AIDS and AFRICA a Gender Driven Catastrophe

Facts

The numbers are staggering. The pain is long term. The affect on society is deep reaching. The word genocide can easily be made to fit this tragedy. And gender exploitation lies at the center of the problem - AIDS in Africa.

There are twenty five million Africans infected with the HIV virus. ¹ This number is probably a minimum, as doctors seldom write 'AIDS' as a cause of death, there is only limited AIDS testing, and what testing is done, occurs on pregnant women who represent a sub-section of the at-risk population. Of this number, 2.4 million Africans died of AIDS last year, out of nearly twelve million who have died since the crisis began. ² There are twelve million AIDS orphans on the continent, with Zimbabwe possessing the largest number with three-quarters of a million, a number which increases by 60,000 a year. ³

Africa possesses two thirds of the world's HIV infected population, and over eighty percent of AIDS related deaths. In many sub-Saharan countries more than ten percent of the population has HIV, in southern Africa this figure lies between fifteen and twenty-five percent. UNAIDS provides the facts: "According to 1999 estimates, by the end of the year 33.6 million men, women and children were living with HIV or AIDS, and 16.3 million had already died from the disease. In 1999, there were 5.6 million new infections worldwide, of which 3.8 million were in sub-Saharan Africa." ⁴

While the United Nations has suggested that three billion dollars are needed for prevention and care services, the world community has provided about five percent of this amount. ⁵ Industrialized countries have turned a blind eye to this tragedy.

Along with a lack of international financing from the countries of the Global North, sub-Saharan governments have failed to use their resources to respond to this health crisis. Despite the fact that AIDS kills more Africans than armed conflicts, heads of state seldom discuss the crisis, much less provide financial support to the fight against HIV. The Boston Globe states that "sub-Saharan countries spend about $160 million fighting 4 million new AIDS cases per year, and most of that is foreign aid, according to US government figures. By contrast, the United States spends $880 million on just 44,000 new cases annually." ⁶

This level of spending becomes all the more criminal when it is clear that many countries spend more on their military than on the fight against AIDS. "By it's own figures the Zimbabwean government spends seventy times the amount that goes to HIV programs on its support of the war in the Congo-a conflict with no direct implications for Zimbabwe." ⁷

South African judge Edwin Cameron, who is HIV positive, observed at the 1999 XIII International AIDS Conference that: "I am here because I can afford to pay for life itself." "Those of us who live affluent lives, well attended with medical care and treatment, should not ask how Germans or white South Africans could tolerate living in proximity to moral evil. We do so ourselves today, in proximity to the impending illness and death of many millions of people with AIDS." ⁸

Gender

UNAIDS writes that "Biological and social factors make women and girls more vulnerable to AIDS than men, especially in adolescence and youth, when in many places HIV infection in young women has been found to be 3-5 times higher than among boys. Violence -- or the threat of violence -- against women increases their vulnerability to HIV and reduces their ability to protect themselves against infection".⁹ Gender also plays a key role in the spread of HIV in three key areas: sexual assault, culture and development.

Sexual Assault

The lack of control over sex, which many women experience, is nowhere more apparent than in societies in the midst of conflict or with uncontrollable crime problems. In countries with ten to twenty five percent infection rates, presumably higher among young male rapists, non-enforced laws and treaties concerning sexual violence do little to prevent the spread of HIV.

Similarly, troops in Sierra Leone, Rwanda, and in the Congo have all been accused of using rape as a weapon of war. With the last conflict involving six other African nations (including Zimbabwe with its 25% infection rate) it is easy to see how armed conflict and male sexual violence are significant conduits for the spread of HIV throughout the continent.

With an eye on African troops, the UN Security Council has sought to mandate HIV tests for all troops participating in peacekeeping operations - a move that has been resisted by African nations upon concerns of privacy violations and discrimination against infected peace-keepers. As the governments of developing countries receive a relatively substantial stipend for the services of their armed forces, there are clear economic reasons for this resistance as well.

The threat, however, is not just from HIV positive soldiers spreading the virus where they are stationed, but also from the real possibility that they will catch such while working internationally. Soldiers from Nigeria and the Netherlands, among others, have already been diagnosed as becoming HIV positive while serving internationally. ¹⁰

Despite their support for testing, the industrialized members of the United Nations have been conspicuously quiet concerning the prosecution of troops sent home for sexually assaulting women or organizing child prostitution rings. The same holds true for discussions of banning prostitution much less prosecuting soldiers who sleep with prostitutes.

