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Introductory comments: Zimbabwe Human Development Report 2003

Highlights of the ZHDR 2003: redirecting our responses to HIV and AIDS

Professor E. Gomo, Principal Editor, University of Zimbabwe

at the launch of the Zimbabwe Human Development Report 2003 on HIV and AIDS

Harare International Conference Centre

6 May 2004

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It is a great honour to stand before you today and share with you some of the highlights of the Zimbabwe Human Development Report 2003. We have just witnessed reality in enactment. A family destroyed by the virus we call HIV. But as I chronicle the highlights of the report 2003, I would like you to pause and think whether it is the virus that was indeed the cause of family destruction or was it something else. As we consider the fundamentals depicted in the play, I urge us all to carefully relate them to the unfolding highlights of the report. The report will provide some of the answers to the questions raised by the UNDP resident Representative, Mr Angelo. Ladies and Gentlemen, the report is not meant to be all exhaustive, but to provoke debate that will generate more questions and answers, to make us think outside the box of standard concepts and responses to the epidemic.

Ladies and Gentlemen, the theme of the Zimbabwe Human Development Report 2003 is Redirecting our responses to HIV and AIDS: Towards reducing vulnerability - The ultimate war for survival. Let me, from the outset, recognize the efforts that have been made in combating HIV and AIDS to date. While overwhelming evidence of impact may not be easily available, it is not difficult to believe that the epidemic could have been much worse without the existing responses. However, the report 2003 firstly recognizes the links between sustainable human development and HIV and AIDS and emphasizes that, unless the fundamental determinants of transmission are identified and addressed, the epidemic will continue to rage on. The report then provides an explanation of how lack of development translates into increased vulnerability. In this context the origins of the vulnerability that explain why HIV has spread so fulminently in Zimbabwe are exposed. National and sectoral manifestations of vulnerability are demonstrated through detailed epidemiologic profiling, expounding the concept of sex networking as driving transmission. Similarly evidence of global and sectoral impact is provided in relation to the vulnerabilities and sex networks. The report also analyses the evolution of current responses, highlighting the merits and weaknesses. Recommendations for turning the tide of infections and improving lives of the infected and affected are made for the various vulnerabilities identified. Thus Redirecting our responses to HIV and AIDS.

CONTEXT OF HIV, AIDS AND HUMAN DEVELOPMENT

I will now focus on the highlights of the links between Human Development, HIV and AIDS. The evolution of the current response and its impact will be presented by the Minister of Health and Child Welfare. The purpose of development is to improve human lives through expanding the range of things a person can do and be i.e. a person's functionings and capabilities to function which include, being healthy and well nourished, being knowledgeable and being able to participate in the life of the community. Thus, development is about removing the obstacles to the things that a person can do and be in life such as, illiteracy, ill health, lack of access to resources including income and employment opportunities, lack of access to a clean and safe physical environment, lack of human security, lack of civil and political freedoms and lack of general human dignity. Thus we need to rescue the concept of human development from the narrow interpretation that has arisen over the years, namely that human development is simply about health, education and income, the three dimensions currently defining the measurement of the Human Development Index.

The links between Human Development, HIV and AIDS derive from a number of observations. These observations are evidence that poverty is the major factor fuelling HIV and that HIV fuels poverty.

  • HIV/AIDS is the leading cause of morbidity in Africa, especially Southern Africa. This region is also well known for poor economic performance and hence poverty.
  • According to the 2003 official figures, prevalence of HIV is 25% among the 15-49 years, the reproductive and economically active age group.
  • The proportion of the population below the Total Consumption Poverty Line was estimated at 74% in 1995 and 2002 estimates are that it had risen to 80%.
  • Social and economic indicators have also progressively worsened in tandem with the increase in prevalence of HIV and AIDS.
  • Infant and child mortality have progressively increased.
  • Child malnutrition, a major problem associated with poverty, has increased and disproportionately affects children in rural areas.
  • Maternal mortality has increased sharply in the past 10 years.
  • Life expectancy at birth has progressively declined from 61 in 1990 to the current 43 years, in tandem with the increase in HIV prevalence. It is striking to note that life expectancy declined most in Midlands, Matabeleland South and Matabeleland North, provinces noted for informal sector income benefits.
  • Gender differentials in poverty are reflected in HIV and AIDS prevalence and impact. Although the sex ratio between males and females is about 1:1, HIV prevalence of young women below the age of 20 is five times higher than their male counterparts.
  • The girl child in particular, due to cultural and traditional beliefs, has been a victim of sexual violence at a time when the HIV and AIDS epidemic is raging.
  • Last but not least, the report shows that between 1995 and 2001, Zimbabwe experienced a 12% reduction in the Human Development Index, moving our country from the medium human development category into the low human development category. Simply put, we have become poorer and unable to satisfactorily fullfil the requirements of well-being of our nation.
Challenges and Recommendations

