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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

From Africa Recovery, Vol.15# 1-2 (June 2001), page 16

UN targets peacekeepers, combatants in war against the disease

By Michael Fleshman

It is now widely accepted that the HIV/AIDS pandemic is, as Secretary-General Kofi Annan asserts in his report on AIDS to the General Assembly special session, "the most formidable development challenge of our time." World leaders increasingly call for a "war" on the deadly infection, and often note that the disease has killed more people in Africa than all of the continent's recent conflicts combined.

African armies and UN peacekeepers are grappling with how to halt the spread of AIDS within their ranks.

Photo: AIM / Santos Finiosse

But there is strong evidence that war itself is a factor in the rapid spread of the virus in Africa. Conflict brings economic and social dislocation, notes the Joint UN Programme on AIDS (UNAIDS), including the forced movement of refugees and internally displaced people and resulting loss of livelihoods, separation of families, collapse of health and education services, and dramatically increased instances of rape and prostitution. All this contributes to conditions for the rapid spread of HIV and other infectious diseases. Military personnel, too, risk contracting or spreading the fatal illness, whether deployed as belligerents or peacekeepers.

On 10 January 2000 the UN Security Council focused international attention on the links between conflict and the disease during an unprecedented debate on the threat of HIV/AIDS to Africa. The Council followed its first-ever consideration of a health issue with the adoption of Resolution 1308 in July, declaring HIV/AIDS "a risk to stability and security" and requesting Mr. Annan to strengthen AIDS education and prevention training for peacekeeping personnel through the UN Department of Peacekeeping Operations (DPKO). Addressing the Security Council's fourth meeting on HIV/AIDS in January 2001, the executive director of UNAIDS, Dr. Peter Piot, applauded the sustained attention: "The simple fact that the Security Council regards AIDS as a significant problem sends a powerful message," he said. "The Council now regards support for the global fight against AIDS as among its core business."

Uncertain impact

The degree to which conflict contributes to the spread of HIV remains uncertain. The conditions which increase the risk of HIV infection in war zones also make it difficult to collect accurate information about infection rates or identify patterns of transmission. The limited data available, however, is alarming. A study of Nigerian troops returning from peacekeeping operations in West Africa, for example, conducted by the non-governmental Civil-Military Alliance to Combat HIV/AIDS (CMA), found infection rates more than double that of the country overall. Significantly, the study also found that a soldier's risk of infection doubled for each year spent on deployment in conflict regions -- suggesting a direct link between duty in the war zone and HIV transmission. (See graph)

Part of the problem, DPKO Medical Unit head Dr. Christen Halle told Africa Recovery, is that conflict tends to bring together two groups at very high risk of HIV infection -- commercial sex workers and 15-24-year-old men. "Among refugees and displaced people it is common for the number of commercial sex workers to increase because women feel they have no other way to keep their families alive."

A similarly risky dynamic, he said, occurs among soldiers. "Military culture tends to exaggerate male behaviour," he explained, by removing thousands of young men in their sexual prime from the behavioural constraints of family and community, inculcating a sense of risk-taking and invincibility, and promoting aggression and toughness as the male ideal -- attitudes that extend to sexual behaviour and often lead to contact with commercial sex workers.

A study of Dutch soldiers on a 5-month peacekeeping mission in Cambodia found that 45 per cent had sexual contact with prostitutes or other members of the local population during their deployment. With 18 violent conflicts, tens of thousands of troops in the field and some 8 million refugees and internally displaced people, Dr. Halle noted, it would be surprising if war were not a major factor in the spread of HIV in Africa. "There is a whole context [in combat areas] which contributes to the spread of infectious diseases, including sexually transmitted diseases like HIV."


High infection rates

The behaviour of the Dutch contingent in Cambodia lends statistical weight to a truism of military life: that for as long as there have been wars and young men to fight them, soldiers have found opportunities for sex and, inevitably, for the transmission of sexually transmitted diseases. Until very recently such illnesses were considered among the least of a soldier's worries -- often handled with "a wink and a nod" by local commanders and a strong dose of antibiotics from the medics. But amid evidence that infection rates for the AIDS virus are soaring among African military and police personnel, African governments, the UN and the international community are taking a closer look at the link between the uniformed services and AIDS, and are expanding education and prevention programmes.

Even in peacetime, UNAIDS estimates, HIV rates are 2-5 times higher among soldiers than for the populace as a whole. During operational deployment in conflict areas, infection rates among military personnel can be as much as 50 times higher than among civilians back home. When CMA first began working with African military leaders in 1993 to develop HIV education and prevention programmes, said CMA Associate Director Dr. Rodger Yeager, the usual response was denial. "For years we were told that AIDS was only a problem for homosexuals and drug addicts in the West," he said. "It was only when AIDS began to degrade readiness" -- the ability of an army to put forces in the field with the training, manpower and equipment to accomplish its mission -- "that the high command stopped denying they had a problem and started asking 'what can we do?'"

