Rethinking Swaziland’s here are eight ‘Red Countries’* in
T southern Africa, so called because
they are shaded dark red on
UNAIDS prevalence maps. They represent
the epicentre of the HIV/AIDS pandemic.
The Need for Urgent Interventions Swaziland has the highest prevalence.1
This epidemic has been characterized by
the slow onset of a myriad of co-factors
Scott Naysmith, MSc1
that have culminated to create a complex
Alan Whiteside, DPhil2 emergency. Rising morbidity and mortali-
Amy Whalley, MSc3 ty mean that every sector of Swazi society
is struggling to cope. Swaziland is losing
large numbers of the most socially and
economically active members of its society,
ABSTRACT leading to mass orphaning and a decline in
agricultural production. This is happening
Swaziland’s HIV/AIDS epidemic has been characterized by the slow onset of a myriad of in the context of gender inequality and cli-
co-factors culminating in a chronic emergency, burdening every sector of society. mate change, especially drought.
Exacerbated by domestic political mismanagement and ill-suited policies of international Paradoxically, Swaziland is classified as a
organizations, impacts will remain endemic for generations. lower-middle income country, which
means it cannot access certain forms of
From near-zero diagnosed HIV infections in 1990, Swaziland now has the highest relative donor support.
prevalence in the world. The impacts of infection are withering the human capacity to The challenges of responding to the cri-
mount effective and systemic interventions. Indicators of social well-being show a sis are exacerbated by the lack of account-
population in distress. Aggravated by gender inequality, drought, agricultural decline and able domestic governance and ill-suited
insufficient financial resources, livelihood failure in Swazi households has become policies of international organizations.
commonplace – and the situation is deteriorating. Without greater support from the govern-
ment and international donors, innovative
This article argues that the brutal reality facing the Swazi population is perpetuated by the community-led interventions may be seri-
lack of political will of government and conditionalities imposed by international donors. ously undermined. 2 Swaziland’s
In the absence of comprehensive government-led programming, many communities have HIV/AIDS epidemic is currently the most
initiated interventions. Assisting these vulnerable populations requires sustained advanced in the world; we posit that it
international financial commitments. This money would be used to best effect if may be a harbinger for what awaits the
accompanied by pressure for domestic political accountability in Swaziland. Such changes other Red Countries.
will facilitate country-wide interventions, particularly those at the community level. While The first case of AIDS in Swaziland was
Swaziland is the case study, many of the findings are applicable to generalized epidemics diagnosed in 1986. In 1992, when the
throughout southern Africa. country’s first antenatal survey was carried
out, HIV prevalence among pregnant
Key words: HIV/AIDS; Swaziland; humanitarian emergency; international aid; disease women attending antenatal clinics was
burden; gender inequality; Southern Africa found to be 3.9%. By 2004, just 14 years
later, antenatal prevalence had jumped to
an astonishing 42.6%. Overall prevalence
in the country is currently estimated near
19%, 3 a figure which, if applied to
American and Canadian populations,
would mean that more than 56 million
Americans and over 6 million Canadians
would be HIV-positive.†
The increase in mortality has already
had measurable and dramatic effects. In
1998, the UN estimated life expectancy in
La traduction du résumé se trouve à la fin de l’article. Swaziland at 60 years. In 2004, after tak-
1. Visiting Research Fellow at the Health Economics and HIV/AIDS Research Division, University of ing AIDS into account, life expectancy was
KwaZulu-Natal, Durban, South Africa
2. Director of Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, * The ‘Red Countries’ are: Swaziland, Lesotho,
Durban, South Africa South Africa, Namibia, Botswana, Zambia,
3. Private consultant Zimbabwe and Mozambique.
Correspondence and reprint requests: Scott Naysmith, University of KwaZulu-Natal, J Block, † Based on a prevalence of 18.8% and a population
4th Floor, Westville Campus, Durban 4041 South Africa, Tel: +27 31 260 2592, Fax: +27 31 260 2587, of 301,140,000 in the USA and 32,000,000 in
E-mail: firstname.lastname@example.org Canada.
