An unprecedented emergency
By Jean Milligan
Over 20 years after it began, the
HIV/AIDS epidemic continues unabated. In the next 12 months
nearly 9,000 people will die each day from the disease. International
organizations, governments and civil society institutions including
the Red Cross and Red Crescent are working together to reverse
the pandemic. To increase awareness of the impact of AIDS worldwide
and the Movement's response, Red Cross, Red Crescent features
an extended cover story on this unprecedented emergency.
Todd Murukai has AIDS and lies in bed with
a fever and tuberculosis. Zimbabwe Red Cross care facilitator,
Josephine Oliver, provides what comfort she can. "Plenty
of the people we care for have passed away. It is painful
to lose a friend but we keep doing it. If we don't, no one
will. We have to show the community that we care." She
An estimated 225,000 people in 1980 were infected with HIV,
the virus that causes AIDS. Today there are some 40 million.
The disease has claimed more than 25 million lives with devastating
social and economic consequences. And this is just the beginning.
Another 3 million are expected to die within the next year.
Tragically, it is the young who are suffering the most as
AIDS strikes the majority in the prime of their life.
Although the figures are impressive, "it's not the statistics
that need attention but the individuals and the real suffering
that lie behind them," explains a Federation report on
HIV/AIDS. Juan M. Suárez del Toro, Federation president,
recalls, "When you can see the drastic physical and emotional
toll on people living with HIV/AIDS, with no access to treatment
or care and facing discrimination and stigma, and when you
see how AIDS has decimated entire communities, leaving behind
only orphans, you really begin to comprehend the magnitude
and impact of the epidemic. AIDS and other diseases are tearing
apart families and communities, robbing people of a life with
dignity and the hope for a better tomorrow."
The International Red Cross and Red Crescent Movement has
mobilized its worldwide network to tackle the pandemic. By
combining education programmes with home-based care intiatives,
the Movement is on the frontline of response. But the grass-root
efforts of National Societies from Fiji to Malawi cannot stop
the epidemic alone. Joint action by governments, civil society,
the private sector and people living with AIDS must take place
to ensure that this war against the greatest threat to human
security and development today is not lost.
A mortal blow
Sub-Saharan Africa is the hardest hit by the pandemic with
70 per cent of the world's HIV/AIDS cases and 75 per cent
of its deaths. The United Nations Children's Fund (UNICEF)
estimates that a 15-year-old boy in Botswana today has an
80 per cent chance of dying of AIDS. HIV is spread in Africa
primarily through unprotected heterosexual intercourse, spurred
on by the migrant labour system, widespread sexual violence
and the presence of other untreated sexually transmitted diseases.
Poverty aggravates the situation limiting the number and
scope of prevention programmes, handicapping overwhelmed health-care
systems and making most treatments unaffordable. Add to this
the lack of political will among many governments and the
international community to address properly Africa's worst-ever
disaster in its early phases and it seems as if things are
only going to get worse.
The AIDS epidemic will reverse hard-won development gains
in southern Africa costing up to 17 per cent of gross domestic
product by 2010, according to published reports. Jeffrey Sachs,
the noted former Harvard economist, now an advisor to the
UN Secretary-General, Kofi Annan, explains: "This single
epidemic can undermine Africa's development over the next
While economic development will be severely impacted, what
concerns many government officials and those in the international
aid community is the dramatic increase in the number of children
orphaned and made vulnerable by AIDS. With some 34 million
orphans in Africa today, UNICEF predicts this figure will
rise to 42 million by the end of the decade, half of them
orphaned by AIDS.
Often left behind after one or both parents have died, extended
family members try to assume responsibility for these children,
but are often overwhelmed and lack the resources to care for
To make matters worse, the current drought in southern Africa
is exacerbating further the HIV/AIDS pandemic. The Federation
estimates that at least 14.4 million people are threatened
by starvation this year. Lesotho, Malawi, Swaziland, Zambia
and Zimbabwe are the most affected by food shortages as a
result of bad harvests, economic decline and poor government
policies. The HIV/AIDS pandemic, which affects up to 34 per
cent of the adult population in some areas of the region,
has depleted the labour force and reduced food production
as well as wage income. Alex de Waal, director of Justice
Africa and an adviser to the UN Economic Commission for Africa
and UNICEF, comments, "We are facing a new variant of
famine: in societies hurt by AIDS, famine more deadly and
less susceptible to existing treatments. The reason is that
AIDS attacks exactly those capacities that enable people to
The face of drought and AIDS
The teacher in a classroom of a primary school in the Lowveld
region of Swaziland is extolling the virtues of a balanced
diet, a key element, he tells his pupils, in avoiding disease.
They look on wide-eyed. Most of them are lucky if they eat
one meal a day.
