The Constant Gardener
Von Chris Simms
The UNAIDS 2012 Annual Report tells us that over the past decade (2001-2011) the annual rate of new infections has been cut by more than 50 percent in 25 low- and middle-income countries and by as much as 70 percent in some African countries. These improvements are partly the result of a ten-fold increase resources invested in ARVs, mother-child transmission, testing, male circumcision, education and condoms initiatives. In the wake of this report, Hilary Clinton, the American Secretary of State has put on the table a blueprint for “an AIDS-free Generation”. The sense of optimism is in sharp contrast to the way the author recalls events of the previous decade.
Its December 1999, Dar es Salaam, Tanzania, days to the Millennium and this Head of Aid, whom I have known both here and Zambia is the quintessential ‘constant gardener’, diligent, self-effacing, modest - is overwhelmed. The source of his distress, like many in Africa’s health sector, is the growing realization that, as millions of Africans are dead or dying from AIDS, few serious efforts have been made to tackle the crisis; instead, most were preoccupied with the health reform agenda.
An epidemic with its own memory
He says, “We saw this early and then ignored it. We gave it free reign for at least 10 years and in the end, it dehumanized us”. He looks at me. “It insinuated itself in me, in you, into the donor community then swallowed us whole. We’re in it and it’s in us.”
In his bewilderment he’s taken to attaching inappropriate attributes to the epidemic; he describes it as self-directed, with a life of its own, taking orders from itself, with its own structure and function, anatomy and physiology, its own memory, a capacity for self-replication and for self-annealing and a collective ‘intelligence’ of sorts that helps guide it to where it would thrive and avoid where it would not. (Christakis/Fowler 2009) He imagines it meandering from Equatorial West Africa eastwards along the Trans-African Highway, along water and trade routes through Congo and Rwanda until reaching the Great Lakes region during the Idi Amin’s war; here it erupts, spreading swiftly into East Africa as if it found its true home - Uganda, Kenya, Tanzania and then Zambia and southwards as nascent epidemics became ‘concentrated’ and then ‘generalized’ and countries tumbled like dominos.
And he imagines the epidemic mimicking the very virus that flows inside, that is, its ability to invade and destroy the systems that are meant to protect. He imagines its tentacles reaching into communities, moving undetected past public and global health systems intended to safeguard at-risk populations, confounding and disarming those very systems. First, trial and error until you find prey that don’t matter, whose hard death will go ignored – those who live at the periphery, social margins, far from the centers of power, out-groups. Go to where there is tumult, a fray, a dust-up; where there is war, forced migration, sexual violence, to where the advantaged and disadvantaged have just met. Go to where power clusters and rests undistributed, where there’s another agenda predominates. Look up into the eyes of the gatekeepers as you slip past for any signs of reproach. Go safely now; you will know your success by their responses - fear, anger, abhorrence, denial, stigmatization and ostracism – these are useful, they will resonate, have the ring of truth. Now trade on your strength, your omnipotence; we are invincible, you easily dissuade the dissuadable, the half-hearted, and even the final hold-outs: you give them what they crave, a reason to explain their docility.
Fourteen years earlier when I arrived in Mbeya, in the southern highlands of Tanzania, this small community had already become an HIV epicenter in Eastern Africa. Staff at Igogwe hospital, a 100-bed mission facility near a truck-stop on the Zambia-Malawi highway, had been reporting “the slimming illness” (Ukimwi) at least since the 1970s. A place of arresting beauty, with undulating rolling hills and valleys over which is cast a net of tiny roads and footpaths connecting one family compound with another, one village with the next; along the nodes and threads of this network, the wanyakusa and wasafwa peoples stop to greet in repetitive fashion as if to affirm and secure the ties that connect. At a distance it looks like an enchanted mathematical ‘fitness landscape’.