Cultures of Masculinity

Many suggest that men are the primary cause of the AIDS epidemic. One Reverend in the United States asserts that male promiscuity, in this context, is akin to male violence. Given the fact that men have more partners than women, generally control when and how sex is conducted and are the driving force behind demand oriented prostitution, this statement seems reasonable. ¹¹

As a result of this perspective there has been a growing trend toward analyzing and attempting to manipulate male values and identity as a solution to the AIDS crisis. The goal has been to move away from a masculinity that is tied directly to how many sexual partners one has, toward one of protecting yourself and your family.

This type of examination, however, identifies only one part of the problem, and ignores the poverty women face economically and powerlessness in negotiating sexual intimacy. The two together make women vulnerable to the unhealthy attitudes of men and should themselves be the focus of anti-AIDS efforts. As is suggested in a Village Voice article, such initiatives are successful: "boosting women's power provides a proven bulwark against the virus. A Zambian study, for example, found that women who finish school are four times more likely to avoid HIV than women who drop out." ¹² Similarly, arguments concerning African culture miss the point.

African Culture

There seems to be a never-ending debate on culture. African leaders get defensive in discussing HIV out of fear of supporting racist caricatures of hyper-sexual black men and sexual frenzied black women. At the same time commentators, dancing the fine line between ignorance and racism, politely suggest that African traditions support polygamy, and thereby promiscuity, and thereby the spread of HIV. Both positions waste our time.

Sadly, men are socialized in very similar ways across the planet: to view sexual contact with women as a sign of their manhood, the more women - the more of a man you are. They are also taught that sex without a condom is preferred. The poorer women are, the less educated, the fewer rights they possess - the lower their ability to choose who they sleep with - and subsequently the higher the rates of HIV infection.

There are of course some relevant cultural issues. Africa has not yet had a prominent popular man's man come forward and discuss HIV/AIDS as occurred in the United States with Magic Johnson. As a result there exists a strong reluctance to discuss promiscuity and sexually transmitted diseases. At the same time, contracting the diseases is viewed as being the fault of the infected person, who is usually ostracized and condemned, and at times physically attacked. Similarly, the Catholic Church, which is very prominent in Africa, has been quiet on the subject of HIV, terrified to say anything more than "abstinence", and has not spoken up for the victims of AIDS and their families.

But these are not African cultural differences, the same sorts of responses have been observed in the United States and Europe. Similarly, where there have been serious efforts by African leaders to combat AIDS, significant reductions in the spread of the disease have occurred. As Kurt Shillinger reports:

"President Yoweri Museveni [of Uganda] was outspoken about HIV long before any of his counterparts, and mobilized his government to treat AIDS as a concern for all ministries and sectors. The country encourages people to have confidential HIV tests prior to marriage and promotes community-based care for those ailing from advancing AIDS. After reaching a peak in the early 1990s, when as many as 36.6 percent of urban pregnant women tested positive for HIV, Uganda has apparently reversed infection rates. By the end of 1997, only 14.8 percent of women attending urban clinics had HIV." ¹³

In addition to these cultures of silence there are also cultural trends in developing country that actively lead to higher rates of HIV infection and the spread of such. In many countries, when a husband dies, his spouse is expected to sleep with her brother in law as a form of ritual cleaning, or to marry him. There is a high probability that the husband has died of AIDS, that the wife is infected, in short time that the brother in-law will also contract HIV and infect others.

Similarly, women have few property rights in many African countries and upon the death of a husband, all land and finances go to the husband's family. In theory this explains why the brother in-law becomes responsible for his sister in-law and marries her, in practice women are kicked out of the family, off of the land, and are forced to resort to prostitution or dependency upon another male in order to survive.

Perhaps the most devastating cultural factor is a new one, strongly related to the development process - namely the sugar daddy factor.

