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Does HIV/AIDS imply a "New Variant Famine"?

Alex de Waal explores hypothesis with Health Task Force.

Reported by Nathaniel Tembo, WHO Emergency Public Health Officer & John Clarke, Information Officer
UN Regional Inter-agency Coordination Support Office (RIACSO)
E-mail: nathaniel.tembo@wfp.org, john.Clarke@wfp.org
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Alex de Waal
Alex de Waal explaining the "New Variant Famine" hypothesis at Health Task Force Meeting, Riasco
Renowned activist and writer Dr Alex de Waal outlined the "new variant famine" concept to UN agencies and NGO partners seeking better ways of responding to the HIV/AIDS induced humanitarian crisis in Southern Africa.

The World Health Organisation convened a special meeting of the Health Task Force at the UN Regional Inter Agency Coordination and Support Office (RIACSO) on 1 April 2003, to explore the implications of the NVF hypothesis for health services in the region. Representatives from Catholic Relief Services, World Vision, the Red Cross, UNAIDS, UNDP, participated in what proved to be the very first meeting for de Waal in his official capacity as Director of the Commission on HIV/AIDS and Governance in Africa (CHGA) recently announced by UN Secretary General Dr Kofi Annan.i



Origin of New Variant Famine hypothesis

Explaining his reasoning for proposing the New Variant Famine (NVF) hypothesis, de Waal argued that, because of the HIV/AIDS pandemic, the current humanitarian crisis in Southern Africa presents a new 'variety' of formidable 'famine' that has a different demographic profile and manifestation to conventional famines. Whereas conventional famines tend to kill children, the elderly and men, HIV/AIDS attacks young, sexually active, adults, with more women than men being affected given their greater social vulnerability.

He explained that in the same way that HIV predisposes the body to opportunistic infections and diseases that lead to increasing morbidity and mortality, so too did it render the community as a whole increasingly vulnerable to hazards and shocks. As younger women - traditionally the main caregivers in society- die the burden of care increases, beyond the coping capacity of communities and families to the point that communities and families as a whole begin to sink into states of collective pathology. This weakened social fabric means that families cannot recover previous levels of social functioning, and may even resort to survival strategies that imperil them still further, because the negative consequences of such remedies are not immediately apparent (such as commercial sex-work).

Mother and Child The Human Face of the NVF - A Mother and Child, both HIV infected and severely malnourished, at therapeutic feeding centre in Blantyre district of Malawi. (Photo by Georgia Paiella, WHO Nutritionist)


Illustrations of NVF

Examples of the manifestation of the NVF were:
  • The progressive increase in cassava production (less labour-intensive) as a shift from the staple-food maize production (more labour-intensive) to compensate for the labour lost through HIV/AIDS in Malawi, Mozambique, Zambia and Zimbabwe over a period of 5 years (1990-2000)
  • Effects of HIV/AIDS on various sectors (manufacturing, mining and agriculture) disaggregated by percentage labour turn-over , skilled labour, female labour, capital, market and 'burden'. (See table below).
Sector Effects of HIV/AIDS on Productive Sectors of Economy
% labour turn-over Skilled labour Female labour Capital Market Burden
Manufacturing X x . x x x
Mining x x . . . .
Agriculture X X X X . X X
. Minimum effects
x Low effects
X High effects
XX Very high effects


Long-term effects

Shocks such as the current crisis impacted negatively on livelihoods, which were already under stress. Affected households will become more vulnerable. Migration to search for food will increase the risk of HIV/AIDS and child mortality among others. Impoverishment and social disruption creep in.

He remarked that initially only mathematicians seemed to really understand the implications of the HIV/AIDS pandemic, because they knew how to model the demographic trends mathematically, such as the graph below illustrates (taken from Barnett and Whiteside, 2002). This graph shows that the HIV prevalence rises well in advance of AIDS mortality, because it takes approximately 7 to 8 years before HIV infected people become seriously ill and die. He explained the implications.

HIV and AIDS curves - Source: de Waal, et al, 2003 HIV, AIDS & Impact curves- Source: de Waal, et al, 2003


"One of the more discouraging aspects of the current crisis in southern Africa is that, for many countries, it has occurred when we are only half way up the curve of cumulative AIDS deaths. If the current levels are sufficient to cause a crisis on today's scale, what does this imply for the levels that are still some years in the future? What does it imply for more structurally vulnerable countries such as Ethiopia, which are in the early stages of their HIV/AIDS epidemics?"

He went on to explain that another unfortunate implication of the crisis is that the NVF itself will exacerbate both HIV transmission and AIDS morbidity and mortality, while simultaneously impeding effective HIV/AIDS programming.

He argued moreover that the above graph did not take into account confounding variables, such as food shortages, conflict, economic depression, the collapse of institutions (including health services), accelerated brain drain, etc. "This may mean that we need to revise the above graphs to include a feedback loop from 'wider impact' to HIV and AIDS: a 'tipping point' has been reached at which these accelerate. We can also re-designate the 'wider impact' curve to represent excess deaths caused by factors unlocked by the HIV/AIDS epidemic such as hunger and infectious disease".

The modified graph illustrates the accelerating effect.

Discussion

While accepting the 'new variant' argument, participants debated the wisdom of using the term 'famine', given the connotations with mass starvation and hunger. De Waal argued that, in line with Nobel Economics Laureate, Prof Amartya Sen's reasoning, the term famine does not necessarily mean a lack of food, but a lack of access to food by significant numbers of a population in a given situation. Even conventional famines are not due to a lack of food, but due to distorted distribution patterns and disrupted markets. He thus saw HIV/AIDS as raising barriers and constraints to people gaining access or producing food, and therefore finding themselves in a state of famine- but of a variant that was not amenable to conventional forms of humanitarian assistance that facilitated recovery in the past.

The way forward?

De Waal urged that, given the cumulative demographic trends, anything done now could have a significant impact in the long term. "Even 'little' initiatives such as food fortification and targeted food handouts to households affected by HIV/AIDS will complement strategies for addressing the NVF. Organisations need to coordinate much more than before because we are faced with a formidable challenge", he concluded.

Health professionals were challenged to look at new approaches - pragmatic approaches, using the same amount of resources available today, without necessarily expanding the health services, to address the NVF.

Reported by Nathaniel Tembo, WHO Emergency Public Health Officer & John Clarke, Information Officer
UN Regional Inter-agency Coordination Support Office (RIACSO)
Idion House, 11 Naivasha Road, Sunninghill 2157, Johannesburg
E-mail: nathaniel.tembo@wfp.org, john.Clarke@wfp.org



Footnote:
  1. Based in the UN Economic Commission for Africa, in Addis Ababa, the Commission will study the links between AIDS and governance in various sectors, including agriculture, youth and the military. It will come up with detailed recommendations for stemming the tide of the disease across Africa, and advise African policymakers on how to address the profound structural impact it is beginning to have on their ability to tackle their many development challenges.


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