result. We’ve also tried to adjust the rates to match the kind of experience that we are getting. We try and price it in. EB: When you say that the rates have gone up considerably, can you give me a percentage figure? Life insurance rates that were being charged before the AIDS pandemic are probably about a third of what’s being charged at the moment. So we’re talking about multiples of 3 to 5 times previous rates.

The majority of Zimbabweans – the 60% who live under the poverty line – cannot even consider getting an insurance policy. According to Dr. Alan Whiteside, one of the world’s leading experts on the socio-economic impact of the epidemic, since the government doesn’t provide a safety net, it’s the poor who are suffering the most.

Dr. Alan Whiteside
Dr. Alan Whiteside

The effect on poverty is that basically any family which is affected by HIV and AIDS is likely to become more impoverished. The reason being: they use up their resources in keeping the breadwinner or the adult alive. That adult’s productive output is lost to the family. So it’s an inevitable cycle of impoverishment which you’d see for that family. Whether or not they’ll recover is actually a debatable point. And the worst of it is, of course, that we don’t measure the worst impact because we can’t, because by the time you go in and look at what’s happening, those people who can’t cope aren’t there to be measured. You are only measuring the people who you can count. And I think the levels of impoverishment, desperation in rural Africa are such that if we understood it, we would be weeping for those people.

Kerry Kay is the director of the Commercial Farmers Union AIDS control programme. She’s seen the dramatic effects AIDS is having on the poor in rural areas. Not only are more and more people getting sick and dying, people are spending more and more time attending funerals.

The cost is really more to the actual worker now because traditionally in the African culture, when they go to a funeral, they contribute towards that in terms of cash or kind. They’ve got the bus fares there and back, and they’ve got time off work. They get their leave every year, but when they’re going off for three or four days maybe once a month or sometimes more than that for funerals, it’s costly to them because they are downing tools and they are not getting paid for the time that they’re away.

So many people both in rural and urban areas are spending time attending funerals that it’s becoming a major drain on the household income. As the number of people infected increases, more and more people are also having to take time off work to take care of their relatives, says Professor Norman Nyamenza of the Department of Clinical Pharmacology at the University of Harare Medical School.

We are as a policy in this country trying to promote home-based care because there’s no essential drugs. The system is overstretched. Yes, at times you would  find quite a number of people in the hospital who are infected with HIV or have got AIDS. But the majority are back home in the community because there is nothing in the hospital. But it’s an expensive process because people in the community themselves are very poor. They don’t have the wherewithal to look after somebody who is HIV positive and has got AIDS. But at the same time also the government is poor. The government has got no money anymore. So it’s really a question of us – government and the people – to share the burden.

But few Zimbabweans believe the government is actually shouldering its share of the burden. Corruption has become so widespread that an authoritative Zimbabwean legal publication has described Zimbabwe as a racketeering state. The Zimbabwean state is spending over 25 million dollars a month supporting a highly unpopular war in the neighbouring Democratic Republic of Congo 2500 people are dying a week of the disease, and still, says Kerry Key, the government won’t declare AIDS a national disaster and reallocate funds.

The political commitment has to be number one before you can succeed. Basically what we are doing is we are working and then we are reaching a ceiling. We can’t help people in the rural areas if they haven’t got access to basic drugs. Primary health care was free to minimum wage earners, and it is no longer free. They’re having to pay. Drugs aren’t always available. What we believe is that if a lot of money was put into primary health care and the prevention and cure of STDs and TB that we would drop our HIV rate considerably. We are in a crisis situation where we are losing hundreds and hundreds of people a day to HIV and AIDS , and when a bus goes off the edge of a bridge in this country and 80 people are killed, it’s declared a national disaster. So why has AIDS not been declared a national disaster?

You don’t want to just stand there and say it’s a national disaster. What you mean is that you are then going to commandeer all the resources towards fighting and helping those people who are suffering from HIV, towards preventing the disease and so forth and so on. EB: Why hasn’t the government done that yet? To be honest with you, there is a lack of political will. It’s not as if people are not aware. When you have 25% of your adult population which is HIV positive, then surely that’s a national disaster. But once they say that, it’s got to be translated into economic terms.

And that’s exactly what Zimbabwean society is demanding, says Dr. Rene Loewenson. After all, how can any government fail to respond when a quarter of its population is falling sick and dying?

I think what’s coming out in the late 1990s is that the society in Zimbabwe is saying enough is enough. Help must be given. The number one priority in the budget. Nothing else can happen if your people are not surviving. We’re hearing that from all kinds of corners. The second thing is one wants leaders to role model the kind of behaviour patterns that they expect the society to do. So when we have any stories of leaders that are in the public eye, that are actually behaving in a manner which signals that – whether they are in sexual relationships with younger people, young females or those kinds of stories, they send very strong negative role models in the community. And I think we have to recognise that leadership is right from the community level right up to the national level.

Dr. Alan Whiteside agrees. Political leaders who fail to address the issues raised by the pandemic do so at their own peril and endanger their country’s future.