Ladies and Gentlemen, the challenge to all of us today is whether we understand the vulnerabilities induced by lack of development. Once we have a clear understanding of the linkage between development and HIV and ensuing vulnerabilities, there is need for commitment at all levels of society to put in place development driven interventions that deal with specific vulnerabilities. The overall recommendation is that Policy is the main tool for reducing vulnerability and hence the HIV new infection cycle. In this context there is need to widen the multi-sectoral response and bias it towards development. This calls on us as a nation to work together in designing and implementing a broad based national poverty reduction strategy. In the same vein, donors should, in the shortest possible time, rethink their role in the fight against HIV and AIDS. They need to fully appreciate that development is inseparable from HIV and AIDS and hence should support interventions that have a developmental context. The government, on the other hand, should have an open door policy to ensure dialogue for development continues to take place. Otherwise we will continue to fire-fight without dealing with the cause. This reminds me of a story about people who were downriver and rescued drowning children. They continued to see more and more children coming down the river, so they put a lot of effort and resources into rescuing children. But nobody ever thought of going upstream to see how and why the children were falling into the river or who was throwing the children into the river, so they could stop the avalanche.

THE ORIGINS OF VULNERABILITY

Ladies and Gentlemen, current responses, which are predominantly biomedical approaches, have played and continue to play an important role in the fight against HIV and AIDS. However they have generally failed to change sexual behaviour hence the continued spread of HIV. The report argues that this is because the responses have not considered the fundamental determinants of sexual behaviour, which are developmental. While the linkages between HIV, AIDS and development may be clear to us, it is equally important that we have a clear understanding of the origins of the vulnerabilities that have exposed us so much to HIV and AIDS. For it is only when we understand the origins that we will be able to tackle the fundamental determinant of sexual behaviour in our society. The report presents evidence that the sexual behaviour existing today is a result of deliberate and non-deliberate pre and post-colonial development processes. Please note that the approach of going back to the fundamentals of vulnerability is not meant to drift the nation of Zimbabwe or the Southern Africa sub-region into a "blame shifting mode" concerning the epidemic but to challenge ourselves into re-shaping a "new development template".

  • We all know that the colonial period was a time of social re-engineering to produce a society that would cater for racist and colonial interests. The social re-engineering project transformed local institutions and their ethos through imposing laws, practices and new value systems which corrupted and destroyed the then existing social institutions. The black African family was a key target, and changing family relations within it was central to this social project. By independence, Zimbabweans had accepted the resultant social changes as "our culture" so that the post independence governance system found it difficult to tamper with these entrenched practices, norms and institutions.
  • The resultant social and economic deprivation introduced new and deepened existing inequalities between men and women and hence the current patterns of HIV infection and AIDS.
  • For employed black men, colonial employers responded by creating compounds in which beer drinking and prostitutes were deliberately provided as antidotes for desires to be with one's family and became colonial methods of labour retention.
  • The dualisation of homes, typical of colonialism in the Southern but not other parts of Africa, created a culture of working men moving between the urban home where they stayed most of the year to the rural home during holidays and weekends, thus creating an efficient transmission route for HIV and sexually transmitted diseases.
  • Thus, inequalities between men and women deepened and a new value system, which sustained this inequality, emerged and strengthened the existing patriarchal system.
  • In an effort to reverse the colonial template, the post-independence government adopted re-distributive policies, such as minimum wage policy, expansion of access to education and healthcare and land redistribution and resettlement programme. However women remained the majority of small-scale farmers but with no ownership of land and no control over the returns of their own labour.
  • Further, the downside of resettlement was that it further weakened kinship ties as people moved and lived apart from their kin. In the process, people lost opportunities for sex education and socially controlled courtship.
  • Failure to realize the ESAP outcomes further deepened insecurities, making people more susceptible and vulnerable to HIV infection and AIDS.
  • While the homegrown economic reform efforts are commendable, the consolidation of vulnerability and insecurity generated by their non-delivery continues to put the population under pressure and stress, leading to the adoption of a variety of risky survival strategies.
  • Some of the survival strategies include cross border trading, gold panning, and informal trading.
Given all this background of social re-engineering, there is no doubt that when HIV and AIDS was first identified in Zimbabwe in 1985, it found "fertile ground" in the form of a social environment conducive for its rapid spread. This social environment was generated by a historical template characterized by rapid social and economic change, changing morals, high mobility, gender inequalities, widespread and deepening poverty, thus, constituting numerous vulnerability factors on the population at large. Individual responses to these conditions made people highly susceptible to HIV infection. In addition, the HIV and AIDS problem initially fell on a policy blind spot under the rubric of denial and the silence about HIV and AIDS in policy discourse.