Yet inside this social network is embedded another more ancient network based on the norm that a man might have more than one wife or partner. It was a culturally accepted practice and certainly not a matter of promiscuity, a reality that even the mission organizations that dominated rural healthcare in east and southern Africa had learned to live with. Even then we knew that overlapping networks greatly raised the probability of transmission of disease. Hospital records, going back eons, show that 40% of attending pregnant women has one or more sexually transmitted infections (STI); visits to Igogwe’s 10 satellite clinics scattered throughout the hospital’s catchment area indicate that 90% of recorded treatments for adults were for antibiotics, most of which were for STIs. By 1988, Igogwe responded to the HIV crisis with a robust program including a sweeping condom distribution initiative, voluntary counseling and testing (VCT), community education programming, and home support funded by European NGOs. Its sensible health education message was “kifuli kimoja, funguo umoja” - one lock one key.
Cost Recovery and Privatization
Four years later in Zambia, where I had first met the ‘constant gardener’ he faces the conundrum writ large: on one hand, Zambia is Africa’s flagship for health sector reform and on the other hand, it is one of the worst hit countries by HIV in the southern region. He is a player at the table, one that supports the idea of improving the way health services are delivered and financed. The means to this end, under the leadership of the World Bank, are cost recovery, privatization, integration and decentralization of services. Donors committed a remarkable $250 million to its health sector - remarkable since it roughly equaled total bank disbursements for HIV for all of Africa (1986-96). Yet early on the bank gives its first warning of what is to come: having recognized the devastation HIV in Africa, it states explicitly and repeatedly beginning in 1992 that “AIDS should not be allowed to overtake the critical agenda for strengthening health systems”. (World Bank 2005) And it did not.
Again like the ‘constant gardener’, he initially does not get out into the field. Yet the files have crossed his desk, he knows the material and had the heard stories: another economic crisis, the worst drought in 50 years, grain production declining 95% in some districts, a 50% rise in childhood malnutrition, a doubling childhood illness, a national poverty rate now at 90%, and a rise in under-five mortality from 150/1000 in 1980 to over 200/1000 in 1996. (Simms 2000) In Lusaka, Christian Aid has photos of children making coffins for children that somehow capture the moment.
Health sector dissolves into chaos
And then the world suddenly changes for him: the National AIDS Programme, already impoverished and fragile, collapses utterly to the point that none of the mid-term plans can be implemented (during the crucial years 1996, 1997 and 1998). Almost simultaneously, the entire health sector dissolves into chaos and donors are fighting with one another, some threatening to leave. The mid-term review of the Zambia health sector reform process, undertaken by a team led by Dr. Mahler (former Director General of the World Health Organization), pinpoints the problem: while reformers focused on improving management practices, they ignored the misery at the periphery and the actual delivery of badly needed services. It said, “We exhort the reformers to listen carefully to the ‘noise’ turbulence produced by the implementation at various practices levels within the system in order not to lose touch with reality on the ground”. (WB/WHO/UNICEF 1997) The Mahler Report was immediately embargoed by the World Bank, not considered a working document and, not publically released until one and half years later. Inside he shouts.
And then he finds himself in the field, in the Copperbelt, the North and Northwest, across to Malawi borders areas and down to Mazabuka. And what he see going from district to district is indeed the specter of human misery, drifting through the empty shells that used to be rural health centers with nothing but the wind blowing through. What he sees confirms the MOH and WHO/ CDD reports (Ministry of Health 1996) – almost no antibiotics, even broad spectrum ampicillin available 7% of the time, only 3% of children are correctly diagnosed and treated at health facilities, only a fraction of women accessing ANC and, EPI coverage rates plummeting. (WHO/CDD 1997)
Now the HIV prevalence rate is reportedly 20% and the epidemic seems to rise phoenix-like above the great plateau that is Zambia. Where services are available at all, they are parodies of a functioning health system: the once furtive exchange of illicit user fees under the table is now normalized even for common HIV-related services, including the diagnosis and treatment of STIs, blood transfusion schemes, and VCT. The deconstruction of provincial structures without suitable replacements, the decline of government oversight functions and the rise of unregulated healthcare mean if services are available at all, they are likely to be useless or dangerous. Treatment protocols for STIs are usually ignored and most injections are unsafe.
