Tag Archives: AIDS

Swaziland: The Crisis Continues: 5 August 2011

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In May 2011 I was asked by the Royal African Society (RAS)2 to prepare a short commentary on the current political situation in Swaziland. There had been an increase in attention towards the country with news of protests and economic decline. The analysis was intended to stimulate discussion on whether political reform was likely.

At the end of July, I spent a few days in the Kingdom. The primary reason was to attend a Governing Council Meeting at Waterford Kamhlaba School but I also took the opportunity to meet with a number of people outside this community. I spent time with the National Emergency Response Council on HIV/AIDS (NERCHA) and presented an update on recent events, including the IAS Pathogenesis Conference.

We were briefed on the Swazi economy; the political situation; and the rule of law. On the basis of all of these meetings, and other observations, I am reporting on the situation. It does not make happy reading. If I were in the prediction business then I would say in the next six months the crisis will reach its peak.

The Economy

The economy is in dire straits and the country is bankrupt. Earlier this year, the International Monetary Fund suggested the government declare a ‘fiscal state of emergency’ and offered support subject to Swaziland following a road map of measures. This would have included laying off staff and reducing government expenditure. The government declined to do this. There was a view that the country would not meet its July 2011 salary bill but it has in fact done so. The civil service and security forces are now under pressure to take cuts in pay.

The country has seen a 60% fall in revenue, primarily because the South African Customs Union (SACU) payments have dropped (SACU members are Botswana, Lesotho, Namibia, South Africa and Swaziland). This was not a surprise. The government, international agencies, donor community and Swaziland watchers have been aware of this expected fall for many years. See for example our brief and longer article on our website. Brief at: www.heard.org.za/downloads/health-expenditure-implications-of-sacus-revenue-volatility-in-blns-countries-issue-brief.pdf.

In early August the King went to South Africa, cap in hand, asking for emergency funding. The country has received R2.4 billion. South Africa has put conditions in place for better fiscal governance (but there are few on democratization, this has caused great unhappiness among South African unions and others). This loan is a stopgap. Until such time as there is good economic governance there will no new investment in the country. At best the economy will slowly contract, with debt rising steadily.

Politics

Swaziland is the last absolute monarchy in Africa. King Mswati III seems oblivious to pressures to reform; the suffering of his people; and does not understand basic economics. Quite how the country operates politically is unclear, even to informed Swazis. It is a nepotistic, autocratic, kleptocracy where the ruling elite treat the national treasury as their own personal bank. The election system of tinkundla is Byzantine and impenetrable. Although there were constitutional reforms in 2006, political opposition remains banned. Nonetheless there are a growing number of protests and the trade unions – possibly with help from across the border – are flexing their muscles.

The Legal Situation

There is a crisis of law and the independence of the judiciary is under threat. Chief Justice Michael Ramodibedi was appointed as Chief Justice by King Mswati. He is from Lesotho and also sits on the appeal court in Botswana. He issued an order preventing anyone from “directly or indirectly” suing the King. He then suspended High Court Judge Thomas Masuku. In a case filed recently with the Judicial Service Commission, the Law Society accused Ramodibedi of sexual harassment. The Judicial Services Commission banned Swazi press from publishing details of the complaint.

There is an excellent source on Swaziland at: http://swazilandcommentary.blogspot.com.

What Does this Mean for HIV/AIDS?

Swaziland has the world’s highest HIV prevalence. In the last ante-natal clinic survey 42% of women tested were HIV-positive. The 2006 Demographic and Health Survey (DHS) found that 26% of all Swazis between 15 and 49 years were infected; among men prevalence was 20% and among women 31%. Overall HIV population prevalence was 18.8% across the nation meaning about 200 000 Swazis are infected. The response, coordinated by NERCHA, ironically is one of the country’s few success stories.

NERCHA was created through an Act of Parliament, in 2001 under the Prime Minister’s office. It is charged with coordinating and facilitating the HIV/AIDS response and implementation of the national strategic plan. Its main sources of funding are government and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, and it acts as a conduit. The second major source of funding in the country is the US government. PEPFAR provided $38 million in the 2011 financial year.

