No one should ever have to choose between starving to death and exposure to HIV, however, millions of women and children struggling to survive in the drought-stricken countries of southern Africa aren’t being given a choice.
When both Somalia and South Sudan declared states of emergency due to severe drought and conflict in February, humanitarian workers knew the crisis would not just mean the starvation of millions. It could also potentially open a Pandora’s box of HIV-related complications.
A March press release from the United Nations Population Fund expressed concern that “famine could worsen already existing conflict-related sexual and gender-based violence” such as rape, forced marriage, and forced prostitution. Famine also leads to displacement and desperation, which can lead to trading sex for food. And with all these violent acts can come HIV infection.
Wilfred Ochan, a representative of the United Nations Population Fund (UNFPA) in South Sudan, said a rise in the rate of HIV is likely during famine: “I think this is expected, especially in towns where the HIV epidemic is generalized—it’s in the general population—so if the general population is having sex, and at this point you are vulnerable, you are not protected, it is a concern.”
Ochan said that he and other staffers at UNFPA have been diligent about ensuring that access to counseling, family planning, post-rape care, and testing is available to individuals in affected areas, however, since HIV testing is voluntary, the current scope and severity of the threat is still unknown.
Currentl, four African nations, South Sudan, Somalia, Nigeria, and, in the north, Yemen, all teetering on the brink of famine due to war or drought or both. Much of the famine in South Sudan alone can be attributed to man-made instability, according to the UN. South Sudan declared a state of emergency in January over its brutal, ongoing war, and Somalia declared one due to hunger in February. All told, 20 million people are facing starvation and displacement in the four affected countries. Those are 20 million people who would be helpless in the path of an epidemic.
Warning signs among the displaced
As famine takes hold in the continent, people have begun to flee drought- and hunger-afflicted areas in search of food. Uganda has so far taken on the lion’s share of displaced people fleeing conflict and famine in nearby South Sudan. But Uganda has become a canary in a coalmine when it comes to HIV rates and deepening unrest and hunger.
During the 1990s, the Ugandan government reported a drop in HIV infections—the fruit of aggressive efforts focused on increasing awareness and empowering young women. After peaking at around 15 percent in the early 1990s, the prevalence rate fell to as low as 5 percent by 2003. Since then, however, fallout from the South Sudanese war (which began in 2013) has sent refugees flooding across the Ugandan border, not only halting the decline but reversing it. According to UNAIDS, as of 2015, the estimated HIV prevalence among adults stood at 7 percent, with the number of new HIV infections up by 21 percent between 2005 and 2013.
If what happened in Uganda were to repeat itself in four countries simultaneously, the effects would be disastrous.
The hunger-afflicted of sub-Saharan Africa are not just settling in Uganda. And refugee camps set up to shelter famine victims across the region pose a complex problem in keeping the spread of infection down. These lifesaving oases that provide food, water, and health care are also often overcrowded makeshift cities that lack privacy and proper sanitation. According to the UN Refugee Agency, the largest refugee camp in the world, Dadaab, in Kenya, hosts 245,126 people—mostly women and children—whose immune systems have already been ravaged by hunger.
“The settlements themselves are obviously very congested and have the ability for the disease to take off right quickly,” said Justin Brady, head of the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) in Somalia.
However, Brady said a spike in infections may be something to grapple with further down the line, as the crisis continues. In the meantime, keeping refugees fed and alive is the first priority, he said.
“I think we’re really so focused right now on saving people’s lives that probably some of these things—to an everyday person living in the West—that would be a major health concern is something that people are living with here,” he said. And thus those dire health problems aren’t necessarily being addressed.
The United Nations estimated in March that more than half the population of Somalia—6.2 million people—were in need of aid, with Somalis starving at a rate of 100 people every 48 hours, according to a statement made by Prime Minister Hassan Ali Khayre.
Understandably, the majority of aid effort is focused on food assistance.
Still, Ochan insists that to let support end there would be shortsighted. “There is, to me, a bigger conversation,” he said. “Humanitarian work in this emergency, in this conflict and this famine—humanitarian work aims to save lives. That’s the immediate priority of humanitarian response, to save lives, but there is an increasing voice that humanitarian action should also give lives. In other words, save the life but also give meaning to the life of the person.”
For women in countries fast approaching disaster, that means not only providing them with basic services like food and shelter but also protecting them from not just starvation but also from sexual assault and the associated stigma, meaning: offer counseling, post-rape and pre- and post-natal care.
Stopping sexual assault means slowing the spread of disease
Brady at OCHA described a precarious life for women in camps so far from home. “They’re living in improvised shelters of branches and fabric and plastic that have no ability to close off, so what we end up with is them becoming victims to gender-based violence from either other IDPs (Internally Displaced People) or from the area that they’ve now moved into,” he said.
From her office in South Sudan, Alice Mangwi, gender-based violence co-coordinator for the Los Angeles-based group International Medical Corps, said that methods as simple as installing doors on latrines have been very successful in preventing attacks on women. The group has been able to increase response to gender-based violence cases by as much as 64 percent since 2015, according to a 2016 annual report prepared by UNFPA.
Mangwi confirmed that, anecdotally, that there have been reports of increased HIV infection, as well as other sexually transmitted diseases such as syphilis, since the drought began to take its toll this year.
She also pointed out that imminent dangers have made it difficult for men to help protect women, even if they wanted to.
“Gender roles have changed,” Mangwi said. “Women are taking on the breadwinner roles because the men can’t leave [their villages] for fear of being abducted, or recruited, or killed.” Women, therefore, must search for food and wood for cooking, often outside the confines of a protected camp. In their sojourns, “they are likely to be raped,” Mangwi said. “But the thinking is, at least they will only be raped.”
Impossible choices abound in a world where safety is a relative concept and the threat of HIV infection is a constant companion for women who shoulder the burden of caring for their communities. And despite humanitarian workers’ best efforts, it seems that even if they are able to beat back one looming disaster, another one may quietly slip into its place.