PLAYING GOD WITH HIV
Rationing HIV treatment in Southern Africa
Randy B Cheek
African Analyst at the Security Strategy and Policy Branch of the National Defense University in Washington DC, United States
Published in African Security Review Vol 10 No 4, 2001
It is generally understood that conflict can contribute to the spread of disease. This paper explains the reverse: how disease, as an accelerating factor, can result in serious conflict. While not a cause of war itself, HIV/AIDS exacerbates existing tensions: social, ethnic and political. Political constituencies concerned about HIV/AIDS will become frustrated if the states leadership does not meet their demands. The demand for medical treatment of the disease is certain to exceed supply in all Southern African states. Projects to treat the disease are small and access is limited. The criteria for access, both real and perceived, will play a critical role in determining the level of conflict and disruption that HIV/AIDS will cause.
The contribution of war to the spread of HIV in Africa is well documented. Social disruption leads to risky behavioural patterns and mobile military forces serve as vectors for transmission of the virus across state lines and between demographic groups. Conflict breaks down the support systems, such as delivery of basic food, health, and educational services that help to mitigate diseases of all kinds. However, what is less understood is the reverse the contribution of HIV to the spread of conflict. In the African environment, HIV is creating a fertile environment for conflict and war. While not in and of itself a casus belli, HIV is exacerbating the existing social, ethnic and political tensions that have historically fed intrastate and interstate conflict in Africa. HIV can be thought of as an accelerant to conflict fuelling latent suspicion, resentment and hatred. HIV serves as an accelerant to conflict in three distinct ways:
- HIV erodes the social, economic and political fabric of nations, increasing instability and unrest at all levels of society.
- HIV generates political constituencies whose demands cannot be met by leadership, thereby increasing political discontent and unrest.
- HIV creates a new scarce commodity of fundamental importance i.e. treatment whose distribution can exacerbate existing ethnic and social tensions.
Any one of theses factors is capable of pushing fragile societies into conflict. The combination of all three occurring simultaneously is an overwhelming burden, which could well result in increased conflict ranging from sporadic social unrest to regional interstate conflict. Uneven distribution of essential HIV treatment based on social, ethnic or political criteria could well put unmanageable pressures on social and political structures, threatening the stability of regimes throughout Southern Africa.
While not traditionally thought of as a source of conflict, disease in general, and HIV in particular, creates conditions that have historically proven to lead to conflict.1 Poverty is a prime example, with the attending decrease in medical services and health. Poor health correlates strongly with distrust in local government, levels of crime and conflict at work all indicators of declining social cohesion.2 According to Andrew Price-Smith, declining health correlates with a decline in state capacity, leading to instability and unrest. A high prevalence of disease diminishes national prosperity, foments inter-elite conflict, exacerbates societal income inequality and significantly depletes human capital.3 Not only does disease increase the demands on government, it diminishes its ability to respond effectively. According to J.S. Kassalow:
Loss of skilled government officials, highly trained military leaders, and members of the entrepreneurial class undermines political leaders capacity to govern.4
This paper will examine the scope of the HIV crisis in Southern Africa, the factors limiting access to treatment, and the potential for conflict resulting from competition among increasingly desperate peoples. The conclusion is that uneven access to HIV treatment has the very real potential to fracture social and political structures and could lead to intrastate and/or interstate conflict. These unintended results must be anticipated and, to the extent possible, mitigated in planning for limited distribution of HIV treatment. The argument is not that the inability to provide universal access to HIV treatment should preclude any attempt to assist those infected. Treatment must be made available. But the results of necessary rationing of treatment cannot be ignored. It is therefore critical that the destabilising implications of deciding who lives and who dies, and the criteria for such decisions, must be fully analysed by policy makers before such programmes are instituted. Failure to do so could cause a problem as great as the one they hope to solve.
