From Africa Recovery, Vol.17 #1 (May 2003), page 11

Famine and AIDS: a lethal mixture

Southern Africa reels from a twin onslaught

By John Nyamu

As Southern Africa's HIV/AIDS infection rates combine with widespread famine conditions, the region faces not only sickness and starvation, but also a severe long-term threat to its economies and societies. This twin onslaught of disease and hunger has dire consequences for families, communities and production systems. Agriculture, Africa's economic mainstay, is being hit especially hard.

Photo : ©WFP / Brenda Barton

The focus of Africa's latest food emergency is not only the arid, drought-prone Horn of Africa or Sahel regions, but also Southern Africa. Most of its countries are largely fertile, well watered and traditionally self-sufficient in food. One reason for Southern Africa's current crisis is that the region also has the world's highest HIV infection levels. The UN Joint Programme on HIV/AIDS (UNAIDS) estimated that infection rates in 2002 ranged from 15 per cent of adults in Malawi up to more than 30 per cent in Swaziland and Lesotho and a staggering 39 per cent in Botswana. Meanwhile, the World Food Programme (WFP) estimates that, as of March, the number of people requiring food assistance in Zimbabwe stood at 7.2 million, or 52 per cent of the population. Nearly 8 million more also need food aid in Malawi, Zambia, Lesotho, Mozambique and Swaziland.

A new kind of famine

Returning from a tour of the region in January, Mr. Stephen Lewis, the UN Secretary-General's special envoy for HIV/AIDS in Africa, noted that the swift delivery of food aid has helped ease the immediate humanitarian crisis. But at the same time, he added, a horrifying new disaster looms as HIV/AIDS threatens the "very existence of whole countries."

Mr. Lewis's trip to Lesotho, Malawi, Zambia and Zimbabwe was part of a joint mission with WFP Executive Director James Morris, who is also the Secretary-General's special envoy for humanitarian needs in Southern Africa. The mission's findings, Mr. Lewis said, conclusively demonstrate that a new kind of crisis has developed in the region, with food shortages and agricultural decline strongly influenced by HIV/AIDS. In all the countries visited, the epidemic has taken a heavy toll on the most productive people -- those between the ages of 15 and 45 years. It also has worsened the effects of agricultural mismanagement and poor governance.

Describing the pandemic as "the most fundamental underlying cause of the Southern African crisis," the two officials said it is changing the nature of famine in Africa by cutting agricultural productivity, sapping the population and undermining people's ability to recover from natural and man-made shocks.

The mechanics are chillingly simple. As farmers fall ill, physical weakness reduces their effectiveness and the area they cultivate shrinks, leading to declining crop yields. Food security is simultaneously jeopardized by the diversion of labour, time and money to deal with the illness. Agricultural households revert to subsistence rather than cash crop farming, bringing a fall in household incomes and the capacity to buy food. Family expenditures on health care rise, eventually consuming savings and other resources.

"The effect of AIDS on food production is both immediate and long-term," UNAIDS Executive Director Peter Piot has pointed out.

Some effects are very direct. As of 2001, the UN Food and Agriculture Organization (FAO) estimated that 7 million of Africa's agricultural workers already had died of AIDS, and that 20 million more may succumb by 2020. Such deaths will seriously deplete Southern Africa's agricultural labour force -- and thereby reduce the region's ability to grow food or other crops (see graph).

A study in a communal area in Zimbabwe has demonstrated that an adult death from the disease can immediately reduce a household's ability to produce different foods. The declines average 61 per cent for maize, 49 per cent for vegetables, 47 per cent for cotton and 37 per cent for groundnuts. In Malawi, death rates among employees of the Ministry of Agriculture and Irrigation have doubled, almost all because of HIV/AIDS. In Namibia, studies indicate that agricultural extension workers spend one-tenth of their work time attending the funerals of people who died of AIDS.

In the long term, orphaned children often lack the skills to farm or look after livestock under their care, and households may be forced to sell their livestock to pay for funeral expenses. On a wider scale, extended family networks, which usually cope with the normal traumas of life in African countries, begin to fray under the weight of orphaned young relatives, as breadwinners can no longer bear the extra costs. It is not unusual for a grandmother to care for 20 orphans.