"Yesterday we didn't eat until afternoon when Mum cooked
porridge," says Nkosinginphile Mamba, 13, who along with
his friends often spends a whole day in school with an empty
stomach. Even so they are the lucky ones. The hunger affecting
this little kingdom landlocked by South Africa means many
children do not go to school at all. Their impoverished parents
have a choice: feed the family or pay school fees. Many are
unable to do either.
Nkosinginphile lives in one of the regions of Swaziland hardest
hit by the southern African drought. A 70 per cent reduction
in crop yield was reported here after the last harvest, partly
the consequence of drought, partly HIV/AIDS.
Says the boy's mother, Busangani Dlamini, "We did plough
but couldn't look after the crops properly because my husband
was already getting seriously ill."
Busangani's family is among the most vulnerable in Swaziland.
Her husband, Samuel, 34, used to work in the mines of South
Africa and, relatively well paid, could easily support his
two wives and six children. But like over 38 per cent of the
adult population he was infected by HIV and is now dying of
"I don't have any money left," he says wearily
from the bed he has been confined to for the past six months,
"so I cannot feed the children properly, and to send
them to school is getting more and more difficult."
The family is heavily dependent on Red Cross food rations
but they still have to acquire other food to keep going, and
the choice between food and education comes ever closer. For
the US$20 a year it costs to send a child to school you can
buy a 50-kilo bag of maize which will feed the family for
The Federation is coordinating a five-country relief operation
to help such families through a food crisis in which at least
14 million people are threatened by starvation.
If sub-Saharan Africa is bearing the brunt of the pandemic
today, predictions by the US-based National Intelligence Council
(NIC) are that the number of people with HIV/AIDS will rise
significantly by 2010 in five "next wave" countries.
"The increase will be driven by the spread of the disease
in five populous countries Nigeria, Ethiopia, Russia,
India, and China where the number of infected people
will grow from around 14 to 23 million currently to an estimated
50 to 75 million by 2010. This estimate eclipses the projected
30 to 35 million cases by the end of the decade in central
and southern Africa, the current focal point of the pandemic,"
explains the NIC report.
The NIC projects that China will have 10 to 15 million HIV/AIDS
cases, India will have 20 to 25 million by 2010 the
highest estimate for any country. By 2010, Nigeria is projected
to have 10 to 15 million cases, Ethiopia 7 to 10 million,
and Russia 5 to 8 million.
The primary cause for the increasing infection rates in all
the countries is unprotected sex and sharing intravenous drug
equipment. The challenge is to begin tackling the problem
now. But without the political will, it will be nearly impossible
to stem the tide of the epidemic in these countries by 2010.
"The disease has built up significant momentum, health
services are inadequate, and the cost of education and treatment
programs will be overwhelming. Government leaders will have
trouble maintaining a priority on HIV/AIDS which has
been key to stemming the disease in Uganda, Thailand, and
Brazil because of other pressing issues and the lack
of AIDS advocacy groups," says the report.
For some there is hope as antiretroviral drugs become much
cheaper and more accessible, but for many in developing countries
the cost of treatment remains too high. Overlooked in the
debate on antiretrovirals is the appalling fact that Africans
are often denied even basic drugs and medications to combat
illnesses such as tuberculosis (TB), diarrhoeal disease and
fungal infections of skin and mouth. For example, many clients
of the Red Cross and Red Crescent home-based care programme
suffer recurring and drug-resistant TB because their treatment
is interrupted when the drugs run out. TB drugs may be free
in Africa but that doesn't help when they are unavailable.
The right to treatment
The vast majority of people living with AIDS will continue
to be denied access to life-saving antiretroviral therapy
(ART) unless considerable additional resources are provided
to the Global Fund for the Fight against AIDS, TB and Malaria,
said Dr. Massimo Barra, a new representative of non-governmental
organizations from developed countries on the Global Fund
Barra, founder and director of "Villa Maraini",
an Italian Red Cross Foundation that has provided direct assistance
to more than 25,000 injecting drug users, said the proposals
which the Global Fund has been able to support to date will
only provide ART to some 492,000 people over the next five
years, leaving the needs of more than 5 million people uncovered.
"This is completely unacceptable and we must do all
in our power to impress on the international community how
shameful it is that so many people will die when affordable
drugs are available on the market," said Barra.
He believes that "the most important thing that the
Global Fund can do is to make access to treatment available.
Otherwise we condemn millions of people to death. This is
a scandal which the Red Cross cannot accept. Therapy is an
important part of prevention, it is not possible that it is
only accessible to 5 or 10 per cent of the affected population."
The heroin trade route that runs out of Afghanistan and travels
north through central Asia to Russia, then west is increasing
intravenous drug use throughout these regions and creating
what today is one of the world's hotspots for the HIV epidemic
Russia and central Europe.