HIV in Southern Africa: a viral holocaust
HIV exists in epidemic proportions throughout Southern Africa. Some 70% of all cases worldwide occur in the region, as well as 90% of all deaths. Statistically, over 20% of the adult population in Southern Africa is infected with the virus that causes HIV, with rates ranging from 13% in Mozambique to nearly 40% in Botswana and Zimbabwe. South Africa, the most populous nation in the region, has an estimated adult infection rate of 2025%, with over 4.7 million HIV-positive citizens, the largest national population in the world. Demographic data suggests that the HIV infection rates will continue to increase. While infection rates among young (1519) women and men in some countries in the region have fallen, rates among adults (2045) continue to rise, suggesting that, while initial efforts at prevention and education may show results, behavioural changes do not last over time. People are becoming infected after their teen years. Most significantly, overall infection rates throughout the region continue to rise. HIV is already a serious threat in Southern Africa, and it continues to worsen. It is estimated that, given current rates of infection, 10 00012 000 people daily will die of HIV by 2005.5
The social implications of HIV are well documented. HIV increases social tensions at the family level, pitting husband against wife in a power struggle to determine both responsibility for the disease and the ability to protect against further infection. Victims lead secretive lives, becoming social outcasts due the pervasive stigma attached to the sexual nature of transmission. Women, often widowed before they, themselves, die of the disease, lose their place in traditional family structures and struggle to keep their families together. Finally, children orphaned by HIV are already beginning to overwhelm traditional coping mechanism, as evidenced by the proliferation of child-headed households by all accounts a solution of last resort. All of these factors are already beginning to fray the fabric of society at the micro level. Increased domestic violence and child abuse is but one indication of this stress. And while the figures are already alarming, the real impact of the HIV crisis will not be felt for another five years, when the masses of those now infected begin to sicken and die.6
Economically, HIV serves as a double-edged sword, decreasing the supply of economic resources while at the same time increasing the demand for expensive health care. Southern African economies, already fragile and barely able to meet the needs of their people, are likely to contract by 1520% over the next decade due to the effects of HIV. Gross domestic product (GDP) growth throughout the region is likely to decline by one per cent a year due solely to HIV.7 Worker vitality and productivity are decreasing, especially in critical mining and industrial sectors. Agricultural production, critical throughout the region, is declining as able men and women are dying, leaving inexperienced children to continue subsistence farming. Absenteeism, both due to sickness and attendance at funerals, is rapidly increasing. Individual businesses are seeing an erosion of profits (68%) that could threaten their existence.8 As businesses fold, unemployment will increase. At the same time the economies of Southern Africa are contracting, the demand for services will increase. Already, HIV is demanding half of the Zimbabwean health care budget, and will absorb nearly two-thirds by 2005. In South Africa, provincial social service budgets are already being absorbed by the demands of treating opportunistic HIV infections. Demand for these expensive services will not peak for at least five years. Clearly, the economic stresses imposed by HIV in Southern Africa have the potential to cause unrest and conflict, as increasing numbers of people compete for a decreasing pool of resources. According to Alan Whiteside, at the University of Natal:
It [HIV] will be an absolute disaster. It is going to put huge demands on the social services which frankly are not prepared for it.9
HIV and health care: biting the hand that treats it
While this is true of all social services, it is especially true of health care. The expense of providing palliative care for HIV patients is overwhelming the limited health budgets of Southern African nations. Throughout Southern Africa, in 1997 public spending for AIDS alone already exceeded two per cent of GDP in seven of 16 African countries sampled a staggering figure in nations where total health spending accounts for 35% of GDP.10 The implications are equally dire at the national level. As Tinashe Madava reports:
According to government figures, AIDS care expenditures in Zambia rose from $1.7 million in 1990 to $12.9 million in 1995, and is expected to rise to $21.0 million in 2005. The effect of increased expenditure on AIDS care is the inevitable diversion of money from other important health care needs.11
According to Grace Hiwa, senior official in the Malawian Ministry of Health and Population:
The uncontrolled prevalence of HIV/AIDS has brought untold pressure on health care delivery services in Malawi
This has created fears within government that in the next few years over 50% of the health budget would be spent on treating patients with AIDS-related conditions.12
The implication of the increasing demands of HIV on national health budgets was summarised by the Africa Faith & Justice Network.
