Dr. Alan Whiteside: The socio-economic impact of HIV/AIDS

AIDS in Africa
AIDS in Africa (©Wikimedia Commons)

Dr. Alan Whiteside teaches at the University of Natal in Durban, South Africa and has been studying the socio-economic impact of the HIV/AIDS epidemic for the past decade. This coming Sunday, the 13th International AIDS conference begins in his home town, Durban. It’s the first time it will be held in Africa. Dr. Whiteside shares insights and the perspectives from his research into the epidemic that is having such a devastating impact in so much of the continent.

Producers: Eric Beauchemin & Ginger da Silva

Broadcast: July 4, 2000


Welcome to this special edition of “A Good Life” from Radio Netherlands, the Dutch International Service. I’m Ginger da Silva.

AIDS can either be extremely divisive to a nation or it can be a nation-building force. In the worst situation, what you find is that people are not open about HIV. They can see their friends and their relatives dying and falling ill. They’re not entirely sure why. There’s no leadership. There’s a feeling of blame, and in that setting, you can find that the society moves into a situation where destruction and disintegration is not impossible. The converse of that is where there’s leadership from the very highest levels, where the society is able to build around it, and to build civil society. In that setting, a society can come out of the epidemic rather stronger than the way they went in.

Dr. Alan Whiteside
Dr. Alan Whiteside 

Dr. Alan Whiteside teaches at the University of Natal in Durban, South Africa and has been studying the socio-economic impact of the AIDS epidemic for the past decade. This coming Sunday, the 13th International AIDS conference begins in his home town, Durban, for the first time held in Africa. We thought it appropriate to devote this edition of the program to Dr. Whiteside’s insights and the perspectives from his research into the epidemic that is having such a devastating impact in so much of the continent.

An estimated 22 million Africans are currently living with HIV or AIDS. 7 out of 10 people newly infected with HIV live in sub-Saharan Africa. AIDS has now become the leading cause of death in the continent. Dr. Whiteside spoke with Radio Netherlands’ Eric Beauchemin. He told Eric that in Africa, as elsewhere, certain sectors, like the military, have much higher HIV-rates than the rest of society, and an infected military presents special dangers.

Basically what you are looking at is a group of young men who are basically recruited as risk-takers and they’re living on their own. They’re living in risky situations. There’s a whole macho image about being a soldier. They’re put in places where they’re likely to meet women who will have sex with them. So inevitably they’re more likely to have unprotected sex. Of course, the converse of that is that if you can identify this group as being at particular risk, you can also do something about it if you’ve got the political will. EB: What are the implications in terms of military planning if you very, very high HIV rates? I think that in a setting where the military is already a threat, the presence of HIV in the security forces has the potential to make them a greater threat to the stability of society. And the reason for this is quite simple: HIV takes out the middle-level people in society. It takes out the lieutenants, the warrant officers, the people who would be expected to provide leadership. In that sort of setting, you’re promoting people more rapidly, probably ahead of themselves. You’re promoting people who are probably not yet capable of being in the positions which they hold. And for that reason, the military with HIV is perhaps a far-greater threat than a military without HIV because of the nature of the beast and the nature of the society which they are operating in.

Another particularly susceptible group is the informal sector: the people you see selling fruits, vegetables, water, cigarettes, nuts and other products in markets and on the side of the road throughout Africa. These traders help keep their families going, even though they earn little for their long hours of work. This extreme poverty puts them at risk – it’s the kind of poverty that makes you willing to do just about anything. The informal sector doesn’t appear in official statistics.

We don’t know what’s happening to people who are being forced out of the informal sector because of HIV and AIDS. And what I think we need to do and need to do as a matter of great urgency is to look at people who are being forced out even of the informal sector, what actually happens to them. Obviously there are more people who can come in. And as long as there are people alive, there will be an informal sector available. If you can’t survive in the informal sector, then one just doesn’t know how you do survive at all. Entry costs are low, exit costs are low. Because the entry costs are so low and because there is so much unskilled labour and so much unemployment, the macro-economic effects – to put it quite crudely – are not that great or even negligible. You’re absolutely correct. The macro-economic effects of AIDS are probably going to be very small. In some settings, you may even find – and the World Bank has shown this in some of their work – that the GDP per capita could – when modelled – go up. In other words, the people that are left are economically better off. EB: Why would it improve? Well, effectively, if you’ve got people who are contributing a small amount to an economy or not contributing at all to the economy, then in theory, if they are lost to the economy, then there is more for everybody else that is left. That is the simple economic argument and the maths works, which means that we are looking at the wrong measures of what this dreadful disease does. What one really needs to be looking at is beyond the macro-economic to the effect on poverty and development. 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. This is the whole problem with what we’re measuring because you can’t measure what isn’t there. And the family that has collapsed and the children who are living on the streets of Bulawayo or Johannesburg, how do you measure it?

