HIV/AIDS in Zimbabwe
By Michael Pappas
HIV, the causative virus of AIDS, knows no boundaries. Over the years, the HIV/AIDS pandemic has ravaged populations, leaving around 20 million dead and 40 million infected worldwide. While HIV can infect almost anyone, this virus takes a particular toll on poor populations all over the world. Individuals living in Sub-Saharan Africa have specifically been affected. Poverty itself is a dynamic, complex, multidimensional process of socio-cultural, political, and economic deprivation. 1 Poverty tends to further marginalize a population and can make its people more susceptible to acquiring infections diseases such as HIV/AIDS. One country that has been substantially affected by poverty and HIV/AIDS is Zimbabwe. Zimbabwe experienced a rise in adult mortality in the mid-1980s through the 1990s, which can be directly related to increases in both poverty and HIV/AIDS prevalence. 2 Even today, HIV/AIDS is a disease that still ravages the health of Zimbabweans. By examining Zimbabwe’s history, it becomes clear how political and economic factors helped to further marginalize the poor in a country and make them vulnerable to the spread the HIV/AIDS.
The following is an analysis of how particular events throughout Zimbabwe’s history have combined to exacerbate the effect of HIV/AIDS throughout the Zimbabwean peasant population. Circumstances, such as drought, economic collapse, land repatriation processes, forced migration through Operation Murambatsvina, and brain drain in the social sector will be examined. By looking at these in detail, it is possible to more clearly illustrate how specific circumstances and decisions made by leaders in a country can increase the number of individuals below the poverty line, as well as the spread of an infectious disease such as HIV.
Drought and Its Effect on HIV/AIDS
In Zimbabwe’s early years after gaining its independence, the agricultural sector was a very important contributor to the economy. In the 1990s, “approximately 60% of the population lived in smallholding farming areas and depended on rain fed agriculture for most of their livelihood.” 3 The sector accounted for 12% of GDP, 24% of formal employment, and was around 40% of Zimbabwe’s main source of foreign currency. 4 The agricultural sector in Zimbabwe could be viewed as being divided between commercial producers and agriculture plots cultivated by peasant farmers on communal lands.
The agricultural sector has clearly been extremely important. Throughout Zimbabwe’s history, this sector has been crippled by multiple droughts that have been detrimental to productivity of much of the population. Notably, droughts from 1982-1984, 1987, 1992, and 1995 “delivered a body blow to rural smallholder livelihoods and led to severe nationwide food shortages.” 3 Droughts during these years hurt both commercial and communal agricultural sectors, but especially had detrimental affects on rural farmers. For example, the droughts of 1982-1984 and 1987, caused nearly total crop failure in some areas. These droughts resulted in almost complete disaster for peasant cattle owners with “700,00 head dying in the 1982-1984 period.” 4 The effects of later droughts in 1992 and 1995 were even more severe than these earlier droughts.
These droughts highlighted above were extremely detrimental to the livelihood in rural areas and helped increase the spread of HIV/AIDS in multiple ways through increased poverty. Firstly, since many poor families relied on farming for food, a decrease in crop production, forced male heads of the household to travel into cities to find work. Being away from their wives for long periods of time could have led to unsafe sex practices with partners other than their wives, which could have spread HIV/AIDS. In addition, because some poor families were suffering from lack of food as a result of the drought, some fathers were forced to actually make the difficult decision of marrying off their daughters in order to have one fewer mouth to feed. The daughters were often married to males who were relatively wealthy, but practiced polygamy. By entering into such a relationship, the daughter’s rights were often stripped from her. In turn, if the husband wanted to practice unsafe sex, she often had no say in the matter. 5 As a result, the likelihood of the daughter contracting HIV was increased.
With a lack of food, severe malnutrition throughout a poor population also increases. HIV/AIDS is a disease that already compromises a victim’s immune system by destroying CD4 cells. If individuals in Zimbabwe who already had HIV/AIDS were not able to keep an adequate diet because they could not grow crops or because their cattle were dying, they were more vulnerable to opportunistic infections. In turn, mortality rates increased. Droughts also reduce an individual’s access to clean water. 5 Without access to clean water, there was often a reduction in hygiene of the rural family, which could opened the door for many different opportunistic infections in the already immunocompromised. If family members were forced to travel further to obtain water, it meant that water reserves in the household were left pooling for longer amounts of time. This allowed for waterborne illnesses to spread to the family, especially family members whose immune systems have already be crippled from the HIV virus.