Challenges and Recommendations

The challenge then is to design and implement a new development template that not only addresses poverty, but also address the cultural issues that have evolved overtime as well those that have remained entrenched. In this context it is critical that the positive cultural practices be identified and harnessed in the fight against HIV and AIDS. Equally important is to identify and deal with the bad practices without stigmatizing the society. Thus we need to build a gender sensitive culture for sustainable development.

EPIDEMIOLOGY OF HIV AND TRANSMISSION DYNAMICS

The vulnerabilities highlighted above explain the current HIV and AIDS profile in the country. The report expounds the concept of sex networks. A sex network is a complex map or web of sexual relationships or patterns which bring many sexual partners of a diverse background, status, behaviours and other attributes into direct (or immediate) and indirect (or remote) sexual contact. Sex networks represent one dimension of behaviour that is usually least understood because sex is about private interaction, which is hardly declared openly. Yet we have to discuss these issues if we are to come up with sustainable solutions.

Firstly it is important that we appreciate that in Zimbabwe and Africa in general, 99% of HIV infection is transmitted heterosexually, considering that vertical transmission is in itself a result of sexual transmission to the mothers. Although the epidemic is considered generalized, it is logical that, depending on the vulnerabilities of different sectors, there is not one epidemic but many, that vary sectorally and demographically. The sectoral epidemics are driven by sector specific sex networks, and therefore, demand different developmental interventions. It is thus particularly important to understand who is infecting who and why in order to understand the underlying factors and to re-design and strengthen existing interventions. The HIV and AIDS profile presented in the report demonstrates the existence of sex networks.

HIV in the general population

  • In its latest national HIV estimates report (2003), the MOHCW, Zimbabwe reported an adult HIV prevalence of 25%.
  • Although the epidemic is generalized, commercial farming and mining areas, border posts and growth points are special areas that best illustrate development vulnerabilities in the population.
  • Of the 2.0 million people living with HIV and AIDS, 1.2 million or 60% are women. HIV prevalence among women aged 15-24 years ranges from 25 to 40%, compared to 10 to 15% for men in the same age cohort. Women, in particular the married, were more likely to get infected.
  • Intergenerational sex has a pivotal role in the persistence of major HIV epidemics. Breaking this link in dynamics of transmission must become the central focus for HIV prevention strategies.
  • Young women often have two types of partners: one an older boyfriend who has accumulated assets and is able to provide money and gifts, the other slightly younger, being cultivated as a potential husband.
  • A growing concern is sexual abuse of children. The number of cases reported in the media has increased frighteningly in recent years. The abuse is mostly driven by the belief that sex with children will cure HIV and AIDS or slow disease progression.
  • Similarly a growing concern is the silence about HIV and AIDS among the disabled. This is based on the misconception that the disabled are sexually inactive.
HIV in the Agriculture Sector

  • Sentinel surveillance data shows that HIV prevalence has remained steadily higher in farming communities than in the general population.
  • As a colonial legacy, workers' compounds on large farms constitute small and very closed communities that are poorly endowed with social and recreational facilities, other than the ubiquitous beer outlet frequented by the young and old, men and women.
HIV in the Education Sector