The second set of indicators are those which are concerned with development. Now effectively here, probably the best indicators are those which have been developed by the United Nations Development Programme. Effectively what the UNDP said was that economic growth is a means, development is the end. Now, if you are not alive, you can’t enjoy the fruits of development. And both the human development index and the human poverty index or HPI have as part of their components life expectancy. Now what we’re seeing is a dramatic and serious deterioration in life expectancy in many African countries, to the point where countries are plummeting down both these indexes, and it is clear that all the development gains of the past 40 years are being lost by these measures. And I think it’s probably high time that we stopped talking about an epidemic because AIDS is endemic. It’s going to be with us for the next generation and probably longer, no matter what we do.

We used to believe in a society that HIV prevalence levels among adults were unlikely to exceed 15%. We’ve been proven wrong. In Botswana, the data shows that HIV prevalence levels among antenatal clinic attenders are already 35%. In other words, of women having babies 35 out of every 100 are already infected. I don’t believe that adult HIV prevalence levels can go much about 25%. Can a society have 25% HIV positive levels for years on end? It would seem that this can happen. Sadly Botswana has certainly had that sort of level of infection for the last 3 years. But the problem is that you need good data and in many countries we don’t have the data which allow us to measure this. But yes, I think it is quite possible that in some countries you might have it for 5, 6, 7, 8 years. And who knows beyond that. The problem with this epidemic is that it’s so new that we’re having to learn as we go along. 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.

We should also be weeping for the future generation, the children. One of the most heavily affected nations in southern Africa is Zimbabwe. A quarter of Zimbabwe’s children have lost one or both of their parents. The figure is expected to double within a few years. An entire generation of children is emerging with little or no education, few or no skills. According to Dr. Alan Whiteside, this is the most serious consequence of the AIDS epidemic.

The children are the future. If they don’t get educated, if they are stunted because they’re not getting proper nutrition, then you’ve got a generation which is not going to function as full members of society. And I think if I was to pick the one area where I would want to put in mitigation programmes, it’s for orphans. It’s to try and ensure that the next generation has less HIV infection and is capable of building and working in the nations. I find the complete inability to comprehend the scale of the problem absolutely bewildering because there are at least 800,000 orphans in Zimbabwe, nearly a tenth of the population is orphaned. Probably a quarter of the children are orphaned. And yet there is this inability to grasp what this means for the future of society. Looking at South Africa, I think that for us it’s even more desperate because effectively what you had was a generation lost because of apartheid, because of the education system crumbling, because of the unwillingness of the young people to be involved in anything that the state was providing. The effect of AIDS is that we now have a second lost generation, a generation whose parents have gone, who are not getting the education, who are not getting the nutrition, and perhaps most importantly are not getting the love and the socialisation that goes towards making future citizens in any citizens. I think what it means is a generation of people who lack social skills, who lack any qualifications right the way down probably to basic literacy, who are extremely de-socialised and who are a real threat to the future of society. When you talk about the dangers. I mean are you talking about things like an increase in violence, an increase in sexual abuse and alcoholism and things like that? What we’re basically talking about is everything that will destroy a society, and here one is talking about all these factors. There’s undoubtedly going to be increasing crime, petty crime particularly, but in South Africa, violent crime is a real possibility. We’re looking at sexual abuse of children who are orphaned, who are on the streets. That happens all the time. 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. That they’ve been abandoned. That they’re abandoned. Yes, they’re abandoned not just by their parents but by the societies in which they live.

Dr. Whiteside and others have been watching the epidemic develop for over a decade now. Even the experts have been dumbfounded by the rate at which AIDS is spreading. In 1996, Dr. Whiteside and other social scientists met in Jaipur in India – another country which is seeing HIV rates skyrocket. They set about creating a conceptual framework in which to better understand and predict the spread of the AIDS epidemic.

