ETHIOPIA: Interview with AIDS economist Alan Whiteside

Addis Ababa, 10 June 2003 (PlusNews) - Professor Alan Whiteside is a leading AIDS economist based in South Africa. During a visit to Ethiopia, he spelt out the scale of the continent’s crisis, explained how the enormous number of AIDS orphans could mean potential disaster, and called on African leaders to start addressing the tragedy.

QUESTION: Why has the HIV/AIDS pandemic reached such levels in Africa?

ANSWER: There is a particular set of circumstances that have made Africa particularly vulnerable to this epidemic. The first is the history, which is one of grotesque exploitation by various colonial powers. The second is the lack of good public health systems, which have been hugely important in sustaining high levels of sexually transmitted diseases that are very important for the transmission. And the third lies around accountable government. One of the realities of post-independent Africa is that only in a few societies do we have governments that have been accountable and governments that have led for the people. So these circumstances coming together have created an environment in which HIV was able to spread very rapidly.

Q: What is the scale of the crisis if we can put it into context?

A: It is worse than the plague. If we were to design a disease which would be the most disruptive possible, it would be very much like AIDS or alternatively an airborne virus like SARS. The reason it is worse than the plague is because it is a slow- acting virus, which means people will be infected for a long time before they fall ill and before they therefore know they are infected, unless they go for voluntary counselling and testing.

It also takes out people in the middle ages; young people who have had their education, have started their families and started up their career paths or are productive in the villages and homesteads. With regard to the scale there are parts of Southern Africa where 35 percent of the adults are infected.

Q: What is the impact of so many orphans?

A: The answer to that is, nobody knows. One of the sad things for me is there are things we could do to look after them. We could look at the way in which orphans were taken care of in post-war Europe. We could look at the way the orphan catastrophe was taken care of in Cambodia. There is no history like this, we are writing history as times passes, and I have come to the conclusion that AIDS is a Darwinian event – it is going to change the way our societies exist and operate in Africa.

Q: How will it change society?

A: I don’t know. I think there are two possibilities. One is the Mad Max world of enclaves of people being treated, and out there the starving masses that are prepared to take up arms and are living a subsistence existence, hand to mouth, dying young and creating more orphans.

The more utopian version is where we come together and say "this is an issue we have to deal with", and we start saying "we have to care for each other", and start saying "I don’t mind paying a little more tax in order to survive". Perhaps the end result will be somewhere between the two, but it will certainly be a different world from the one we live in now.

Q: Will the infection rate eventually plateau?

A: It has to plateau, and where it will plateau we don’t know. That is why prevention remains so important. So far, we have been consistently wrong and overly optimistic in terms of our estimations of what is going on in the epidemic. But I would say the levels you get in Botswana and Swaziland have got to be very near the peak, which is 35 percent of adults. There are going to be parts of Africa where this simply won’t happen.

Senegal has it under control, Uganda has brought it right down, and there are indications in some African countries it is not more than 10 percent. Tanzania has been consistently below 10 percent.

Q: Do you think the political will by African governments is there to tackle the virus?

A: I think the will is there in some countries and when you look at where the epidemic has been controlled, it is in countries where there is the political will to control it. Here we are talking about Senegal and Uganda, which are the two African examples. It is happening, but it is happening very late and that is the tragedy of Africa. I think we must have the political leadership if we are going to respond to this epidemic.

Q: What would you want to see African leaders doing?

A: Well, the first thing is you have to talk about it, you have got to be open and honest about it all the time. If you do that you are creating a space in which the ordinary citizen can acknowledge its existence. You have to put resources towards it. Here we really are talking about finding domestic resources as well as international donor resources. There has to be a commitment from the local budget. You must also work out ways of putting AIDS into everything you do.

So if you have a Ministry of Defence activity they need to be thinking AIDS. If you have got the Ministry of Agriculture – they need to be thinking AIDS. It has got to be there as part of your mainstream activities.

Q: Is there sufficient capacity to absorb the enormous levels of funding?

A: Finance isn’t a constraint. This problem is a low-finance, high-human-resource problem. One of the most effective ways of dealing with the epidemic is to encourage people to go for voluntary counselling and testing. That means you need hundreds and hundreds of voluntary counsellors because they have to deal with people pretty much on an individual basis.

Q: Is poverty a key ingredient in this crisis?

A: Poverty is not only pushing people into being infected because they are less healthy and women are more likely to engage in commercial sex, because of mobility; it is also stopping people from staying alive longer and it will certainly stop people accessing anti-retroviral drugs.

Q: Are anti-retroviral drugs [ARVs] a solution?

A: For an individual who is infected and who has access to all the things that will enable them to sustain life and take ARVs, then they are the answer. In some settings they are being rolled out very successfully - like the diamond mines in Botswana. They are part of the answer – we have to be providing treatment for people - but only part.

Q: What else needs to be done?

A: If you were to take someone who is HIV-positive, then obviously first prize is to prevent them being infected. But we have to be realistic and recognise there are 30 million Africans plus who are infected. What can we do to make them live as long as possible before they need any form of treatment? What can we do to ensure they don’t progress to the point where they have ARVs – in other words treating opportunistic infections and providing prophylactic treatment? The third question is, what do we do to keep them alive when they have fallen to the point where they do need ARVs, and that is when you would start introducing them.

Q: Is there hope?

A: Of course there is, the hope we see in Uganda and Senegal – the hope of preventing the epidemic we see in Senegal and the hope of turning it around we see in Uganda and increasingly in countries like Zambia. I think what we are learning is if you are going to deal with this epidemic, it requires a new way of looking at development and at people. You need development that is people-centred, which is equity-centred and which is caring. And that unfortunately has been sadly lacking in the world.

Q: But development agencies will tell you their approach is people-centred, equity-based and caring?

A: That is seeing development as being a function of development agencies. I think it is a function of good governance supported by development agencies. Development agencies are part of the problem thus far, not part of the solution. What we have is a picture of development agencies going into certain countries and telling people how to develop.

At the moment it may be people-caring, but 10 years ago the development paradigm was inward industrialisation, and before that it was rural development. Development isn’t about development agencies. They are to facilitate and to provide resources. Development is about governments saying we are actually going to take care of our people.

Q: And do you think governments have not said that?

A: For the first 10 years of the epidemic the people who were most concerned about it were donor agencies, which meant that the disease was seen as a problem by the west – Africa did not see it as a problem. I think that has changed very much in the last few years because we are burying people.

Q: What do you see as the next step and are we moving in the right direction?

Part of the problem is people like me. I am very vocal, I talk a lot but I am a middle-aged white male academic. The people who need to be vocalising about this should be more people from Africa, women, and they have got to speak to their audiences. We do need to see a broader range of people talking about this.

Theme (s): Other,

[This report does not necessarily reflect the views of the United Nations]