The African AIDS crisis and international indifference.

THESE WORDS by Joel Pauls Wohlgemut, appearing in his 2002 prize-winning Canadian Medical Association Journal article, "AIDS, Africa and indifference: A confession," are arguably some of the most courageous to appear in the academic literature in recent times. It is a confession of indifference: indifference to the African AIDS crisis that now claims the lives of about 5,000 Africans daily and accounts for 80 percent of the world's AIDS deaths. Africa is also a continent that houses 95 percent of the world's AIDS orphans, 70 percent of the people newly infected by HIV, and 90 percent of the world's children living with HIV/AIDS. Needless to say, the amount of human suffering behind these figures is almost unimaginable. "Viewed from the perspective of suffering," writes P. Farmer and A. Kleinman in "AIDS as Human Suffering" (published in 1998 in P. J. Brown's Understanding and Applying Medical Anthropology), AIDS must rank with smallpox, plague, and leprosy in its capacity to menace and hurt, to burden and spoil human experience, and to elicit questions about the nature of life and its significance. Suffering extends from those inflicted ... to their families and intimates, to the practitioners and institutions who care for them, and to their neighborhoods and the rest of society

Africa's past advances in human development have been literally reversed by the HIV/AIDS epidemic, with indices such as life expectancy plummeting by twenty years in some countries. The burden of this pandemic no doubt presents an economic nightmare for an economy already in distress--where about 300 million (approximately 50 percent) of the continent's people live in extreme poverty, fewer than half the children complete primary school, and drought cycles have become more frequent, greatly affecting the capacity to produce food. Recently, proportions of the African population having access to health services, safe water, and sanitation have been reported to be 51 percent, 40 percent, and 31 percent, respectively. The debt burden for Africa stood at $315 billion in 2000, and all African countries except the Republic of South Africa were reported to be spending more on servicing this debt than on health care. With some African countries now receiving aid in the form of loans, the economic situation can only get worse.

Accounting for less than 1 percent of world exports, it is clear that Africa will never emerge from the AIDS calamity on its own. Despite aspirations of better healthcare for all Africans, many would now agree that most African countries are just too poor to doctor themselves against AIDS and its consequences. Perhaps what remains their only hope is that other nations, acting out of concern and respect for human dignity or whatever moral code, might come to their aid and provide relief.

Over the past years, however, the AIDS crisis in Africa has worsened to catastrophic levels, with little being done to arrest the progress of the disease there because many in the affluent world, as A. Trowbridge wrote in the November/December 2000 Humanist, "looked upon assistance to Africa as charity that [they] had a right to offer or withhold." As a consequence, with too few domestic resources of its own, what contributions Africa has received have had little meaningful success in staunching the growth of HIV and AIDS on that continent. The 1990s saw the commitments of many donors decline to a trickle and become increasingly sporadic. Aid levels have dropped relative to the growth of HIV--to the extent that the lack of finances has become the primary constraint on progress against AIDS in Africa. And as we saw recently when the G-8 met at Gleneagles in Scotland, it now takes the world's biggest rock concert to focus the attention of the world on the plight of Africa's poor.

In response to the plummeting aid levels, the United Nations introduced the Global Health Fund with the goal of raising $10 billion annually--from governments of the economically affluent countries as well as private donors--for the fight against HIV/AIDS, tuberculosis, and malaria in the developing countries. In 2002, its first year of operation, only one-tenth of the needed amount was received--once again illustrating the lack of commitment to the cause on the part of the so-called donor community. Today, as highlighted at the 2004 World AIDS Conference, the Global Health Fund continues to fall short of meeting its $10 billion annual goal. With four-fifths of the world's wealth, and only 5 percent of the world's HIV cases, the question must be asked: how can governments and individuals of the developed nations continue to ignore their moral responsibility to do all they can to significantly reduce the suffering of fellow human beings?

At the heart of all this is the old, difficult philosophical dilemma of what are the responsibilities of the wealthy to address the needs of the poor? Previous literature on the subject--especially on duty to aid and famine relief--provides some basic answers as to why the rich should be expected to act in the current crisis. This is especially appropriate given the fact that conditions of poverty are a major contributing factor to the level of vulnerability to HIV infection.

As S. R. Benatar and Peter A. Singer point out in their 2000 British Medical Journal article, "A New Look at International Research Ethics," ethical reasoning shouldn't merely follow simple prescribed rules but should consider each case as it exists in its own context, "weighing and balancing competing moral requirements and developing justifiable conclusions." So how do these classical arguments or "rules" on the relationship of the rich and the poor relate to the African AIDS crisis? Does AIDS in Africa raise any new or special issues that might compel the skeptics of such rules to believe that maybe, at least in the context of Africa and AIDS, the deaths of the poor are the responsibilities of the rich? In the light of the ever-growing problem, these discussions are critical because, if ceased or forgotten, lives will continue to be lost. However, if governments and individuals are continually reminded of the situation and their responsibility to their fellow human beings, their contributions will increase and some lives may be saved.

