In the next part of this paper we outline two scenarios. We borrow from the Anglo-American terminology and have a high road where the response to HIV/AIDS is open, destigmatising and nation building, and takes place in a supportive international environment. The low road is where denial continues and AIDS is stigmatising, in addition the global environment is negative, here HIV/AIDS splits and fractures Southern African countries. These stories are written as they have happened and take us up to about 2010. There are two key points to be made: first this is a gross oversimplification the reality will be somewhere in between what is outlined here; secondly the future is something we can individually and collectively change and that is the challenge for SCF and SCF staff.
The High Road
There is a growing understanding of the dynamics of the HIV/AIDS epidemic in governments, communities and among donors. People use the modelling tools at many levels to predict the number of infections, illnesses and deaths and make a realistic assessment of the number of orphans. In addition there is a growing realisation that the epidemic is cutting away at human capital, teachers, doctors and nurses are being lost both to AIDS and emigration. Emigration is not a uniquely South African phenomenon; indeed South Africa is guilty of attracting skilled people from the rest of SADC.
The response to the epidemic occurs at many levels and depends on the resources and leadership by country. The Botswana theme вЂњTowards an AIDS Free GenerationвЂќ is picked up by other countries in the region and there is increased emphasis on trying to ensure that young people remain uninfected and are cared for and educated. The next generation is crucial. As a result campaigns such as вЂњLove lifeвЂќ anti-AIDS clubs and school-based activities are expanded and, with constant evaluation, made more effective. By 2005 HIV prevalence in the under 25-age group is actually falling while overall it has stabilised in all countries except Angola and the DRC. In both these countries the peace processes have worked but result in increased mobility as soldiers are demobilised and refugees return to their home. This creates the potential for the continued spread of HIV, however the governments and donor agencies have been made aware of this and have developed innovative and realistic interventions. In Zimbabwe and Swaziland political changes have also occurred and allow the governments to address the HIV/AIDS issue.
The greatest challenge is recognized to be to provide care to the sick, welfare for the impoverished and a future for the children. Governments recognise the need for treatment and although (with the exception of Botswana) the general populations do not get access to ART they do have a range of other treatments. By 2006 it is possible for most SADC nationals to gain access to Voluntary Counselling and Testing and learn their status. The new openness and lack of stigma mean people do seek this information, especially before making life decisions such as getting married or having children.
The governments are working closely with traditional healers who have a recognised role in treating HIV and AIDS, indeed in some countries there is talk of providing a per patient subvention provided the healers are registered and compliant with certain standards. The role of communities is recognised as for many home-based care is the only option, the Home Care Kit developed by the AIDS Unit of the University of Pretoria is widely available in SADC and donors are supporting its production and distribution. Health facilities continue to be over extended but clear syndromic care management guidelines mean that patients are seen quickly and provided with the necessary treatments. There is however pressure on the governments to provide ART, and Botswana is facing an increasing problem of вЂњmedical migrantsвЂќ, people who cross into the border and claim to be citizens in order to access ART.
The governments have recognised that illness and death is causing problems in delivery. In particular the human resource intensive sectors of education, health and welfare are loosing staff, and the private sector has little compunction about recruiting government employees to meet their needs. Governments have revised their terms and conditions of service. Innovative responses are:
The overarching problem of increasing poverty and growing numbers of orphans continues to be vexing. In South Africa the basic income grant is seen as a way of supporting vulnerable people and individuals, and while there is some evidence of вЂњorphan farmingвЂќ the general consensus is that this, and increased pensions, mean that most children have some resources. What is particularly encouraging is the range of innovative responses at the local government level. The emphasis is on supporting community lead efforts, especially those driven by women. Botswana and Namibia are following a similar pattern and the countries are learning from each other.
- they try to retain staff beyond the normal retirement age;
- staff are multi-skilled through continued in service training; and
- new cadres of skills are createdвЂ”for example teachers receive only two years of training in colleges and on receipt of their diplomas are deployed to schools, but they do have the opportunity to gain further qualification through distance learning.
- Secondment of staff from the private sector; NGOs and CBOs.
