A few years back, I was visiting the offices of a government aid agency in Accra with a colleague from the company – IESC – that had bought my organization, Geekcorps. We’d talked with this funder about their priorities in Ghana, and my colleague was very surprised that HIV/AIDS was not at the top of this funder’s list of priorities. She mentioned this, and I pointed out that HIV hadn’t affected Ghana to the extent that it had affected southern Africa, quoting 6% as the adult infection rate. Convinced that I must have my numbers wrong, she went back into the funder’s office to ask what the rate was – they confirmed the figure I’d offered.
My colleague lived in Zambia, where the adult HIV rate was reported at 21.5%. At that point in Zambia, it was very difficult to talk about anything other than HIV in the context of development, and she was shocked that the incidence of the disease in West Africa was comparatively so low.
As it turns out, the figure I quoted my colleague was high by almost a factor of three. The adult AIDS rate (15-49) in Ghana is 2.2%… higher than in many developing nations, but nowhere near the rates of incidence seen in nations like Botswana, where that rate is above 30%. I’m not the only one who got it wrong – almost everyone working in Africa for the past decade has paid close attention to statistics compiled by UNAIDS. And, according to recent research by ORC Macro, a research company hired by USAID to conduct HIV infection studies across the continent, UNAIDS got their numbers badly wrong.
UNAIDS based their numbers on tests performed on women they saw at prenatal clinics. The infection figure for these women was used as a proxy for the infection rate for the adult (15-49) population. As it turns out, this is a really bad proxy. Health clinics were in urban areas, and the women living in these areas turn out to have a much higher rate of infection than women in rural areas. And women, in general, have a higher HIV infection rate, than men in Africa. ORC Macro tested randomly selected men and women, in rural and urban areas, and performed two blood tests on each individual, to reduce the number of false positive tests. They were able to lower the estimate of HIV incidence in Zambia from 21.5% to 15.6% and in Rwanda from 8.3% to 5.4%. UNAIDS had estimated HIV incidence in Sierra Leone at 7% – it turned out to be less than 1%.
UNAIDS is aware that their numbers are high, and is now gradually revising their estimates downward. Craig Timberg’s story in the Washington Post includes a couple of quotes that imply that the inaccuracy was perpetuated to make it easier for UNAIDS and other groups to raise money to combat the disease. The article quotes a British economist who argues “They were not predisposed, let’s put it that way, to weigh the counterevidence. They were looking to generate big bucks.”
Whether or not UNAIDS consciously misled donors, or whether they simply had a hard time letting go of overestimates, their statistics did help raise consciousness of the disease and raise money towards combatting it. Perhaps this is a good thing – AIDS is a major health crisis in Southern Africa and resources are desperately needed to combat it. Maybe it’s okay that the crisis was overstated since the result was increased aid, and increased awareness, which led towards prevention efforts. Given the high cost of anti-retroviral drugs, perhaps any money towards combatting AIDS is a blessing.
Or perhaps it’s not okay. If AIDS had been recognized as the primary health crisis in Southern Africa and one of several major health crises – including endemic malaria – on the rest of the continent, it’s possible that some of the money raised to focus on HIV could have focused on the other diseases that shorten Africans’ lives. Or perhaps some of the money could have gone towards other pressing development needs, like education, water and sewage systems, food security. When deciding between school funding and health funding, it makes a big difference whether you’re dealing with a 7% HIV rate or a 1% rate.
There’s a more subtle effect of the UN’s misstated numbers: the extent to which the story of contemporary Africa and AIDS have been intertwined. At the Pop!Tech 2005 panel on African issues, moderator David Kirkpatrick expressed surprise that a two-hour conversation hadn’t touched on AIDS, and asked the panelists to address the crisis. Panelists responded angrily, with Emeka Okafor of Timbuktu Chronicles declaring:
My problem with the question is that when mainstream media frames Africa, two or three topics come up again and again: AIDS, AIDS and AIDS. The relentless focus on AIDS plays into the framework of helplessness associated with the continent.
In framing Africa as “ravaged” by AIDS, it’s hard to see it – simultaneously – as a hotbed of business innovation or an exporter of culture. The repetition of the truths – and half truths – about Africa and AIDS build the story that Africa is a problem, a crisis, a land in need of ever-increasing amounts of outside aid to address these problems. My friends got angry at Pop!Tech because Kirkpatrick forced a discussion about Africa’s potential into a discussion about intractable African problems. Discovering that this problem was exaggerated on much of the continent – and perhaps intentionally so – is profoundly frustrating for everyone invested in the business of imagining, promoting and rebranding Africa as a land of opportunity, not of crisis.