Women hit hard

One aspect of the crisis in Southern Africa has been its disproportionate impact on women. The mission report noted that the prevalence of HIV infection is highest among women and girls, who generally take on nearly all the responsibilities of caring for the sick and orphaned, in addition to their regular obligations to provide food for their households. Yet, the report adds, "very little is being done to reduce women's risks, to protect them from sexual aggression and violence, to ease their burdens or to support their coping and caring efforts."

UN Secretary-General Kofi Annan raised the same concern at the Africa-France Summit in February, highlighting the clear gender dimension to AIDS-related food insecurity. Women care for the young, old, sick and dying, he said, and they nurture social networks that help societies share burdens. "In the past, it was their expert knowledge of alternative foods that kept their families going during times of drought. Yet with AIDS rising dramatically and disproportionately among women, that lifeline is being threatened." In an address last December, he cited 2002 estimates to emphasize the dramatic spread of HIV/AIDS among women. For the first time, he noted, women make up some 50 per cent of HIV-positive people worldwide, with the share rising to 58 per cent in sub-Saharan Africa.

Photo : ©United Nations

Meanwhile, a study on HIV/AIDS and African agriculture by the FAO has shown that with the deaths of increasing numbers of male farmers, rural women, who are already overburdened, are becoming responsible for even more tasks. "These structural changes in smallholder agriculture," concluded the study, "are likely to contribute to increased malnutrition and an overall decline in the nutritional status of a growing number of resource-poor farmers, particularly women and children, with far-reaching consequences for the health and productivity of the agricultural labour force."

'Grinding down'

Mr. Lewis associated AIDS with "the grinding down of society," stressing that the decay of Africa's agricultural sector could be a harbinger of worse to come. Among countries on his tour, Malawi offers a graphic illustration. While several rivers crisscross the lush, green countryside and Africa's third-largest lake forms its eastern border, Malawi is losing people to work its fertile land. It has an annual rate of 70,000 deaths from AIDS-related illnesses (including tuberculosis, malaria and cholera), and life expectancy has fallen from 46 years to 36 years, according to the UN Development Programme. Partly as a result, Malawi has sought emergency food assistance, including donations of maize -- the key staple of East and Southern Africa.

In the mountainous kingdom of Lesotho, HIV/AIDS has exacerbated the impact of the crop failures of the last two years, caused by unusual weather patterns. Rains have come too early or too late. Hailstorms, tornadoes and even summertime frost have damaged newly sprouting maize. Lesotho has the world's fourth-highest HIV infection rate, with nearly one-third of working-age adults infected with the virus. "We're told repeatedly by donors that we don't have capacity. I know we have no capacity; give us some help and we'll build the capacity," Prime Minister Pakalitha B. Mosisili told Mr. Lewis when the mission visited the country.

In Zimbabwe, some 2.2 million people are infected with the virus, of whom 600,000 have developed full-blown AIDS. According to the Ministry of Health, 70 per cent of hospital admissions are HIV-related. Expressing concern over the government's lack of capacity or willingness to address the deepening crisis, the mission report predicted that Zimbabweans would become more vulnerable throughout 2003 because "it is clear that 2002/2003 agricultural production will fall far short of national needs." The deficit is expected to also affect neighbouring countries, many of which have previously depended on food imports from Zimbabwe, particularly in times of drought.

The drought has been particularly severe in Zambia, where the HIV/AIDS pandemic has not only devastated agricultural production and depleted the work force, but also affected every other aspect of life and society. Some 40,000 to 90,000 people had died of AIDS by the end of 2000, most of them men between the ages of 20 and 45, according to one study. The epidemic's particularly high toll on the country's teachers has been aggravated by the high social stigma surrounding the disease. According to Mr. Lewis, former President Frederick Chiluba denied the reality of AIDS and threw obstacles in the way of those keen to confront it. Since last year's election of President Levy Mwanawasa, Mr. Lewis noted, there has been a dramatic improvement in political leadership on the subject of AIDS.