The exceptional measurable progress is that approximately 70% of those who should be on anti-retroviral therapy are receiving the drugs. This is 65 000 of 84 000 people and therapy is administered at the 350 or lower CD4 cell count level which is extremely impressive. There has been great success in the area of prevention of mother to child transmission. Approximately 97% of women visit the ante-natal clinics, and 85% of those who need drugs are started on therapy. Prevention has been slow to show results. There is a major programme of medical male circumcision with over 30 000 men circumcised in the last three years. Various other initiatives are also in place.

Threats

The lack of government money means that NERCHA’s funding is under threat. They asked for E63 million3 for the April 2011 to March 2012 financial year. They were allocated E47 million (about E4 million per month). For the four-month period ending 31 July 2011 they have only received E4 million of the E16 million allocated. There is no indication as to when, or indeed if they will get the next subvention.

Swaziland was unsuccessful in its last Global Fund bid. Globally there are concerns about US funding. The US House of Representatives Appropriations Subcommittee Bill would cut 9% from current global health funding levels and 18% from President Obama’s FY2012 budget request. It is not clear how this will operationalise in Swaziland.

The Ministry of Health is charged with implementation but government is creaking and it is unclear as to how sustainable the response will be.

Conclusion

As early as 1993 we were warning of the potential social and economic consequences of this epidemic for Swaziland. While it has taken longer than anticipated, the AIDS epidemic in combination with the failure of governance and economic contraction means Swaziland faces a bleak future. Ironically the glimmer of hope is in the response to HIV and AIDS where civil society is powerful and the receipt and disbursement of outside funding is efficient and honest.

1Alan Whiteside grew up in Swaziland and maintains close links with the country. He has written extensively about Swaziland, and is working on a book The Political Economy of Swaziland intended for publication in early 2012
2The RAS undertakes research, analysis and host lectures and meetings of African interest. Its website with commentary is African Arguments
3The Swazi Currency the Emalangeni (sing. Lilangeni) is on a par with the Rand, and Swaziland is in a Common Monetary area with South Africa.

Swaziland: Trouble In Paradise

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Since the beginning of 2010 I have made three trips to Swaziland, twice flying in and once driving up. The reason is, primarily, that I am desperate to write my book The Political Economy of Swaziland. Although I know the country well, am a regular visitor, and try to stay in touch I need to collect data, do research and check facts.

There is also the Waterford connection as one of the trips coincided with the School Governing Council meeting. We have a new development officer in post and have great expectations going forward. Do visit the website at www.waterford.sz.

 

Swaziland is such a beautiful country, at the end of this summer it seems to be exceptionally green and lush. I drove from the airport to Mbabane in the late evening on my last trip. There had been rain and the sky was overcast and quite ominous. We had dodged thunderstorms en route from Johannesburg to Matsapha. There was a band of cloud halfway up the Mdimba mountains on the side of the Ezulwini valley. The contrast between the black glistening rock, the green of the grass and vegetation and the pure white of the cloud was remarkable. I wished I had a camera because words can not begin to capture the scene.

The story of Swaziland is being written slowly. I have divided the book into four key periods. The first the history up to independence in 1968; second the reign of King Sobhuza over the independent nation from 1968 to his death in 1983; then the time up to 1994, a defining moment when South Africa gained independence and Swaziland began to slip off the international radar screens; and finally the story to 2010. This last part is dominated by two themes, the change in South Africa and the inability of Swaziland to adapt to it; and the HIV/AIDS epidemic. As with many activities this book is so clear in my head, but then I sit down to write and it slips away like water between my fingers.

There are also distractions that mean I literally loose the plot. The big diversions have been the HEARD board and donor meetings and international travel. We gathered with our key donors in Durban on the 17th March and on the 18th we held the first board meeting of 2010. The good news is that the organization will continue to be funded; it seems that we will have support for the next four years. This means we can plan serious work, and I can continue to put time and resources into Swaziland, one of the themes of this letter. These meetings need a great deal of work, thought, preparation and co-ordination and are ‘core business’.