A fragile health care system has thus been unable to cope with the ensuing spread of infection. The sudden influx of patients has brought many hospitals
to the brink of collapse.13
This is true throughout Southern Africa for a variety of reasons. HIV patients are flooding Southern African hospitals. In South Africas Gauteng province, 50% of hospital beds are filled by AIDS patients. Chris Hani Baragwanath Hospital the largest in South Africa and main service provider to Soweto has seen a 500% increase in HIV-positive patients in the past five years.14 In Zimbabwe, the main hospital in Bulawayo nearly closed for lack of funds. Government could only provide enough to ensure two months of operation.15 In Malawi, hospitals can no longer cope with the patient load, and AIDS patients are shuffled off to home-based care, a euphemism for managed death.16 Training of health care professionals is also at risk. In Zambia, the university teaching hospital closed in February 2000 due to a doctor strike precipitated by lack of drugs and medical equipment.17 In Zimbabwe, the country loses an average of 300 nurses annually to the private sector or brain drain.18 More significantly, HIV is killing medical professionals. In Zambia and Malawi, doctors and nurses are dying faster than they can be trained.19 Combined with the loss of medical practitioners due to burnout and brain drain, Southern Africas ability to address the growing HIV epidemic is likely to be inhibited as much by a lack of trained professionals as by a lack of financial resources.
HIV treatment: the devil in the details
For years after it was first discovered in the West, there was no treatment for HIV. The disease could be tracked and monitored, and opportunistic infections could be treated, thus postponing deaths. But in all cases, HIV led to the degradation of the patients immune system causing a slow and certain death within eight to ten years. The development of AZT by western drug companies in the late 1980s gave some a glimmer of hope, but was not an effective long-term treatment. It was only in 1996, with the approval in the United States (US) of triple drug therapy, that the word treatment could be legitimately applied to HIV. This combination of drugs, one that suppresses reproduction of the virus, one that reduces viral loads, and the final drug that repairs damage to the immune system, make it possible to begin thinking of HIV as a chronic, but not immediately terminal illness. Triple drug therapy or Highly Active Anti-Retroviral Therapy (HAART) has been in existence since 1996, and has shown great promise in restoring HIV- positive patients to productive lives in the short time it has been used.20
However, the treatment developed by western drug companies for western medical systems is both expensive and complicated. Those in the west typically pay between $10 00015 000 a year.21 HAART requires a complicated regimen of up to 17 pills, drugs and vitamins, taken several times daily on a strict schedule. The medications are timed specifically with meals high in protein and calories, and low in fat. Patients are required to maximise rest and minimise stress. All of these conditions are essential to achieve full benefit from the treatment. Regular monitoring by doctors is necessary to fine-tune the combination and dosage of the drugs. Failure to meet these exacting conditions not only reduces the benefits of the treatment, it risks creating an environment within the body in which the HIV virus can mutate, developing strains that are resistant to the drugs and thus untreatable.22
HAART presents many obstacles when it is extrapolated to Southern Africa. Cost is a fundamental, but not prohibitive concern. Certainly, in a region where the average GDP of those infected is less than $1000, spending $10 00015 000 a year for medical care is beyond comprehension. Endemic poverty will mandate that HIV treatment remains scarce. Public pressure and social conscience have, however, caused western drug companies to reduce drastically their prices, and in some cases make the drugs available at no cost on a limited basis. What is not certain is that this will continue indefinitely. HIV is a chronic disease only so long as treatment continues by definition for the remainder of the patients life. If at any point in the future, costs increase or supplies decline, those dependent on treatment will relapse into the HIV cycle, progressing toward full-blown AIDS and a slow, painful death. Those contemplating large-scale HAART in Africa must understand fully the implications, both in depth and breadth, of their decisions. HIV treatment is not short term. It lasts forever, at least from the perspective of the patient.23
Although cost is a long-range complication leading to scarcity of HIV treatment in Southern Africa, other factors represent more inherent barriers to providing HAART in sufficient quantity. Poverty impacts on the price of treatment, creating economic scarcity. Poverty, however, complicates treatment in other ways. The extremely poor (those living on less than $2 a day) typically have limited access to regular, preventive medical care, lacking insurance. Maintaining a HAART follow-up and monitoring regimen would be extremely difficult for those able to access free drugs. South Africa currently has one trained health care professional for each 50 000 HIV-positive citizens.24 Zambia has only 400 doctors in the entire country, serving nine million people.25 The inability of Southern African governments to cope with HIV/AIDS is demonstrated by the prevalence of home-based care. This coping mechanism in which patients are sent home to be cared for by family until they die; little more than a hospice programme demonstrates the inability of the health care system to address the needs of current HIV/AIDS patients. In Malawi, Zambia, Zimbabwe, Mozambique and poorer sections of South Africa, home-based care is the only form of treatment available to AIDS patients.