AIDS can either be extremely divisive to a nation or it can be a nation-building force. It depends on how the nation responds to it. In the worst situation, what you find is that people are not open about HIV. They know there is a problem in their midst. They don’t know the magnitude of the problem. They can see their friends and their relatives dying and falling ill. They’re not entirely sure why. There’s no leadership. I find the Zimbabwean experience to be perhaps one of the most tragic in Africa because honestly, I do not believe that the leadership there is really aware of the magnitude of the problem. There’s a feeling of blame, a feeling of desperation. And in that setting, you can find that the society moves into a situation where destruction and disintegration is not impossible.

Even though the Zimbabwean government is unwilling to acknowledge the catastrophic consequences that AIDS is having, it has taken one step in the right direction. Last year, it passed a law called Statutory Instrument 202, which deals with HIV and AIDS in the workplace. The legislation contains some important guarantees for workers, says Isaac Iganderawa (sp?), the head of the Health and Safety Department of the Zimbabwean Congress of Trade Unions.

The basic tenant is that the law provides against discrimination on the grounds of HIV status and that no company should include HIV as part of pre-employment testing or no one should be compulsory tested for HIV or AIDS. And also the fact that no one should be denied promotion or access to work as a result of their HIV or AIDS status, or in terms of promotion or other benefits.

All employers are also required to set up AIDS awareness programmes in their workplaces. Sori Suba (sp?) works for MAC, the Matabeleland AIDS Council, a local non-governmental organisation which is conducting AIDS prevention programmes at the request of the business community, like in this pharmaceutical company in Bulawayo.

So, do you think we need to revisit it as a society? Do we need to revisit some of those values we have attached to manhood?….

Some workplaces will just opt for what we call awareness sessions where periodically or sporadically, they invite us for short sessions over lunchtime or one or two hour sessions for their workers, where we discuss pertinent HIV/AIDS issues. Some will then say: look, it’s better if we have people that are trained in peer education who will then actually disseminate information to our workers and continually seek latest information and disseminate it to their peers. EB: But here at this pharmaceutical company, you’re actually spending an entire week, and it covers much more than just HIV and AIDS. Yes, during our peer education training week, we actually cover all topics that we think are pertinent to HIV or centre or interact with HIV, things like sex and sexuality, things like gender issues and condom use and so forth because we feel that people have to look at AIDS from a practical point of view.

EB: Brian, you’re one of the participants in this peer training workshop. Can you tell me what you think of the message that you’re hearing? Well, it has been an experience because really I hadn’t any information because when you’re out there without information, you really think like everyone else. EB: But what about some of the other issues that were raised. For example, this morning they were talking about gender and relationships between men and women. Did what the women have to say make you think differently about how you treat women and how you interact with women? Yeah, here in Zimbabwe, men we grow up being told some values and things that men are supposed to do. Now when you hear women talking from their own point of view, you tend to look at some of those so-called values critically, and you see that there is a problem. There really is a disadvantage on the part of women when it comes to HIV and AIDS.

Non-governmental organisations are not the only ones trying to increase awareness about HIV and AIDS. The private sector is also setting up its own AIDS programmes. The first organisation to do so was the Commercial Famers Union.

We have drama groups on the farms. We do video presentations. We encourage the children on farms to form drama groups, and they are actually excellent because they emulate their parents in the beer halls at weekends and how not to behave. So that’s actually really good. We’ve now grown from six people to about 10,000 volunteers in all. I think the voluntary aspect of it is what has kept it sustainable and cost effective, although at this moment we are being funded by the Royal Netherlands government for a three-year period, which assists us in our administration costs and so on. But the work that everybody does is actually voluntary.

But changing traditions and attitudes towards sex and gender is not easy, and it’s difficult to measure success.

Behaviour change is difficult to monitor, and that’s always an issue. People say: all the work that you do, is it having an effect? But we do see behaviour change, certainly in terms of condoms. In the beginning, the question was do you eat a sweet with a paper on? And now people are actually asking for condoms and wanting them.

Free condoms are also an element of the transport sector’s AIDS programme. They’re distributed by a group of commercial sex workers or prostitutes who’ve received AIDS training. Every evening, says David Howe, they put on plays complete with marimba music at six heavily populated truck stops.

It’s not a professional play. It can change from day to day. They might actually pick on a common driver who has a very good personality that is there that evening. They could possibly get the drivers involved. It all depends on the evening itself and how people view the play, how they play it. EB: What has been the reaction from the drivers to these different approaches that you’re taking? The plays are the only way we can physically get in a humane manner the story and the impact of AIDS on the population, than rather sitting down and lecturing them in a theatre situation that the drivers don’t understand and they don’t like it. To portray it in a type of play is more receptive to them, and they can understand it and remember what we’re trying to get across.

Prevention not only saves lives. It also saves money. Currently, AIDS is costing companies between 20 and 200 US dollars per worker per year.

HIV prevention in a company, we’ve costed it at about between 6 and 10 US dollars for programmes that have the ability to reduce HIV/AIDS transmission by about 30% in workers. So it’s definitely…there’s a cost-benefit ratio to investing in prevention for a company. Unfortunately, you reap the benefits about 10 years down the line because it takes about 5 to 8 years for an HIV infection to show as an illness. And in an environment of insecurity, some companies are not willing to invest today for something that is going to show effect 5 to 8 years down the line. But then I think many companies now really have taken prevention `much more seriously because they are beginning to see the impact of ill-health losses.