The most recent international travel involved going to British Department of International Development organized ‘High Level Meeting on HIV/AIDS’ which was held in the House of Lords. My word it was interesting, the setting alone was amazing. The Houses of Parliament must be among the most majestic gilded buildings of any national assembly anywhere in the world. The meeting was held in a committee room called ‘The Moses Room’ because of the huge painting on the back wall. This is of Moses bringing tablets of stone (the commandments) down from the mountain to the people of Israel. I suppose one could make a link between these tablets and anti-retroviral therapy – but it would be a stretch!

The purpose of the meeting was to assess how we, the global community, are doing in achieving the targets for 2010. It was attended by the core international leaders of the HIV response and I was invited to give the opening remarks and set the scene. Of course the power point presentation I had prepared was not on the projector and so I had to start without the pictures. Despite this it was a good presentation and a great meeting.

I flew from London to New York for the International AIDS Vaccine Initiative’s Policy Advisory Committee meeting and was there from Wednesday to Saturday when I was scheduled to fly back to Durban. The hotel in New York was at the end of the Island of Manhattan just off Wall Street. The weather was uniformly windy and miserably wet, so walking back to the hotel I ducked into a stationary office supply shop that had a most unlikely selection of secondhand books. One of these was called “How we die” and the details are at the end of this letter.

The highlights of New York were having dinner with Stephen Lewis and Paula Donavan of AIDS Free World (www.aidsfreeworld.org), this was really fun; and sitting at JFK Airport with no flights taking off or landing because of strong wind which was not fun. A key theme of the dinner was what is going on in Swaziland. Among Stephen’s many activities has been mobilizing grandmothers primarily in Canada to work with their African counterparts. The details of this remarkable initiative can be found on the Stephen Lewis Foundation website at http://www.stephenlewisfoundation.org . There will be a “Grandmother’s Gathering” in Swaziland in early May. One of the big questions is how to reach the political leadership in Swaziland and, specifically, the King. There is so much misuse of money that it becomes hard to argue for continued support without real changes at the top. This, importantly, does not mean change of leadership, but rather change of heart and style.

I expected to leave New York at six o’clock on Saturday and be back in Durban early on Monday having slept overnight in Johannesburg. It was a filthy day so I took the taxi to the airport well ahead of time, checked in and went to the lounge. The wind was incredibly strong, gusting across the airport, making the building shake and the luggage containers dance. There was no activity at all out on the apron. The boarding time came and went. We were informed that the airport was closed, flights were being diverted or cancelled and we just had to be patient. I know I had missed my connection and that there was nothing I could do so I just chilled out.

At ten pm that evening the flight was boarded and the captain came on the public address system and said something like: “Welcome aboard ladies and gentlemen, you all understand the reason for the delay. We have been told a lull in the wind is forecast, so we will taxi down to the end of the runway, and if it is safe we will take off. But don’t worry if it is not safe we won’t. I am afraid the wind was so strong that there has been no baggage or food loaded onto the plane. However we did bring cookies on through the front door”.

We duly taxied to the end of the runway. I could see from the windsock that the wind was blowing straight down the runway (which was good), and the lights of two other planes landing. I was reasonably confident that we would be able to leave. The crew put on full power and, after the shortest take off run, I have ever experienced we were in the air and on our way.

There was a small degree of chaos in Amsterdam, but eventually I got to the front of the queue to see what my options were. The ground staff had already booked me on a flight from Amsterdam to Cape Town the next morning, which was a rather a long way round so we looked at other routes. In the end the best option was to fly to Paris then go overnight on the Air France flight to Johannesburg. I only looked at my boarding card when I was in Paris – and then saw that I was in seat 68F. After a moment of bafflement I realized that this was the new airbus, the biggest plane in the world. I walked to the gate to look at it and it is amazingly huge! It does not feel that different inside. As I boarded I asked the steward where my seat was.

“Hang on”, he said with a delightful French accent, “I will have a look at the map”.

They are having teething problems, in the case of this flight the entertainment system did not work. Oh well what can you say. At least I got back to Durban and having been there a couple of days had the donor meeting then drove up to Swaziland with a colleagues from the SIDA team in Lusaka. Then back to Durban to welcome Rowan my daughter and her boyfriend for their ‘South African holiday’. They arrived and went to a party this evening so I headed for the cinema. The film that was on when I got there was called “It’s complicated”. With Steve Martin, Meryl Streep and Jack Baldwin. I found it both touching and though provoking.

