Hein Marais reviews the HIV/Aids pandemic in South Africa, describing how “the costs of Aids are being socialised, deflected back into the lives, homes and neighbourhoods of the poor”.

Shelve the abiding fiction that disasters do not discriminate - that they flatten everything in their path with “democratic” disregard. Plagues zero in on the dispossessed, on those forced to build their lives in the path of danger. Aids is no different. In South Africa, where at least five million people are living with HIV, the epidemic is entangled in the circuitries that determine the distribution of power and privilege.

The mainstays of South Africa’s efforts to fend off the impact of the HIV/Aids epidemic are anti-retroviral (ARV) therapy provision and home-based care. While vitally important, each in current form also expresses the kinds of prevailing inequalities that warp society.

Today, of the estimated one million South Africans in need of ARVs, only about 200 000 are receiving such therapy - half of them through the private health sector, which is accessible to a small minority of South Africans. According to Statistics SA, only about 15% of South Africans (and a mere 7% of black Africans) belong to medical insurance schemes.

The bulk of ARV provision will have to occur through the public health sector, which is being pummelled by Aids. According to research by the Human Sciences Research Council in 2003, Aids was responsible for about 13% of deaths among health workers between 1997 and 2001 - when the wave of Aids mortality was still beginning to crest. Yet the need for well-trained health personnel has never been greater. Completing the rollout of the government’s ARV programme will require an additional 3 200 doctors, 2 400 nurses, 765 social workers and 112 pharmacists in the public health system by 2009. Need far outstrips supply.

Meanwhile, care needs surge. At the turn of the century, researchers were already finding that almost one in two patients in public medical and paediatric wards was HIV-positive, and that their hospital stays were almost twice as long as those of non-Aids patients. Staff workloads and stress mounted accordingly.

All this is overlaid with broader inequity. A large share of South Africa’s gross domestic product - about 9% - goes to healthcare. However, the spending occurs in a two-tier system. About 60% of the funds pay for the healthcare of the 15% of South Africans with private medical insurance. Annual per capita expenditure on healthcare in the private sector is almost six times larger than that in the public sector, and fully 80% of specialists and at least 60% of general practitioners now work in the private sector. As a general rule, income determines who gets what sort of healthcare.

It’s obvious that in an epidemic this severe, some form of home- and community-based care is vital; otherwise the sheer volume of care needs would swamp the public health system. This has been an important element of the post-1994 overhaul of the health system. In theory, by creating a “continuum of care” that links contributions and resources from the public health system and others, home- and community-based care would boost the quality, scale and sustainability of the care effort.

The reality is rather more profane. Most of the burden of Aids care is being displaced into the “invisible” zones of the home - and onto the shoulders of women.

As practiced, Aids care in South Africa today relies on retrograde notions of womanhood and domesticity, casting women in the roles of bearers of children, nurses of the frail, guardians of the hearth. Women oblige with extraordinary stoicism and courage. But that does not disguise the fact that home-based care, as currently practiced, codifies and exalts the rampant exploitation of women’s labour, financial and emotional reserves.

This form of value extraction subsidises the economy at every level from the household outward, yet remains invisible in political and economic discourse. If nothing else, home-based care lays bare the coercive subtext that nestles in the notion of “mothers of the nation”.

But life, and the struggles to guard it, go on. Patients and their care-givers must subsidise many aspects of care provision, and bear the costs of not receiving the levels of care and support they require - the consequences of which spill across households and families in the forms of stress, trauma and depression.

Although thrust into the roles of mediators, counsellors and saviours, care-givers often are unable to provide things as basic as pain-killers or a meal. They typically admit to feeling overwhelmed and alone, buckled by emotional stress and fatigue. Aids stigma poisons these experiences even further.

Home-based care appears to be a more “realistic” or “affordable” option because its true costs are hidden, deflected back into the domestic zones of the poor. In doing so, it adheres to the same polarising logic that defines our society.

Not only is this unjust, it also undermines the sustainability of care provision in the face of a crisis set to continue well into the future. Aids is meshing with the routine distress endured by millions of South Africans - but to pummelling effect, as it intensifies those hardships, and drives an even thicker wedge between the privileged and the deprived.