Four years ago, we were working with a group of students in Jaipur in India, and we were trying to work out how we could explain the current epidemics in some countries, and try and predict where future epidemics might occur, and this idea came out of that group. The reason it’s called the Jaipur Paradigm is quite simply we said to the students, we can’t write this up and put 30 names on the list of people who’ve been involved in developing this idea. We’re going to call it the Jaipur Paradigm and if you ever hear it mentioned, anywhere in the world, in print or on Radio Nederland, you’ll know that you were part of this. You were part of the intellectual exercise which brought this idea to fruition. And basically what we say is that there are only two factors that are important in predicting where the AIDS epidemic will be and in showing why it has been where it has been. This is of course a gross oversimplification and these are extremes, but nonetheless it does work. The two factors are on the first hand, levels of income in a society, whether it’s high, medium or low. The second factor is whether or not the society is a cohesive society.

Cohesive societies are societies with a high-level of social control, in other words societies in which individual rights are subservient to the authorities, traditions or religion.

It could be – as we see in the Moslem states, the extreme Moslem states, where the women are not allowed outside unless they’re dressed in a chador. It means that there is extreme sanction for being found with somebody else’s wife. So it’s a very controlling environment. It may be political control, as in communism where effectively you were very restricted in what you could do in your personal life because the state was in control. It may be authoritarian. It may be a strong military government. An authoritarian government could achieve the same levels of social control as a religious government or a communist government. The alternative to social control in a society is the level of civil society. Now this is defined as that which occupies the space between the state and the household but which isn’t concerned with production. So it’s people coming together for reasons which are not centred around the production of goods. It’s people coming together for football clubs, for church groups, for flower arranging, for boy scouts, for non-governmental organisations. Anything which is not concerned with production and a pay packet can be defined as civil society. And we argue in the Jaipur Paradigm that societies where there is a strong civil society are unlikely to have an AIDS epidemic and the reason is basically because people take responsibility for each other and for their own actions, and the impact that their actions may have on others. So you’ve got an environment in which AIDS is unlikely to spread.

There are four possible scenarios in the Jaipur Paradigm. Once the virus emerges in poor countries with little social cohesion, it’s likely to spread quickly, as it has in many countries in sub-Saharan Africa.

The second possibility is a society where you have a low income but you have a high level of social cohesion, and we’d argue that in those societies it’s unlikely that the epidemic would take off. It’ll trickle along and it may rise to a certain level, but it’s unlikely to rise very high unless something changes in the society. The example of that is probably going to be epitomised by Senegal. Low incomes but relatively high levels of social cohesion and the epidemic seems to be very much under control in that society. Another example of course is Cuba: a highly authoritarian regime. For 10 years they stopped the AIDS epidemic simply by testing all the time and exiling people to sanitoria where they were basically restricted in their movements and so the epidemic was kept under control. But Cuba also provides an example of the society where there has been change, where the level of social control is no longer as strict, and one is seeing the burgeoning epidemic there.

The third group are rich nations with very developed civil societies, countries like Holland and other industrialised nations.

The fourth example and, I think, the one which made this paradigm come to life and actually for me proved it was countries where you have a high level of income – of course, high may be relative – and low levels of social cohesion, and here you’d expect the epidemic to take off very rapidly and to reach extremely high levels. That is the case in South Africa, in Botswana, in Namibia. The epidemic here has taken off and risen at rates which we would not have believed possible, simply because there are many rich men and many, many poor women. There is inequality. There is a lack of willingness to take responsibility for one’s actions. The society is not cohesive. The other thing which I think for us proved that there is validity in these ideas was to look at countries where the epidemic was under control. And here undoubtedly there are two examples which one can look at. The first is Uganda and the second is Thailand. Thailand where the condom programmes which were introduced in the commercial sex establishments brought down STD rates and certainly brought down the levels of HIV. And I think it’s noteworthy that in this society, 100% condom use was enforced. People had to do it. I think it was also a little irony that it was introduced at a time when there was a military government in Thailand, where there was the authoritarian regime which enabled this control to be brought in, but of course the government changed and the controls have remained. Thailand is a highly civil society. Uganda is fascinating because I think that what we have seen there is that the new government mobilised people down to the lowest level and as a result they have been open, honest, frank about the epidemic and are succeeding in bringing it under control. They really have been building civil society, and I think many of the AIDS interventions have been as important because of what they’ve done with civil society as they have been because of what they’ve done because of AIDS.

