Joint Epidemics

Article excerpt

Poverty and AIDS in Sub-Saharan Africa

Former US Ambassador to the United Nations Richard Holbrooke made a striking statement in a speech for World AIDS day at the United Nations last year. "I have come to the conclusion over the last few years...that the most important issue in the world today...is dealing with the spread of HIV and AIDS." He continued, "No one in this room can say that we are winning the war against HIV and AIDS, [though] there are some positive signs that the world leadership is beginning to address it, finally and belatedly." Indeed, the UN Security Council has discussed the HIV epidemic twice within the past year, largely due to pressure from the United States, and against the opposition of some members of the Council.

Still, the question remains: why has the international community largely ignored the social, economic, and political development issues raised by the epidemic, and why has it allocated such scarce resources to an effective global response? These are questions more easily posed than answered, although many nations harbor the suspicion that developed countries perceive the epidemic as being "out there," not their concern, something that can be relegated to the public-health community through the use of their dwindling quantity of overseas development assistance. But because of this neglect, it will prove much more costly to address the impact of AIDS today than it would have been in the 1980s, or even in the 1990s, before the epidemic intensified and expanded.

Poverty Trends in Africa

Although the epidemic is truly global in its scope, it is most pervasive in sub-Saharan Africa. Not surprisingly, it is concentrated in developing countries, which suggests that poverty is a significant causal factor for infection: poor people are more likely to become infected with HIV, and the disease in turn intensifies their poverty. In the case of sub-saharan Africa, the World Bank estimates that in 1998 some 291 million people lived on less than US$1 a day, and that between 1987 and 1998 the percentage of the total sub-Saharan African population living at this level remained constant at 46 percent, implying a significantly increased absolute number of poor people.

While in 1987 sub-Saharan Africa accounted for 18 percent of those living in poverty worldwide, by 1998 this figure had risen to more than 24 percent. Between 1990 and 1999, real GDP per capita in sub-Saharan Africa increased at an annual rate of 0.1 percent, compared to 2.8 percent in the years 1965 to 1980. Not only has there been roughly zero growth in real income in Africa over the past decade, but incomes have substantially declined in countries such as Zambia, and the already large disparities between urban and rural in comes have only grown. This devastatingly poor economic performance has been accompanied by further worsening in the quality of and access to basic social services in many countries, leading to deteriorating school enrollment, nutrition, and health, as well as to an increasingly impoverished population.

In spite of the fact that poverty has a clear causal role in the dynamics of the HTV epidemic, development agencies who trumpet their role as institutions engaged in poverty eradication have done little to integrate HIV into their poverty programs. Thus, the September 2000 World Bank Development Report, Attacking World Poverty, allocated about two pages to HIV and AIDS in its comprehensive study of global poverty. The report displayed little or no understanding of the relationship between poverty and HIV and made no attempt to integrate HIV into its analysis of poverty and its policy recommendations. This is an appalling omission in a world where, according to the World Bank's own data, poverty is increasingly concentrated in Africa and where HIV and AIDS are undermining development performance.

Current Evidence

Of the 36 million persons worldwide infected with HIV in 2000, almost 70 percent, or 25. …