Supported by consistent but modest economic growth, infrastructure development and service delivery have improved markedly since 1994 - but on a scale that does not match mushrooming needs, and on terms that bow to the logic of the market.

With access to secure, paid employment at a premium, and institutionalised forms of support deficient, the poor have to absorb shocks themselves. Their margins of safety are wafer-thin. Savings are very low, debt is high and access to medical and other forms of insurance rare. For many millions of South Africans, a regular, living wage is a comparative luxury. According to the 2005 Afrobarometer survey, four in 10 respondents said they went without food or were unable to buy medicine they needed, three in 10 couldn’t afford to pay for water, and six in 10 went without an income at some stage in the past year. African women are hit particularly hard.

At the institutional level, Aids will leave its mark as higher morbidity and mortality rates translate into increased absenteeism and personnel losses - trends already vivid elsewhere in Southern Africa. Especially vulnerable are those sectors of the state and civil society most closely involved in the reproduction of “human” and “social capital”.

Aids mortality now ranks among the top causes of staff losses in the public education system - which says something in a sector already racked by low morale. More than half the educators polled by the Human Sciences Research Council in 2005 said they intended leaving their jobs. Training capacity lags far behind need, with management and administrative skills replenishment especially weak.

In such a context, Aids is likely to aggravate dysfunction in the public school system. The effects could spill wide. If basic education suffers, the springboard for higher education and skills training weakens - to unhappy effect in an economy that has been geared to rely more heavily on a strong skills base. Channels for quality educational advancement will of course be available - to those who can afford them.

What might this mean for inter-generational social mobility? If the quality of public school education deteriorates further, against a backdrop of continuing marginalisation of the poorest households - and of overall polarisation - social mobility will be hobbled, trapping more in the mire of chronic poverty. Whether South Africa can avert such consequences will help decide what kind of society future generations will inherit.

Overall, Aids will corrode institutions’ capacities to provide predictable, consistent and acceptable standards of service. Already saddled with hulking workloads and compromised capacity, the police, correctional and judicial services seem especially vulnerable to additional debilities. So, too, the many community-based organisations that play vital welfarist roles at local level - many of which rely on a few key individuals.

How does this tally on the bottom line? It seems indisputable that the epidemic will affect the economy - but how and to what extent is not easily gauged. Some estimates seem almost to trivialise the effect of Aids by suggesting a negligible effect on national economic output. Other projections anticipate severe damage.

The disagreements stem from the fact that the estimates rest on varying assessments of the epidemic’s demographic impact, the channels along which Aids affects the economy, and the nature of those effects.

Such bird’s-eye views of economic impact carry some illustrative value, but they provide little substantive insight. As usual, the devil resides in the details. And it’s there that one encounters further evidence of the uneven and discriminatory impact of Aids.

A handful of major companies have introduced high-profile ARV treatment programmes for some of their employees, and some also emphasise prevention. Most companies, though, seem to be taking Aids in their stride. They have considerable leeway for deflecting the effects of the epidemic - and they’re using it.

Companies continue to shift the terms on which they use labour, a trend that predates Aids but is having a huge effect on working South Africans’ abilities to cushion themselves against the repercussions of the epidemic.

For more than a decade, companies have been intensifying the adoption of labour-saving work methods and technologies, the outsourcing and casualisation of jobs, and cutting worker benefits. The effects have been particularly harsh on workers in the middle and lower skills tiers.

Medical benefits are now customarily capped at levels far too low to cover the costs of serious ill health or injury. Companies have been cutting death and disability benefits, limiting employer contributions and requiring that workers pay a larger share of the premiums for the same benefits. A mammoth shift has occurred from defined-benefit retirement funds to defined-contribution funds (the latter offering scant help to workers felled, for example, by disease in the prime of their lives).

The net effect has been a constant paring of real wages and benefits for those South Africans with formal employment - at a time when they and their families are at increased risk of severe illness and premature death. Recall that we’re talking here about those workers with relatively secure, and probably unionised, jobs. Left to fend for themselves are the masses of “casual” workers, and the unemployed.