SINGER'S ETHICS OF BENEVOLENCE 

Princeton University professor Singer is an Australian philosopher and teacher and founder of the Center for Human Bioethics at Monash University in Melbourne. His 1972 Philosophy and Public Affairs article, "Famine, Affluence, and Morality," is widely recognized as pioneering discussion on morality, affluence, and the needs of the poor. In writing about Singer's work in his 1994 Ethics article, "International Aid and the Scope of Kindness," G. Cullity says Singer has "stimulated philosophical discussion of whether affluence is immoral in a world where there is starvation." The fact that Singer's article has been reprinted more than two dozen times may just be a demonstration of its stature within philosophical circles.

In "Famine, Affluence, and Morality," Singer concludes that the affluent have an obligation to assist those whose lives are in danger, such as those living in conditions of absolute poverty. His argument is anchored in two basic principles:

Principle 1: Suffering and death from lack of food, shelter, and medical care are bad.

Principle 2: If we can prevent something bad without sacrificing anything of comparable moral significance, we ought to do it. Or, at least, if we can prevent something bad without sacrificing anything of any moral significance, we ought to do it.

The first principle--also stated simply by Singer as "absolute poverty is bad"--appears to be widely accepted. Singer says it would be hard to find any plausible ethical view that didn't regard absolute poverty as bad, especially considering its definition, which he cites in his 1979 book, Practical Ethics, as "a condition of life so characterized by malnutrition, illiteracy, disease, squalid surroundings, high infant mortality and low life expectancy as to be beneath any reasonable definition of human decency." John Arthur, in his 1996 article, "Rights and the Duty to Bring Aid," in W. Aiken and H. LaFollette's World Hunger and Morality, says Singer's first principle is "obviously true." In relation to HIV/AIDS, which is increasingly being recognized as a disease of the poor, it would seem reasonable for one to expect a broad agreement to the proposition that it is bad for African people to be dying of AIDS, almost defenseless against it because of their absolute poverty.

The question of whose responsibility it should be to offer aid in such bad situations is what the second principle attempts to answer. By the phrase something of comparable moral significance, Singer refers to sacrificing "without causing anything else comparably bad to happen, or doing something that is wrong in itself, or failing to promote some moral good, comparable in significance to the bad thing we can prevent." This principle, as indicated, has two versions; the latter weaker than the first. The weaker one substitutes the word comparable for the phrase any moral significance in order to reduce what Singer perceives as an incredibly high standard set by the stronger version.

Unlike the first principle, the second has attracted some controversy. Arthur, for example, has argued that such an obligation for the rich to give some of their wealth to those in absolute poverty contradicts their right to their private property. In talking about the rights of ownership Arthur asserts that if P acquires x, for example, in a just social arrangement without violating others' rights, then P has a special title to x that P is entitled to weigh against the desires of others. P need not, in determining whether he ought to give x to another, overlook the fact that x is his; he acquired it fairly, and so has special say in what happens to it.

In the light of this view, Arthur goes on to propose what he thinks would be the "most adequate" principle which would take into consideration the rights of the affluent: "If it is in our power to prevent death of an innocent without sacrificing anything of substantial significance then we ought morally to do it." Arthur doesn't explain exactly what determines "substantial significance" but does suggest two factors to determine whether what is given up by the affluent is of substantial significance. First, he says, the needs to be considered to be of substantial significance must be identified. These would include those things a person can't function physically without--such as food, clothing, health care, and housing. Secondly, he suggests that, "if the lack of x would not affect the long-term happiness of a person, then x is of no substantial significance" to give.

Turning this to the African HIV/AIDS crisis, it is vital to determine how much is enough to give. Here, the United Nations' projected annual figure of $10 billion may reasonably be taken as the minimum beyond which the wealthy can say they have fulfilled their moral obligations to help in the AIDS crisis. Applying this figure to their differing principles may diffuse the debate between Singer and Arthur. What, and exactly how much, is of "comparable moral significance" in Singer's principle or is of "substantial significance" in Arthur's may not be relevant to HIV/AIDS when we consider how much the UN asks the affluent countries to give to the Global Health Fund. The $10 billion needed annually to produce a meaningful response to the AIDS epidemic in the developing countries is estimated by Africa Action to constitute only 0.005 percent of the economies of the collective seven richest countries. This amount is only a minute fraction of the surplus these countries possess and is thus far too low to cause anything that could be described as "comparably bad" in the event they gave the requested amount.

