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Reviewing 'emergencies' for Swaziland: shifting the paradigm in a new era
Alan Whiteside, Amy Whalley
Health Economics & HIV/AIDS Research Division (HEARD)

Acknowledgements: FANRPAN acknowledges the HEARD website as the source of this report:

Executive Summary

The world’s highest HIV prevalence and the increasing number of deaths due to AIDS is having unprecedented impact on Swaziland. Worryingly, with a generation of orphans and rapidly escalating poverty, this desperate situation is being accepted as ‘normal’. HIV/AIDS in Swaziland has been characterized by a slow onset of impacts that have failed to command an emergency response. With insufficient resource allocation and a lack of capacity, slow onset events can become emergencies. The absence of an agreed definition of “disaster” or “emergency” has helped to sustain this characterisation. The nature of these terms is changing. The case of Swaziland emphasizes that they can be long-term, complex, widespread events that evolve over years.

Swaziland is experiencing a generalized epidemic. National sero-sentinel surveillance prevalence increased from 3.9% in 1992 to 42.6% in 2004 (MOHSW, 2006). HIV prevalence is estimated at 19% among the entire population and 26% among productive adults (CSO, 2007). Currently, there are around 220,000 people living with HIV. At similar prevalence rates, this would equate to 56 million and 92 million infected individuals in the USA and EU respectively. Prevalence is similar in rural and urban areas, and all districts. Unless the trajectory changes, AIDS may claim the lives of two thirds of all 15 year olds (UNAIDS, 2000).

HIV/AIDS is different from past diseases. Previous epidemics were short-term and worked their way through society or were treated and eliminated. HIV/AIDS is a long-term event. Rising HIV prevalence predates intensified impact. The multidimensional impact of infections will last generations. Negative effects on families become embedded within Swazi society, altering the future development path of the country. Although dramatic, the estimates cited in this paper are conservative. Effective interventions will require an emergency response aimed at building capacity for long-term programmes founded on the realities driving Swazilandís epidemic.

HIV/AIDS is permanently altering the structure of Swazi society. By 2025 there will be a thinning of the older age groups and the very young. Deaths among productive age groups are increasing the dependency ratio, constraining coping mechanisms and economic growth. Life expectancy fell from 60 years in 1997 to 31.3 years in 2004 - the worldís lowest. Mortality has risen significantly across the entire population over the past fifteen years. Infant mortality increased from 79 per 1,000 births in 1992 to 108 in 2004. Maternal mortality has increased from 230 per 100,000 births in 2000 to 370 in 2004. The crude death rate has doubled from 11 deaths per 1,000 people in the early 1990ís to 21.2 in 2004. Recent analysis show deaths rates in all regions in Swaziland now exceed emergency thresholds.

HIV/AIDS is negatively impacting Swaziland’s health systems, as rising morbidity increases the patient loads at all levels. While demand for services increase, there is a parallel reduction in the capacity to supply them. Rising TB prevalence is compounding this public health disaster. The provision of ART is placing significant strain on current public health systems.

Hospitals are working beyond capacity. Since the late 1990’s there has been a rapid increase in the demand for beds. HIV/AIDS patients are more susceptible to opportunistic infections, thus complicating medical treatment they must receive. The demand for services over the next ten years will grow. This increased demand will place additional strain on staff, effectively ìcrowding outî other health and support services. This will further foster demoralization among remaining staff and contribute to the migration of health workers from Swaziland.

In addition, TB prevalence rose from 263 cases per 10,000 in 1990 to 1262 in 2005. Increases of this magnitude and a low treatment completion rate raise the risk of MDR and XDR TB outbreaks. As TB can infect the general population, it has the potential to turn the HIV epidemic into a wider public health emergency.

ART roll-out could avert many deaths and reduce impacts across society. Currently, only 28% of those in need are receiving treatment. More resources dedicated to building capcity are required to ensure the success of treatment programmes.

HIV affected households become further impoverished as income-earning adults die. In 2001, 69% of the population - 80% in rural areas - were living below the poverty line. It is likely that this has increased further. Swaziland’s Human Development Index (HDI) ranking has fallen sharply since 2000, reflecting an overall fall in socio-economic conditions. This is despite a per capita GDP ranking that is 3 times higher than what is considered ‘low human development’. The impact of HIV/AIDS has reduced Swaziland’s social indicators (for example: life expectancy and crude death rate) to the point where the country is only slightly above the lowest HDI category.

There are 130,000 orphans and vulnerable children (OVC) in Swaziland - 31.3% of all children. This number is projected to increase to 200,000 by 2010. The impact of this on community and household structures cannot be overstated, as 43.4% of households are hosting orphans (Swazi VAC, 2006). At present, grandparents are masking the true extent of the orphan problem. However, as these elder caregivers die, this vulnerable population will be left without a support network. Inadequate socialisation of a large group of orphans may result in the creation of a dysfunctional generation of Swazi citizens. Increasingly, Swazi society has come to see the OVC status of one-third of all children as ‘normal’. This abnormal ‘normality’ is reflective of a desperate society that has run out of options.

Swazi households are forced to use drastic coping strategies in order to survive. The number of people reducing meal sizes fell between 2006 and 2007, but those not eating for an entire day or selling assets for food increased. Households are no longer vulnerable to, but rather suffer from, livelihood failure (Swazi VAC, 2004). In turn, this has created a societal exhaustion that decreases individuals ability to care for those in need or plan for the uncertainty of their future.

There has been a downturn in the Swazi economy over the past ten years. A reduction in annual growth rates from 6% in the 1990’s to a current level of around 2% has resulted in negative per capita growth. The average loss in GDP growth attributable to HIV/AIDS is around 1.6% per year (Muwanga, 2004). However, this estimate is from the early 1990’s when prevalence rates had not reached the levels seen in the past four years. Current figures may starkly highlight the negative impact of HIV/AIDS on economic growth.

Swaziland has experienced a significant reduction in agricultural production. Bad weather exacerbated by climate change is in part to blame. The multi-dimensional impacts of HIV/AIDS are also responsible. AIDS affected households experience a 54.2% reduction in maize production and a 34.2% reduction in the area of land cultivated. The national cattle population is estimated to have fallen by 11% between 2000 and 2002. Reductions in agricultural output and livestock ownership have led to increasing vulnerability and food insecurity. In 2007, over 400,000 people in Swaziland required food aid - approximately 40% of the entire population.

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