In such ways, the costs of Aids are being socialised, deflected back into the lives, homes and neighbourhoods of the poor. This amounts to a massive, regressive redistribution of risk and responsibility. These sorts of adjustments are enabling many companies (particularly larger ones) to sidestep the worst of the epidemic’s impact. But many thousands of enterprises lack that evasive agility.

Smaller firms, especially those that rely heavily on the custom of poor households, will be hit hardest, to say nothing of informal retailers, spaza shops and “microenterprise”.

The Aids epidemic meshes with the social relations that reproduce inequality and deprivation, generating a glacial, miserable crush. Aids unmasks the world we live in, and underlines the need for drastic change that unreservedly favours the dispossessed. In a society in which millions are impoverished in the midst of abundance, this crisis demands nothing less than a new strategy - and struggle - for realising social rights.

At the very least, this implies an upgraded social package that slots into an accelerated programme of redistribution and rights-realisation. It would include safeguarded food security, the provision of affordable (that is to say, decommodified) essential services, job creation and workers’ rights protection, and the alignment of social transfers to unfolding needs.

Shirk that duty, and current trends will harden and intensify. For hundreds of thousands of people, Aids is already dismantling the hope of a better life in the most incontrovertible way possible: by killing them. It threatens to steal from many millions more the very idea of a different, better world.

* Hein Marais’s new book, ‘Buckling: The Impact of Aids in South Africa’, is published by the Centre for the Study of Aids at the University of Pretoria. It can be ordered at [email][email protected] or http://www.csa.za.org

* This article was first published in the Mail and Guardian newspaper (http://www.mg.co.za) It is reproduced here with kind permission of the author and the Mail and Guardian

* Please send comments to [email protected] or comment online at www.pambazuka.org

AIDS. It killed roughly 3 million people last year, most of them poor, and most of them in Africa. Between 34 and 42 million people are living with HIV. Absent antiretroviral therapies, AIDS will have killed the vast majority of them by 2015.

In such a world, time can seem a luxury, and the rigours of critical enquiry an indulgence. We need things done now, yesterday, last year. Indeed, an overdue sense of urgency has taken hold in the past five years - much of it thanks to relentless AIDS advocacy efforts. Along with sets of received wisdoms, a more or less standardized framework for understanding the epidemic and its effects has evolved, and a lexicon for expressing this knowledge has been established. All this has helped put and keep AIDS in the spotlight. It has popularized knowledge of the epidemic, countered the earlier sense of paralysis or denial, helped marshal billions of dollars in funding and goad dozens of foot-dragging countries into action. It has worked wonders.

But alongside these achievements are some troubling trends. There has emerged a roster of truisms that, in some respects, convey a misleading sense of certitude, and that might even be steering institutional responses in ineffectual directions. As well, awkward gaps are cleaving the AIDS world - gaps that threaten to detach the staples of advocacy from the riches of epidemiological and social research, and spoil the kind of multidisciplinary ferment that the struggle against AIDS dearly needs.

Strong advocacy tends to convey trim, crisp, unequivocal information. But in achieving this, vital complexity and ambivalence is often snipped and siphoned out. At times, research findings are casually interpreted or contradictory evidence is ignored. Sometimes intuitive reasoning is made to stand-in for absent empirical evidence. Much of the time, eclectic dynamics are jammed into simplistic, AIDS-centric frameworks.

All this occurs in good faith - and with the pressures of time and the palpable need to spur countries into action snapping at advocates’ heels. But it shouldn’t stand in the way of doing the right things and doing them properly. And that’s the danger we’re flirting with at the moment.

Effective advocacy is not simply a neutral catalyst. It also invests activities with a specific content and character - all the more so when the advocacy carries the imprint and financial heft of key donors and multilateral agencies. This isn’t just a matter of how knowledge is being constructed and assimilated; it has very practical consequences. Big-gun advocacy often prefigures key elements and features of AIDS programming around the world. But we’re seeing an unhappy antinomy develop between the streamlined demands of AIDS advocacy (and their translation into policy), and the generation and interpretation of reliable AIDS research and analysis.