I will in my next posting, describe going on a canopy tour , which basically meant being terrified, the pictures are on the website. They say: “The canopy tour involves traversing from one platform to another along a steel cable suspended up to 30m above the forest floor. The tour comprises seven platforms and eight slides that zig-zag down a pristine forested valley”. Nothing about the fear and horror and getting stuck!

Books

Thirteen Moons; by William Frazier Random House 2007 432 pages

About 12 or so years ago William Frazier published his first novel called “Cold Mountain” set in the American Civil War. He has not published anything since. A couple of weeks ago I was passing though the airport in Durban and Exclusive Books had a sale on. In among the piles of books I spotted “Thirteen Moons”. It is an excellent and thought provoking book. It tells of an indentured boy who is sent to manage a trading post in the Cherokee nation. The main characters are the boy, Will Cooper; his adoptive father Bear, a Cherokee Chief; Claire with whom he has a complicated sporadic relationship, but who the wife to an aristocratic Indian called Featherstone. The love story is between Claire and Will, but there is also a deep relationship between him, Bear and in complex ways, with Featherstone.

The Cherokee Nation and indeed all the Indians in the East of the United States were forced to move to ‘beyond the Mississippi’, something I did not know and which resonates with South Africa. Will and Bear fight to keep land for the Cherokee Nation and succeed in doing so. Will ends up re-meeting with Claire at a Spa towards the end of the book and the end of his life. According to Wikapedia again the book is loosely based on the life of William Holden Thomas who was the principal chief of the eastern band of Cherokee Indians and served in the Confederate Army during the Civil War who lived from 1805 to 1893. Charles Frazier was given an advance payment of over 8 million dollars for the proposal and of its initial print run of 750 000 only half were sold so the publisher may lost money on the advance. It deserves to do better. I learnt a huge amount from the book about the United States, the removals of the Indians and was surprised to learn that it was set in North Carolina. It is clear that this part of the world had a bloody history of which I know only a small part. I find myself wondering why we are so slow to learn from experience.

Perhaps the most poignant is the way in which the book is written as an older man sitting and reliving his life. He is perceptive but desperately alone, and I have to say I found it to be most moving especially as I have aged (although I am certainly not in my 90’s, I sometimes just feel it). I wonder if this is sort of thing that my father and others went through as they moved through their lives. I hope it is more widely read, it certainly is a classic and is deeply moving.

“How We Die: Reflections of Life’s Final Chapter” by Sherwin B. Nuland (Vintage 1995, 304 pages).

Nuland examines what death means to the doctor, patient, nurse, and family. It was thought provoking and humane. He draws on his own experiences with various people close to him: the deaths of his aunt, his older brother, and a longtime patient. Disease, not death, is the real enemy. However there is not much comfort as he warns most deaths are unpleasant, and painful. It is an excellent book and certainly one we should all read. I found myself thinking of it as the South African Deputy Health Minister Sefularo died in a car accident last week. I had met him some months ago and was so impressed, what an excellent man and what a loss

A Response to ‘Experts want African aid funds channelled away from HIV’

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I was quoted in a recent article which appeared in the Observer and published on guardian.co.uk However, the news article bears little resemblance to the headline, which I find sensational and does not reflect my views as I emphasised that AIDS spending is crucial “for those already on or requiring treatment”.

Click here to read the news story and here for my official response.

At last, progress in developing an AIDS vaccine

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According to recent media reports, an experimental HIV vaccine has for the first time cut risk of infection. I was invited by OUPblog to post my views on this recent development. OUPblog is Oxford University Press’ blogosphere for learning, understanding and reflection. To read the posting, click here.

AIDS, Security And Conflict Initiative

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Alan Whiteside, will be a discussant at the HIV/AIDS Security and Conflict Initiative: A Briefing and Discussion, to be held 21 September, 2009 at the Hague.