Decline in Formal Economic Sector and Its Effect on HIV/AIDS
Economic collapse throughout the country also had an adverse effect on the health of the Zimbabwean people and helped to spread HIV/AIDS. As a result of economic policies in the 1970s and 1980s, Zimbabwe’s economy had historically been focused on domestic, rather than foreign market concerns. 6 The domestic market was strictly regulated in the form of export and import controls through the 1980s. In the 1990s though, the government adopted economic changes called Economic Structural Adjustment Programs (ESAPs), which were recommended by the International Monetary Fund (IMF) and World Bank. The World Bank and IMF claimed that ESAPs would rapidly stimulate the Zimbabwean economy through non-interventionism, privatization, and deregulation. 6 While the goals of enacting ESAPs⎯ or so they were claimed to be⎯ were to stimulate rapid growth of the economy and help the entire population of Zimbabwe, these structural adjustment programs actually had detrimental effects on the economic sector and the health of the Zimbabwean people.
After ESAPs were enacted, Zimbabwe saw a decrease in wages and rise in unemployment throughout the country. Relaxed import restrictions led to more competition from outside industry and, in turn, less job creation inside the country. According to Marquette, “real wages dropped by a quarter after 1990 largely due to the continued relaxation of government regulation of labor markets under ESAP.” 6 Additionally, until the late 1980s, there were strict regulations on hiring, firing, and maximum wage determination in Zimbabwe. Beginning in the late 1980s though, restrictions such as these were relaxed and workers were often moved into lower paying jobs to cut costs. 6 As Marquette highlights, “the combined effects of declining wages, rising unemployment, and inflation, probably led to drops in real income of the poor from 1990-1994.” 6 The effect that these changes had on an already poor population was staggering. According to a Poverty Assessment survey in 1995, close to half of the poor households reported unemployment and low wages as a main cause of poverty. 6
This rise in the level of poverty and unemployment as a result of economic problems caused largely by programs instituted through ESAPs, greatly affected the spread of HIV/AIDS throughout the population. Since individuals could not find modest wages to support a family they were more likely to go to desperate measures in order to make money. Since many women were put out of work as a result of ESAPs, they could have been more desperate to find a mate who was making a decent living. As a result women, would have been less likely to advocate for condom use by a male partner in fear that they may have been forced back out on the streets. Some women may not have been able to find work or a partner that could support them. These women could have fallen into sex work in order to make a living.
The availability of health services also decreased as a result of ESAPs. Before ESAPs, user fees existed in both the rural and urban areas, but were not very strictly enforced. Once the programs were instituted in 1990, not only were fees enforced, but they suddenly increased in order to achieve cost-recovery. 6 As a result, poor individuals who were HIV-positive and were already struggling to pay for their medical bills were often no longer were to. This would have directly affected the number of individuals seeking treatment and helped to increase the effect of HIV. In addition, since the poor were not only being charged, but charged more for medical services, they would have been less likely to get tested for HIV, which would have increased the chance of transmission of the virus.
Fast-Track Land Reform and Its Effect on HIV/AIDS
As a result of the high degree of poverty and suffering in Zimbabwe, a popular party called the Movement for Democratic Change (MDC) began to emerge. The MDC, lead by Morgan Tsvangirai, campaigned on the idea of a “people-driven constitution” and was largely supported by the poor individuals who were suffering as a result of the economic crisis previously highlighted. 7 With a parliamentary election scheduled for June of 2000, the leading ZANU-PF party, led by Robert Mugabe, quickly realized that the MDC was a threat that had to be dealt with. The ZANU-PF proceeded to advocate for war veterans to violently invade and drive existing farmers off their land. As a reward, the war veterans were promised ownership of 20% of the land that was taken over by the state. 8 By driving existing white farmers off their land, Mugabe claimed to be giving the land back to the people. In reality, much of the land was allocated to Mugabe’s friends and family. Land was also given to Mugabe’s political allies. These were often inexperienced indigenous farmers who supported him. 9
There were many unforeseen consequences that came out of this land reform process. The violence that was occurring could have scared away many international non-governmental organizations (NGOs) that were working inside of Zimbabwe. NGOs often help reach marginalized groups in countries and provide healthcare services. If NGOs were not able to reach poor individuals infected with HIV, those individuals may not have been able to receive treatment or testing services that normally would have been provided. This obviously would help to spread HIV throughout the population.