EB: Why is the Jaipur Paradigm so important, besides getting a better understanding of how the epidemic develops and where it’s likely to develop? I think it’s extremely important because it shows us that prevention needs to address the underlying social factors. It’s no good going in and giving condoms. It’s no good going in and even giving STD treatment. We have to understand how a society works. And at the end of the day, it tells us that development is about those warm fuzzy things like caring for each other, not just about making money, and if we don’t have those warm fuzzy things like caring for each other and caring for the society, then AIDS will continue to cut a swathe through the societies. The Jaipur Paradigm tells you that development is about more than economic things. It’s about a lot more than we’ve taken it to be in the past. If we are going to succeed in preventing this epidemic, we need to understand how societies work. The tragedy of Africa and of the AIDS epidemic is that there are some countries where that is never going to be done. I think that the reality in some parts of Africa this epidemic is out of control and will remain out of control. It’s interesting because the latest thoughts of the World Bank are moving down this line but they still haven’t got there. You said that the World Bank is moving in the direction of taking these ideas on board. Does it take the World Bank, the IMF and the donor community to actually push governments and societies in a direction, or does it actually need to come from societies themselves? I think you’re absolutely right. I think the responsibility of agencies like the World Bank, like the donor countries, the governments of the European countries is not to force anybody to do something. They can’t. The response has to come from within the countries. And that’s why I believe there are some countries where it’s never going to happen. The environment is not right for people to mobilise around this issue. There is too little leadership. There’s too much suspicion. Basically what we’re looking at is a situation where if people want to build society, if people want to be responsible citizens, then you’ve got a setting in which you can actually respond to this epidemic. Otherwise you can forget. You can’t do it. You just can’t do it. So what’s the message from the Jaipur Paradigm? Get down there at the grassroots, get down there where the people are, get down there and help them. The message is also that big spends don’t help. It’s no good throwing millions at the problem. It’s got to happen at the local level. It’s got to happen from the local level and basically the best we can do is create the enabling environment for it to happen at that level.

Creating the enabling environment, believes Dr Whiteside, can be done if people think clearly about how the disease is spread and creatively about ways to stop it. Measures to fight the spread of AIDS don’t need to cost donor countries a lot of money, insists Dr. Whiteside.

Let’s suppose a country is providing foreign aid and the thing which they’re most keen on doing in providing foreign aid is providing roads, infrastructure. Now they could require that 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. And to give you another example: a very simple example. 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. We know that the best programme for reducing infant mortality is the education of the mothers. That alone allows you to bring down infant morality levels in a society. Obviously there are very many reasons for it. So maybe the answer is to start providing education for children, for girl children particularly, for girl children who are at risk because they would not otherwise be educated. Something as simple as providing fees for those children would go a long way towards stopping the epidemic. And 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. And then the other responsibility is to be saying hey, this is about reaching African leadership. I think that every foreign minister, every ambassador, every visiting delegation that sees an African head of state has a responsibility to ask about their AIDS control programmes, how they are dealing with the AIDS epidemic. I think if the countries of the West can show that they really care about it, they may be able to get the people who are not caring about it to start doing so.

There are leaderships that seem to be totally oblivious to the fact that this epidemic is killing millions of their people, and I don’t understand how they can stand by and let this happen. I think that it may be that we have to take responsibility in some settings for saying, OK, if this is your response, we cannot support you further because we realise that we are just supporting a regime which really doesn’t care. A response to AIDS ought to be part of the conditionality for providing aid, and 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. The only way forward is to build a strong, cohesive 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 a 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, in 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, decaying and the result is huge miseration of many, many people. We have been pointing to these issues for the last 10 years as being important and no one has listened. And one feels that sometimes that one is just crying in the wilderness with the ideas, with the realities that one faces. Some weeks ago, someone asked me what effect working on AIDS for the last 10 years has had on me personally. And after I thought about it, the response that I came up with was that it makes me angry. It makes me incredibly angry that we in South Africa sat in 1990 and looked at HIV prevalence rates of only 0.76%. Today we’re looking at 22.8% among antenatal clinic attendants. We’ve seen it coming. We failed to stop it and I am angry about this. I am emotional and I’m angry about the fact that we have done so little to stop the epidemic, that so many people are going to suffer miserable deaths, that there are going to be so many orphans.

Dr. Alan Whiteside of the University of Natal in Durban, in conversation with Eric Beauchemin. We have more on the impact of AIDS in Zimbabwe, one of the countries most heavily affected by the epidemic on our Web site, www.rnw.nl. We’ve also linked the Web site of the 13th annual International AIDS conference which begins on Sunday. That’s all for A Good Life this week. I’m Ginger da Silva. Stay well.