For soldiers and police already infected with HIV, the answer is very little. African militaries, like the states they defend, lack the resources to provide the afflicted with life-saving medications. Indeed, said Dr. Yeager, while almost all African militaries have adopted model "best practice" policies to provide troops with voluntary testing and counseling, few can afford to actually provide such services. Nor is there any guarantee that individual soldiers would step forward for voluntary testing, given the stigma that still surrounds the disease in many countries and the danger of dismissal from the armed services if tested positive.

African military leaders and the international community have focused instead on preventing the illness, developing HIV education and prevention materials for inclusion in existing military training programmes. In Uganda, President Yoweri Museveni told the African Development Forum in December (see Africa Recovery January 2001), the military has a strict policy of non-discrimination against HIV-positive soldiers. The former guerrilla commander, who is widely credited for Uganda's success in halving the country's rate of new infections, stressed that infected personnel are kept in the military and assigned less strenuous duties until they become too ill to serve.

A few other African countries already are beginning to focus some of their limited resources on HIV education for the military. In February, Burkina Faso's defence and health ministers met with the top armed forces officers to agree on a plan of action against HIV/AIDS in the military, as one component of the government's national anti-AIDS programme. This followed earlier, confidential studies on the extent and nature of the epidemic within the army. The plan of action provides for:

-- reducing the rate of new infections among soldiers by 5 per cent annually through educational and preventive measures;

-- ensuring that new recruits are HIV-negative;

-- voluntary, anonymous and confidential testing of military personnel;

-- counseling and the provision of generic medications to ill soldiers;

-- social and economic assistance to the families and survivors of ill soldiers.

During 2001, the total cost of the plan is estimated at CFA 178 mn (about $250,000), with the funding coming from the UN Development Programme, World Bank, a dozen bilateral donors and several national anti-AIDS organizations. Col. Ali Traoré, the armed forces commander, pledged that the fight against AIDS would henceforth feature in the annual defence plan.

In other countries, bilateral assistance to African military organizations also has begun to arrive. In October, for example, the US Department of Defence launched a $10 mn Leadership and Investment in Fighting an Epidemic (LIFE) project to assist its African military partners in HIV prevention. According to LIFE Policy Director David Hamon, the US effort is focused on "training the trainers" in HIV prevention, providing technical assistance in the development of ongoing training methods and underwriting research on the prevalence and transmission of HIV in the uniformed services.

Are peacekeepers spreading HIV?

The policies and attitudes of member states, particularly those of the major troop contributors, are central to the UN's own efforts to combat HIV among peacekeeping personnel. Troop contributing states are responsible for the training and outfitting of the soldiers they make available to the UN, and DPKO can advise -- but not dictate to -- member states about their HIV/AIDS programmes. The issue has grown in significance amid concerns that the UN itself may be an unwitting agent for the spread of the virus around the world. "I regret to say," the former US Ambassador to the UN, Richard Holbrooke, told the Security Council in January 2000, "that AIDS is being spread, among other people, by peacekeepers."

While researchers agree that Mr. Holbrooke's statement is almost certainly true, a lack of data makes it impossible to accurately gauge the severity of the problem. Only a handful of cases have been publicly documented, and the most reliable way to measure the risk -- mandatory testing of personnel before and after deployment abroad -- is favoured by only a few countries.

The concern is justified: "We are huge movers of young people across borders and between continents," Dr. Halle noted. "Some come from non-endemic countries for deployment in endemic areas. Others come from endemic countries to non-endemic areas. It is a huge concern of ours that the legacy of the

UN not be that of bringing the virus into the local environment. The legacy to the country providing the peacekeepers should not be to have them bring the HIV virus back home."

The principle objection to mandatory testing of peacekeepers, he explained, is on human rights grounds. "We cannot force a person to take a test that would exclude him or her from their chosen profession. Until we have a guarantee from troop contributors that the soldier found HIV-positive will not be discriminated against, we will find it very hard to change the policy."


Current DPKO policy as established by the General Assembly is to strongly encourage member states to offer voluntary and confidential counseling and testing (VCCT) to peacekeeping personnel, and encourage troop contributing countries to strengthen HIV/AIDS education and prevention courses in national military training programmes.