Some examples. By the late 1990s it was widely assumed that conflict heightened the likelihood of HIV spread. Why? Because people are dislodged from their homes, their “normal” rhythms of social organization are disrupted, they lack access to many essential services, and women especially are vulnerable to sexual violence and might be forced to adopt, in the preferred euphemism, risky survival strategies (i.e. trade sex for favours, goods and services). It made good, intuitive sense. And by the early 2000s the view that conflict led to rising HIV rates was in wide circulation.

Evidence for these assertions was scant, though. Data from the Balkans showed no sign of significantly expanding epidemics there, for instance. In Africa, neither Angola, Sierra Leone, Sudan nor the Great Lakes region offered evidence that conflicts there were triggering rising HIV rates. (Instead, in northwestern Kenya, for example, the HIV infection rates in some refugee camps in 2002 were found to be much lower than they were in surrounding areas.) It now appears that chronic conflicts like that in Angola might actually have curbed the spread of HIV by limiting mobility (transport infrastructure was badly damaged, trading networks were truncated etc.). It might be that the threat of a surging epidemic is greater as peace is recuperated and as normality returns in post-conflict settings. The lesson? Assumptions, no matter how logical they seem, should be tested before they’re paraded as facts.

Eclectic realities

Indeed, thanks to the massive output of AIDS impact literature in the past 5 years it’s becoming increasingly evident how multifaceted and complex the responses of people and systems are to the epidemic - and not least in southern Africa, where AIDS is hitting hardest. Yet, the popularized knowledge of AIDS impact is, in some cases, as roughly-hewn as it is loud.

One example is the understandable temptation to distil generalized and ubiquitous “truths” from very specific, usually highly localized research findings. Thus, labour losses attributed to AIDS on a single farming estate in Zimbabwe, for example, can end up being extrapolated to all of Zimbabwe (or even to “Africa” as a whole). From this there might emerge a claim that, say, “AIDS is cutting agricultural productivity by one-third in Africa”. In advocacy terms, of course, this has great currency - it is the stuff of headlines and sound bytes that jolt. But it matters that the statement is inaccurate - and not just for didactic reasons.

The epidemic’s socioeconomic impact is varied and complex, and operates as part of a web of other, richly varied factors. Neither the epidemic’s effects nor the responses they elicit necessarily adhere to a predictable, homogenous, linear paths. This has important bearing on the kinds of policies and interventions that are most likely to trump or at least cushion the epidemic’s impact. Once such variety and contingency is scrubbed out - and reality is rendered as a mechanistic and predictable sequence of events - the effects can be both unhappy and wasteful.

Another example. There has emerged a palpable tendency to single out and over-privilege AIDS as a debilitating factor, as illustrated during the 2002-2003 food crisis in southern Africa. There is ample evidence showing that the effects of AIDS in rural households, particularly those engaged in agricultural production, are pernicious. Where one or two key crops must be planted and harvested at specific times of the year, for example, losing even a few workers at the crucial planting and harvesting periods could scuttle production. But then came a grand leap of logic. With little but anecdotal evidence, a causal and definitive link was asserted between the AIDS epidemic and the food shortages.

The reasoning hinged mainly on reduced labour inputs (due to widespread illness and death of working-age adults). But these inputs figure among a wide range of variables needed to achieve food security - including marketing systems, food reserve stores, rain patterns, soil quality, affordability of seeds, fertilizers and pesticides, security of tenure, food prices, income levels, access to and the terms of financing etc. It is difficult, perhaps even impossible to unscramble the effects of AIDS on rural communities and food security from economic, climatic, environmental and governance developments. The epidemic’s apparent effect on food production occurred in concert with a series of other factors, including aberrant weather patterns and an ongoing narrative of unbridled market liberalization, hobbled governance and wretched policy decisions.