With respect to the weaker version of Singer's second principle, if the 0.005 percent (or 2 cents out of $100 according to other estimates)--could be considered by anyone to be too significant to give away for such a good cause, then nothing would likely ever be considered of the right significance. Following Arthur's criteria, it is clear that meeting the needs of the poor and the HIV infected in the less affluent countries would count as of substantial significance. This is also consistent with conclusions drawn elsewhere that the claims of those who have urgent unmet needs simply outweigh the claims of those who possess more than they need.

THE ETHICS OF "LETTING DIE"

Lifeboat ethics is a theory proposed in 1974 by bio-ethicist and ecologist Garrett Hardin that offers a general case against helping the poor. Published in Psychology Today, the theory divides the world into two, with two-thirds of it made up of poor nations while one-third is comprised of rich nations. The following metaphor is then used to represent the situation: the rich nations are seen collectively as a lifeboat almost full of comparatively rich people, and the poor are represented as people swimming in the ocean, begging to be allowed into the lifeboat. The question is then asked: what should the lifeboat passengers do, given that their boat has room that could accommodate only a small proportion of those drowning outside? Hardin suggests that, to ensure their survival (and avoid drowning in case the boat's carrying capacity is exceeded or safety factors, predetermined by the manufacturers, are compromised), the rich shouldn't allow any of the swimmers into the lifeboat.

Hardin asserts in "Lifeboat Ethics: The Case Against Helping the Poor" that this is "the basic metaphor within which we must work out our solutions."

But does this faithfully represent reality as we know it? According to environmental ethicist H. Rolston III, the so-called G-7 nations, which are populated by one-fifth of the world's peoples, produce and consume about four-fifths of the world's goods and services while the developing nations, with four-fifths of the world's population, produce and consume just one-fifth of the world's resources. In 1989 the richest 20 percent of the world's people received 83 percent of the global income while the poorest 20 percent only received 1.4 percent.

Africa, a home to more than 10 percent of the global population, lives on just 1 percent of the global economy. In 1993 Richard Smith reported in "Overpopulation and Overconsumption: Combating the Two Main Drivers of Global Destruction" in the British Medical Journal, that people in the developing world each use 0.28 kilowatts of energy per year and those in the developed world use 3.2 kilowatts, with those in the United States using an incredible 9 kilowatts. From just these few examples one can't help but conclude--as ethicists, including J. P. Sterba in his 1996 paper "Global Justice" (in William Aiken and Hugh Lafollette's World Hunger and Morality), have--that "there is still enough resources worldwide to put an end to absolute poverty. The problem is still one of distribution."

Adopting Hardin's metaphor, this conclusion tells us that the lifeboat is far from full. Lifeboat? Perhaps a more accurate metaphor would be that of an ocean liner with a handful of people on board who continue to refuse safety to near drowning people nearby. Therefore, a scenario of letting the poor die can't be applied to the issues that affect the real world and its affairs. In fact, even applied to the AIDS situation, it would be hard to see how anyone could equate the $10 billion asked for annually by the UN with begging to enter a lifeboat. The poor of the world aren't asking to live in the luxuries of the rich, nor to live with them in their own countries, but merely for the basics: food, health, and a dignified survival where they are.

In the light of such an analysis, lifeboat ethics becomes an excuse to continue to "let die" those who are poor, and consequently those with HIV and AIDS. And this is indeed what we are witnessing with the AIDS crisis. As mentioned previously, life expectancies in Africa have fallen in some countries by twenty years or more. In Botswana, for instance, the life expectancy has fallen from sixty-seven years to forty since the HIV crisis. In many sub-Saharan countries, the chances that an adolescent will ultimately die of AIDS is greater than 50 percent. Antenatal HIV prevalence has also been reported as greater than 10 percent and as much as 30 percent in some countries. What all these figures represent is the scale of premature death of Africans due to AIDS. By not supporting the UN's Global Health Fund and the other efforts that would ultimately preserve these lives, the developed countries could rightly be seen as letting the poor die. And if no moral significance exists between killing someone and letting someone die, then these deaths of the poor may indeed be viewed as a responsibility of the economically affluent.

CONCLUSION

In a world priding itself as civilized, the African AIDS statistics and the extent of suffering they reveal should be devastating enough to provoke those with extra resources to spontaneous benevolent action. In the absence of such compassionate spontaneity, however, resort to reason isn't an improper thing to do. I hope this article reminds us all of why the 5,000 African lives lost daily should be saved; if it isn't just because they are fellow humans then let it be because of Singer's principles of benevolence, which may rightly be seen as philosophies of hope for a dying continent. It is only a positive response to these principles by those with extra resources that will ultimately bring life to Africa, as well as communicating the warm message to the world's poor that the world is not such a cruel place after all.

Mpho Selemogo, a national of Botswana, has just completed his medical (MBBS) degree at the University of Melbourne, Australia. He has contributed to Developing World Bioethics, the Indian Journal of Medical Ethics, and Eubios Journal of Asian & International Bioethics.