AIDS AND AFRICA--BECKER

As Posner's data indicate, the world AIDS problem is now largely concentrated in Sub-Saharan Africa. Even there, the incidence varies a lot, with approximately 10 percent of the sub-Saharan population infected with the HIV virus, and with some countries like South Africa having incidences of over 20 percent. AIDS is a major problem for Africa not only because it has killed many millions of men, women, and children there, but also because it has further disorganized their economies, and pushed them further behind more rapidly growing parts of the world. A high incidence of AIDS produces a sluggish population and cuts work effort. A study by Jane Forston of Princeton University shows that young persons in areas with high HIV incidence invest less in their schooling than do those in comparable areas but with lower rates of HIV infections Several studies have shown that sexual behavior in Africa did not change much after this virus was discovered, whereas it did change significantly in the United States after this discovery. The incidence of new cases of HIV infection began to decline in the United States as American populations at especially high risk, such as gay men, began to change their behavior: toward greater use of condoms, lower promiscuity--many bathhouses that catered to gays were forced to close by drop in business--and other changes. After the antiretroviral drugs were discovered, some of the behavior returned to what it had been. Why didn't risky sexual behavior decline much in Africa, especially since antiretroviral drugs are much less common there? A study in progress by Emily Oster of the University of Chicago shows the importance of two "economic" factors. One is the lower income of Africans, which means that the gain to them in terms of lost future income from taking actions to reduce their exposure to the AIDS virus is smaller than it would be in a richer country like the United States. The second is that the much greater prospect in Africa of death at younger ages from other diseases, such as malaria, reduced the gain to them from lowering the risk of contracting the AIDS virus. These factors are very important but perhaps not the whole story. Posner mentions several other candidates for the low response in Africa. Although undoubtedly some Africans are ignorant about what causes AIDS, this is probably no longer of crucial importance. For the rate of HIV infections is apparently not much lower among relatively well-educated Africans than among those with very little schooling, even after controlling for income and some other variables. Women are much more likely to become infected with the AIDS virus from heterosexual sex than are men, and women are less likely to infect others. The low status of women in many African countries may well explain their relatively high rates of AIDS infections there, but it does not help much in understanding the very high rates among men. I share Posner's skepticism about the effectiveness of government aid from Western countries to fight AIDS in Africa. I am less convinced than he is that there is little value from the activities of private foundations and other private groups from the West that operate in Africa to try to reduce the incidence of the AIDS virus. These groups compete among themselves, and have been responsible I believe for some of the few bright spots in the African AIDS situation. They have had more flexibility than governments in setting up useful clinics that offer practical information and advise about this scourge. They have helped spread knowledge--such as the importance of circumcision in reducing vulnerability to AIDS--sometimes in opposition to the official policy of certain African nations. I cannot claim, however, that I have seen any evidence evaluating the effectiveness of the large spending on AIDS in Africa by big foundations like the Gates foundation. I also do not know the answer to the more important question: how effective have these AIDS expenditures been relative to spending by these and other foundations on diseases elsewhere, or on anything else? Some might argue that the tax-exempt status that the U.S. grants its private foundations (see our discussion last week) should not apply to monies spent by foundations in Africa and other countries outside the United States. But that would imply that they should also not be allowed to support with tax-free dollars grants given to groups operating abroad, or to studies of urban activities in say India. These are types of activities supported by many American foundations. My own guess is that spending by American foundations to reduce the incidence of AIDS in Africa is at least as valuable to the interests of this country as much of what else these foundations spend their resources on. Posner concludes that not much can be done to combat AIDS in Africa until African nations achieve better economic growth, more extensive education, improve the position of women, etc. These factors may be important, but Africa has made great strides in reducing deaths from other diseases during the decades since 1960. A reasonable expectation is that they will also do much better at combating deaths from AIDS, partly because the cost of the antiretroviral drugs will come down. I believe they will do better also because some African countries are beginning to adopt more sensible economic policies, and this has been reflected in good growth rates during the past few years.

Comments

[robert]

That Africa suffers from a high mortality rate for malaria--which, unlike AIDS, already has a cure--is suggestive of shortcomings that gives one pause for thought concerning progress on the African AIDS front. Until the end of depostic and pathological regimes (with "leaders" that have squired billions of dollars to Swiss bank accounts), AIDS in Africa will continue to be a significant problem.

[Benzion Chinn]

What, in your opinion, is the responsibility for religious groups such as the Catholic Church in the struggle to make the use of condoms more prevalent in countries that have high infection rates for AIDS?

[Jack]

"One is the lower income of Africans, which means that the gain to them in terms of lost future income from taking actions to reduce their exposure to the AIDS virus is smaller than it would be in a richer country like the United States."

Does anyone else here think that this statement of Posner represents reality?

[Jack]

sorry.. That's Becker's... I looked at the posted by

[Haris]

Jack
I'd have to say yes and no. No in the sense that Africans probably don't sit down and think, "well, the present value of my future utility is X, which is so low that I'll go have unprotected sex with a prostitute and contract AIDS with a probability P." However, I do think that people who think they have little or nothing to lose engage in riskier behavior than those with something. So yeah, I think on some level, having less to look forward and less to lose definitely affects the risks you take and the precautions you don't. By analogy, think of two high school students, one of whom is very likely to go to college on scholarship, while another will, if he graduates at all, take a factory job upon graduation. Obviously the former is less likely to engage in crime, underage drinking, etc, so as not to risk losing his future. The latter doesn't have much to lose [perhaps he doesn't get the factory job, but he can still work at Walmart], so he might engage in such behaviors.

[Jack]

Haris, thanks, and while I'd buy a part of your explanation I'm still a bit disgusted with an academic advancing the "life is cheap" in poor countries mythology. I spent a year in Korea when income was $350/year and that bought barely rice for most. The manner in which they clung to life and raising their families under extreme duress was, well, humbling to this lower middle class kid.

The risks they "willingly took" were pushed by extreme poverty ie. working in unsafe factories and building modern high rise buildings working barefoot on bamboo "scaffolding" or driving cabs in miserable traffic 16 hours a day.

I guess the part I'd buy is that when life is that brutal a bit of pleasure stands out more, regardless of risk. I've seen that effect in "rich" Alaskan pipeliners or fishermen who had a lot of money but tried to cram too much "living" into their very short breaks.

Your college/non-college example seems more a result of dysfunctional families where the planning and delayed gratification taken for granted in middle class just doesn't exist. I don't know much about African culture but imagine the grinding poverty and hopelessness creates a lot of what we'd call dysfunctional families and a sense of fatalism.

The South Koreans, I think, achieved their economic miracle because neither Japanese occupation nor having their country divided and flattened destroyed their earlier culture and discipline.

I'd agree with Randall and others here that even w/o the scourge of AIDS Africa would be a tough problem to solve.

[Matt]

Circumcision is clearly not the solution to AIDS in Africa--it is barbaric and costly. Historically it had been used (by the Victorians) as a procedure to control male sexual behavior of all sorts: masturbation, bed wetting, syphilis. Still, it is surprising to me that it comes up as a solution to problems of health care sexual education. There are many books on the subject, one most recently published by the U of Chicago Press by Robert Darby titled "A Surgical Temptation."

Give a man a condom and show him how to use is. Don't cut off his foreskin.

Clearly, from an economic perspective, if the funds used to circumcise African men (roughly $200 per person) were reallocated toward an education campaign for both men and women, the African AIDS epidemic would be reduced significantly.

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