Aiding and Abetting an Epidemic.

As the rate of HIV-AIDS reaches record highs in Africa, the burden of foreign debt depletes scarce resources for prevention and care.

Sub-Saharan African countries owe the IMF, World Bank, and rich countries more than $220 billion dollars. Such debt diverts funds from domestic needs. The disastrous impact can be seen in the lack of resources available to address the AIDS epidemic that is ravaging many of these countries. Perhaps nothing better illustrates why advocates for debt cancellation see the Jubilee 2000 movement as a vital opportunity to bring a glimmer of hope to places where it is desperately needed. Recent moves by the World Bank, IMF, and industrialized countries to improve debt relief are a start--but more is needed.

Debt: An Obstacle to Change

Ironically enough, the poverty of many people in sub-Saharan Africa has been made worse by previous efforts at debt relief. The World Bank and International Monetary Fund have linked any debt cancellation with sweeping, externally imposed economic reforms. The "HIPC Initiative" (for "heavily indebted poor countries"), drafted by the World Bank and the IMF in 1996, forces indebted nations to enact draconian economic measures in order to receive even limited debt relief.

International financial institutions insist these reforms are necessary to create economies that work. Plainly put, the managers of the global economy insist that such measures are "pain for gain." But many feel that the suffering caused in the reform process is damaging the affected societies beyond repair. Governments try to implement the reform guidelines despite harm to their citizens, in a desperate attempt to qualify for international relief.

Of the countries poor enough to enroll in the World Bank/IMF initiative, only four--Uganda, Bolivia, Guyana, and Mozambique--have received aid. The others stand in line hoping to prove themselves worthy of the much-needed relief. Critics of the plan say it is an unmitigated failure. "The only winners are the staffs of the IMF and World Bank, which have invented a perpetual motion machine for endless missions to these hapless countries," wrote Harvard economist Jeffrey Sachs in a New York Times op-ed piece earlier this year.

Jubilee 2000/USA, the U.S. component of the largely faith-based global group dedicated to winning debt relief for the most heavily indebted countries, says that each citizen of the targeted nations owes at least twice as much as they are able to earn in a year. And the suffering such indebtedness brings is very concrete. "African countries on average spend twice as much on repaying foreign debt as on providing health care," says David Bryden, spokesperson for Jubilee 2000/USA.

The real cost of foreign debt is that it prevents the poorest countries in the world from providing even the most basic social safety net. The result? The needless death each year of millions of people. "Relieved of their annual debt repayments, the severely indebted countries could use the funds for investments that in Africa alone would save the lives of 21 million children by the year 2000," according to the United Nations Development Program, which has long advocated debt cancellation.

During the past year the World Bank, the G7 industrialized countries, and the IMF have come to acknowledge the ineffectiveness of the HIPC Initiative. Changes have been made that IMF officials say will allow countries to qualify for relief sooner and will guarantee that saved funds go towards reducing poverty. Funding for relief also has been increased. But according to The Washington Post, "the 26 countries first in line to benefit from the aid still would carry about $45 billion in loans." Jubilee 2000 activists also question the continuing central role of the IMF in designing the proposed poverty reduction plans, since it has a record of failing to promote sustainable development.

Critics who argue for full debt cancellation point out that ordinary citizens in indebted countries will still suffer the burden of repayment, even though they were never beneficiaries of the enormous loans from the West. Western governments often lent to undemocratic and corrupt governments, whose leaders played the West against the Soviets during the Cold War years. Many of these corrupt leaders now live in luxurious exile on the funds they stole from their country's coffers.

Debt + AIDS = a Nightmare

AIDS is an insidious cataclysm that the debt crisis intensifies to unimaginable proportions of human misery and despair. Already AIDS has reversed hard-won gains in life expectancy, infant mortality, and virtually every other measure of human development.

Peter Henriot, S J, has lived and worked for the past 11 years in Zambia, where he directs the Jesuit Center for Theological Reflection in Lusaka. Henriot has had a firsthand look at the devastation that HIV-AIDS has wreaked in this decade. In 1991, the average life expectancy in Zambia was 54; today, it has plunged to 44 and continues to decline. "All of this decline is attributable to AIDS, compounded by inadequate health services--the lack of essential medicines and medical personnel, and imposition of fees that discourage use of health facilities by the poor," says Henriot.