Singling AIDS out as a primary, salient factor is a lot easier than fingering and tackling the other, more prickly factors - many of them tied to formidable interests and forces - that are at play. But it can be misleading and tempt short-sighted and ineffectual policy responses. When it comes to the epidemic’s mangling consequences, policy responses are more likely to make a genuine difference if AIDS is made to take its place in the dock alongside the other culprits, which often include agricultural, trade and macroeconomic policies, land tenure and inheritance systems, and the capacity of the state to provide and maintain vital support services in rural areas. The over-privileging of AIDS lets decision-makers off the hook by endorsing fashionable courses of action that can fail to go to the heart of the matter.

The ground zero of this epidemic is where community and household life is built. And there’s no doubt that, win or lose, the outcome of societies’ encounters with AIDS ultimately depends on how communities and households are able to respond. This is widely recognized, hence the emphasis on so-called community safety nets and household “coping” strategies in AIDS impact writing and policy outlines. There’s the danger, though, that unless these mechanisms are buttressed with other, stout forms of structural support, we may end up fencing off much of the AIDS burden within already-strained households and communities. Yet, such forms of structural support have been systematically dismantled or neglected in many of the hardest-hit countries - typically as part of structural adjustments demanded by international financial institutions. Some of those same institutions are now enthusiastic fans of community resilience. Indeed, after years of scorched-earth social policy directives they are now casting the “community” in an almost redemptive role. And this while much of social life has been subordinated to the reign of the market and the state shorn of its ability to fulfil societal duties.

The safety net and coping pieties sometimes skip around other important facets. Since many informal safety nets tend to centre on reciprocity, they run the risk of reproducing the inequalities that characterize social relations at community level. One study in Kagera, Tanzania, for example, found that the poorest households plunged deeper into debt because they lacked the wherewithal to enter into reciprocal arrangements. Women in particular found themselves sidelined. “Communities” and “the poor” are not homogenous.

Overall, a potentially treacherous distance is opening between the imperatives of advocacy and outlines of big-league programming, on the one hand, and rigorous epidemiological and social research and analysis, on the other. Part of this is a hazard of advocacy, which tends to favour declamation over explanation. Part of it is inflected with institutional “cultures” and ideologies. Part of it is panic-induced; it’s 2004, and we can count the national “success stories” against the epidemic on one hand. Understandably, there’s a rush on.

But part of the problem also lies in a failure to reconcile the schizoid aspects of AIDS - as a short-term emergency and a long-term crisis. It’s become second-nature to hitch the word “AIDS” to “development”. Google that phrase and the search engine will fling 5 million hits back at you. This implies a buzzing cross-pollination of expertise, inquisitiveness and knowledge-building. That’s an illusion, though. AIDS advocacy might have embraced some of the lingo, but it has assimilated very little of the critical knowledge built in development theory and practice over the past quarter century, not to mention other pertinent fields such as sociology, political geography and economics. There is precious little genuine, multidisciplinary rigour evident in AIDS discourse. And the smorgasbord feel of many AIDS programmes reflects this shortcoming. It’s as if, once declarative truisms are achieved, serious reflection becomes a luxury. In a race against the clock, programmes and strategies must now be crafted. New insights or complicating information become a headache. And so the incipient interdisciplinary dialogue splutters into the intellectual equivalent of a one-night-stand. Don’t call me, I’ll call you.

All this is unfortunate and, ultimately, counter-productive. Because AIDS advocacy is not just about sharing vital nuggets of knowledge, it is aimed also at promoting specific types of practice and forms of policy. If that knowledge is stunted, stripped of its riches and whittled into slim proclamations, we run a real risk of embarking on inadequate or inappropriate action. And all the while, that clock would still be ticking.

* World Aids Day is on 1 December.

* Hein Marais is a South African writer and journalist. A former chief writer for the Joint United Nations Programme on HIV/AIDS (UNAIDS), his work is focused largely on AIDS and on political-economic issues. He is the author of South Africa: Limits to Change - The Political-economy of Transition (Zed Books/UCT Press). This article first appeared in the e-newsletter of the Isandla Institute, which can be visited at

* Please send comments to [email protected]