Additionally, poverty impacts on nutrition. The extremely poor often find it difficult to meet basic caloric requirements, let alone the particular mix of proteins and calories necessary for HAART benefits. In many cases, extremely poor HIV-positive patients lack access to clean, safe drinking water, making the taking of pills problematic at best. These are definite economic factors contributing to the scarcity of effective treatment, beyond the absolute price of drugs.
Macro-level infrastructure inadequacies aggravate delivery of complicated HAART on a necessary scale. Throughout Southern Africa, medical services are highly concentrated in urban areas, and are further concentrated in wealthier sections of cities. Rural and urban poor often have limited or no regular access to clinics or doctors. In order to provide HAART, doctors, nurses and clinicians must be trained on its specific requirements.26 Such highly trained personnel are likely to be limited in number and reluctant to locate in rural and/or poor areas. The lack of adequate health care infrastructure and medical personnel makes distribution of HAART problematic. These same structural issues make monitoring, as essential to the long-term effectiveness of HAART as distribution, nearly impossible. Clearly, structural and economic barriers to treatment are certain to result in an uneven availability and a resultant scarcity.27
Providing treatment: when demand meets supply
The demand for HIV treatment is certain to exceed its supply in Southern Africa, regardless of the best efforts of regional governments and donor nations. This will be true for the economic and structural reasons discussed above. Given the scarce nature of the treatment, and its critical nature for those who suffer from HIV, the distribution of limited supplies has the potential to foment conflict and violence. Some conflict and social stress is inevitable, due to the economics of poverty and the structural limitations imposed by the health care system in Southern Africa.
As access to treatment is restricted by availability of adequate health care infrastructure, rural and urban poor populations will suffer disproportionately. In the region, only Botswana has attempted to provide any HIV treatment on a wide scale, and this has been limited to mother-to-child-transmission (MTCT) treatment. MTCT is relatively inexpensive and simple compared to HAART and Botswana possesses greater resources and a more comprehensive health care system than any nation in Southern Africa. Still, despite its best efforts, distribution and infrastructure problems result in 11 out of 12 HIV-positive pregnant women in Botswana failing to get MTCT treatment.28 Most of those getting treatment reside in urban areas.
Given the poor results for MTCT, the implications for provision of HAART are staggering. The rural and urban poor will be denied access to HIV treatment based solely on economic and demographic reasons. South Africa is currently attempting limited MTCT pilot projects at 12 sites.29
Namibia, Zambia and Zimbabwe have no national programme and rely on the sporadic efforts of well-meaning non-governmental organisations (NGOs). Access to treatment based on income or infrastructure criteria could be perceived as passive social engineering.
The criteria for access, both real and perceived, will play a critical role in determining the resulting level of conflict. Currently, in South Africa, access to pilot projects is determined by strict adherence to medical criteria.30 Continuation of this practice will minimise social unrest among those not eligible for treatment, but only while the programmes remain small and are perceived as test cases in effect a promise of more to come.
As treatment programmes expand and criteria are necessarily expanded, some polarisation seems inevitable. Unless trial programmes are expanded into rural areas as well as urban, polarisation could result, as those denied treatment based solely on their residence demand access. The lack of sufficient medical infrastructure in rural and urban poor areas, unfortunately, represents an inherent barrier to such expansion.
Other social factors represent an even greater opportunity for polarisation and conflict. Restriction of access to HIV treatment based on education, employment or highly-valued skills could also be viewed as social engineering, dividing societies and fuelling conflict. Governments will be tempted to seriously consider such criteria. Scarce HIV resources represent real national treasure. Given the economic implications of HIV infection rates (1520% decrease in economic growth over the next decade) governments will be tempted to save those best able to contribute to growth and recovery. Southern Africa has a vast surplus of unskilled, unutilised labour and a critical shortage of skilled, highly educated people.
The desire to protect the expensive investments in educating and training this skilled labour pool will be great and has already been demonstrated. Zambia screens management applicants in the mining industry for HIV status.31 Botswana restricts highly-valued study abroad to HIV-negative applicants.32
The link between HIV and economic benefits has already been established. Restricting treatment based on these criteria seems a logical extension. It is unlikely, however, that those deemed expendable the unskilled and uneducated will appreciate such pragmatic decisions based on cost-benefit analyses. To them and their loved ones, their lack of advantage makes their lives no less valuable and no less deserving of protection. Denial of education or training has economic implications. Denial of treatment means death.