Unlike traditional polygamy, in Africa and elsewhere, where men - who can financially and sexually support more than one wife - do so, sugar daddies trade gifts, money, and promises to girls and young women for sexual favors. There is no long-term financial commitment, nor any rules offered by society in regards to the woman's rights, as is the case with polygamy. This type of exploitation is a major problem, in fact one study suggests that 60 percent of women are HIV-positive by the time they are 25.¹⁴ While culture is not the driving force behind the spread of HIV, it is clear that African leaders and people must address and alter some key social norms.

Development - The Answer?

With poverty leading to conflict, prostitution and the sugar daddy syndrome, the solution should be obvious - development is the answer. Sadly, this is not the case; all too often development has resulted in the increased economic exploitation and impoverishment of women and subsequently a reduction in their negotiating power in sexual relationships.

Development in most sub-Saharan African countries has meant one of three prospects: 1) Mining for precious minerals/oil 2) Export of Crops 3) Tourism. Concurrently there has been an increase in education, intensive urban migration and the creation of an upper class of men who are able to exploit poor women.

1) Across the continent, developing mines for the extraction of minerals means the creation of sleeping facilities for the workers, who are hundreds of miles away from their female partners or major cities in which to meet new ones. Not surprisingly when you have men with money and no women around, prostitution appears.

Concurrently, as many female partners are left in rural areas without significant financial support, they often develop sugar-daddy relationships with employed men in the region. This dynamic holds true for urban migration as well. Women who remain in rural areas often seek the services of sugar-daddies, men in new urban areas solicit prostitutes, and women encountering labor market discrimination in urban areas enter into prostitution/sugar daddy relationships. South Africa serves as an excellent example:

The miners, who migrate from all over southern Africa, are barracked in all-male hostels, in which a dozen or more men share rooms as small as 20-by-20 feet. Most can afford to visit their families no more than one weekend every other month. With such separations from wives and girlfriends commonplace, the sex trade flourishes -- and so does HIV. Between 27 and 41 percent of miners around the town of Carletonville, where the East Driefontein mine is located, are HIV-positive. So are two-thirds of the women in so-called hot spots like Mogweba's squatter camp. ¹⁵

2) Increasing the export of agricultural goods often directly hurts women financially. They are no longer able to produce food for consumption and are instead dependent upon the whims of their spouses who sell crops to exporters and subsequently control the profits. This has a two-fold effect of lowering a woman's ability to reject her husband's infidelity, or unsafe sexual practices, and providing male partners with the cash to engage in prostitution or sugar-daddy interactions outside of the marriage.

3) While tourism can bring in substantial revenue for a country, it inevitably also invites single males looking for 'a good time' or child prostitution, and where there is demand - there is supply, with prostitutes quickly becoming fixtures at major hotels and bars. Indeed, East Africa was the primary spot for sex tourism in the 1980s (South-Asia subsequently claiming this mantle as men attempted to avoid East Africa, which had become equated with HIV).

Because large parts of Africa's population live in rural areas, development efforts require sending doctors, engineers, teachers, tax collectors, and civil service administrators into these areas. Labor market discrimination ensures that the majority of these individuals are men, while male dominated urban migration guarantees that most of the rural residents are women.

In this context, it is easy to see how sex can be traded for administrative or financial favors - for health services/in place of taxes. In setting up systems in poor communities where health care, education, clean water, and sanitation are fee driven, governments invite exploitation and the spread of HIV to its civil servants and rural areas. Sadly, this type of exploitation occurs too often and those who should be most aware of HIV, and attempt to avoid such, are some of its biggest victims. In Namibia, for example, after the military and truck drivers - teachers have the highest rate of HIV infection in a given employment category. ¹⁶

Clearly universal and free health care, education, and sanitation would be an ideal, as well as utopian, solution in much of sub-Saharan Africa. It is also easy to see how enforcing laws prohibiting prostitution could damage one of the countries primary sources of income. Similarly, requiring extraction companies to provide lodging for female partners would place African countries at a competitive disadvantage relative to other regions. These consequences, however, do not suggest that some of these steps should not be taken - the benefits of saving a generation of Africans may be more important that export revenue.

Regardless of how one calculates this cost-benefit analysis there are other means of fighting HIV that result in no net loss to the economy. One such example, while only addressing one of the ways AIDS is spread, is implementing a diversity program that ensures that the majority of civil servants in rural areas are women. Doing so would economically empower the women who administer these programs, thereby lowering their dependency upon men and exposure to unsafe sexual practices, and removes sex from negotiations concerning government services.