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RETHINKING SWAZILAND’S HIV/AIDS EPIDEMIC
estimated to be just 31.3 years – the lowest Swazis engage in subsistence agriculture,11 International Development Assistance
in the world. 4 Government population this is having devastating effects on the (IDA) loans. Some bilateral donors, such
projections in 1986 estimated the popula- majority of the people. Malnutrition as the UK’s Department for International
tion would grow from about 900,000 in increases the transmissibility of HIV, has- Development (DFID), use these catego-
1986 to 1,203,000 by 2006.5 The 1997 tens the onset of AIDS, and makes individ- rizations to guide their allocation of for-
population census recorded 929,718 peo- uals more susceptible to opportunistic eign aid. These ratings are based on a
ple in Swaziland. A preliminary result of infections. In 2007, roughly 40% of Swazis country’s Gross National Income (GNI)
the 2007 census indicates the population required food aid, yet the government per capita – the total national income
has declined to 912,229. 6 Although recently decided to cultivate cassava for divided by the population. As mortality
Swaziland is faced with poverty, malnutri- bio-fuel production.12 from AIDS increases, Swaziland’s national
tion and drought, AIDS deaths are central Many of the government’s actions con- wealth is divided among fewer Swazis.
to understanding this reversal. tinue to be out of sync with the reality Consequently, AIDS deaths may be lead-
One consequence of premature adult experienced by the majority of Swazis. The ing to an increase in Swaziland’s GNI per
death is the growing number of orphans suppression of trade unions from public capita. We argue that GNI per capita
and vulnerable children (OVC). There are assembly13 shows that Swazis are more sub- should not be the measure used to assign
an estimated 120,000 OVC in Swaziland, jects than citizens. The 2006 constitution international assistance in the Red
a number projected to rise to 200,000 by reaffirms that executive, legislative, and Countries because it is not reflective of
2010.7 Grandparents have largely assumed judiciary authority rest with King Mswati social and structural realities.
the role of primary caregivers. As they die, III, who has ruled Swaziland since 1986. Compounding these misleading catego-
many of these children are left without In terms of political freedom and civil lib- rizations, the IMF insists that public sector
support networks. This threatens inter- erties, Swaziland is on par with Sudan and expenditure be cut and the public service
generational transfers of knowledge sur- Zimbabwe.14 Engaged, accountable domes- be reduced in size18 – this at a time when
rounding work and family values, and tic leadership is essential for implementing additional human capacity is needed to
increases vulnerability to external shocks. holistic interventions to contain the spread respond to the crisis. As the largest
Regrettably, the harsh circumstances and impact of HIV/AIDS. It will be employer in Swaziland, the public sector is
afflicting a third of Swazi children have increasingly difficult to reverse the deterio- both financially responsible for many
come to be seen as normal and inevitable8 rating conditions in Swaziland without dependants and essential to implementing
– an abnormal normality reflecting a des- basic human rights of political representa- alleviation efforts. Cutting the public sec-
perate society. tion and gender equality. tor could have long-term negative ramifica-
Women too suffer disproportionately. Mortality figures now exceed the thresh- tions for Swaziland’s development.
Females in Swaziland are economically and olds used by humanitarian agencies to The absence of sustained financial and
politically marginalized. They also shoul- determine when a population requires institutional support has not resulted in a
der the burden of the epidemic and are immediate emergency interventions. In total absence of action in Swaziland. Despite
more vulnerable to infection. Of females every region in Swaziland, the crude mor- inadequate resources, some community-led
aged 25-29, 49% are HIV-positive, com- tality rate has exceeded the threshold of initiatives, facilitated in part by the
pared to 28% of males in the same cohort.3 1 death per 10,000 persons per day.15 In National Emergency Response Council on
The feminization of the epidemic is a the context of development indicators, the HIV/AIDS (NERCHA), are reaching vul-
reflection of the low status of women. In Human Development Index rating for nerable populations.2 KaGogo centres, tra-
Swaziland, women were only granted full Swaziland shows a steady decline since ditionally used as a place for resolving dis-
legal rights in 2006.9 A recent national sur- 2000. From a ranking of 112 among 174 putes, have been transformed into coordi-
vey on violence experienced by female chil- countries in 2000,16 Swaziland has fallen to nating centres for wider community inter-
dren and youths in Swaziland found that, 141 out of 177 countries in 2007. 17 ventions such as food distribution and
of respondents, nearly 66% of females aged Indicators of social well-being clearly assert orphan registration and care. Providing
18-24 had experienced sexual violence and that Swaziland is experiencing an emer- sponsorship to orphans and vulnerable
approximately two thirds of 13-24 year old gency – a national disaster driven by individuals for schooling, food and cloth-
Swazi females reported being coerced or HIV/AIDS. Shockingly, this has not set off ing costs, the “Young Heroes” initiative
forced into their first sexual experience.10 alarm bells in the international community. assists children affected by the epidemic.