Additionally, by pushing experienced farmers off of their land and giving the land to inexperienced farmers who supported the ZANU-PF, Mugabe helped to exacerbate the already crippling agricultural crisis that the country was experiencing. The inexperienced farmers now on the land were often not able to be as productive as the previous farmers and food shortages increased. As highlighted earlier, when individuals do not have a sufficient diet, they can be more easily affected by the HIV virus. If people are receiving ARV treatment, it is extremely important for them to be on an appropriate diet. However, with the agricultural sector further damaged, this type of diet would have been difficult to maintain. Without a proper diet while on ARVs, the treatment would not be completely affective at controlling the HIV virus and resistance could arise.
Operation Murambatsvina and Its Effect on HIV/AIDS
In May of 2005, the ZANU-PF government began what it titled “Operation Murambatsvina” or “Operation Drive Out the Fifth”. The project destroyed what the government claimed to be illegal vending sites and informal businesses that had arisen in the form of an informal economic sector. The rise of the informal sector came as a result of the economic crisis previously addressed that was affecting Zimbabwe. Since many could not find work, this sector was important to the livelihood of numerous Zimbabweans. In 2005, the International Labour Organization reported that 3 to 4 million Zimbabweans earned their living through the informal sector employment. 9
Many of the people who benefitted from the informal economic sector were poor individuals who supported the growing Movement for Democratic Change (MDC) party. Some even argue that Operation Murambatsvina was used as a means to target the MDC supporters and punish them for supporting the party in 2005 elections⎯elections in which the party won 26 of 30 parliamentary seats in major towns and cities. 10 Whatever the reasons for the operation, this governmental decision caused massive amounts of destruction and suffering for Zimbabweans and actually led to the increase of the spread of HIV/AIDS.10 In June 2005, official government figures revealed that the operation left 92,640 housing structures demolished and 650,000 to 700,000 people were directly affected. Many individuals not only lost their homes, but also lost their source of income.
This large number of people left homeless and without work would inevitably have led to an increased vulnerability of the poor population. Acts of desperation, such as taking part in sex work, could have quickly spread HIV/AIDS throughout the displaced population. Also, as previously touched upon, if an individual was forced to migrate to look for work, he or she would have been be away from his or her spouse, which could have led to that person having sex with alternate partners and having the chance of spreading HIV to other parts of the country.
Home-based care systems, which were a main way that people affected by HIV/AIDS in Zimbabwe obtained treatment, were also disrupted through the operation. As the UN special envoy report found, “Home-based care (HBC) for AIDS sufferers has been disrupted in many places, and several organizations have indicated a 15-25% reduction in the number of patients accessing their programmes.” 8 Home-based care programs often employ local residents to distribute services, such as medication, to a particular area they are familiar with. This is a way to empower the local population and also tend to as many people as reasonably possible in isolated areas. As a result of Operation Murambatsvina though, many of the volunteers themselves were displaced and forced to migrate somewhere else, which led to even fewer individuals who were able to access treatment.
Operation Murambatsvina also hurt any preventative efforts that were in place in the form of sexual education. Since many people were forced to leave their homes, existing health networks in the form of clinics and educational services were destroyed. Many lost access to sexual counseling services that had been available to them. According to the UN Special Envoy Report, nationwide sales of male and female condoms reportedly dropped by 20% and 40% respectively from May to June of 2005. This can be heavily attributed to the fact that many of the outlets previously distributing condoms had been shut down during the operation. 8 By not allowing access to condoms for individuals who want to practice safe sex, HIV was spread quickly through a population.
Brain Drain and Its Effect on Health Sector and HIV/AIDS
While there were obviously still problems in the country, prior to 1990, Zimbabwean leaders were claiming they were trying to improve healthcare services for the population. The government at the time had even promised “free healthcare for all by 2000,” but because of drought and economic collapse, this did not happen. From 1990 to 2000, child mortality actually rose to 123 per 1000 children. In 2003, HIV/AIDS prevalence was at 34% among adults, which was the second highest in the world at the time—behind only Botswana. 11 While many of the factors previously highlighted could have factored into this increase in HIV prevalence, one that has yet to be addressed is the migration of trained healthcare professionals out of Zimbabwe or what some call the “brain drain” that occurred.