'Mass murder by complacency'

Although heartened by African leaders' new willingness to discuss the epidemic, Mr. Lewis pointed out that money remains a critical missing element. He called the lack of resources to fight the epidemic "mass murder by complacency," and said that those who watched it unfold "with a kind of pathological equanimity" must be held to account.

Photo: ©WFP / Brenda Barton

Echoing the special envoy's concern about international complacency, Mr. Richard Feachem, executive director of the UN's Global Fund to Fight AIDS, Tuberculosis and Malaria, wrote in a Washington Post commentary: "The world's failure to fully fund our efforts -- or any comparable effort -- is yet another indication that people lack the sense of urgency this crisis demands." The Global Fund has agreed to support programmes worth $1.5 bn over the next two years in more than 80 countries. But to carry out further essential activities, it needs an additional $2 bn in 2003 and $4.6 bn next year.

US President George W. Bush's recent pledge to add $10 bn in anti-AIDS funding for Africa to the $5 bn previously promised may go some way towards addressing these concerns, UN officials note. However, disputes over unrelated issues within the US Congress may yet jeopardize approval.

In South Africa, Finance Minister Trevor Manuel announced in his February budget proposals an intention to commit approximately R2 bn (US$233 mn) to provide antiretroviral treatment for people living with HIV. The government also announced that it would sign an agreement with the Global Fund. While drought has not so seriously affected South Africa or Botswana, the region's two most prosperous nations, their infection rates are among the highest in the world.

More attention to nutrition

Proper nutrition for people living with HIV is another basic issue that is rarely addressed. The FAO and World Health Organization (WHO) have jointly published a manual, Living Well with HIV/AIDS, which offers dietary suggestions for people with HIV/AIDS.*

"The relationship between HIV/AIDS and malnutrition is a particularly extreme example of the vicious cycle of immune dysfunction, infectious disease and malnutrition," said Dr. David Nabarro, WHO executive director for sustainable development and healthy environments, in late February. According to Mr. Kraisid Tontisirin, director of FAO's food and nutrition division, "The nutritional aspect of HIV/AIDS has been ignored for a long time. The attention was always focused on drugs."

Dr. Graeme Clugston, director of WHO's department for nutrition in health and development, also affirms the need to pay special attention to the relationship between nutrition and HIV/AIDS: "The effect of HIV on nutrition begins early in the course of the disease, even before an individual may be aware that he or she is infected with the virus."

Pointing out the effects of AIDS on nutritional well-being -- including reduced nutrient absorption, disruption of appetite and metabolism and wasting of muscles, organs and other tissue -- the manual emphasizes that eating considerably more food helps to fight the illness and make up for weight loss. A balanced diet requires more protein to rebuild muscle tissue, more energy-rich foods for weight gain, immune system-boosting vitamins and minerals and water to combat dehydration, it adds. Herbs and spices can stimulate a sluggish appetite or digestion and may have other beneficial effects. However, with extreme poverty widespread in Southern Africa, many people cannot afford to buy the right kinds of foods.

New approaches needed

Amid the harsh realities of HIV/AIDS, particularly in Southern Africa, no single action will make much headway. A combination of actions is needed, experts say: against HIV/AIDS, hunger and rural poverty, and for improved agricultural systems and social services.

The joint mission to Southern Africa by Mr. Lewis and Mr. Morris suggested combining food aid with far-reaching agricultural development strategies and labour-saving technologies that increase resilience to erratic rainfall. It recommended help to generate income and restimulate local food production without adding extra burdens to households affected by HIV/AIDS.

"Relevant actions in education, health, nutrition, water, hygiene and sanitation-related interventions will also be necessary," the mission report said. "The pandemic's steady weakening of national governments and its erosion of their social services call for measures that go beyond building capacity; it is also time to speak of capacity replacement and replenishment." The mission called for long-term measures to strengthen coping skills and ease the burdens on poor and vulnerable households and social groups in order to prevent repeated food shortages.

Mr. Annan told the General Council of the International Fund for Agricultural Development (IFAD) in February that emergency responses to immediate food crises must at the same time be accompanied by long-term development and health initiatives. "We must," he said, "combine food assistance and new approaches to farming with treatment and prevention of HIV/AIDS."

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