Already in Zimbabwe, 800,000 children have either lost one or both parents to the disease, that’s one in five Zimbabwean children, and the figure is expected to double within the next few years. More and more of these children are growing up on their own without any support, supervision or love from adults. Dr. Whiteside again.

I think what it means is a generation of people who lack social skills, who lack any qualifications right the way down to probably basic literacy, who are extremely de-socialised and who are a real threat to the future of society. There’s undoubtedly going to be increasing crime. We’re looking at sexual abuse of children who are orphaned, who are on the streets. And basically among these children, there’s going to be a feeling that they have no stake in the future of the society and indeed that these children have no future themselves. EB: That they’ve been abandoned. That they’re abandoned. They’re abandoned not just by their parents but by the societies in which they live.

Over a decade and a half into the pandemic, the donor community is only now beginning to realise the dramatic toll AIDS is taking in countries like Zimbabwe.

One has to feel that there is some level of cynicism about the way in which the international community is responding to the AIDS epidemic in Africa because it is not just a national disaster. In fact, it is a global disaster the way we see it. What we could call the social debt that’s building should not be taken so lightly while the economic debt is taken with such seriousness. EB: So what do you think that international lending institutions such as the IMF and the World Bank should be doing in terms of the AIDS epidemic? All international institutions, and I think we need to include the trade and investment institutions, firstly need to look at not unduly penalising the economies in this part of the world. It’s not that Africa invented the AIDS virus, and it’s not that it should be punished for having the AIDS virus. But secondly I think all the programmes have to factor in AIDS, not just in their lending, but also into their development work and so on, and realise that there’s going to be issues that take us 20 to 25 years to deal with in their lending. We’re not simply talking about health systems, but basic education, poverty reducing measures, etc.

Even if the virus were stopped today, the impact of AIDS will be felt for more than a generation. Within the next decade, almost all of the 22 million Africans infected with HIV will be dead, in part because virtually no one in the continent can afford retroviral drugs. The most productive, skilled and educated people are dying, and they’re leaving behind millions of children, children denied even their simplest dreams. Given the epidemic’s long-term impact, believes Dr.Whiteside, donors must invest in the future, in the children, particularly girls.

Girl children taken out of school because someone is ill, maybe not with AIDS, but in societies where you have HIV, of course many, many more girl children are taken out of school. We know that the impact of that is obviously immediately on that child. They fail to get an education. Then the next generation, they’re more likely not to get a job because they don’t have the education. Therefore they’re more likely to become infected because they are more likely to have to rely on sex as a survival mechanism. If they have to rely on sex as a survival mechanism, they are less likely to have feelings of self-worth.  So something as simple as providing fees for those children would go a long way towards stopping the epidemic. That’s a sort of revolutionary idea: providing school fees for children at risk provides an AIDS intervention and people don’t seem to understand that.

In other cases, donors must be more creative.

Let’s suppose a country is providing foreign aid and the thing they’re most keen on doing is providing foreign aid for roads, infrastructure. Now, they could require anyone who bids for a contract to build a road is required to provide maximum employment to local people rather than bringing in gangs of men. They could require that there be health and safety and STI treatment on site. They could require that the contractor takes the families with the men as far as possible. That’s the sort of influence that the donor community could have on the developing world.

It’s the type of influence which donors are beginning to realise that they must use, even if it leads to charges of meddling, even if it violates the traditional prudishness about discussing sex. Development, says Dr. Whiteside, cannot take place if a quarter of the population is dying.

I think actually a response to AIDS ought to be part of the conditionality for providing aid, and I think if we see that it falls short of that which we would have it do, we ought to stop providing aid. I think a decent AIDS programme is as important and indeed inter-linked with many things like human rights and gender issues and good governance and lack of corruption.

That is perhaps the only good thing that will come out of AIDS. To effectively combat the epidemic, societies will have to deal with issues such as the position of women, human rights, good governance, in short the building blocks of a fair and egalitarian society.

The only way forward is to build a cohesive, strong civil society in which people care for each other, in which they have the ability to care for each other, which is the enabling environment, in which they have the leadership that allows them to care for each other, in which they have terms of trade that allow them to care for each other, in a global economy, a global society which is conducive to this. Otherwise you face the situation you face in the Zimbabwes of this world, in the Rwandas, in the Somalias, Liberia, Sierra Leone, where a society is disintegrating and decaying, and the result is huge miserisation of many, many people. For many, many millions of Africans, AIDS is a disaster. For many, many billions of people, we have a responsibility to try and make them survive this epidemic. I do not believe we can give up. I do think we have a responsibility in some settings to say to governments that actually, what you are doing is wrong or not enough, and you really do need to take this on. We’ve done it for human rights. We should do it for AIDS.

Dr. Alan Whiteside of the University of KwaZulu Natal, ending this special edition of “A Good Life”, prepared by Eric Beauchemin. Technical production today was by Tieman Boelens. I’m Ginger da Silva, until next week stay well.