After the economic collapse, many doctors began getting paid much less. This economic factor, along with the fact that violence was occurring in parts of the country because of fast track land reform, led health professionals to look in different countries for better, safer opportunities for themselves and their families. Even if Zimbabwean health professionals chose to stay in the country, since these professionals were working longer hours for less pay, many moved out of the public sector and into to the private sector to try to make a more substantial living. 12 This led the public sector, which many poor individuals depended on, with much fewer doctors and nurses to provide care.
Overall, the migration of skilled professionals out of the country led to more work for the doctors and nurses who decided to stay. In 2002, Zimbabwe’s Ministry for Health and Child Welfare estimated that the doctor patient ratio was at 1:6,000 and the nurse patient ratio was 1:700. Nurses were so important at that time, that they were forced to take on an increasingly expanded role, taking on such responsibilities as pharmacists, doctors, and physiotherapists. 12 While these numbers are staggering by themselves, they could be estimated to be much higher in different areas of the country. Nurses ran most of the health clinics in economically disadvantaged areas where HIV/AIDS was more prevalent. Since there were now fewer of them, HIV/AIDS treatment for the poor substantially declined.
At health institutions in Zimbabwe, fewer professionals were forced to teach more students, which meant that the professionals going into the field were often poorly trained. 12 Additionally, in the field, nurses and doctors were so overworked, that it was often necessary for “cadres who are not professionally qualified to attend to patients.” 12 These circumstances obviously are extremely dangerous because if individuals who have little or no training were working with HIV-positive patients in clinics for example, there would be a much greater chance of transmission.
As a result of this brain drain and the huge demand for more health professionals, it is not surprising that the quality of care administered to patients, especially HIV/AIDS patients in economically disadvantaged areas, was damaged. Doctors and nurses being overworked and underpaid could have affected how much time and effort they put into caring for each patient. Mutizwa-Mangiza reported that standards of care decreased to include ‘uncaring and abusive’ attitudes toward patients, which could have been “largely attributed to low morale resulting from an excessive workload associated with the stress of dealing with so many dying patients.” 12 Additionally, there were reports of doctors and nurses turning patients away from clinics because of the overabundance. If patients were being turned away from clinics, they would not have been able to obtain treatment, in the form of ARVs for example. If individuals did not have access to ARVs, mortality and mother-child transmission of the HIV virus could have increased. If patients were seeking testing and were turned away, they would then be unaware of their status and may have been more likely to spread the disease.
Due to the collapse of the health care system in Zimbabwe, many individuals also began to turn to traditional healers for treatment. 12 This could have been problematic because taking combinations of traditional medicines, especially if a patient was on ARVs and suddenly stopped because he or she could not be seen at a clinic, could have led to increased viral mutation and resistance. Also, some traditional healers claimed to be able to “cure” the patient of HIV. 12 If this was occurring, the patient then may have been more likely to go out, have unprotected sex, and spread the virus.
By analyzing each of the issues highlighted above separately, it becomes evident that each could have augmented the spread of HIV/AIDS throughout Zimbabwe in various ways. Anytime a poor population is forced to change their way of life suddenly, they can become further marginalized and more vulnerable to HIV/AIDS and the suffering that comes along with the disease. Sudden changes, such as the forced evictions that were seen during the fast-track land reform process and Operation Murambatsvina, increased poverty by putting people out of work and destroyed social networks that the poor relied on. Droughts over multiple years substantially hurt the agricultural sector and made the poor population of Zimbabwe even poorer. To add to the suffering in Zimbabwe, because of the poor economic situation health professionals began to move out of the country to look for better opportunities, so there were fewer people left to care for the growing poor population.
While this paper speaks of each of these incidences as isolated occurrences, it is important to understand that these all were going on during essentially the same time period. They all basically combined to increase the suffering and helped to spread HIV/AIDS throughout the population. Discourse on HIV/AIDS is often focused on blaming the rational individual, but circumstances often actually restrict and guide the decision-making of individuals in a population. By increasing poverty, the potential for poor Zimbabweans to fend for themselves was decreased and large and these individuals became victims that were more vulnerable to contracting HIV. As Paul Farmer states in his book Infections and Inequalities: The Modern Plagues, “social forces and processes come to be embodied as biological events.” 1 The social forces highlighted came to become part of the HIV/AIDS problem in Zimbabwe. It is imperative to understand the implications of these forces and how they affect the people of a country in order to achieve a full grasp of how exactly HIV/AIDS can spread through a population.
1. Farmer, Paul. 1999. “Infections and Inequalities: The Modern Plagues.” Retrieved December 5, 2011.
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