It is difficult to explain the impact of HIV/AIDS on nurses in South Africa. One way of looking at the disease is to examine the statistics. In a recent inaugural lecture at the University of Natal, Professor Alan Whiteside, Director of the Health Economics and AIDS Research Division (HEARD), sketched a frightening picture of the epidemic in terms of the African continent (Whiteside 2003). Life expectancy has fallen from 60 years in 1995 to 50 years now, and it is still declining. In 2000, men aged between 30 and 35 years were twice as likely to die than in 1985, and for women between 25 and 29 years of age the chances of dying are 3·5 times that of 1985. In Swaziland, the obituary notices of people aged between 26 and 40 years have increased fivefold between 1995 and 1999, and in 2010 we can expect to have 42 million orphans in Africa, of whom 20 million will have lost their parents to AIDS. Clearly, death stalks the continent.
Another way of looking at the epidemic is to take a closer, qualitative look. Consider a rural home in KwaZulu Natal Province where four young children were recently found living alone. The eldest, called Gift in Zulu, was only 8 years old. She referred to the three younger children as her brother and sisters, but a neighbour says two are cousins. The neighbour is an old woman who walked about 12 km to the nearest clinic to seek help from the Community Caregivers. She cannot help the children as she is already looking after her own daughter, who is suffering from AIDS, and her two grandchildren. The four orphans have been surviving by begging from neighbouring households and living off the land: not an easy task in a poor rural area where AIDS is stigmatized. Gift is small for her age, and painfully thin, but she has a ready smile, and says she loves looking after her siblings. She cannot go to school as she looks after the younger ones, but sends her six-year-old sister, who gets one meal at school and sometimes manages to bring home a sandwich.
There is a third way of looking at the epidemic, and to my mind this poses the greatest challenge for Africa. The first cases of HIV/AIDS were diagnosed in North America and Europe but, over the intervening 20 years, its spread has been most prolific in Africa. Now the problem is controlled in the first two continents, and out of control in Africa. This escalation of HIV/AIDS in Africa follows the pattern of many problems including floods, drought, political disputes, and economic downturn. In developed countries these problems are contained. In Africa they escalate dramatically. What is a problem in the USA is a disaster in Africa.
Africa can be compared to a patient with a suppressed immune system. On our continent any germ of a problem lands on a fertile growth culture of low general and higher education levels, low food security, extremely limited communication systems (from roads to television), and suppressive ideologies (such as the subordination of women). When even a small problem falls on such fertile ground, it grows into something terrible, and in the process it makes the whole system less able to deal with any future threat. That is what happened with HIV/AIDS. It came, it found fertile ground for calamity, and now it threatens all our dreams for the future of the continent.
When we, as nurses from Africa, therefore look at the problems confronting us, including that of HIV/AIDS, we are challenged to find solutions that will not only deal with the current crisis, but will make us less vulnerable in the future. When there is drought in Ethiopia, and the solution implemented is sending ships full of food from North America, it solves the immediate problem. But it does not make Ethiopia more able to cope with future drought and prevent future hunger. Similarly, cheap AIDS drugs will help the current African people living with AIDS to survive a little longer, but it does not help the continent to be more able to deal with future threat to its health when the response must be embedded in health behaviour. Let me be very clear; I do think we should give food to hungry people, and I do think affordable medication is essential, but it is not enough.
This is the message of community health nursing or primary health care. Let me give an example of what I mean. In 2000, the University of Natal and the McMaster University of Canada launched a project in rural KwaZulu Natal, sponsored by the Canadian International Development Agency. Professor Basu Majumdar was the director from McMaster University. In this area of Africa the HIV/AIDS prevalence is very high, and we could have focused on educating the women to deal with it through prevention and care. Instead we developed a broad curriculum dealing with gender issues, informing them of the human rights culture introduced in the country's new constitution, and explaining how they can use governmental services such as those provided by the justice system and the education system. We also included strategies and processes for economic empowerment to assist the women in increasing their household income. It was only after having dealt with these broader development issues that we came to the more immediate issues of how to keep yourself and your family healthy, and look after them when they are ill. The primary health nurses who implemented this curriculum with the women found many topics that usually fell outside of their expertise, but said that they themselves learnt much in the process. Having established 34 groups of women over a period of two years, we now have a core of women who are essentially less vulnerable.
In a similar way the agricultural, health, economic, and all other systems of Africa need to become less vulnerable. This is the challenge of the new millennium for Africa. If the resources flowing into the country to address the AIDS pandemic can be used in a way that promotes this ideal, this will ensure that the thousands of AIDS victims did not die in vain.