High Charges of Pharmaceutical Companies

We've identified that the economic empowerment of women needs to be centered in the development process for any successful effort to combat the spread of AIDS to occur. But what about the 25 million men, women, and children who currently have HIV? While drugs that slow AIDS are available and used in the industrialized world they are but legend and the stuff of gods in sub-Saharan countries. The majority of people in said nations have disposable annual incomes ranging from two hundred to one thousand dollars (US), with most toward the bottom of this scale, while the annual costs of HIV drugs average from five to fifteen thousand dollars (US).

Of course these prices don't measure the cost to produce anti-AIDS drugs, or even the research and advertising fees, but all of the above in addition to a large profit - which economic theory suggests is necessary to induce future innovations from firms. Given this logic, it seems reasonable that countries joining the World Trade Organization (WTO) would agree to respect the right of drug companies to be the sole producers of medicines for a number of years. All the more sensible when high tariffs, and bans of access to industrialized markets, are the results of not doing so. But the trade off, for such an agreement, is the abandonment of millions of lives.

As more men, women, and children have died of AIDS, activists in developing countries have demanded the right to produce the drugs themselves, at much lower costs, if companies will not cut what they charge themselves. South Africa is debating doing the latter, but has been reluctant to begin, as they have been threatened with trade sanctions.

Brazil, like India, however, has had a grace period in which it can ignore intellectual property rights, as part of its WTO agreement, and it has used this time fully. The Brazilian government has produced anti-AIDS drugs with the goal of providing care to all individuals with AIDS, and the results are clear. The HIV death rate in Brazil was cut in half in four years and hospital admissions for AIDS patients have fallen by 80 percent. ¹⁷ In the process, Brazil has also proved wrong pundits who stated a developing country could not manage the logistics of distribution and supervision. India has also produced a number of generic copies of anti retro-viral drugs and is offering to sell them to African countries at a cost well below the prices demanded by European and US firms. [India, unlike Brazil, has not instituted a countrywide campaign against HIV and as a result the disease continues to spread rapidly].

There are of course many critics. They state that many developing countries have a much larger problem than Brazil, where only one percent of its population was infected, and will therefore will be unable to accurately dispense the drugs, which could result in the appearance of new drug resistant strains of HIV.

Others suggest that if companies are forced to provide their drugs at lower rates in one area then they will be forced to do so in others. And indeed, many AIDS activists in the US and Europe have been calling for cheaper medicine in these regions - it's not as though poor/working class people in the Global North, without health insurance, have six thousand dollars in annual disposable income for fighting the AIDS virus.

Meanwhile, pharmaceutical companies are doing their best to maintain whatever profits they can. It might be possible to have empathy for their position if their goal was anything but profit. Sadly, this is not the case. If these firms were attempting to balance profit and saving millions of lives, they would be the strongest advocates for:

differential pricing for countries and communities with divergent economic status;
tight restrictions to prevent the re-sale of drugs; and
government support when the sales price from producing at cost is still too high for some countries.

Instead they have stood by and watched twelve million people die. They have instead hid behind the notion of intellectual property rights and suggestions that developing countries don't have the infrastructure to distribute the medicine. Instead they have refused to provide medicine to dying people - even in capital cities where the infrastructure is clearly in place.

The United Nations has tried to serve as a negotiator between pharmaceutical companies and those dying of AIDS, and has even convinced major companies to reduce some of their fees by sixty to eighty percent. The results, however, have not been impressive. Through this haggling UNAIDS, for example, was able to gain a three dollar reduction in the price of a particular drug for a pilot program, from the US price to $6.20(US) a day. ¹⁸ At over two thousand dollars a year, even with this reduction, the price of life is well above the annual income of most Africans -- Brazil produces the same drug for less than a tenth of the cost.

In addition to lowering prices to a level that the vast majority of the dying can't afford, others have reduced the price on one type of drug but not the ones that should accompany such and still others have offered reduced prices but only in limited quantities. ¹⁹ Some companies have offered to donate medicine for a limited time. This move, however, has been viewed with suspicion as an attempt coerce governments into purchasing drugs at their inflated prices, once the donations stop, and it's citizens have grown accustomed to life saving medicine.