Perceptions of ethnic or political criteria for access to treatment are also potential sources of conflict. In South Africa, where HIV prevalence rates are highest in the province of KwaZulu-Natal, Zulu-speaking people generally face much higher infection rates than Xhosa-speaking people in the Eastern Cape.33 Violent conflict between these two groups has a long history in South Africa, exacerbated by the pre-1994 apartheid governments efforts to divide the black population. As recently as the mid-1990s, ethnic and political violence between Zulu and Xhosa destabilised KwaZulu-Natal, with thousands killed throughout the province. The Inkatha Freedom Party (IFP) political voice of many Zulu-speaking people threatened with a secession of KwaZulu-Natal from South Africa prior to the countrys first non-racial election in 1994. If access to HIV treatment is perceived to be restricted along ethnic lines, these latent animosities could erupt. Certainly, if Zulu-speaking people begin succumbing to AIDS in greater numbers than their Xhosa-speaking compatriots, due solely to demographic factors absent any malicious intent on the part of government, radical elements in the IFP will have a new weapon in their fight for separation.
Ethnic issues also exist in other Southern African states. Non-Shona people in Zimbabwe primarily the Matabele in the south which comprise roughly 10% of the population suffer higher infection rates and have less adequate health care than the Shona in the north.34 In Namibia, Herero and Damara have less access to government resources and health care infrastructure.35
Throughout Southern Africa, access to health care is distributed unevenly across ethnic lines, often due to economic limitations, but occasionally as in the cases of Zimbabwe and Namibia due to government decisions to reward dominant ethnic groups at the expense of minority groups. This inequity correlates directly with access to HIV treatment, and has the potential to turn HAART into a weapon of ethnic division and conflict even in the absence of overt efforts to use it as a tool.
Zimbabwean President Robert Mugabe and the ZANU-PF leadership have not in the past hesitated to use other critical resources such as food and fuel as political weapons. ZANU-PF supporters, traditionally Shona-speaking people in the north and west, have benefited the most from government-provided services and investments on infrastructure.36 When basic foodstuffs and fuel were short in 2000, the majority of deliveries went to ZANU-PF Shona-speaking supporters of President Mugabe. The Matabele and non-Shona people of the south and east were denied access, in part because of their ethnic identities, but primarily because they supported the opposition Movement for Democratic Change.37
HIV has already emerged as a political issue in South Africa. A public opinion poll conducted by the Institute for Democracy in South Africa (IDASA), in October 2000 identified failure to respond to the HIV crisis as the primary cause for President Thabo Mbekis drop in popularity. Only 38% approved of his and the African National Congress (ANCs) attempts to deal with the crisis.38 Criticism of his vacillation and lack of action on the issue has come from all political directions. Indeed, during the last local government elections, the main opposition party, the Democratic Alliance (DA), attempted to use HIV as a political weapon, promising free HIV treatment to rape victims and pregnant women in any district they carried.39 The politicisation of HIV has already occurred in South Africa. Access to treatment will only exacerbate the tensions, raising the stakes for those left out. Political parties and factions will certainly seize the opportunity, threatening stability and radicalising the political landscape.
HIV treatment not only presents an opportunity for opposition parties in South Africa, it also threatens to split the ANC along ideological lines. The ANC has a contentious coalition with the South African Communist Party (SACP) and the Congress of South African Trade Unions (COSATU). President Mbeki and the senior ANC leadership are committed to the Growth, Employment and Redistribution (GEAR) strategy, the governments market-friendly macro-economic plan.
Both coalition members have clashed with ANC leaders over the focus and nature of social and economic policy manifested in GEAR. Demands for universal HIV treatment will put increasing pressure on ANC leaders to abandon their market-friendly investment policies in favour of massive government programmes and a more socialist restructuring policy.
Recent evidence suggests that HIV is exacerbating this fault line, as COSATU and the SACP as well as those representing the ANC dissidents, are demanding greater government action in providing services. The resulting political tensions could threaten the ANC ruling coalition.