The shadow cast by HIV-AIDS on the future of sub-Saharan Africa is so foreboding as to be almost incomprehensible. Nowhere else in the world is the rate of infection as high as it is in sub-Saharan Africa. Of the 14 million people worldwide who have died of AIDS, more than 11 million have been Africans. Put another way, the HIV-AIDS infection rates are 9 to 20 percent in sub-Saharan Africa. By contrast, the rest of the world has a less than 6 percent rate of infection.

Nowhere to Go

These terrible numbers hit harder when you look at the fact that AIDS in Africa overwhelmingly affects fathers and mothers of children. Most African families are large, often with five or six children who will be left to fend for themselves in countries without foster care programs, food stamps, or Medicaid. Even soup kitchens do not exist in these countries, and primary schools all require tuition--there are no "public" school systems.

With estimates of adults infected by HIV-AIDS pushing past the 22 million mark for the region, almost all of whom will certainly die of the disease, by conservative estimate there will be 40 million AIDS orphans by the year 2005. "Ninety-five percent of the world's orphans will be in Africa," says Doug Huber of Pathfinder International, an organization committed to development through practical family planning.

Where the rates of infection are highest--in Zambia and Zimbabwe, for instance, as many as 32 percent of all adults are infected--the impact of HIV-AIDS on children is most devastating. "A child born in Zambia or Zimbabwe today is more likely than not to die of AIDS," says Robert Calderisi, vice president for external affairs at the World Bank in Washington, D.C.

In these countries it would normally fall to a child's relatives to step in to care for those who become orphans. But with the infection rate so high, AIDS also strikes down many potential caregivers. When relatives do take in orphans, the burden of care is great for families whose resources are already meager. According to Nobel Prize-winning economist Amartya Sen, three billion people live on less than $2 a day, with most of them living in sub-Saharan Africa. "How then can a family take in the four, five, or six children of a relative who has died from AIDS?" asks Henriot. He also points out the additional burden of burial costs to AIDS victims' relatives, which further depletes limited funds needed for food, shelter, and essential survival goods.

In Tanzania, "half of the families are taking care of other people's children, whose parents were lost to AIDS," says Calderisi. Tanzania has an infection rate of just under 10 percent. According to UNICEF, "Children who have lost their mother or both parents are society's most vulnerable members. Socially isolated because of the stigma of AIDS, they are less likely to be immunized, more likely to be malnourished and illiterate, and more vulnerable to abuse and exploitation."

Because AIDS is striking the most productive and educated segments of the population in sub-Saharan Africa, there is also a shortage of primary schoolteachers. This is especially true in rural areas, where there is also a high rate of infection among agricultural workers, which further reduces the local food supply. A UNAIDS office survey found that one-third of rural households affected by AIDS experienced a 50 percent reduction in agricultural output. Says the World Bank's Calderisi, "This makes it difficult even for children with two healthy parents to get an education in these areas."

According to the World Bank, "stunting" from lack of nutrition affects around 50 percent of AIDS orphans, with possible permanent effects on the child's mental ability.

What Can Be Done?

While in the West drug treatments have extended the lives of many with AIDS, these drugs can't reach the debt-ridden countries of sub-Saharan Africa. "To treat the infected in just two countries, Kenya and Uganda, with these drugs, you would have to have $30 billion to $38 billion dollars in your health budget," says World Bank HIV-AIDS coordinator Dr. Debrewerk Zewdie. "At most, these countries will have $100 to $200 million for their annual health budgets--so these anti-retroviral regimes are just impossible."

Adds Zewdie, an immunologist from Ethiopia, "People there do not eat three meals a day. These drugs all require that they be taken with food or some specific time period before or after eating throughout the day. So you would have to attack the food problem as well as find overwhelming amounts of funding just to buy the drugs. Impossible."

But Zewdie says we must do what can be done immediately. The World Bank is currently intensifying its efforts to address the sub-Saharan AIDS problem. It will consist of a three-tiered approach that will begin with making palliative over-the-counter medicines available. "Aspirin, painkillers are not widely available in Africa, and they should be. We need to focus on what is doable today--how can we make life more comfortable," says Zewdie.