As developing countries are dependent upon industrialized ones for the purchase of their exports, they are hesitant to anger their Northern counterparts by violating 'international trade rules' such as intellectual property rights - even when the goal is free market capitalism. Most of these countries, however, have a clause in their WTO agreements that allow them to copy drugs in cases of national emergency. If pharmaceutical companies continue to place profit before millions of lives, hopefully many more countries will begin to produce the medicines themselves.

The European Union has already called upon drug companies to end their legal attack against South Africa's decision to import anti-AIDS drugs. Similarly, during his second term in office, President Clinton issued an Executive Order stating that the US would not legally challenge African countries attempting to import anti-AIDS medicines. Recently in South Africa, pharmaceutical companies agreed to drop their law-suits against the government, while the two continue negotiating. It remains to be seen whether this truce will last. As the US Executive Order was instituted under intense protest from Republicans it is also unclear how long it will remain in place.²⁰

Conclusion

Millions have died, millions more will die, and if the current situation is not addressed these deaths will occur at a faster pace. Indeed, South Asia has the necessary conditions for an AIDS explosion:

High levels of poverty

Violence against women

Military conflict

Trafficking in women

High levels of prostitution

Cultural prohibitions on land ownership by wives

Economic displacement being disproportionately borne by women

And an upper class of men who can exploit poor women

All too often, the debate concerning HIV/AIDS has circled around cultural differences, when in fact; discussion should focus on cultural similarities - the patriarchy. Only through empowering women and girls economically will they have options besides prostitution and sugar daddies. Similarly, only through providing education to girls and women, will they feel empowered to fight for greater control over sexual interactions.

We must force international drug companies to put lives before high levels of profit and demand that industrialized countries not take trade action against nations that create generic copies of life saving medicines. But the pharmaceutical companies are not solely to blame, industrialized governments must provide funding to nations that can not afford generic copies or lower priced patented versions.

Providing 150 million dollars (US) every year to 4 million new African AIDS victims is a travesty. We have seen the level of resources provided to combat a glimmer of this crisis in the industrialized world. African women and men deserve the same response.

End Notes

1. Bruce Japsen, "Abbott to Sell HIV Drugs at Cost in Africa Other Countries May Want Cuts", Tribune 03/28/01.

2. Rachel Swarns, "AIDS Drug Battle Deepens in Africa", New York Times , 03/08/01.

3. Wil Haygood, "Aids and The African", Boston Globe, 10/11/99.

4. The Joint United Nations Programme on HIV/AIDS, Gender Is Crucial Issue In Fight Against Aids, Says Head of UNAID, (UNAIDS. 06/05/00).

5. Mark Schoofs, "The Deadly Gender Gap", Village Voice. 12/30/98.

6. Kurt Shillinger, "AIDS and The African Denial", Boston Globe. 10/12/99.

7. Mark Schoofs, "Africa Responds", Village Voice.11/17-23/99.

8. Mark Schoofs, "The International AIDS Conference Makes a Commitment to Saving Third-World Lives", Village Voice. 08/19/00.

9. UNAIDS, ibid.

10. Mark Schoofs, "The Security Council Declares AIDS in Africa a Threat to World Stability", Village Voice. 01/12-18/00

11. Kurt Shillinger, "The Outsider. Minister tries to shame officials into action", Boston Globe. 10/13/99.

12. Mark Schoofs, ibid., 12/30/98

13. Kurt Shillinger, "Aids and The African Denial", Boston Globe. 10/12/99.

14. Kurt Shillinger, "A Continents Crisis Aids and the African", Boston Globe. 10/10/99. (The Pretoria-based Council for Scientific and Industrial Research).

15. Mark Schoofs, "How HIV Caught Fire in South Africa", Village Voice. 04/28/99.

16. Shillinger, ibid., 10/12/99.

17. Schoofs, ibid., 08/19/00.

18. Schoofs, ibid., 08/19/00.

19. Schoofs, "An American Pharmaceutical Giant Offers to Donate an AIDS Drug to South Africa", Village Voice. 04/4-10/00.

20. Johanna McGeary, "Paying for AIDS Cocktails who should pick up the tab for the Third World?", Time Special 2001.