  • In the rural areas, teachers are considered to have relatively high incomes. They are also generally regarded as educated and knowledgeable, and all these factors enhance their social status. This tends to significantly raise their level of risk to HIV infection as their relatively privileged socio-economic position puts additional pressure on multiple relationships because they are attractive clients in transactional sex.
  • Female students and young girls in general also noted that some men pay huge amounts for un-condomised sex.
  • Omnibus crews and taxi drivers give schoolgirls free rides to and from school and buy the girls food from fast food shops.
  • Lack of accommodation is also a problem in secondary and tertiary institutions in the face of increasing enrolments and student population in an environment of shrinking resources
HIV in the Public Sector

  • Deployment of staff without due consideration of the working locations of their spouses was cited as an important determinant of risky behaviour.
  • For example, the Ministry of Local Government has identified several high-risk groups within its employees. These include engineers, artisans, surveyors and technicians who are highly mobile and spend long periods of time on field trips. Similarly, construction workers in the Department of Roads who also spend a lot of time away from their spouses and families are particularly vulnerable. The Ministry of Public Service, Labour and Social Welfare also identified highly mobile employees as being at very high risk. In addition, the employees often receive substantial travel and subsistence allowance, making them relatively wealthy in the midst of poverty, especially in rural areas. Young pension clerks have been cited as being highly vulnerable as they attend to desperate clients such as young widows. The clerks are not only seduced by the widows for fast tracking pension claims, but are themselves also attracted by the pension benefits of these women.
HIV in the Security Sector

  • In the military, young and socially inexperienced people are recruited and trained to be fearless and aggressive. While this is good for war situations, research shows that the youthful soldiers carry this approach in civilian life and into their private sexual interactions. In addition, armies are very mobile and, often, military barracks are found in outlying areas that are poor so that the barracks are a high-income area, thereby nurturing transactional sex.
HIV in Prisons

  • A number of reasons explain the HIV profile in prisons. Chief among them is the overcrowding in single-sex living conditions, which promote casual or non-consensual homosexual relationships mostly involving anal sex. Although usually denied by Africans, anal sex between men in prisons takes place in Zimbabwe and most other countries.
HIV AND AIDS IMPACTS: DEVELOPMENT PUT UNDER THREAT

The epidemic profile highlighted above reflects the impact of HIV and AIDS. I will therefore note belabour you with details of the impacts. Suffice to say that the impact of HIV and AIDS is first experienced at individual, household and family levels, and gradually, more widely in the community. HIV and AIDS cut across all socio-economic groups and because it affects, primarily, the reproductive and productive age groups, its increasing impact is seen in the rising numbers of orphans, the elderly and children living on the streets. The epidemic is decimating the limited pool of skilled workers and managers and eroding the already faltering economy. The impact of AIDS is also being felt at unskilled labour level, as absenteeism increases due to deaths, illness or attendance at funerals. Even more distressing is the poverty and gender dimension of this impact. Of particular concern in the increasing number of orphans in the face of dwindling national, community, family, household and individual income and capacity to care for them. Similarly the elderly and disabled have become more vulnerable to the impact of HIV and AIDS as they lose their care givers and are themselves turned into full time carers and parents.

Challenges

In summary, despite the epidemic being generalized at this high level of infection, there is evidence of heterogeneity in transmission patterns reflected as demographic, geographic and sectoral epidemiological differences. In general, social, economic and cultural factors interact in influencing vulnerability. Furthermore, a common thread weaving through all sectors is poverty, more so with a gender dimension.

The greatest challenge facing us is how to turn around the epidemic. The heterogeneity of spread of the HIV poses serious challenges to the current concept of multi-sectoral response. Poverty and culture are inter-linked in determining gendered vulnerability partly as a consequence of pre- and post-colonial socio-economic engineering. What is required now is to devise strategies that are not only pro-poor but should generate new value systems that ensure establishment of social institutions that control sexual behaviour in communities, to replace those destroyed by the colonial and post colonial social engineering and how gender inequity and inequality can be further reduced in order to reduce vulnerability of women in general.