The event marks the release of the new report, “HIV/AIDS, Security and Conflict: New Realities, New Responses.” The results of 29 global research studies on HIV/AIDS and fragile states, uniformed services, humanitarian crises and post-conflict transitions will be presented and discussed.

When: September 21, 2009, 11:30 – 16:00
Where: Ministry of Foreign Affairs, Bezuidenhoutseweg 67, The Hague De Oude Perszaal 00C 33
Presenters and Discussants: Alex De Waal, Georg Frerks, Charlotte Watts, Manuel Carballo, Anyieth D’Awol, and Pamela De Largy
Contact: Georg Frerks, + 31 (0) 30 253 6549, g.frerks@uu.nl

Circumcised Statues In Oslo

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Over the past ten days my destinations have been Olso, Stockholm, Uppsala and Liverpool. I was invited to take part in an interesting conference in Uppsala on “HIV and AIDS, Political Mobilization and Democracy?” This was organised by Forumsyd a Swedish NGO (forum south in English); SIDA, the Swedish Development Agency and Uppsala University. Given that I had to go to Scandinavia I decided to visit HEARD’s supporters in Oslo and Stockholm.

I flew over to Oslo on Sunday 10th May. Or at least I thought I was flying to Oslo but on getting to Amsterdam I looked at the departure board and saw that there was a plane to Oslo and then mine to Sandefjord Airport. This airport does indeed serve Oslo but is nearly 120 kilometres south! On arrival I had to work out how to get to Oslo – The choices were bus (nearly 2 hours); train but this required taking a shuttle bus to the station; or taxi which would have been impossibly expensive. I asked the driver of the rail shuttle bus which he thought would be my best option and he charmingly and honestly said: “Train of course, it is much nicer”, but then added “but not today we are using buses because there is a problem on the line”. I took the express bus!

I had looked at the weather forecast and it had seemed to be unrelentingly wet and cool, but this was not the case, it was sunny and pleasant the whole time and everywhere! What was striking was the extra daylight. I went to bed at 10 pm it was light; I woke up at 3 am and it was light again! This would take some getting used to if one lived there. In addition the size of the rooms and beds in the cheaper (but still expensive) hotels required a mental adjustment. In all three locations there was only a shower in the room and two had very small single beds.

I had a very useful day and a half in Oslo. Unfortunately my last appointment was in a slightly run down part of the city. Try as we might neither the taxi driver nor I could find the office, so I had to miss that meeting. The driver having taken money for the  trip to the location hung around and helped me look then took me back to my hotel so I could head for the airport without charging for the additional time, which was really decent. I felt so guilty about it though.

I was taken out to a really nice restaurant and told by my host that if I did only one thing in Oslo, I had to go to Frogner Park and look at the Vigeland Sculpture. She kindly put on the right tram to get there. It was a really beautiful evening so this was not a hardship. The sculptures are amazing, the website I found ishttp://en.wikipedia.org/wiki/Vigeland_Sculpture_Park and it is worth a look. The sculptures consist mainly of large naked men, with fewer women and some children and animals. They were sculpted in clay and caste in bronze or carved from granite. My favourite was the Wheel of Life. It was also clear that his male models were not circumcised! I walked back to the city and hotel, easy because it was all down hill, enjoying the evening.

From there it was off to Stockholm. This time I went from Oslo airport, but it was still a 65 minute trip on the bus from the city centre! The flight was 50 minutes, the plane was packed and the cabin crew still managed to serve drinks, a meal and tea and coffee in this time, while remaining calm, amazing. Arlanda airport is well seved by an efficient train that runs into Stockholm and I then headed to my hotel for my one night in the city..

Over the course of the trip I gave two presentations in Oslo and one each in Uppsala and Stockholm. The conference was interesting, there were new ideas and a number of people I had not met. It was particularly pleasing to have a chance to talk to a PhD candidate who is looking at the role of media in the response to the epidemic in Lesotho and Namibia. It it is clear to me that we, in Southern Africa and at HEARD, are ahead in our thinking, and that kind of affirmation is much appreciated.