A Model Approach

Uganda is one of the hardest hit of all countries in the AIDS epidemic; it is also now one of the most successful and focused in confronting and managing the crisis. According to World Bank reports, Uganda's program, which is strong on preventative education, has lowered the rate of HIV-AIDS infection to below 10 percent. In 1992, when Uganda elected a new president, Yoweri Museveni, the rates of infection there were the highest in the world, exceeding 25 percent of the adult population, and were continuing to skyrocket with every passing month.

"The Museveni government took the HIV-AIDS problem seriously and incorporated their AIDS prevention initiative into their overall development program," said the World Bank's Calderisi. "And Uganda took development very seriously. They are the first African HIPC country to qualify for debt relief, which they rolled into their HIV-AIDS program."

Uganda's success in coping with the AIDS crisis could be a model for other sub-Saharan countries to use in developing HIV-AIDS programs of their own, which is the next step of the World Bank's new push to fight the disease in Africa. But many advocates of debt relief, as well as advocates for HIV-AIDS control, caution that Western nations must be respectful of African nations and listen to their ideas for what will work to combat AIDS. "In the past, Western nations have just rushed in like a firehouse crew and attacked the AIDS emergency in Africa," says Zewdie. "While it's good to have the awareness that there is a crisis in Africa in HIV-AIDS infection and death, each country will have its own best solution for what will work there."

Preventative education, new drug treatments, support for orphans and caregivers--all these take money, money that debt relief could help provide. Peter Henriot expresses the frustration that many Jubilee 2000 advocates have with the slow pace of funding debt relief, especially in light of such deep human needs: "Look at the year 2000 computer problem--billions were found instantly to fix that problem. What about the people in the highly indebted countries?"

Actions in the immediate future by the sub-Saharan governments as well as by creditor nations will have an enormous impact on the lives of millions in Africa. In the West, people of faith can answer the call in the Book of Leviticus for a Jubilee of debt cancellation with rollovers to be directed toward controlling HIV-AIDS, health, and education in sub-Saharan Africa. Visit www.j2000usa.org for information about Jubilee events you can be part of and news about the debt relief effort. Life for millions is in the balance.

VITAL STATISTICS

* Of the 14 million people worldwide who have died of AIDS, more than 11 million have been Africans.

* A child born in Zambia or Zimbabwe today is more likely than not to die of AIDS.

* Uganda's HIV-AIDS prevention program has reduced the rate of infection in adults from more than 25 percent to less than 10 percent.

RELATED ARTICLE: A Breakthrough Provides Hope

DESPITE THE PALL that HIV-AIDS casts across Africa, a few bright spots offer some relief. One of the most promising is a new way to reduce mother-to-child transmission rates using the long-acting antiviral drug nevirapine.

While not quite as effective as the method used in Western countries, nevirapine costs just $3 per course of treatment. Unlike its far more expensive counterparts, a single dose of nevirapine is administered during labor and another during the infant's first week after birth. AZT, the drug of choice in the West, must begin to be administered in the last two months of a woman's pregnancy to be most effective, and the infant must continue to receive the drug for the first six weeks of life. The AZT treatment costs about $800 per mother and child, an amount beyond the means of most people in developing countries.

In a study in Uganda released this summer, babies whose infected mothers received experimental short-term courses of AZT--still a far more involved process than the nevirapine treatment--had a 25 percent HIV infection rate. Babies whose mothers were given the nevirapine regime had only a 13 percent HIV infection rate.

With counseling and HIV testing--a necessary part of any prevention program--the cost of nevirapine will be higher than just the cost of the drug. But with a discount that the manufacturer of the drug is expected to offer, nevirapine looks like a positive breakthrough for even the poorest countries, provided they use the opportunity to address their AIDS crisis. Douglas Wilson, an executive of the German company that makes nevirapine, Boehringer Ingelheim, told The Washington Post when the Ugandan study was released that the company "is committed in principle to making the drug as widely available as possible."

LAURA DELY is a free-lance writer living in Arlington, Virginia. She writes frequently on human rights and social justice issues.