The Red Cross and Red Crescent is scaling up its programmes
to help drug users. Several National Societies are running
centres that offer needle exchange, free testing for AIDS,
and support groups. These programmes follow the harm reduction
approach and aim to help the drug user while preventing the
spread of HIV into the general population. As the Croatian
Red Cross health coordinator, Sinisa Zovko, notes: "You
cannot separate HIV from drug programmes. Along with safer
sex we must have safer fixing."
Although a preventive public health strategy, harm reduction
is not without controversy. Some people question the value
of reaching out to such a marginalized group whose behaviour
is unacceptable to some. But most health professionals point
out that while HIV infection may first occur in those on the
fringe of society, it does not take very long for it to enter
the mainstream and become a widespread public health problem.
Zovko explains: "Drug abusers are members of the community.
They are ill because of addiction, and they have rights. My
job is to help and advise them, reduce the risk they are exposed
to. We must help them to protect themselves and in doing that
protect the community."
The problem of complacency
While much of the developing world is fighting to gain access
to treatment and expand prevention programmes, in Western
Europe and the United States the greatest threat is a widespread
and alarming complacency among young people. Although new
drugs are succeeding in prolonging the lives of people with
HIV/AIDS, prevention programmes have not kept pace and involved
younger generations. The danger is that infection no longer
seems so life threatening. As proof, a recent study by the
Terrence Higgins Trust, the largest AIDS organization in the
UK, revealed that one-third of 18- to 24-year-olds in the
country believe there is a cure for HIV/AIDS.
And infection rates are rising as a result of the complacency.
In 2001, there were 4,419 people diagnosed with the disease
in the UK, an increase of 17 per cent on 2000 according to
the Guardian newspaper. The profile of those infected is also
changing. HIV/AIDS is no longer primarily an infection of
gay men or intravenous drug users in the UK; an estimated
54 per cent of new infections were between heterosexual couples.
The situation is repeated in the US. According to the US
Centers for Disease Control (CDC), while the number of AIDS
cases in the country is declining, the number of people living
with HIV is growing. "This increased prevalence of HIV
in the population means that even more prevention efforts
are needed, not fewer," explains a CDC report.
To prove their point, the CDC refers to research done among
gay and bi-sexual men. It suggests that some respondents are
less alarmed about the threat of becoming infected than in
the past and "may be inclined to take more risks".
The research also states that this is most likely true for
other groups as well who may have unprotected sex in the belief
that the available medication is effective in treating HIV.
The CDC concludes with a warning: "The truth is, despite
medical advances, HIV remains a serious and usually fatal
disease that requires complex, costly, and difficult treatment
regimens. These treatments don't work for everyone."
Prevention through puppets
"What's the matter? Don't you love me?"
"Of course I love you, my darling, but you promised not
to hurt me..."
The audience's eyes are glued to the stage where a girl finds
herself alone in a boy's apartment. He says he doesn't need
a condom everything will be just fine. Besides, he
loves her very, very much.
The boy is blue with yellow-greenish hair, the girl is orange
with purple hair.
That's all right it's all make-believe. The boy and
the girl are puppets, given movement and voices by young Red
Cross volunteers from Pacific countries who have gathered
in the Fijian resort town of Nadi for a two-week Federation-sponsored
workshop on puppetry and HIV/AIDS awareness. This is the last
day of the intensive workshop and they're rehearsing for a
performance for a local community group and a secondary school
Not only have they made the puppets from scratch, they've
also written the script and built the stage. Now they're heading
home to make puppets in their own National Societies and to
take their HIV/AIDS awareness puppet shows to local communities.
"Puppet theatre can be a very good tool in our communities,"
says Norman Ben from the Vanuatu Red Cross. "Puppets
are a good source of entertainment and therefore a good way
to convey powerful messages to the public."
And the message certainly needs to be conveyed. HIV prevalence
is on the increase in the remote and isolated communities
of the Pacific island countries.
The Fiji Red Cross has been using puppets to spread various
messages to local communities for a number of years. It has
been difficult to get the church to accept the HIV/AIDS-prevention
message. The one time Fijian Red Cross puppeteers performed
in a church setting, they were stopped in the middle of the
show and haven't been invited back.
"We are hoping to be able to support a number of societies
in the region to develop relevant programmes in this field,"
says Milja Heinonen, the Federation's regional health delegate
in the Pacific.
"So far sorry to say the Red Cross is
not really recognized in the Pacific as a key player when
it comes to HIV/AIDS. Puppetry is one of the tools we have
and that appears to have an appeal here," she says. However,
she points out that the National Societies need to commit
themselves to this work, in collaboration with other actors.
