Marko Kokic/International Federation

Chapter 6 - summary
AIDS: Communities pulling out of downward spiral

Across southern Africa, HIV/AIDS is combining with food insecurity, poverty, worsening health care, dirty water and sanitation, uncontrolled urbanization and common disease to create an unprecedented disaster that conventional intervention can no longer contain.

When farmers fall ill, wives leave the fields to nurse them. Fewer hands mean fewer crops and coupled with drought may bring famine. With the land producing little, the widows fall into debt. When they are gone, the eldest child takes over. Many of southern Africa's four million AIDS orphans are in 'child-headed households', where neither tomorrow's meal nor education is certain. Agricultural skills are being lost. Schools exclude those who cannot afford fees, exercise books or uniforms. While one generation dies of AIDS, another is denied a future.

During previous emergencies, households coped by seeking paid casual work, reducing daily meals, sending children to wealthier relatives, or selling livestock. But the time spent looking after HIV/AIDS patients means that carers cannot find alternative jobs. And relatives are equally affected.

Scarcity of labour leaves more people dependent on fewer breadwinners. Zimbabwe will lose a fifth of its workforce by 2005. Among HIV-affected households, the burden of care reduces cropyields by 60 per cent. Women are infected at twice the rate of men. Yet they form over two thirds of the agricultural labour force. They nurse the sick and, with husbands gone, face debt and the dilemma of feeding or educating their youngsters.

Aid policy is lagging behind. Prompt international action in 2002-03 postponed famine for 14 million people. But hunger was symptomatic of a more complex crisis that food aid alone cannot address. With over 70 per cent of Africa's population dependent on agriculture for their livelihood, HIV/AIDS threatens unprecedented social calamity. Efforts to prevent new infections have not made a major impact. Where HIV prevalence is highest, life expectancy will drop below 20 years by 2020.

HIV/AIDS increases vulnerability to diseases like measles, malaria and TB, now spreading rapidly. Yet government investment in healthcare is under US$ 50 per person per year - making it almost impossible to vaccinate children and meet the increasing demand for care and prevention. Poor healthcare structures hamper the delivery of antiretroviral drugs that could prolong lives by 20 years. Without a new aid paradigm, the destitution of whole communities is inevitable.

Long-term, people-centred support is vital. Removing the stigma surrounding HIV/AIDS is a first step. But surveys in Swaziland show risk-taking continues despite widespread information campaigns. Chief Masilela of Evusweni village has found success elsewhere. He persuaded elders to reserve land to feed orphans and advocated communal farming on idle land. Rather than providing food, humanitarian aid should help the community help itself, he said. Outside support for irrigation would end farmers' dependence on erratic rains, while safe drinking water could reduce the spread of deadly cholera and diarrhoea.

Masilela knows his community's needs. If Evusweni is to recover, he and his neighbours will be central to the solution. It's a simple premise often forgotten. However, evaluations criticised international aid organizations for not fully understanding the communities where they worked during 2002-03. Targeting food aid at specific families undermined the cohesion of rural communities, which traditionally share resources during hardship.

Vertical, sector-specific aid programming must end. Reducing hunger, strengthening livelihoods, spreading awareness, dispelling stigma and changing behaviour are equally vital tools. Three issues must be addressed: stop accelerating poverty; reduce new HIV infections; and reduce vulnerability to disease and disasters.

Creating the right aid programmes means carrying out multi-sectoral vulnerability and capacity assessments, backed by donors committed to holistic programming. Delivering this requires a comprehensive package, implemented by a consortium of partners. The Swaziland Red Cross has teamed with food security specialists, universities and the government to combine home-based care, improved farming through irrigation, and income generation through poultry breeding and vegetable gardening.

Africa's disasters were once characterized by television images of skeletal refugees and fly-eyed, wasting children. But today's disaster is silent. Most of those dying stay at home. Out of sight and out of mind of an indifferent world, millions are dying. Within a decade, Swaziland will lose half its working-age population.

There are some rays of hope. Red Cross volunteers provide home care - they nurse, cook, clean, listen and counsel those infected and affected. They bring food, hygiene parcels and medicine. They provide health education and keep watch for deadly diseases such as TB, which half those living with HIV/AIDS develop. Home care is linked to food distribution and water and sanitation programmes. Most people, lacking latrines, defecate in the bush. When it rains, the faeces are washed into the rivers, from which people drink. So the Red Cross is feeding streams into filtration tanks and piping clean water into clinics and homes. But aid organizations cannot cope alone. Only governments have the capacity to match needs at a national level.

HIV/AIDS has exposed the weak link between relief and development. The humanitarian intervention during 2002-03 to provide millions of people with food was hailed as successful pre-emptive action. Yet it only deferred death. Worse, it sent the wrong signal that 'disaster' was averted - when last year, AIDS killed at least 2.2 million people in sub-Saharan Africa. The pandemic exposes the futility of temporary solutions for complex problems. Stopping at food aid is not enough.

Only a developmental approach, with a detailed understanding of local needs and capacities, can ensure that interventions are effective and sustainable. To achieve this, international aid organizations must cooperate together and with community groups, local NGOs, municipalities and governments.

A multi-dimensional response is needed, combining support for local livelihoods, agricultural irrigation and production, urban food security, education, clean water and sanitation - as well as disease prevention and care. Above all, success will be built on the courage, skills and resilience of those who wake up to the disease every day of their lives.

John Sparrow, the International Federation's regional information delegate in east Asia and formerly based in southern Africa, was principal contributor to this chapter. The box is an excerpt from a press briefing delivered by Stephen Lewis, UN Secretary-General's Special Envoy for HIV/AIDS in Africa.