Despite their marginal status, females are The politics of aid have restricted the Another innovative response has been the
the primary caregivers of both children and external funding that is available to revitalization of the Indlunkhulu fields, a
the sick. When they die from AIDS, cop- Swaziland, and consequently international traditional practice where a Chief allocates
ing strategies become increasingly desper- assistance has been limited. Swaziland’s land for the community to grow food for
ate. rating by the World Bank as a “lower- vulnerable members in the chiefdom.
Livelihood failure has become common- middle income” country means that the Community-led initiatives are most effec-
place in Swaziland. Consecutive years of Kingdom cannot access the financial tive when supported by domestic and
drought, compounded by the incapacita- resources available to “low income” coun- political resources.
tion of infected individuals, have led to tries by the International Monetary Fund The most recent UNAIDS report is a
falling agricultural production. As 70% of (IMF), including non-concessional welcome flicker of hope in containing the
MAY – JUNE 2008 CANADIAN JOURNAL OF PUBLIC HEALTH S9
RETHINKING SWAZILAND’S HIV/AIDS EPIDEMIC
(CASP): Final Draft. Mbabane, Swaziland, May
global spread of the disease.1 The fact that REFERENCES 2005.
world prevalence estimates have been 12. UN Office for the Coordination of
1. UNAIDS. AIDS Epidemic Update 2007. Humanitarian Affairs. Swaziland: Food or
scaled down, however, should not encour- Geneva, Switzerland: Joint United Nations Biofuel Seems to be the Question. IRIN.
age complacency. The situation in south- Programme on HIV/AIDS (UNAIDS) and the Available online at: http://www.irinnews.org
World Health Organization (WHO), December (Accessed October 25, 2007).
ern Africa has not improved. 2007. 13. Zvomuya P. Swaziland’s Constitutional Crisis.
We do not know the full impacts that 2. Helping Ourselves: Community Responses to Mail and Guardian. Available online at:
AIDS in Swaziland. UNAIDS Best Practice
HIV/AIDS will have in the Kingdom. We Collection. Geneva, Switzerland: Joint United
http://www.mg.co.za (Accessed November 25,
do know that policies must be recast to Nations Programme on AIDS (UNAIDS), June 14. Puddington A. Freedom in the World 2007:
recognize the state of emergency facing 2006. Freedom Stagnation Amid Pushback Against
3. Government of Swaziland, Demographic Health Democracy. Freedom in Africa 2007. Freedom
hundreds of thousands of Swazis now. The Survey, 2007. House, 2007.
aftershocks of HIV/AIDS will reverberate 4. UNDP Human Development Report 2006. New 15. Whiteside A, Whalley A, (Scott Naysmith editor).
York, NY: United Nations Development Reviewing ‘Emergencies’ for Swaziland: Shifting the
throughout every sector of Swazi society Programme, 2006. Paradigm in a New Era. Health Economics and
threatening human development, econom- 5. Swaziland Population Projections (1986-2016). HIV/AIDS Research Division (HEARD) and the
ic growth, cultural inheritance and the nat- Population Projections: Volume 5. Mbabane, National Emergency Response Council on
Swaziland: Central Statistical Office, 1986. HIV/AIDS (NERCHA). Durban, South Africa
ural environment for generations. The fact 6. Swaziland Population and Housing Census and Mbabane, Swaziland, 2007.
that hundreds of thousands of Swazi chil- (2007): Provisional Results. Mbabane, Swaziland: 16. UNDP Human Development Report 2000. New
Central Statistical Office, 2007. York: United Nations Development Programme,
dren will grow up without parents presents 7. Government of Swaziland. National Plan of 2000.
a problem without precedent. Combined Action for Orphans and Vulnerable Children 2006- 17. UNDP Human Development Report
with drought, an inefficient public sector 2010. Mbabane: Government of the Kingdom of 2007/2008. New York: United Nations
Swaziland, 2006. Development Programme, 2007.
and political mismanagement, the situa- 8. Zwane, Teettee. No need for aid in SD – agen- 18. UN Office for the Coordination of
tion in Swaziland is devastating. cies. The Swazi Observer Available online at: Humanitarian Affairs. Swaziland: IMF Urges
http://www.observer.org.sz (Accessed November Economic Reforms. IRIN Available online at:
Swaziland is experiencing an 23, 2007). http://www.irinnews.org/Report.aspx?ReportId=
HIV/AIDS-induced complex emergency 9. Government of Swaziland. The National 70824 (Accessed March 20, 2007).