In the resource constrained countries of the region the problems are more difficult but even here there are some innovative developments. Governments ensure that children not excluded from schools through not being able to afford fees or uniforms. Donors including the Global Fund for AIDS, TB and Malaria, have begun to appreciate the need to transfer resources to communities and mechanisms are being set up to do this. The pilot projects developed in 2004/05 are beginning to be taken to scale. The projects include keeping children in school through fee remissions, uniform and book grants; schemes to ensure orphans are cared for through surrogate mothers; and food and basic necessity packages for the poor and the elderly. NGOs have played a particularly important role in the development of this policy and its implementation.
The role of NGOвЂ™s and civil society has other benefits as well. The decision to sub-contract the responsibility for managing AIDS to local governments, businesses and voluntary organizations was a short-term crisis measure. But the new civil connections that were created stimulated greater confidence in society at large, which in turn strengthened confidence in government itself. By the 2010, governments are smaller, but more effective. Tax structures have been redesigned to support civic organisations, while the governmentsвЂ™ own cost of managing AIDS has been met through new taxes and international support.
Although AIDS is hitting economic growth there is a new spirit abroad. The sincere efforts being made by African governments to address poverty and inequality strike a cord with the international community. (The open and innovative approaches to HIV/AIDS are an important trigger to this). By 2006 SADC is experiencing a GNP growth rate of between 3 and 5 percent. It is faster in Mozambique, Zimbabwe and Angola (where reconstruction is boosting economic activity), albeit off a lower base, but is still low in Lesotho and Swaziland. These marginalized countries are benefiting from NEPAD though. NEPAD after getting off to a shaky start is increasingly important as leaders ask each other how they are addressing the epidemic, plan human resource needs on a continental scale, and begin to ensure that they use their clout as trade bloc.
At the international level the debt forgiveness initiatives have finally borne fruit and most of the SADC countries have experienced a large measure of debt relief. The resources freed up are being allocated to the social sectors. The WTO has finally come through with more favourable trade agreements and the SADC countries have greater access to the US and EC markets through bilateral initiatives. These developments in turn are feeding into economic growth.
Private sector investment is increasing, although Africa is still getting the least investment there are encouraging signs of new investment. Companies are moving here to take advantage of growing markets, readily available labour and natural resource endowments. One of the most interesting developments is that larger companies are routinely providing AIDS education, basic health care and condoms. Smaller ones are being assisted through chambers of commerce or industry and associations with larger companies. By 2007 it is routine for companies to strive for the вЂњAIDS StandardвЂќ or вЂњkite-markвЂќ and the private sector and community activists are driving this initiative. The Debswana model of requiring people doing business with them to be вЂњAIDS compliantвЂќ has spread not just to other companies but also to donors, NGOs and government. Governments are supporting these initiatives through tax breaks for HIV/AIDS training and care. One very interesting development is that an increasing number of companies are following the Debswana lead and providing subsidised ART through medical schemes for employees and spouses. This is prolonging the lives of infected workers and while a simple cost benefit analysis shows that in pure financial terms this is not worth it, the message it sends to workers about how they are valued is increasingly important.
Across the region there is a new optimism. The increased community action and support is significant, as AIDS becomes a normal disease. The language around AIDS has changed. During the worst years of 2001-2004, when HIV-positive people had said, вЂњ I will not die alone,вЂќ it meant they would spread the HIV so that others would accompany them to the grave. Now, barely six years later, HIV-positive people would hear others say: вЂњYou will not die alone, because we are all here with youвЂќ.
Despite the stabilising of HIV prevalence, the death rate during the following years continues to rise up to 2010, as those who were infected in the 1990s fall ill and die. Women are hit particularly hard, having been infected in their earliest adult years. They worry above all about the future of their children. They do not want to leave them in institutions, but want to know who is going to care for them after they have died. As early as 2002-3, personal requests for help multiply in all directionsвЂ”to family, friends, neighbours, bosses and organizations located near by. Everyone is asked to take children in or at least support their education. Companies are also expected to help, not just as organizations, but as communities of individuals who have personal resources to share. It is around the children that the high road of caring compassionate societies is taken. There is also a new gender relationship as women become increasingly mobilised and vocal about the situation.
