HIV rates in Uganda’s Karamoja region are rising fast. Non-governmental organizations (NGOs) are well placed to tackle the problem through medical and public health services. Many of these organizations have been dealing with HIV for decades. They have the resources and experience to make a great, positive difference. However, in the case of Karamoja there is not much anyone can do.
Karamoja is the Afghanistan of Africa: tribal, pastoral, violent, and without infrastructure. Government control, let alone health services, in the region is minimal. In this environment NGOs have been largely forced out by instability.
Most aid organisations function with only essential personnel on the ground, if at all, because of the region’s insecurity - cattle raids on neighbouring communities are common, and increasingly fatal with the introduction of modern arms - while the difficulty of travelling between districts forces non-governmental organisations (NGOs) either to manage their programmes in Karamoja remotely or give the region a wide berth.
…
“We can’t invest more money because of the limited capacity for absorption; loads of money can go into Karamoja, but if no infrastructure or conducive policy environment is built, then the possibilities are limited,” said Savio Carvalho, Oxfam’s country programme manager. “There needs to be a framework.”
Carvalho is talking about system disruption. The roads, energy, social services , security, political control, and social network of a region are all part of its ’system’. Conflicts disrupt these systems. The role of IGOs/NGOs is to repair or strengthen areas of systems through various methods. These include building new infrastructures (wells, clinics, schools) and providing health services. The problem in Karamoja is that the region’s system is below the threshold necessary for NGOs to operate. NGOs are designed to build upon existing systems, not create them from scratch. Carvalho refers to the existing system as the needed “framework”.
HIV health services are particularly vulnerable to system disruption. Antiretrovirals (ARVs), which make HIV a chronic (opposed to fatal) disease, must be taken regularly for the entire lifespan of the patient. When the system is disrupted (through road blocks, population movements, looting, etc…) and access to ARVs is interrupted, there is the very real risk the virus will become resistant to the treatment. Thus, ARVs are highly dependent on a stable system enabling the medical/logistical operation required to deliver and distribute the drugs throughout the region.
The takeaway point: The provision of health services requires a certain level of ’system’ in place. When conflict is the primary disruptor of a region’s system, the ability to provide long term security (either from national or international sources) is a prerequisite to successful health interventions.
When discussing the relationship between HIV/AIDS and developing world militaries, some statements are generally accepted as fact. First, there is a higher HIV/AIDS prevalence amongst military services than amongst comparable civilians. Second, HIV/AIDS prevalence cripples the ability of the armed forces to conduct their duties. Third, war spreads HIV/AIDS. Fourth, HIV/AIDS is a threat to national security. In a 2006 journal article, Alan Whiteside, Alex de Waal, and Tsadkan Gebre-Tensae analyzed these four accepted wisdoms in African militaries.
1. Do soldiers have higher HIV prevalence?
Whiteside, de Waal, and Gebre-Tensae conclude HIV/AIDS prevalence in militaries is determined by two competing factors. First, young recruits typically have less HIV prevalence than the general population, driving down the overall prevalence. Second, older servicemen often have higher prevalence than the source civilian population raising prevalence. These factors work against each other, with the latter likely having more sway. Thus, the statement that militaries typically have three or four times the HIV/AIDS prevalence than civilians is unlikely.
2. Does HIV/AIDS undermine military effectiveness?
On this point the authors argue HIV/AIDS could -and likely (in the case of Uganda) has- undermined military effectiveness. However, militaries are specifically structured to absorb losses and built in redundancies likely negate most negative effects of HIV/AIDS losses.
3. Does war contribute to the spread of HIV?
Against this point the authors argue there is not the data to support it either way. Specifically they argue that since Rwanda was the only example of HIV/AIDS used as a weapon, the military use of HIV/AIDS is essentially an anomaly. That is, armed conflict spreading HIV/AIDS is the exception, not the rule.
4. Does HIV/AIDS imperil national security?
The authors argue the connection between HIV/AIDS and political instability is inconclusive. High HIV/AIDS prevalence is correlated with a number of other factors likely contributing to political instability. With this in mind, it is impossible to claim HIV/AIDS is a cause of instability any more than other factors.
My point in highlighting this article is not to argue it either way, but to make a simple assertion: political science and public health lack even basic understanding of the interrelationship between armed conflict and HIV/AIDS. That is, there is work to be done.
Source:
Whiteside, Alan, Alex de Waal, and Tsadkan Gebre-Tensae. 2006. “AIDS, security and the military in Africa: A sober appraisal.” Afr Aff (Lond) 105(419):201-218.
IRIN has a story on the risk of HIV amongst former child soldiers through sex or drug abuse, particularly in Uganda. This phenomena, well studied in public health research literature, finds that both the ability of an individual to adapt (strong social connections, etc…) and the rate of change in their environment (social, economic, etc…) are powerful determinants of health. But, as far as I know, this research has not been extended into the developing world.
“We have found that in places like Sierra Leone, large numbers of demobilised child soldiers are increasingly injecting illegal drugs,” said Dr Josef Decosas, senior HIV policy adviser at Plan International, a development agency working for and with children. “And we know that as soon as HIV comes into a network of drug users it spreads like wildfire.”
He said recent research had shown that conflict tended to curb the spread of HIV by limiting movement and social interactions, but when wars ended these communities returned to normal and mobility increased, so HIV became a real issue.
“In Uganda, the HIV prevalence in the LRA [rebel Lord's Resistance Army] is thought to be quite low, but in northern Uganda’s local population it is quite high, so demobilised children need to be prepared to avoid HIV,” he said.