Oslo is a beautiful small city. It was good to finally get there as I have never visited it. Stockholm is much busier. I had a city map for both locations and was amused to do a little analysis of the avertisments in the boxes around the central plan. They have about the same number of boxed adverts. On the Oslo map five of the 23 were for shops selling sweaters or other knitted goods, the balance were for resturants and sightseeing. The Swedes by contrast are more into general shopping including jewelery, there was not a single sweater shop.

Uppsala is a bucolic small town a forty minute train ride from Stockholm. We were housed is quite odd little hotel called the Muttern with only 26 rooms. Their website is  http://www.hotellmuttern.se The wardrobe was on a swivel stand, one side the mirror the other the opening for clothes and hanging jackets. It smacked of Ikea! The cathedral which was begun in 1287 is an amazing brick building.

The town itself is centred around the University, and so had all the standard features of such towns. These included hordes of students riding bicycles; cheap eating places and lots of pubs; and in the evening students staggering through the streets with open bottles and tins in their hands. They lined up at the pedestrian crossings and then eratically weaved the way across. I have not seen men urinating in public in the northern hemishere (except next to roads, and then with the car door as concealment), well in Uppsala brought that experience as well. The other striking feature was the largen numbers of Goths, who seemed to congregate like crows in the open spaces, sitting in circles and passing joints and booze.

I took a taxi from the hotel to the airport, it was driven by a melancholic Swede in his 40s, who unusually, did not speak English. It is, of course, possible that he choose not to speak though. As I  sat in the front I had ample opportunity to study his picture on the licence, and learn his name, Kenneth Lars Lindstrom. I could not decide if he looked shifty or sad, and eventually concluded he was carrying the weight of being Swedish on his shoulders. The driver from the Liverpool School of Tropical Medicine by contrast did not stop talking. He said he really enjoys his job because he gets to meet all these interesting people. Quite how he knows they are interesting was unclear as he does all the talking. He has collected me a few times and I know a lot about him, but he does not remember this.

The visit to Liverpool was to attend a meeting on “Strengthening the research to policy and practice interface: Exploring strategies used by research organisations working on Sexual and Reproductive Health and HIV and AIDS”. We had three HEARD, two by Tim Quinlan and one co-authored by myself and Fiona Henry on Swaziland, Fiona gave the presentation which was excellent. It is clear we are punching above our weight.

And my reading:The Virus, Vitamins and Vegatables: The South African HIV/AIDS Mystery, eds Kerry Cullinan and Anso Thom, Jacana media, Aukland Park, 2009, 211 page.
In their foreword, the editors write: “This book is an attempt to document some of the madness, sheer weirdness and despair of a decade with Mbeki and Tshabalala-Msimang. We are doing so to safeguard the future. We want to present this book as evidence to citizens of this country and the world and say, ‘This is what happened and we need to ensure that it never happens again.'”  Worth reading? Absolutely! 9 out of 10 for content; 8 for perception and 7 for writing style, this last because it is an edited collection it is a bit uneven.
Sexuality: A Very Short Introduction, Veronique Mottier, Oxford University Press Oxford, 2008, 160 pages.
This looks at how sexuality is determined, our genes or is it shaped by the social norms and expectations. It claims to provide an accessible, thoughtful and thought-provoking introduction to major debates around sexuality in the modern world, highlighting the social and political aspects of sexuality. It also looks at how governments have tried to regulate sexualities. It finishes by discussing political activism around sexuality. I found it useful however am not convinced of the perspective that she takes at the end. I think there is too much on gay politics. Worth reading? Yes because it is a VSI! 7 out of 10 for content; 7 for perception and 7 for writing style.
Dead aid: why aid is not working and how there is a better way for Africa, Dambisa Moyo, Farrar, Straus and Giroux,, New York, 2009 188 pages
This is a short but powerful book. The author, a Zambian woman, grew up in Lusaka but left to study in the US. She has worked for the World Bank and Goldman Sachs and has a PhD from Oxford. Her credentials are impeccable. Moyo argues the problem with Africa, the reason it is not developing, is the trillions of dollars in aid that has been poured into the continent. Her critique of aid in the first part of this little book is damning in the second part she has policy prescriptions.  Worth reading? Yes because if you are interested in Africa and development aid, otherwise probably not! 8 out of 10 for content; 7 for perception and 6 for writing style.