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Ethiopia

Focus on Ethiopia - May/Jun 2004

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Question: HIV/AIDS a Major Humanitarian and Development Issue in Ethiopia?

Ethiopia is one of the four countries in the world with the highest number of HIV/AIDS infected people. Close to 6.6% of the sexually active adult population (about two million adults) and 200,000 children are currently infected with HIV/AIDS. So far, about 1.2 million children have lost one or both of their parents to HIV/AIDS and the figure is expected to double by 2014 (AIDS in Ethiopia, MoH, 2002).

Reflecting the growing concern about HIV/AIDS and its humanitarian implications in Ethiopia, UN OCHA conducted an interview with Alex De Waal, director of Justice in Africa and an advisor to UNICEF. 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.

Question: what are the linkages between drought and HIV/AIDS and food insecurity and HIV/AIDS?

AdeW: There is interaction between drought and other causes of vulnerability and HIV/AIDS - they all contribute to food insecurity. They do it in different ways and they interact with each other, so that drought as we know creates food insecurity, HIV/AIDS also creates food insecurity in rural populations. It does it in a different way in that it creates a longer term problem by making the reproductive adults in a household or community fall sick and die. So this places additional burdens on the family. In the short term they have to spend more money on health expenditures. Since the sick adult is less able to work, more time and energy needs to be put into caring for sick adults. And then when that person dies there is spending on funeral expenses. In other instances, when the head of a household is sick the household may find that some of its assets are no longer secured. For example land may be taken by relatives. When adults depart, surviving adults need to work in order to feed the children and old people that remain. We may find the surviving children who are orphaned by HIV/AIDS have fewer farming skills than their parents, they have not had time to learn how to farm properly, or they may not be strong enough as they may not be fully grown yet. These are the immediate ways in which HIV/AIDS impacts on a family. Also, many families take in the orphans of relatives putting increased strain on scarce resources. Many rural households also rely on money sent by people who are working in the towns. If those individuals also die then that source of money dries up or individuals who are in cities who fall sick may go home to rural areas to be cared for or to die. And that person is a burden on rural families. In addition, what we find is the interaction between drought and HIV/AIDS is particularly nasty when drought clearly creates a certain degree of food insecurity and malnutrition amongst children, and HIV/AIDS the epidemic also does that. When you get HIV/AIDS and drought together the effect is worse, when the two are combined then it is a multiplicative effect.

Question: have you noticed any similarities and/or differences in the pattern of spreading of HIV/AIDS and stigmatization between other African countries and Ethiopia?

AdeW: The HIV/AIDS epidemic in Ethiopia is much less advanced than in Southern Africa. The level of HIV is lower and particularly so in rural areas. However, the amount of information that we have about HIV/AIDS prevalence in Ethiopia is very poor. There is really a lack of data. So it is hard to draw reliable conclusions. But from what we do know, the prevalence of HIV/AIDS in Southern Africa is a lot higher and it got higher earlier. So the impacts are more clearly found in Southern Africa. Stigma is still a major problem in Southern Africa. It is difficult to compare whether the stigma is greater in Ethiopia than in Southern Africa or the other way round. What we do not know is whether Ethiopia is going to follow the same track as countries like Malawi, Zambia and Zimbabwe of moving to high prevalence rates in rural areas. It may be that rural areas in Ethiopia will still continue to have a relatively low prevalence rate, or it may be that the prevalence rate within 5 or 10 years will increase and become like that of Zambia. If that happens it would be an absolute disaster for Ethiopia. The other thing that is important in comparing Ethiopian experience with Southern Africa is that in many parts of Southern Africa the key factor of production is labour, and households that are short of labour really suffer. In many parts of Ethiopia this is not the case. In thickly populated parts of say Wolayita or Sidama the key problem is land. So that there is quite a lot of rural unemployment and if people fall sick or die in those environments their families will certainly suffer and they will be a general burden on the community, but we may not see the same crisis in the rural economy here that we see in some southern African countries where labour shortages are becoming critical.

Question: how do you evaluate the governments', NGOs and other partners' interventions? Why is it so difficult to bring change?

AdeW: Everywhere you travel in Ethiopia you see posters, bill boards for HIV/AIDS and clearly there are big attempts to inform the public. However, I think Ethiopia has special obstacles to information reaching the majority of people. First of all, so few people go to school and many are illiterate. Secondly, the human resources and infrastructure in the health and education centers are so poor. For example last week I visited one wereda called Melokoza in SNNPR and in this wereda there are around 140,000 people and the most senior medical staff member was a sanitarian. There was not even a medical assistant for the whole area. In these circumstances it is very hard to run any sort of serious health and information campaign and make it stick. The additional problem we should mention in this respect is that even in countries with much higher literacy and much greater capacity such as the central areas of Uganda, South Africa, Namibia, Bostwana, the effect of information, education and communication campaigns has been very limited. It has not really changed that much in terms of people's behaviour, so we need to recognize that these campaigns are important but also that they will not succeed on their own. What is necessary for them to succeed are the kinds of socio-economic programs that maintain social cohesion, that reduce poverty and in particular give women more control over their own lives and their own sexuality. And it's the combination of those two, education and socio- economic empowerment, that will make the difference. You can't just give information and then education and expect it to make an impact.

Question: is there a criterion for declaring the pandemic an emergency in Ethiopia? Do you think the government should declare it an emergency?

