|The Courier N° 138 - March - April 1993 Dossier: Africa's New Democracies - Country Reports : Jamaica - Zambia (EC Courier, 1993, 96 p.)|
Hardly a day passes but Zambia's newspapers report the death of yet another person who had been making a useful contribution to the public life of the country. It may be a businessman, a banker, a member of the armed forces, a mining engineer, a politician, a lawyer; many of them have died relatively young, and death is often said to have occured 'after a long illness'. It is an open secret that most of the people who die of this unspecified disease are victims of AIDS (acquired immune-deficiency syndrome) or AIDS-related conditions.
Those who figure in newspaper obituaries, of course, are only the comparatively prominent members of society. But there is disturbing evidence that AIDS is a threat to all classes and social groups in the Zambian population, and on a scale that is only now becoming clear. A recent report by the Zambian Ministry of Health and the World Health Organisation said that there had been a steady increase in the number of new cases of infection by HIV (the human immunodeficiency virus, which is responsible for AIDS) over the past seven years, and quoted several alarming figures. In the urban population-and Zambia is a highly urbanised country-the highest recorded HIV-positive figures were among patients who already had another sexually transmissible disease: 54% of new attenders at STD clinics proved to have the virus. Of women attending antenatal clinics, the proportion found to be HIV-positive rose from 12% in 1988 to 24% in 1990 (the current figure from the Ministry of Health is 40%). Medical workers estimate that 50% of the children of infected women also have HIV; their sexual partners are, of course, also likely to be infected. Ten per cent of would-be blood donors tested HlV-positive in 1987, rising to 18% in 1990. The figures for semi-urban and rural areas are also rising, but are generally lower, owing to more traditional morality and lower mobility outside towns and cities.
The figures for AlDS-related fatalities have, however, to be regarded as erring on the side of caution, as reporting mechanisms are faulty, and many deaths are ascribed to opportunistic diseases rather than to the underlying AIDS condition. This is particularly true of tuberculosis, the incidence of which has risen sharply over the past year. Secondly, many sufferers, when they realise that conventional medicine has no cure for AIDS, turn to traditional healers in rural areas, and their eventual deaths from AIDS are not recorded as such.
According to Elizabeth Mataka of the Family Health Trust, a voluntary, nongovernmental organisation working on AIDS prevention and care, the situation is critical, and every Zambian has lost a relation, a neighbour, a friend or a colleague to the disease. Nor has the full seriousness of the situation yet become apparent. As AIDS has a long incubation period, and prevention campaigns did not start until the late 1980s, cases appearing now are manifestations of infections which occurred as far back as the 1970s. Most cases contracted before the late 1980s have yet to show. Mrs Mataka says health workers' worst fear is that up to 25% of the population could be infected, most of them without knowing it.
In fact AIDS is increasingly regarded as not just a medical but also a socioeconomic problem. The social impact of the epidemic is to be seen, for example, in the rising infant mortality rate among children of infected women. Most of the children affected die by the age of one, their condition exacerbated by poor nutrition, difficult living conditions and the inadequacy of healthcare services. All HIV carriers in the country, in fact, tend to develop full AIDS symptoms earlier than their counterparts in developed countries, as the general state of public health is poor.
As adults die, more children are being orphaned, so that the burden of caring for them falls on grandparents or other family members who may not have the resources to cope. A study carried out by the Family Health Trust in the Matero East district of Lusaka found that 10.2% of children questioned had lost one or both parents, the usual figure in peacetime being two to three per cent; further questions showed that the difference was accounted for by AIDS. The survey also uncovered resulting problems of lack of education, crime and vagrancy among orphaned children. As far as care for AIDS sufferers and unattached children is concerned, family culture in Zambia is very supportive of sick or needy relatives, but caregivers themselves may be, or later become, infected, and when they in their turn fall ill both they and those they were looking after become a burden on a dwindling family base or the underdeveloped social services.
In the economic sphere, not only is health spending having to rise; the labour force is being weakened and reduced, a fact which trade and industry are now becoming alive to as productivity and profits fall through absenteeism and loss of skilled workers. The cost of training staff who may soon after fall ill and ultimately die is one which fewer and fewer companies can afford to pay.
AIDS prevention efforts in any country must, of course, address the reasons for the spread of the disease. In Zambia these are similar to those found elsewhere, though for cultural reasons, it is claimed, sexual transmission is predominantly through heterosexual, not homosexual, contact. A further explanation is said to lie in sociocultural practices such as the ritual cleansing of a recent widow through sexual intercourse with her dead husband's brother, and the belief among some older people that sex with young partners, whom they pay, carries less risk of infection (here it is precisely the younger partner who is usually put at risk).
Zambia has a National AIDS Prevention and Control Programme, and recognises the need for a multisectoral, grassroots approach by several Ministries at once. The Government, however, is unable to bear the full cost of the programme, which for 1992 was expected to reach ZMK 80 million (some ECU 200 000 at current exchange rates), and international donors such as the European Community have become involved. Several years ago the EC provided HIV test kits and financed a seminar for health workers on identification and treatment, but the main contribution has been the allocation of just over ECU I million for a three-year project to establish an organised national blood transfusion system, which has so far not existed. It is hoped that an additional ECU 1.5m will be available under LomV.
The NAPCP, and public health bodies organised into an Anti-AIDS Project, have produced AIDS information messages, some in local languages, for public display, as well as printed material and educational plays. The slant of the messages is positive: while warning of the dangers, they seek to promote hope, encourage safe life styles and teach compassion for sufferers. AIDS prevention has been incorporated into the school curriculum, and to protect the rising generation the emphasis is being placed on getting the message through to children before the age of 16. Other target groups for information and education work have included 'street-kids' (homeless children living on their wits in urban centres) and employees in the workplace.
A pioneering example of this last type of approach is the policy of Barclays Bank in Zambia, which used to make HIV testing a condition of employment.
The Bank soon realised that this served no purpose, as antibodies to HIV do not appear until some three months after infection, so a negative result does not necessarily prove that the subject is free of the virus, and in any case staff could become infected at any time after the test. The emphasis therefore shifted to preventive education and supportive counselling, and the Bank now employs its own health adviser, as well as contributing generously to the nongovernmental organisations which, incidentally, handle 90% of AlDS-related care work in the country.
The challenge is enormous, but measurable progress is being made. The Ministry of Health/WHO report said that, thanks to public information campaigns, 99% of women throughout the country were now aware of HIV, 89% of them knew it could be transmitted through sexual intercourse and 62% believed it was preventable. Condoms are consequently in higher demand and in 1992, for the first time, funds were allocated from the national budget for procurement of supplies of condoms, which are tested for safety and distributed all over Zambia using the existing drugs distribution system. The number of pregnancies among schoolgirls is falling, as is the incidence of STD. This suggests (though it does not prove) that HIV infection too may now be retreating; but if so, the resulting fall in the number of AIDS cases will not occur for some years yet, owing, as explained above, to the long incubation period of the disease.
Programmes of counselling, homebased care and orphan care are now in place. Elizabeth Mataka of the Family Health Trust reports that a home-based healthcare programme for AIDS sufferers in Lusaka which started in 1987 had cared for 5030 patients at home by August 1992. The purpose of such programmes is not only to teach proper care and nutrition in the home but also to relieve pressure on Zambia's hardpressed hospitals. This is the way forward as far as care is concerned, according to the NGOs: even if no extra money is available, they want the Government to second personnel to help them in their vital work. The NGOs also want industry to give them more financial support, stressing that the future of the country's expanding private sector depends not just on the success of the structural adjustment programme but on companies having healthy employees. R.R.