I do not mean to dismiss the magnitude of the AIDS crisis on the continent, especially in Southern Africa where AIDS is a tremendous health problem and one of the major issues governments and donors need to address. Even in West Africa, AIDS is a huge health problem and one that needs to be addressed. Organizations that are working to make antiretroviral drugs available and affordable, and to help prevent the spread of the disease – including UNAIDS – should be commended and supported.
But Africa needs help beyond AIDS. And Africa is hurt in some complicated ways by the reinforcement of the equation “Africa = AIDS”. UNAIDS and others have worked very hard to help people understand that AIDS is a crisis for Africa. How hard will we have to work to get people to understand what the crisis really is… and really isn’t?
This is fascinating. If I were to speculate wildly about something outside my area of expertise (and I am about to, right now) I’d say that tackling AIDS may be more appealing to many not only because it’s a terrifying illness that rakes in the big dough, but also because it appeals to the unfortunate desire of many to demonize sex and marginalize Africans, along the lines of “if only those backwaters could learn to control themselves.” Of course, there are many, many people working in less heavy-handed ways to curb the spread and effects of AIDS (drugs, condoms, etc.) but it’s easy to see how it becomes a hot-button, attention-grabbing issue to the exclusion of others.
Anyway, thanks for the food for thought.
There is much money to be paid out of AIDS by NGOs, the UN, drug companies and so on who all have a vested interest in perpetuating or overstating the problem on the continent. There are a number of factors that need to be addressed on the AIDS issue. The refusal to recognise that Africa is vast continent rather than one big country and thereby conflate the whole mass into one bigs AIDS arena is yet another reason why the focus on AIDS is overstated, often misdirected and contributes to wastage. A second problem is the focus needs to be on primary health care including nutrition rather than on one illness.
Nonetheless I believe it is possible to focus on AIDS in the context of an overall Health Policy relative to the incidence of the illness on a country by country basis AND discuss Africa’s business potential in a positive manner. We have to be careful that we do not overstate or understate because the reality is that the majority do not have adequate health care and do live in relative poverty. The business and investment sectors need to be promoted but please let us not deceive ourselves by closing our eyes to the social injustice and poor governance.
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Amen! The same could be said about Haiti and many other non-african countries, I’m sure. With Haiti, it’s not so much AIDS (although that’s there too) but “violence”, “unrest” and “poorest country in the western hemisphere”. That’s why I make sure to talk about more than politics, violence and poverty that we always read about on my blog… I hope journalists don’t realize how much harm they do when they only cover the bad… Otherwise, maybe it’s time to really start quantifying the ways in which they do hurt and the ways in which “reputations” built on sensationalism can impoverish…
I wouldn’t jump to conclusions that the numbers were purposely overstated. Those sorts of stats are hard to collect, and it could very well be an accident. I try to give people, especially people doing a difficult thing, the benefit of the doubt. But I might be too nice that way. I imagine going forward, we’ll find out more by who continues to use old numbers vs new.
I wonder if much money that would have gone to malaria got redirected to HIV. People in the developed countries get HIV, not malaria, and that influences things all the way up.
OTOH, whether the perception of Africa as a victim cause it to be seen as HIV ridden, or HIV has contributed to Africa being seen as a victim, it’s al very annoying.
I sought an email address on your site, but could not find one. Please forgive me for writing to you in a comment.
My name is Ron Hudson and I have been living with HIV/AIDS since the early 1980s. In June, I founded the International Carnival of Pozitivities (http://www.internationalcarnivalofpozitivities.blogspot.com) to provide a forum for people living with HIV/AIDS worldwide, as well as to their families, friends, caregivers and policy-makers.
I just found your article about the overstatement of the per capita HIV infection rates in Africa. I was wondering if you would mind submitting it to the Third Edition of the Carnival by 2 Sep 2006 at midnight US eastern time. You can find the submission form at the Carnival homepage listed above.
I think actually that after they had used up enough money on one issue, they’d use the rest for another. Either way, it helps Africa.
And part of it IS education. Education would help to stabilize the government, making it more likely that they’d try to prevent diseases and establish hospitals. Education is partially NEEDED to help with AIDS/HIV, e.g. campaigns against premarital sex and sex with various partners educate people not to do that kind of thing. So that could kind of escalate into formal education, and more things would be taken care of.
Thanks for writing your article. Articles are good for homework. :) Not that I have any, I could have kids with homework…