One of the biggest obstacles to voluntary testing, however, is cost. "Africans are the most vocal about the need for [voluntary] testing, but also that testing is expensive," said Dr. Halle. "They have the will to do it. They have the policy to do it. But they do not have the financial means to do it." There has been some indication that industrialized countries are willing to underwrite the cost of VCCT by the UN, but even then, said Dr. Halle, there are serious human rights and ethical issues: "It is important in a way that the results belong to us," and not the soldier's government, he asserted. "Because then we can oversee the way we use it so that the results are not used to discriminate.... The confidentiality issue is important here." Like many of the issues surrounding HIV testing, however, there is no consensus among member states about UN testing of peacekeepers. Some countries have reportedly insisted in preliminary discussions that any future HIV test results be made available to the soldier's government.

Focus on prevention

While the debate over testing continues, the UN is greatly expanding its education and prevention programmes among both civil and military members of peace missions. On the eve of a 19 January 2001 Security Council meeting, UNAIDS and the peacekeeping department initialed a cooperation agreement formalizing a joint effort to "develop the capacity of peacekeepers to become advocates and actors for awareness and prevention of HIV transmission." The existing 50-page DPKO booklet on HIV/AIDS will be simplified and released as a pocket card to every peacekeeping soldier. The card will be printed not just in the UN's official languages but in the languages of all major troop-contributing states, and tailored to the cultural norms and sensibilities of the readers.

In line with the recommendations of a UNAIDS experts meeting on HIV and peacekeeping in Stockholm last December (see box, page 19), regional centres, including two in Africa, will be established to encourage greater cooperation among countries. Dr. Halle, as DPKO's chief medical officer, has been designated the focal point for all DPKO efforts to combat the disease. All future UN peace missions will include a similar HIV/AIDS focal point to ensure that HIV awareness and prevention is integrated into all aspects of peacemaking and post-conflict peace-building, that programmes reach mission personnel and humanitarian workers, and that cooperation with local and international civil society organizations is enhanced. Condom distribution has been greatly increased, available not just in the medical tent, but wherever soldiers congregate -- in the bathrooms, dining halls, bars and recreational facilities. The first test of the new approach began in Sierra Leone in March.

Changing attitudes

For Dr. Halle, the real challenge of reducing HIV in UN ranks comes not from the difficulty of developing culturally appropriate training materials, but in changing the attitudes that lead to unsafe and unacceptable behaviour -- particularly towards women and children. For that reason, Dr. Halle noted, DPKO's HIV/AIDS initiative is guided as much by Security Council Resolution 1325 emphasizing the rights of women and children in conflict as it is by Resolution 1308 on HIV and conflict. Rape and prostitution are often seen as inevitable consequences of war, he observed, "but they shouldn't be. These things should be no more tolerated in war than they are in peacetime."

By changing attitudes, he said, DPKO hopes not just to change the behaviour of peacekeeping troops in the mission area, "but to make them activists and advocates to stop the spread of HIV when they get back home. We are trying to develop responsible peacekeepers -- responsible not only in the way they handle their weapons and their direct tasks as peacekeepers, but responsible also in the way of handling their relationship to the population in the mission area and back home."

In the struggle to change attitudes, Dr. Halle said the UN's greatest allies are the religious leaders who accompany their troops into the field. For all the differences in culture, policy and approach, he concluded, there is a standard of decency and behaviour common to all humanity. "I do not expect a Muslim imam to promote the use of condoms. Nor do I expect a Catholic padre to do that. But what I have every right to expect, and where they do comply, is in talking about how you treat the people around you, especially the most vulnerable, the women and children. If you do that within the context of the Universal Declaration of Human Rights, within the context of global ethics, then you do something to contain the epidemic."

 ****Box 1****

"Advocates and actors" against AIDS

From 11-13 December 2000, the Joint UN Programme on AIDS (UNAIDS) convened a group of experts in Stockholm to review current DPKO procedures to combat the disease and recommend improvements. Peacekeeping personnel should be understood as "advocates and potential actors" in the fight against HIV/AIDS, the group declared, and all UN policies should be geared toward equipping them for that role. Key recommendations include:

Training: The UN must develop minimum standards for pre-deployment training on HIV/AIDS for use by troop-contributing countries and UN training personnel. The number of UN Training Assistance Teams must be increased to reflect increased peacekeeping deployments with emphasis on "training the trainers." Education and training for mission personnel should continue during and after deployment.

Codes of conduct: The UN should encourage the development of updated and enforceable codes of conduct for troops, governing all aspects of contact with civilian populations and emphasizing HIV/AIDS prevention. Mission commanders should be empowered to repatriate peacekeepers in gross violation of the code.

Testing: In light of the complexity of the issue, the executive director of UNAIDS and the under-secretary-general for peacekeeping operations should urgently establish a senior expert panel to analyze and develop a comprehensive proposal on the issue of HIV testing.

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