The Low Road
In this scenario denial continues and there is little leadership or understanding of the terrible impoverishment going on in much of the region. In South Africa and some of its neighbours senior politicians and leaders die in increasing numbers of вЂњpneumoniaвЂќ and вЂњrespiratory failureвЂќ. AIDS is never mentioned and the effect of this is to demoralise and bewilder citizens who see clearly that not all is well with their worlds. They are burying their children, brothers and sisters with no acknowledgement and little assistance from their governments.
This means that prevention messages are not received and not believed when they are received. HIV prevalence continues to rise until the susceptible populations are saturated, but worse than this new cohorts of young people are being infected as well. In Botswana, Swaziland, Lesotho and Zimbabwe HIV prevalence levels off at between 35 and 40%, Mozambique, Zambia, and Malawi see HIV prevalence rising into the low 20% rangeвЂ”the poverty, rural urban mix and Muslim populations ensuring lower prevalence rates than elsewhere. South AfricaвЂ™s national prevalence peaks below 30% but this hides great differences between provinces. In some such as KwaZulu-Natal and Mpumalanga HIV levels are comparable with the worst in the world. In others, Western and Northern Cape the prevalence stays around the 10 % level. By 2006 prevalences have peaked and there signs of hope in Botswana, Zambia and Mozambique, but these are the exceptions.
The political situation is not encouraging. In Angola and the DRC the fragile peace has not held and conflict begins again. There are fresh contingents of troops sent from Namibia, Zimbabwe, Rwanda, and Uganda and these troops play a role in HIV transmission, but more importantly resources are diverted to fund the war. Zimbabwe continues to spiral into political and economic anarchy. AIDS and HIV become increasingly irrelevant in the battle for daily survival. In South AfricaвЂ™s 2004 election the main victor is apathy, but AIDS is an election issue and the ANC majority is sharply reduced. The leadership become increasingly intransigent and dictatorial.
Those who are wealthy and infected receive private, state of the art medication, but others are dying more quickly without nourishment or hope. In South Africa the language of AIDS reflects a sense of exclusion from the benefits of the new regime. вЂњWhat did the struggle achieve?вЂќ ask many people. A sense of desperation grows. Street demonstrations multiply from people who are demanding drugs, believing these will cure an illness which cannot be cured.
Violence and crime increase, as desperate people look for any way to raise the money to treat the disease. There is a growing division in society as the wealthy retreat behind razor-wired walls or leave the country. Privately, people who have been asking themselves where this HIV comes from, revive the apartheid-era stories that AIDS is spread by white men who want to kill off the black population, and that it is the west that wants to eliminate Africa. Arguments are more and more violently polarized. There is continued denial and blame on all sides. Activists blame the government for not taking the lead. This is whipped up by the press, who seize on every utterance made by the President with gleeful and vitriolic disbelief.
This spills over into Southern AfricaвЂ™s international, African and regional relations. As South Africa is the economic, political and intellectual leader in the region many of the other African countries take their cue from Mbeki. The complete inability to respond to the AIDS epidemic leads to growing frustrations among the international community, and this combined with the collapse of Zimbabwe, the continued conflict in the DRC and political intransigence in Swaziland and Lesotho leads many to shrug their shoulders, ask why they expected anything different and move on to deal with other parts of the world.
Globally debt relief has simply not gotten anywhere, indeed many countries are finding themselves falling deeper into debt. A similar situation applies to the global trade negotiations. The region finds itself increasing locked out for the lucrative American and EU markets. The result of the political problems is investors are not prepared to put money into the region and economic growth is slow. Over the period to 2007 some momentum is maintained through NEPAD and the вЂњAfrican renaissanceвЂќвЂ”the view that Africa can develop itself. However by 2007 growth begins to falter and fall below 2 percent per annum.