More significantly, tensions over economic and restructuring policies exist within the ANC itself. Proponents of the more socialist wing of the ANC, whose popular face is Winnie Mandela, oppose the GEAR programme and demand faster paced economic reform with a stronger government role. Demands for increased access to HIV treatment will play into the hands of those who insist that greater government spending is needed to address the inadequacies inherited from the pre-1994 apartheid regime. The resulting political standoff could split the ANC and result in political turmoil. Rifts between ANC leadership and the rank and file have already developed over HIV/AIDS.40
Confronting conflict: facing Sophies Choice
A simple fact must be stated no Southern African nation currently possesses the economic resources or the health care infrastructure to effectively administer existing HIV treatment to all those who need it. However, while HAART cannot be made available universally to all HIV- positive people in Southern Africa, some will have access to the drugs. It will be politically untenable for any government to deny HAART to those who can afford it, and no government in Southern Africa, President Mbekis inclinations notwithstanding, can continue to restrict access to treatment solely on cost. Those who can currently afford the high prices are already taking treatments. These are mostly urban elites and represent a small, statistically insignificant minority. Expanded access to HAART, at greatly reduced prices, will require extensive national programmes and subsidies. Due to the nature of the health care system, the vast majority of those able to participate in such programmes will reside in urban areas, where doctors, nurses, and clinics are concentrated. It seems certain that the future of HIV treatment in Southern Africa will see a small pool of haves among a vast ocean of have-nots.
This division into haves and have-nots, based on income and access to health care, has the potential to polarise society and exacerbate already existing schisms based on income distribution and access to basic human services. In fact, it can and has been argued that access to necessary health care is a basic human right, guaranteed by constitutions throughout Southern Africa. Certainly, as some regain their health under HAART while others deteriorate and die, based solely on the vagaries of poverty and urbanisation, social class conflict is certain to erupt. Governments in the region will inevitably be faced with the difficult prospect of deciding which of its citizens will live and which will die. This Sophies Choice condemning some to death so that others can live is the root of potential conflict surrounding access to HIV treatment. It is absolutely critical that these decisions be as transparent as possible and free from any perceived or real allegations of abuse.
Clearly, given the breadth and depth of Southern Africas HIV epidemic, prevention is the only long-term solution. Education programmes must demonstrate the ability to modify behaviours that put large numbers of people at risk, and infection rates must begin to drop across all age groups. Only when the infection rate significantly falls below the death rate can we see, to paraphrase Churchill, the end of the beginning of the war on HIV. However, as important as education and prevention are to the long-term war on HIV, they will not assist governments in managing the ethnic, demographic and political tensions that are certain to arise as those already infected with HIV progress toward AIDS and death. That will require treatment.
If access to HIV treatment is to be necessarily limited due to cost and infrastructure, as it seems certain it must, then social, political and ethnic tensions will certainly follow. After all, to be denied access to treatment is the same as a death sentence. If some are to be spared while others condemned, special attention must be given to the criteria for access, as well as public perceptions of discrimination. For most states in the region, the problems will be social and political, as most governments can be expected to act in the best interests of their people, distributing limited resources as fairly as possible. Others may be tempted to take a less altruistic course, and use the epidemic for political gain. It is the responsibility of all concerned, western donor states, international drug companies, NGOs and especially the governments of Southern Africa, to ensure that the inevitable inequities of HIV treatment distribution are key factors in planning and distribution, and the potential civil unrest and ethnic violence are minimised. Failure to do so could result in widespread violence and state failure.
It is HIVs ability to disrupt the social, ethnic and political fabric of Southern Africa that is most alarming. This is due to the tenuous nature of stability in the region and the political, ethnic and social divisions that contribute to that fragility. As the HIV virus continues to infect greater numbers throughout the region, and those already infected begin to manifest symptoms of AIDS, the potential exists for already diverse communities to fragment further.
In the best of cases, where a far-sighted and responsive leadership tries its best to manage the fractures, the result could be only a diminished ability to govern and an increase in social unrest. In the worst of cases, where a beleaguered regime attempts to use HIV to further its own short-sighted goals, the result could be widespread violence, threatening neighbouring states and the entire region with civil violence.
- Kassalow, J.S., Why health is important to US foreign policy. Council on Foreign Relations, Milbank Memorial Fund. 2001, p.9.
- Kennedy, B.P., I. Kawachi, and E. Brainerd. The role of social capital in the Russian mortality crisis. World Development, 1998, pp 26:2029-43.
