Helen Epstein’s insight into the Underground Economy of AIDS

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A couple of days ago, I posted a review of a fantastic book by Helen Epstein, The Invisible Cure. I have been following Mrs. Epstein’s work and have found a great essay she wrote for the Virginia Quarterly Review. The theme of this essay was taken up in The Invisible Cure, so this post is more for those of you who haven’t read the book (yet).

The Underground Economy of AIDS

By Helen Epstein

In 2001, a group of scholars at University of California, San Francisco came up with a scheme that they hoped would protect African women from HIV. They had been working in Zimbabwe, a poor, politically troubled nation in Southern Africa, where the epidemic had killed more than a million people over two decades. Virtually everyone in Zimbabwe was aware of AIDS. The country had been exposed to anti-AIDS media campaigns since the 1980s and a school-based AIDS education program since 1994. Nevertheless, by 2001, around a quarter of all Zimbabwean adults were infected with HIV, and the virus was spreading rapidly, especially among teenage girls. It was urgent for researchers like them to come up with a solution.

Their idea seemed simple. For years, UCSF graduate student Megan Dunbar had been interviewing teenage girls living in the slums around Zimbabwe’s capital, Harare, and like many AIDS experts, she had come to recognize how the spread of HIV was driven by poverty and by unequal power relations between men and women. Many of the girls told her that they relied on boyfriends for material support. Although few of the girls were truly destitute, Dunbar came to see how their bleak, impoverished lives led them to place great value on the smallest gifts of cash, jewelry, make-up, and clothes. Most of the girls said they had only one sexual partner and were not prostitutes. But the transactional nature of their relationships placed them at very high risk of HIV, because some of their boyfriends were supporting other girlfriends at the same time, and they were thus at high risk of HIV themselves. Some of the girls said they used condoms, but since several of them had been pregnant, they cannot have used them all the time. When Dunbar asked them about the risks they were taking, they said that their economic difficulties were a far greater concern for them than AIDS was.

Dunbar reasoned that helping these young women earn enough money to meet their material needs would protect them from AIDS. Boys could always find odd jobs like running errands or helping out in the bus park, the girls said, but people didn’t hire girls. So Dunbar decided to set up a small loan—or microfinance-program to enable the girls to start their own small businesses. Since the 1970s, similar “microenterprise” programs had helped many poor women around the world gain a degree of financial independence. In some cases researchers had found that women who participate in such programs have fewer children than other women, and those children are healthier. Dunbar wanted to see whether such a program could also help protect young African women from HIV by giving them more personal autonomy and control over their sexual lives so they could assert their rights within relationships and decide for themselves whether to have sex or not, and insist on condom use if they did.

Admittedly, this was not an auspicious time for anyone to start a business in Zimbabwe. The economy was in a dire state, due to a combination of disastrous leadership by the country’s president Robert Mugabe and ruinous advice from foreign creditors such as the IMF and World Bank. The 1990s had seen the closing of numerous factories and the firing of thousands of public sector teachers and health care workers. The poor young women Dunbar wanted to help had few skills; some could barely read. Even in better days, Zimbabwe’s formal economy would have offered them few opportunities. However, the slums around Harare, like those surrounding cities and towns across Africa, were home to a bustling informal economy in which cheap food, clothes, and household products were traded at makeshift markets and among neighbors, relatives, and friends. Millions of poor, unskilled Africans, including women, earn their living in the informal economy, even in relatively wealthy countries like South Africa and Botswana. Dunbar reasoned that with a small amount of capital, girls in the slums of Zimbabwe could do so too.

During the past twenty years, public health and population experts have come to recognize the fundamental links between women’s health and women’s empowerment. Strengthening women’s economic independence has been declared an important HIV prevention strategy by the UN Commission on the Status of Women and by UN Special Envoy for HIV/AIDS in Africa Stephen Lewis. “Finally the world seems to understand that [in Africa] this is a gender-based pandemic,” he said in 2001. “Unless there is recognition that women are most vulnerable . . . and you do something about social and cultural equality for women, you’re never going to defeat this pandemic. This is the fundamental centerpiece of the whole blessed crisis! Men haven’t changed their behavior, so women somehow have to be strengthened to be able to ward off the men.” If Dunbar’s scheme worked, it would provide further confirmation of the strong links between women’s empowerment and AIDS, and provide a remedy as well.

Dunbar’s study was funded by the US National Institutes of Health, a vast organization that spends some $3 billion a year on AIDS research and has a powerful influence on global health policy. It is not surprising that NIH would have looked favorably on Dunbar’s proposal. US foreign policy experts increasingly recognize that gender inequality is not only an injustice in its own right, it also hinders economic development. Women’s labor generates most of the wealth in developing countries, but most of it is unpaid. Microfinance programs bring women into the cash economy, which could help spur economic growth, instill the poor with entrepreneurial habits, and encourage greater understanding of the benefits of free markets.

During the summer of 2004, Dunbar’s program, which was called Shaping the Health of Adolescents in Zimbabwe, or SHAZ, recruited fifty young women aged 16 to 20 from Chitungwiza and Epworth, two slum neighborhoods near Harare. The women were given training in entrepreneurial skills such as making a business plan, identifying markets, and managing finances. The young women also attended a series of workshops in the subject of AIDS prevention that included sessions on sexual relationships, gender inequality, and the use of condoms. In September, each woman chose a business to go into and received a loan of about $150, to be repaid in monthly installments with their profits.

When I arrived in Harare six months later, only 5% of the girls had met their loan repayment targets, one of the worst records of any microfinance project, anywhere in the world. Zambuko Trust, the microfinance agency that administered the loans for SHAZ had actually lost track of nearly half the girls in the program. More worrisome still was that SHAZ seemed to be having the opposite of its intended effect on the young women’s sexual behavior. The researchers had not anticipated that their program to “empower” these poor women was actually placing them right in the path of HIV.

Copyright © by Helen Epstein

Read the rest of this great essay here.

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