In a country heaving under an immense economic burden, how can the window of hope be expanded and maintained? The provision for youth friendly services and an education curriculum sensitive to the ravages of the epidemic are necessities. Furthermore, efforts are required to reduce vulnerability in schools and tertiary institutions by providing adequate support and resources to students and staff. Economic recovery, and hence reduction of poverty driven vulnerability, is centred on agriculture, yet this is one of the sectors hardest hit by HIV and AIDS. Cross border trading and informal mining pose serious challenges with regards HIV control. Ladies and Gentlemen, there are many more challenges and some are detailed in the report. With regards impact of HIV and AIDS, the challenge is to prolong the lives of people living with HIV and AIDS so that they will be able to give proper socialization to their children. How do we protect the uninfected children who are the window of hope? What strategies can be put in place to ensure that orphans are well cared for and are made self- reliant?

Recommendations

The challenges call for bold recommendations, decisions and implementation. Generally, there is need for concerted effort to continuously review cultural beliefs and practices and enforce legal instruments, continuously review human resource needs, salaries and working conditions. Equally important is the need to invest in the treatment of opportunistic infections, on antiretrovirals and the provision of support and care for vulnerable children, particularly, orphans. These general recommendations should be strongly complemented by sector specific interventions to deal with identified and defined vulnerabilities.

Agricultural Sector

  • Train extension workers in HIV and AIDS
  • Integrate HIV and AIDS into agricultural curricula
  • Mainstream agriculture into education curricula to ensure basic sustenance for the nation
  • Provide agricultural finance to farmers
  • Research into and disseminate less labour intensive agricultural technologies
Education Sector

  • Provide skills based education
  • Provide "schools-only" transport
  • Provide school accommodation in rural secondary schools and tertiary institutions
  • Tertiary institutions should provide food to students
Private Sector

  • Continuously conduct vulnerability assessments to direct HIV and AIDS policies
  • Expand and enforce HIV and AIDS programmes in the workplace
  • Enforce insolvency laws that protect workers
Transport Sector

  • Provide decent and affordable accommodation for truckers and cross border traders
  • Intensify HIV and AIDS information dissemination to travelers
  • Shorten process of goods clearance at border points
  • Organise cross border traders for bulk trading
  • Provide short distance cross border transport for small traders
  • Expand information, education and communication at all strategic points
  • Train local authority employees to deliver HIV and AIDS messages to travelers
Tourism Sub-Sector

  • Intensify IEC messages in all tourism transport and facilities
  • Provide condoms in all hotels
Micro, Small To Medium Enterprises Sector

  • Provide financial and technical support for MSMEs
  • Organise MSMEs for bulk production and marketing of their products
Mining Sub-Sector

  • Provide comprehensive social services in mines
  • Design and implement comprehensive HIV and AIDS programs in mines
  • Organise small scale miners for support and services
  • Support indigenisation in the mining sector
Public Sector

  • Reduce duration of field trips
  • Provide decent and affordable accommodation in border towns
Uniformed Forces

  • Use military discipline to enforce safe sex
  • Provide family accommodation in barracks.
Prisons
  • Increase community service for petty crime
  • Improve living conditions in prisons
  • Pre and post counseling and HIV testing of prisoners
  • Improve health services in the prisons
  • Improve transport services in the prison sector
Conclusion

Those of you who have seen the report will agree that it is a fairly big document. I could therefore go on and on. In conclusion, the greatest challenge to the survival of our nation is combating the HIV and AIDS epidemic. This is precisely because, HIV and AIDS is using the developmentally re-engineered socio-cultural and economic value systems of our society to permeate insidiously, wrecking unprecedented havoc in the history of our nation. More people have died of AIDS than through all the wars fought in Zimbabwe combined. I hope that I have provided some of the answers to the questions raised earlier, and perhaps to some questions that will be raised later. The gravity of our situation requires all of us to seriously heed the message of the ZHDR 2003 to Redirect our responses to HIV and AIDS towards a developmental framework. Only then will we be able to Reduce Vulnerability. Halting the spread and mitigating the impact of HIV and AIDS is so critical that I am sure all of us know that IT IS THE ULTIMATE WAR FOR SURVIVAL.



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