Constitution of the Kingdom of Swaziland,
that is unparalleled. Severe epidemics in 2006.
19. UNAIDS. Quality and Coverage of HIV
Sentinel Surveillance with a Brief History of the
other countries did not reach the level of 10. National Survey on Violence Experienced by HIV/AIDS Epidemic. Paper presented at
crisis present in Swaziland. Uganda’s Female Children and Youths in Swaziland. Workshop on HIV/AIDS and Adult Mortality in
Violence Against Children in Swaziland: Developing Countries. New York, 8-13
prevalence peaked near 14%19 and has now October, 2007. Mbabane, Swaziland: Center for September, 2003;6.
fallen below 10%,1 and Botswana has been Disease Control and Prevention and Swaziland 20. WHO. Epidemiological Fact Sheets on
United Nations Children’s Fund, 2007;19, 17. HIV/AIDS and Sexually Transmitted Infections:
able to respond by rolling out treatment.20 11. Food and Agriculture Organization (FAO) of the Botswana, 2006 Update. Geneva, Switzerland:
This is not to minimize the devastating United Nations and the Government of the World Health Organization, 2006.
and continued impacts of HIV/AIDS in Kingdom of Swaziland (TCP/SWA/2907).
Comprehensive Agricultural Sector Policy
those countries, but to highlight that
Swaziland is facing the most severe and RÉSUMÉ
complex HIV/AIDS epidemic to date.
Au Swaziland, l’épidémie de sida se caractérise par la lente apparition d’une multitude de
Urgent interventions are needed. cofacteurs qui ont mené à un état d’urgence chronique et compliquent l’existence de toutes les
Mitigating long-term effects will require couches de la société. Exacerbées par la mauvaise gestion politique interne et par les politiques
sustained financial commitments from the malavisées des organisations internationales, les répercussions de l’épidémie se feront sentir
pendant plusieurs générations.
international community. This money
would be used to best effect in supporting Alors qu’on ne diagnostiquait presque aucune infection à VIH au Swaziland en 1990, le pays
the work of civil society and NERCHA, affiche maintenant la prévalence relative la plus élevée au monde. L’infection mine la capacité des
Swazis de monter des mesures d’intervention efficaces et systémiques. Selon les indicateurs du
and pressuring the government to increase bien-être social, la population est en détresse. Sous le poids combiné des inégalités entre les sexes,
political accountability. Community-led de la sécheresse, du déclin de l’agriculture et de la pénurie de ressources financières, les ménages
responses have, of necessity, endeavoured n’arrivent plus à assurer leur subsistance, et la situation ne cesse de se détériorer.
to address the needs of vulnerable popula- Dans cet article, nous faisons valoir que la réalité brutale à laquelle la population swazie est
tions throughout the country. While the confrontée est perpétuée par le manque de volonté politique du gouvernement et les conditions
case of Swaziland has been highlighted, imposées par les donateurs internationaux. En l’absence de programmes gouvernementaux intégrés,
de nombreuses communautés amorcent leurs propres interventions. Pour aider ces populations
many of these findings are applicable to vulnérables, il faut des engagements financiers internationaux soutenus. Et pour qu’on en fasse une
generalized epidemics throughout southern utilisation optimale, les fonds doivent être accompagnés d’appels à la responsabilisation politique
Africa. The positive benefits of community interne. De tels changements faciliteront les interventions nationales, surtout les projets à l’échelle
communautaire. Nous nous sommes concentrés sur le cas du Swaziland, mais bon nombre de nos
initiatives throughout the Red Countries constatations s’appliquent aux épidémies généralisées en Afrique australe.
would be dramatically augmented with
greater institutional and financial support Mots clés : VIH/sida; Swaziland; urgence humanitaire; aide internationale; charge de morbidité;
inégalités entre les sexes; Afrique australe
from domestic and international sources.
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