Painting the picture - impact of AIDS on
development in Africa
Professor Alan Whiteside
People in their 20's and 40s are being lost, infants are dying -or not being
born. Is it true, as the CIA has suggested, that high levels of child
mortality are a predictor of state failure? What does this mean for a country's
development?
In 12 years since the first HIV prevalence survey was conducted in South
Africa in 1990, national HIV prevalence levels at public antenatal clinics (ANC)
have increased from 0.8% to 24.8%
HIV prevalence is not uniformly distributed through South Africa's nine
provinces. KwaZulu-Natal (KZN) has the highest prevalence rate, a trend that has
been sustained since the first survey in 1990.
The results suggest that the prevalence rates may have begun to stabilise
over the last two years. However this interpretation may be misleading. These
figures indicate prevalence, i.e. the number of people infected at any given
period; they do not indicate incidence, i.e. the number of new infections in a
defined period. One needs to bear in mind that when prevalence begins to
stabilise this could be a reflection of people beginning to die. The total
number of people infected may be declining because of deaths balancing out new
infections, and not because fewer people are becoming infected.
Just as there are geographical (provincial) variations, there are also
differing prevalence rates amongst men and women and in different age cohorts.
The epidemic peaks at a slightly younger age in women than in men. The figure
below shows that HIV prevalence peaks in women in the age cohort 20 - 29 years.
Here there is some good news because the level of HIV infection has fallen in
the under 20 age group over the past few years.
Fig 1. HIV Prevalence of Women by Age Group: ANC Attendees 1994 - 2001
A peak in 2005?
The Actuarial Society of South Africa model predicts the HIV epidemic will
peak around 2005 when close to four million South African women and eight
million South Africans will be HIV positive. This is the challenge for
prevention.
HIV and AIDS are different to other epidemics as there are two
epidemiological curves. The HIV curve precedes the AIDS curve by about six to
eight years - the incubation period between HIV infection and AIDS illness. In
other words, people contract HIV about 6 to 8 years before they develop
full-blown AIDS, meaning that the full impact of the epidemic and the greatest
need for treatment and care will occur six to ten years after the peak of the
HIV epidemic.
The figure below shows the projected impact that AIDS will have on mortality
in South Africa. The result will be that there is a more than doubling of
expected deaths. These deaths will occur predominately among the economically
active age groups. The people who die are those who have had their education,
and who in many cases, have children.
Fig 2. Projected AIDS and Non-AIDS Deaths in South Africa
The result of such a high level of mortality is a radically altered population
structure, with implications not only for who will become the target of
prevention strategies or the clients of care and treatment services; but also
for who is able to implement the various programmes. In addition it will change
the classic dependency relationships in society.
AIDS and development
The effect of these high levels of illness and death will have very adverse
effects on development in South Africa, and indeed across Africa generally.
However it is particularly desperate for South and Southern Africa. In 1990 the
ANC was unbanned, Nelson Mandela freed and the country set on a path towards
democratic government. In the same year Namibia gained independence. During the
1990s South Africa saw the transition (and the passing of the Presidency from
Mandela to Mbeki), Mozambique's long running civil war came to an end and the
region seemed poised for an era of prosperity. It is into this context that
HIV/AIDS was introduced, and it is because of this that all development gains
are in great danger.
In a short paper it is not possible to outline all the possible impacts the
disease may be having on development. This has been done in other publications .
We would need to look at the economic impact at various levels - from the
national or macro-economic to the household; at the effect of AIDS on poverty
and equity; on services such as health and education; and even on investment and
trade. Rather than do this I will focus on the demographic impact of this
disease.
Put simply population structures are going to change. What we are seeing is a
change in population pyramids. People in their 20's and 40s are being lost,
infants are dying -or not being born. What does this mean for development. What
happens when infants are not there, or die? Is it true, as the CIA has
suggested, that high levels of child mortality are a predictor of state failure?
And then we also need to address the gender balance. What happens when young
women die in disproportionate numbers? What are the consequences for gender
equity, and equality?
Are there examples we can learn from? Not in the developing world. But maybe
we need to look to Europe, and particularly the former Soviet Union.
Life expectancy
Finally there is the issue of life expectancy. This has been explored in
particular by Alex de Waal . He suggests that the fact that HIV/AIDS primarily
causes mortality among adults has important methodological implications for the
study of its impact. "We need to distinguish between life expectancy at
birth (LEB) and life expectancy at adulthood (LEA). In the past most of the
demographic gains have been in reduced infant and child mortality which have
pushed up LEB. In pre-AIDS populations, mortality was largely bimodal: many
deaths occurred among infants and young children, and most of the remainder
among the elderly. Wars, accidents and maternal mortality contributed to a
smaller third mortality peak among young adults, but these deaths were fast
dwindling".
De Waal goes on to note that "LEA of 40-50 has implicitly underpinned a
whole range of assumptions made by economists, political scientists, and society
at large. For example, it is on this basis that we save for retirement, take out
25-year mortgages, expect to see our children into adulthood and become parents
themselves, appreciate the value of specialist training over many years, and
plan our professional and commercial careers. It is likely that the whole
process of economic development and the growth of complex institutions is
premised on assumptions about LEA, which have been so deeply embedded in our
expectations that they have never needed to be spelled out".
A person who saw the disease as an issue many years ago, and understood that
it was more than a health issue was Lars Kallings. It was and is a development
issue. In Africa it is the development issue. I wish I could say that we know
what to do but we don't. We are at the point when we need to set some of the
research agendas and try to understand what AIDS is going to do to us.
More information
Professor Whiteside is the Director, Health Economics and HIV/AIDS Research
Division, University of Natal, Durban.
This article courtesy of the International AIDS Society
Sources used in this article:
Fig.1 Department of Health, 2000 & 2001.
Fig.2 Source: National HIV and Syphilis Sero-Prevalence Survey of Women
attending Public Antenatal Clinics in South Africa, 2000 & 2001.
A Report on HIV/AIDS in South Africa for the:Oxfam South African Programme
Design Exercise, a report Prepared for Oxfam, UK by the Health Economics and
HIV/AIDS Research Division, (HEARD), University of Natal.
Tony Barnett and Alan Whiteside, AIDS in the twenty-first century: Disease and
Globalisation' Plagrave, Basinstoke 2002
Alex de Waal, How Will HIV/AIDS Transform African Governance? Towards a Unified
Framework, paper circulated for comment.
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