Unfortunately growth is further hampered by loss of skilled people and in some countries a decline in the market. Many private sector firms and investment advisors are taking a long hard look at what HIV/AIDS may mean to the business climate and they do not like what they see. There is capital flight and the share of Foreign Direct Investment falls further as people regard the HIV risk as significant. The tourist industry throughout the region is particularly badly hit. In addition government operations become increasingly inefficient as civil servants fall ill, taking long period of sick leave, die or poached by the private sector. Getting permits to operate, tax clearance and so on becomes increasingly difficult and as result bribery and corruption becomes part of the business environment. Poorly paid government employees, supporting increasing numbers of orphans and impoverished relatives are happy to make what ever extra money they can.
Little attention is paid to the impact AIDS is having on education. As AIDS hits families, children are withdrawn from school. Not only can families not afford to educate their children if any financial contribution is required, they increasingly need the childrenвЂ™s labour at home. Orphans have little incentive to attend school, and their numbers grow as their parentsвЂ™ die of AIDS. However even those children who manage to get to school are getting a lower quality of education. Teachers are falling ill and leaving their classrooms for long periods. Nor can they be easily replaced as government conditions of service allow for lengthy periods of sick leave and medical boarding that can take months. Things are made even worse because the epidemic also cuts a swathe through the private sector workforce. In order to replace staff, teachers are poached by the private sector (a chemistry teacher can be turned into an industrial chemist, a mathematician into an accountant). The result is that education deteriorates further and, with jobs hard to find, people question its value.
In this climate, many health professionals find they are unable to work in the government system. There is little they can offer patients, and they feel at risk. The public health system begins to collapse while in society at large many people are вЂњjust hanging onвЂќ. They hope that things will improve but have little expectation of this happening. Worse, with the lack of any clear policy on the treatment of AIDS, there is a growing black market in anti-retroviral drugs. This market is often based on illegal import licences obtained through bribery. In many cases these drugs are sub-standard or fake. Even legal drugs are often used improperly, or shared with others, reducing their efficacy. The result is a virus that mutates quickly. Soon there is no effective treatment available for the strains of HIV in South Africa.
The result in this bleak scenario is that skill flight increases in momentum and the crisis of confidence in the region deepens. The land issue once a burning problem becomes less important, morbidity and mortality mean that there is land enough to spare but the skills and capital to cultivate it are no longer available. The AIDS related food crisis of 2002/03 deepens and malnutrition becomes the norm. This further fuels the epidemic.
PeoplesвЂ™ vision narrows as they seek to protect and support their immediate families. Society factures into interest groups or coalesces around powerful people including criminals and warlords. This is clearly evident by 2006, and results in further economic stagnation. When the impact of AIDS is added, the numbers show that economic activity has actually declined. By 2007 skills flight is at an all time high and investors choose to avoid the region. Southern Africans are not politically engaged, and will not hold the government or state bureaucracy to account. They have come to expect and accept poor service and the need to pay bribes for ordinary government services. With little employment available, there is an increase in government patronage jobs, causing a further decline in the quality of government service
In Swaziland and Lesotho events move more swiftly as they are so much poorer at the start; by 2007 the countries seem to be in terminal meltdown. Mozambique manages to keep HIV prevalence lower, which is attributed to its poverty, Catholicism and poor infrastructure. But the вЂњbad neighbourвЂќ effects of being located next to South Africa slow growth there. Botswana is the exception in this story. Here powerful government leadership, the willingness to import labour and the fact that it is the global test case for response to the epidemic encourages massive inflows of aid, helping the economy to grow, even when diamond sales drop off. A major new economic activity is health care and the country attracts medical вЂњtouristsвЂќ and medical refugees from as far away as Kenya and Nigeria. However the proximity to South Africa and Zimbabwe is detrimental to economic growth and development efforts.
By the end of our scenario period (2010) there has been an additional and very worrying development with regard to the rights and status of women. There has been a general move towards conservatism and tradition. However a major problem is that the gender ratio has changed. There are now about 85 women to every 100 men (a reversal of the previous 102 women to 100 men). The loss of women is particularly marked in the under 30 age group. This leads to a commoditisation of women, they are regarded as valuable for care and their reproductive capacity.
Effectively in the low road the development gains of the past few decades are reversed in every arena. Political, economic and social deterioration seems to feed on each other and the long term prospect look bleak.