The young puppet masters from Cook Islands, Fiji, Samoa,
Tonga and Vanuatu who have been learning the art in Nadi are
fully aware that theirs will not be an easy task. Gradually,
they say, as more puppeteers are trained and their message
is taken to local communities, attitudes may begin to change.
A global effort
If the AIDS pandemic is to be reversed, not only the disease
but poverty, ignorance, stigmatisation and violence must be
confronted. Efforts are underway but a greater political will
and a massive mobilization of resources needs to take place.
Stephen Lewis, the UNAIDS special envoy, explained it this
way: "In times of war, resources are somehow found that
are thought not to exist just think of the so-called
war on terrorism, with scores of billions of dollars hurled
into the fray overnight to avenge the horrendous deaths of
3,000 people. So explain to me why we have to grovel to extract
a few billion dollars to prevent the deaths of over 2 million
people every year, year after year after year?"
Jean Milligan is Federation editor of Red Cross, Red Crescent
action at a glance
The ICRC HIV/AIDS programmes concentrate primarily on detainees,
displaced persons, refugees, unaccompanied minors, armed forces
and the war wounded. As a rule, the ICRC implements programmes
within the framework of national policies against AIDS as
well as those of the Movement and the United Nations.
In the case of detainees, the ICRC focuses on the prevention
of AIDS. It works closely with detaining authorities and with
local non-governmental organizations running programmes for
HIV-positive inmates. It also has developed tuberculosis treatment
and prevention programmes, in particular in the southern Caucasus
(Georgia, Armenia, Azerbaijan) and in various African countries
where multi-resistant strands of tuberculosis are especially
National Society initiatives
In the 50 countries hardest hit by HIV/AIDS as well as China,
India and Indonesia, 80 per cent of Red Cross and Red Crescent
Societies have either launched new programmes, scaled up existing
ones or incorporated an HIV/AIDS component into health initiatives.
Among these are:
In China's Yunnan and Xinjiang provinces, the Red Cross
is running youth peer education programmes. Currently, the
programmes are being scaled up in other regions. Last year,
the National Society was praised for its efforts by UN Secretary-General
The Thai Red Cross, a pioneer in the fight against
the spread of HIV/AIDS in Asia, manages a clinic that provides
anonymous counselling and testing. The clinic is considered
a national model by the Ministry of Health. The National Society
also has a support group for people living with HIV/AIDS.
In part through its efforts, stigma and discrimination have
been dramatically reduced in Thailand.
In southern Africa, where drought and HIV/AIDS have
combined for a deadly mix, the National Societies of several
countries are providing food packages along with crucial home-based
In east Africa, Red Cross Red Crescent Societies are
developing new HIV/AIDS programmes and expanding existing
Several thousand people participated in Red Cross HIV/AIDS
education initiatives in central Africa. In particular, peer
education programmes, public forums, theatrical productions,
chat rooms and anti-AIDS clubs reached out to young people
throughout the region. A number of home-based care programmes
were initiated offering much-needed care and support to people
living with the virus.
The Croatian Red Cross is implementing ground-breaking
harm reduction strategies, including a needle exchange programme.
More than 50 European National Societies issued a joint
declaration in 2002 calling for renewed attention to the health
needs of vulnerable people, particularly those affected by
HIV/AIDS and tuberculosis. The declaration calls for the use
of harm reduction strategies where necessary and appropriate.
The National Societies of the Dominican Republic and
Honduras have provided a powerful example of how collaboration
with organizations of people living with HIV/AIDS can reinvigorate
the national response
The Federation's Governing Board has adopted a new HIV/AIDS
policy which recommits the Red Cross Red Crescent to support
and scale up efforts on prevention, de-stigmatization, advocacy,
the provision of health care and other services related to
HIV/AIDS, in particular to vulnerable populations. Most significantly,
it endorses and advocates harm reduction strategies as key
to stemming the spread of HIV/AIDS.
Guidelines developed by the Federation help National Societies
to implement programmes for home-based care and for orphans
and other children made vulnerable by HIV/AIDS.
The Federation also has forged strong partnerships with organizations
concerned with HIV/AIDS and corporate institutions. These
include a partnership with the Global Network of People living
with HIV/AIDS. The launch of the world-wide campaign to reduce
AIDS related stigma and discrimination, "The truth about
pass it on", was the highlight last year of
this partnership. A formal framework for cooperation was developed
with the Pan American Health Organization, focusing on joint
health initiatives in the Americas to extend HIV/AIDS prevention
efforts and increase supplies of safe blood. And the OPEC
Fund for International Development and several National Societies
in Asia and the South Pacific are combining efforts to scale
up programmes in response to the expanding HIV/AIDS epidemic
in the region.
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