Back in Dar now, he says “Of course, it has dehumanized us; how else do you explain 30 million Africans dead or dying yet we cut HIV spending by 50% to $3 per person. Here, tell me what it says” pointing to the yellow highlighted paragraph from a recent bank report. It reads - “these allocations are remarkably large relative to national spending on the same problem and probably in comparison with international spending on any other disease. Perhaps only the international campaign to eradicate smallpox in the 1970s benefited from such a large preponderance of donor funds.” (World Bank 1997)
Reasons for optimism
There is a sense among the local ex-pats and the donor community generally, that an era is coming to an end; but how could it be otherwise? The HIV/AIDS crisis, the first post-modern epidemic, represents the first time donors have been truly tested and they failed, publically. Most aid agencies and international financial institutions are saying mea culpa, that it was a mistake not to focus on the poor, not to reach out to the periphery and anticipate the more pernicious aspects of their reform policies, their distributional effects. They report that they have learned from past mistakes and forging forward in a new direction.
A dozen years on, there are reasons for optimism. In Zambia and Tanzania for example the rate of new infections has been cut by 58% and 38% respectively over the last 10 years. An AIDS free generation is achievable by applying existing strategies. Yet it is clear that the global community is still in the grips of the pandemic: there is little taste for accountability research into events of the 1990s and in its stead there appears to be a tendency smooth over the record. For example, the pandemic is referred to as a long-wave event the sequelae of which could not have been anticipated by the donors. As to the future, lack of money and political will still hobble efforts to reach a tipping point. There is nothing capricious about the HIV pandemic, just the opposite: it seems unerring in its ability to seek out and find our individual and institutional weakness. This human superorganism knows the material, it knows the process.
“The Constant Gardener”,a novel by John le Carré (2001), later made into a movie (2005) portrays a self-facing, dedicated, if naïve expatriate civil servant working in Sub-Saharan Africa who slowly discovers the various agendas at play in global health.
*Dr. Chris Simms is assistant professor at the School of Health Administration, Dalhousie University, in Halifax. He has spent most of the last 20 years living and working in Africa and Asia. His areas of interest include the influence of reform and globalization on access to effective health care particularly by the poorest quintile, aid effectiveness, the policy process, and the HIV pandemic. Chris is on the Board of Directors of the Canadian Society for International Health, and editorial board member of the International Journal of Clinical Practice. Contact: ch638828@DAL.CA
- UNAIDS 2012 “UNAIDS World AIDS Day Report 2012”, Geneva 2012 http://bit.ly/URnKAF
- N. Christakis and J Fowler, Connected: The Surprising Power of Our Social Networks and How They ShapeOur Lives, 2009 University of Chicago. USA
- World Bank, Committing to results: improving the effectiveness of HIV/AIDS assistance: an OED evaluation of the World Bank’s assistance for HIV/AIDS control. Washington (DC): World Bank; 2005. p.15. http://www.worldbank.org/oed/aids/docs/report/hiv_complete_report.pdf
- Chris Simms, “Health Reformers’ Response to Zambia’s Childhood Mortality Crisis”, Institute of Development Studies (IDS), IDS Working Paper Series, No 121, 2000
- WB/WHO/UNICEF 1997 Review of Zambia Health Reforms (Mahler Report), Lusaka, Zambia
- Ministry of Health , Family Health Unit, 1996 Zambia Safe Motherhood Needs Assessment Lusaka Zambia
- WHO/CDD 1997 CDD Health Facility Survey in Zambia, Lusaka
- World Bank. Confronting AIDS: public priorities in a global epidemic. Oxford (UK): Oxford University Press for the World Bank; 1997. p. 245. http://bit.ly/ZwZQ1G