AdeW: The WHO declared HIV/AIDS a global emergency in September 2003. The World Health Report which came out on May 11, is entirely on HIV/AIDS calling it a global health emergency. If it is a global health emergency then it certainly is a health emergency in Ethiopia, which is one of the countries with the largest number of people living with HIV/AIDS in the world. In the Africa Development Forum in December 2000, the former president of Ethiopia Negasso Gidada declared war on HIV/AIDS. He said that the government would treat HIV/AIDS on the same basis as a war emergency; I do not however think that statement was actually translated into policy. There is no war - military style or emergency style mobilization - against HIV/AIDS after that but there is no question that it ought to be regarded as an emergency.

I have seen some statistics and have heard some statements that imply the government believes that HIV/AIDS rates are coming down in Ethiopia, for example that the level of HIV in Addis Ababa has been reducing in recent years. I do not think that the data exists to allow you to make that statement with any confidence. The data are simply too poor and too unreliable to be able to say that this is happening.

Question: what humanitarian actions should be taken against HIV/AIDS?

AdeW: In terms of what is required for a humanitarian response to HIV/AIDS, there are a number of issues, for instance a significant number of children are orphaned by HIV/AIDS and there needs to be a sound program to assist them. The number will continue to grow and that should be considered as an emergency too. The other issue is that in all African countries more women are infected than men. They are infected at younger ages and also women have to bear the greater burden of care. It is women who look after orphans; it is women who look after the sick; it is women who do the majority of food preparation as well. So when there is an HIV/AIDS epidemic in a society it means the burden falling on women is substantially increased. Any assistance that can be given to lessen that burden, so that women don't need to work so many hours, walk so far for water or fire-wood, spend so much time on basic domestic duties - anything that can be done in that respect would be positive.

Question: do you think addressing HIV/AIDS is also addressing developmental issues?

AdeW: HIV/AIDS is a particular crisis because it is both developmental and humanitarian. There is a tendency to conclude that it must be treated as a developmental issue, but if you treat it only as a developmental issue, you run the risk of missing the immediate humanitarian needs. And if you treat it as a purely humanitarian or medical crisis, you run the risk of overlooking the developmental dimension. So both dimensions need to be addressed at once. There is also a danger in a country like Ethiopia where you have major problems of hunger, malaria etc and more people die from malnutrition every year, more people die from malaria than die from HIV/AIDS. Therefore it could be said "let us make HIV/AIDS less of a priority", but the danger with that is that you overlook two things. The first is that HIV/AIDS kills the most productive sector of society, and while any human death is a tragedy, the socio-economic impact of killing young children is not as grave as that of killing women in their 20's or men in their 30's, and for that hard socioeconomic reason alone HIV/AIDS is special. The second is that if HIV/AIDS is not addressed over a longer period of time, the higher the prevalence gets, the harder it is to tackle it. If you tackle it early, when prevalence is still low, it is much easier. And the costs that you save by early prevention are much greater. So even though some people may not see it as the most immediate crisis facing this country, action to address HIV/AIDS now will have much greater payoff in five, ten or twenty years time than would be the case if HIV/AIDS is neglected and we wait until it becomes a crisis before addressing it.

Question: what is your opinion of how HIV/AIDS might influence sending and receiving areas in the resettlement program? How can the spread of HIV/AIDS be reduced in such areas?

AdeW: Well ... any program or initiative that involves moving people, and especially that involves separating spouses, is increasing the risk factors for HIV/AIDS transmission. Because when people move around, particularly when spouses are separated, they are more likely to have sexual relations with other individuals. This is just a fact. Whatever is done in terms of education is not going to prevent the increased risk of HIV associated with something like the resettlement program.

Question: what do you think is the cause of the huge discrepancy between official HIV statistics and other data?

AdeW: I think that the Ethiopian data are just not good enough. There hasn't been enough of an investment in actually obtaining real data. For example, there are only around 23 sentinel sites where HIV/AIDS prevalence is monitored. For a country of 70 million people this is almost nothing. It is only by getting really good coverage and much higher levels of reliable information that we can seriously say whether HIV is going up, down, stabilizing or it is higher in some areas than in other areas.

Question: What are the lessons Ethiopia can learn from other countries' experiences?

AdeW: A couple of things ought to be mentioned. One is that even in a poor country like Ethiopia, it is still economically logical to give anti-retroviral (ART) treatment. This is because the price of the drugs has now come down so much, and the benefits of extending peoples' lives also gives hope to people who have HIV/AIDS and encourages people to come for Voluntary Counselling and Testing (VCT). The government should not hesitate to begin providing ART drugs. The second point related to that is that Ethiopia has just achieved its completion point on a big debt relief last month, and the precondition was that Ethiopia keep its deficit very low. Ethiopia had to actually reduce its public spending so that the key allocations in the national budget, including health, have not increased over recent years. They have actually been kept, even during the drought of 2002/2003, even when logic and humanitarianism would have dictated increasing spending. I think Ethiopia needs to re-negotiate with the international community, especially the IMF, the macro-economic framework under which its spending ceiling is set, because it needs to spend a lot more money on education, health and food security. Ethiopia has no chance of achieving food security or development goals unless a lot more money is spent, and Ethiopia cannot wait for economic growth to make the country that much richer. It needs to spend the money, so let's change the macro-economic framework and spend the money now!

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