In-depth: Winning the peace: The challenge of AIDS in post-war countries
AFRICA: Home sweet home? The challenge of peace
Ganta Methodist Hospital - one of six new ART sites in Liberia
MONROVIA, 7 February 2007 (IRIN) - "Post-conflict reconstruction" is a neat phrase, which utterly fails to convey the monumental challenge countries face as they try and rebuild after the chaos of war.
Liberia is a good example. After 14 years of warlord violence, its socioeconomic indicators are among the worst in the world. According to the International Monetary Fund, unemployment is estimated at about 85 percent, around three-quarters of the population lives on less than US$1 per day, and approximately 90 percent of Liberians are considered to be food insecure.
The newly elected government of President Ellen Johnson-Sirleaf is expected to make a dent in poverty levels, on top of re-establishing infrastructure and social services for three million people, on a national budget of just $128 million.
HIV/AIDS is an additional challenge. Liberia currently has an estimated HIV prevalence of 8 percent, but peace can often lead to a surge of new infections. Renewed mobility is one reason, the dislocation of families another. "Additional factors spreading HIV/AIDS in post-war situations include prostitution and destruction of health and information-dissemination infrastructure," said a research paper on gender and post-conflict reconstruction by the United Nations University.
"Men in war, women who were refugees, and children who were separated from parents and families constitute a mixed challenge from the perspective of HIV/AIDS. Each of them may have become more vulnerable to HIV during and as a result of conflicts, and for a variety of reasons may go into post-conflict situations with new levels of risk," noted a report by Manuel Carballo and Steve Solby of the Switzerland-based International Centre for Migration and Health.
The development agency, Save the Children, has underlined the extreme vulnerability of conflict-affected people. In a discussion paper on Liberia, released in 2006, the organisation pointed to the alarmingly routine practice of transactional sex between children and those in authority - including peacekeepers and humanitarian workers.
"Parents reported feeling powerless to stop children who were having sex in exchange for goods and services, as they did not have the economic means to provide for their children. In some instances, families cited that transactional sex was a means of supporting the wider family to access things such as food, or money to purchase food," the paper said.Weak national authorities
Liberian refugees who fled to neighbouring Guinea and Cote d'Ivoire are still arriving in the border town of Ganta, in the northeast of the country, three years after the end of Liberia's civil war. Among them are unaccompanied children, raising real concerns over trafficking and sexual exploitation, as well as their possible enlistment as fighters in what remains a volatile region.
The International Rescue Committee (IRC), a relief organisation assisting victims of armed conflict, has set up child protection units that try to provide support. But they operate against the backdrop of porous borders and weak local authorities, unable to regulate mushrooming private "orphanages" and koranic schools, in which children run the potential risk of abuse.
"Nobody seems to be using condoms, there's a lack of awareness [about HIV/AIDS] and a lot of prostitution," said Geoffrey Kirenga, the IRC's senior progamme manager in Ganta.
Providing safe and effective anti-AIDS treatment used to be seen as something only to be considered in the most stable of settings; it has since been shown that it can be rolled out in a war zone, and in countries recovering from conflict.
However, the challenges are significant, especially for national authorities that are supposed to perform a coordinating role but have only limited capacity. There are never enough skilled local medical staff, who tend to be poached by better-paying private programmes.
Liberia has six antiretroviral therapy (ART) centres, reaching 800 people, operated by churches, aid agencies the private sector, and just one by the government. Gaps in the response are a critical issue. "Agencies tend to do their own thing," one humanitarian worker acknowledged, and the government's National AIDS Control Programme, which is supposed to oversee interventions, is at times sidelined.
The lack of public information on HIV/AIDS means high rates of stigma, and the problem of patients who fail to appreciate that treatment is lifelong defaulting on their drug programme. "Adherence is a challenge," admitted a Medicine Sans Frontieres (MSF) official working with the medical charity's treatment clinic in Sanniquelie, a two-hour drive north of Ganta, but did not provide figures on the extent of non-adherence.
MSF is expected to pull out of Sanniquelie in April and hand responsibility for 60 patients on antiretroviral drugs to the ministry of health. "It's going to be a difficult inheritance for the government," the MSF official noted. "If you don't have motivated clinical staff, it's going to be a problem."