Out of Conflict, a Chance for Health

by George Bogden:

Corporal Gaspar Salvador has traveled a long way with his wife, Maria, to reach a military hospital in Angola. Just a few days before the journey, he explained to her that he was HIV-positive and that she should be tested. Anticipation grips the soldier’s wife as she waits to hear the results of her test. She believes—with reason—that contracting HIV is a death-sentence. The test results come back: she is positive.

Stunned, she collapses and weeps. Her dreams of finishing her education, raising children, and building a home disintegrate as she realizes the gravity of the results. This agonizing scene appears in Andrew Young’s documentary “AIDS Warriors,” which chronicles the Angolan military’s fight against HIV/AIDS.

The couple’s misery conveys the suffering of people throughout southern Africa who face reproductive health issues. But the fate of reproductive health in Angola overall is not as certain—or necessarily as dire—as Maria’s test results. In fact, Angola has a comparatively low prevalence of HIV/AIDS, a unique situation for a country in southern Africa. This provides the country with the opportunity to improve reproductive healthcare and prevent widespread HIV. But in post-civil war Angola, the government is struggling to rebuild its infrastructure, let alone confront the country’s reproductive health issues head-on.

The War’s Effect on Reproductive Health

The limited health care infrastructure that was in place at the start of Angola’s civil war in 1975 did not survive the fighting between two rival factions, the People’s Movement for the Liberation of Angola and the National Union for the Total Independence of Angola. George Ngwa, the regional information adviser for Sub-Saharan Africa for the United Nations Population Fund (UNFPA), described how the conflict destroyed most clinics, especially in southern Angola. “Women could not attend clinics for basic antenatal and reproductive healthcare,” said Ngwa. Today, he continued, “the government has to start from nothing.”

The nearly three-decade-long civil war also brought lengthy periods of lawlessness that kept Angolans from seeking proper reproductive healthcare. Incidences of rape and violence against women rose as Angola’s civil war—the longest in Africa’s history—raged on. Dr. Ndola Prata of the University of California at Berkeley’s School of Public Health explained: “Gender-based violence is always a weapon of war and girls and women had to pay the price.” Perhaps the most damaging result of the civil war was the displacement of up to 3.7 million people, comprising the largest internally displaced population in the world. Individuals in internal displacement camps continue to receive fewer health resources and remain the most vulnerable to problems associated with reproductive health.

Yet the state of reproductive health in Angola today is not a simple story of war and its destructive consequences. Dr. Kaveh Khoshnood, an assistant professor at Yale University’s School of Public Health, cautions that causal relationships between conflict and reproductive health problems cannot always be clearly established. This is because the underlying factors that contribute to both are linked and often appear in the same regions and in the same historical periods. Examples of factors that complicate analysis of conflict and reproductive health include poverty, gender inequalities, domestic violence, ethnic tensions, and inadequate social and medical services. These factors were most likely present in the lives of Angolans while under the colonial rule of the Portuguese. For this reason, the dire reproductive health situation in Angola today cannot be entirely attributed to the last few decades of civil conflict.

A New Battle with HIV

The war also resulted in an unexpected and advantageous public health development: Angola’s relatively low HIV/AIDS prevalence of 3.7 percent (neighboring Botswana has a prevalence rate of 24.1 percent). Many aid workers and analysts believe that Angola was isolated from the sudden increases in HIV/AIDS prevalence in southern Africa because the violence and troop movements of the civil war acted as a buffer and restricted movements between the populations within and around the country. This provides an opportunity for the country to avoid an upsurge of infections like those that ravaged other southern African nations.

International organizations are playing a large role and hold their own opinions about how to improve reproductive health, especially about how to curb the rise of HIV. The UNFPA is sponsoring projects in family planning, research, and public information on reproductive health-related matters. Ngwa, of the UNFPA, argued that while “there is a lot of talk of ARVs [Anti-Retroviral Drugs] and so on, ARVs are very expensive.” He stated that “the most important approach that is being used now is the education of the young people.”

Non-governmental organizations are also taking action. Fernando Macedo, president of the Association for Justice, Democracy, and Peace (AJDP) in Angola, explained to the Globalist that the AJDP is currently monitoring government assistance in hospitals while promoting reproductive health issues and lobbying the government. The AJDP has also developed the “Charter of the Rights for HIV-positive people” and has organized two national conferences on the relationship between human rights and HIV/AIDS. Macedo claimed that “the AJDP has been able to mobilize government authorities and civil-society organizations to come up with discussions and conclusions and recommendations at the end of our events and meetings.”

There have been some governmental successes. In 2002, the army recognized that soldiers, who have a three to five times higher rate of infection, were one of the high-risk groups spreading the disease. As the only effectively functioning agency able to take state action, the army responded with a bold program of education and outreach testing. The 25 new military-trained AIDS educators are working to address the ten percent HIV/AIDS prevalence rate among soldiers.

The Role of Education

These relentless prevention efforts are especially important given the many obstacles faced by Angolans who are already HIV-positive. While around 50 percent of HIV-positive Angolans have access to ARV drugs, distant clinics and the lack of basic public services keep many of them from being tested and receiving treatment. The conflict’s third and most recent ceasefire, which was declared in 2002, offers a chance for stability and sustained improvements. Yet the government is not seizing this opportunity to improve reproductive health. Reports from NGOs like Global Witness, which focuses on economic governance and natural resource revenue issues, point to the  rampant corruption and exploitation of natural resources within the Angolan government. The most recent press release from Global Witness decries the natural resource-rich nation’s earmarking of 70 percent of its budget for “special use.” According to Global Witness, there is “no clarity over how this money is used.”

Leaders of NGOs point to still more obstacles to improving reproductive health. Macedo, of the AJDP, blames the lack of credible discussion of national health issues on the media. “Most of the time, the media just tends to spew propaganda of the government’s side, and they don’t go further in terms of offering deep public debate about these issues,” Macedo lamented. “In my humble opinion, what we need is to be able to discuss critically and seriously what is going well and what is not going well in the Angolan government programs.”

The absence of true discussion of these programs results in a lack of concerted effort to improve reproductive health. “There are many people working, but we have not been able to sit and, in a very democratic manner, address these issues in terms of accountability,” said Macedo.

There are no simple conclusions about what the government and international organizations should do to improve reproductive health in Angola. However, most would agree with Dr. Prata’s assertion: “education is the key.” According to the Joint United Nations Program on HIV/AIDS (UNAIDS), only 42.7 percent of men and 35.2 percent of woman between the ages of 15 and 24 in Angola are able to correctly identify ways to prevent HIV. If these circumstances do not change, Angola could experience the escalating rates of HIV/AIDS that have been seen in most of southern Africa. This threat is particularly relevant as millions of displaced Angolans return home from high-risk border regions. The future of reproductive health in Angola depends on whether the country’s leaders recognize the essential role of education in the fight against HIV/AIDS and take advantage of this opportunity arising out of the civil war. If those in power do not commit to guaranteeing not only peace but also health to all Angolans, the story of Corporal Salvador and Maria, made famous in the documentary, could become the story of too many in the country.