- Price-Smith, A.T. The health of nations: Infectious disease and its effects on state capacity, prosperity, and stability. Ph.D. diss., University of Toronto, 1999.
- Kassalow, J.S., op cit. p 10.
- AIDS epidemic update: December 2000, UNAIDS and World Health Organisation Report.
- US Census Bureau Report, Demographic implications of HIV in Africa, 2000.
- UNAIDS Global Update 2000.
- Desmond Cohen, The economic implications of HIV in Southern Africa, UNAIDS, 2000.
- Dr Alan Whiteside, Director, Health, Economics and Research Division, University of Natal, in, AIDS exacerbates hospital crisis, Daily Mail & Guardian, Johannesburg, South Africa, 30 June 1999.
- UNAIDS Factsheet: HIV/AIDS in Africa, 2000.
- Is AIDS destroying Southern Africas health system?, Tinashe Madava, SARDC, 1999.
- Grace Hiwa, Malawian Ministry of Health and Population, as quoted in, HIV/AIDS piles pressure on Malawis health budget, Rapheal Tenthani, Pan African News Agency, 8 September 2000.
- Unpayable debt and AIDS in Africa, The HIAD and Health Care Working Group of the Advocacy Network for Africa, Africa Faith & Justice Network, January 2001.
- Daily Mail & Guardian, 20 April 1999.
- David Karanja, Health-Zimbabwe: Health service on the brink of collapse, African International Agency, 26 July 2000.
- Grace Hiwa, op cit.
- Zambia: Health crisis deepens, Integrated Regional Information Network (IRIN), UN Office for the Coordination of Humanitarian Affairs, 17 February 2000.
- David Karanja, op cit.
- AIDS Epidemic Update, op cit.
- US Department of Health and Human Services Newsletter, Health Resources and Services Administration, 22 June 1999.
- Times of Zambia, 21 March 2000.
- David Gilden, Simplifying anti-retroviral treatment regimes: A summary of current research, Forum for Collaborative HIV Research, Centre for Health and Policy Research, George Washington University School of Public Health and Health Sciences, January 1999.
- Chris Griffin, How the body fights back against HIV, Being Alive Newsletter, 5th National Conference on Retroviruses, March 1998.
- Daily Mail & Guardian, 12 July 2001.
- Will AIDS destroy Africas economies?, African Business, March 1998.
- A.D. Harries, D.S. Myangulu, et. al. Preventing anti-retroviral anarchy in sub-Saharan Africa, The Lancet, 4 August 2001.
- Sarah Ramsey, Raising the profile of palliative care for Africa, The Lancet, 1 September 2001.
- Interview by author with Dr Thomas Kenyon, Director, Centres for Disease Control, Botswana, July 2001.
- Interview by author with Dr Ivan Toms, Director of Health Services, City of Cape Town, Western Cape Province, Republic of South Africa, July 2001.
- For the MSF Khyaletsia Pilot Project, the criteria are: demonstrated regular clinic attendance; a T-4 cell count of 200, and family knowledge and acceptance of the patients HIV-positive status. Although the project was anticipated to include 120 patients, only 40 are currently enrolled. Interview by author with MSF staff, Khyaletsia, South Africa, July 2001.
- Interview by author with Troy Fitrell, Political/ Economic Officer, US Embassy, Lusaka, Zambia, July 2001.
- Interview by author with Robert Greener, Senior Research Fellow, Botswana Institute for Development Policy Analysis (BIDPA), July 2001.
- Linda Stannard, South African Department of Health Statistics, February 2001.
- Zimbabwe National Health and Demographic Survey, United States Agency for International Development and Zimbabwe Ministry of Health Publication, December 2000.
- Desmond Cohen, Socio-economic causes and consequences of the HIV epidemic in Southern Africa: A case study of Namibia, HIV and Development Programme, UNDP, 1998.
- Report on the 1980s disturbances in Matabeleland and the Midlands, Catholic Commission for Justice and Peace in Zimbabwe, March 1997.
- Daily Mail & Guardian, 12 February 2000.
- Howard Barrell, Mbekis popularity plummets, Mail & Guardian, 20 October 2000.
- Rena Singer, South Africa: To tap voters, politicians promise water, Christian Science Monitor, 7 November 2000.
- ANC committee demand clarity on AIDS, Mail & Guardian, 14 September 2000.