Saving the next generation: a call to action

In his Foreword to the book, Alan Whiteside writes that the challenge of HIV/AIDS facing South Africa is nowhere more important than in regard to "children and the next generation." Chillingly, Whiteside states that "South Africa has experienced one lost generation, we cannot afford another." "This book," however, states Whiteside hopefully, "goes a long way towards addressing these (AIDS) issues. I commend it to you and urge you to read it with the care and attention it deserves." In fact, Whiteside is saying, a whole generation is in need of saving now. Thus Impacts and interventions is intended as a call to action to initiate the 'care and attention' that the endangered generation needs.

The editors of Impacts and interventions clearly had ample justification for putting together the book. "Currently," Alan Whiteside states in his Foreword, "there are an estimated 300 000 AIDS orphans in South Africa as a result of the HIV/AIDS epidemic. By 2015 there will be almost 2 million AIDS orphans, an increase of over 600 percent. This is clearly a catastrophe of considerable magnitude." Even so, wonders Whiteside, despite us having ample warning of what is going to happen, "one has to ask why is there the lack of planning and of response? Until very recently no one, from international agencies through to local departments of welfare in the national and provincial government, had begun to grapple with the magnitude of the problem, the resources required to respond to it, and the mechanisms with which to do this."

Impacts and interventions is an effort to address this dearth of 'grappling with the magnitude of the problem.' The idea for the book was born when the authors (under the auspices of the Health Economics and HIV/AIDS Research Division, or HEARD) were invited to participate in a UNICEF seminar regarding 'Policies to sustain child welfare over the long term in countries affected by HIV/AIDS.' As part of the project HEARD commissioned a number of papers and these were then summarised for a conference in Florence in 2001. Subsequently HEARD obtained permission from UNICEF to have the papers edited and put into book form.

Straddled by an Introduction and a Conclusion, the book is divided into two sections. Part one, entitled 'Impacts,' contains chapters that analyse the impact of HIV/AIDS on children in a number of disciplines: epidemiology and demographics, health, welfare, education, and households. Part two focuses on 'interventions,' and contains chapters on 'Mitigating the impacts with a focus on government responses'; 'Treatment of HIV/AIDS and related illnesses'; and 'Preventing transmission of HIV.' The book is amply furnished with graphs and case studies, and all the chapters portray a well-researched account of the HIV/AIDS epidemic.

The extensive chapter on epidemiology and demographics is a highly constructive in-depth analysis of the HIV/AIDS epidemic in South Africa. The authors review at length the factors driving the epidemic in South Africa, mentioning, for instance, the high-prevalence of sexually transmitted diseases as an important bio-medical factor driving the epidemic. The authors investigate the usual culprits of poverty, gender inequality, migration patterns, and overcrowding to form an extensive understanding of the reasons contributing to the scale of the epidemic in South Africa. The authors also venture to analyse the demographic permutations engendered by the epidemic, providing feasible projections and models for interpreting the impact of HIV/AIDS. In a particularly insightful conclusion to the chapters the authors deduce "That South Africa has experienced such a rapid spread of the HIV/AIDS epidemic should not come as a surprise to anyone familiar with the conditions in the country prior to 1994. Apartheid left the country with all the ingredients to ensure that it would have the most explosive and extensive epidemic in the world. This, coupled with mismanagement of the epidemic at virtually every turn, has meant that the country is now facing a disaster which it barely comprehends."

In the following chapters on the impact of HIV/AIDS regarding child health, child welfare, education and households some startling information are brought to light regarding the plight of South Africa's children. In the chapter on child health, for instance, the author claims that "HIV-positive children spend an estimated 3.4 times longer in hospital and require multiple admissions…in areas of the country with very high rates of infection, up to 75 per cent of beds in the children's wards are occupied by children with AIDS-related conditions." In the chapter on the influence of HIV/AIDS on child welfare the author makes the startling claim that "Of the 17 million children in South Africa, about 12 million are classified as living in poverty."

"HIV/AIDS," the author states in the chapter on HIV/AIDS and education, "is the wild card that entirely confounds the rational business of education planning and management." The author investigates the impacts of HIV/AIDS on education and children in South Africa, probing such issues as declining Grade 1 enrolment in KwaZulu Natal and the high rate of loss of educators and managers through HIV/AIDS. Interestingly, the author mentions that "there is evidence that educators…are more HIV prevalent than the general population they serve, possibly for reasons of comparatively high income, social status and mobility, and positions of power over large numbers of learners."

In part two of the book the attempts at interventions in the HIV/AIDS epidemic are investigated, with reference to the role of the government, treatment programmes and prevention initiatives. In the chapter probing the role of the government the author discusses at length the National Plan for Children Infected and Affected by HIV/AIDS (IP) that was developed early in 2000, and places it into the context of the HIV/AIDS/STD Strategic Plan for 2000-2005 (HIVSP). The chapter also highlights the expenditure and budget issues in the government's response to HIV/AIDS and children, and investigates the service delivery problems experienced by the government sector in responding to the HIV/AIDS epidemic. The chapters on treatment and prevention responses investigate the nature of the intervention programmes piloted in South Africa in the 1990s and the current decade, and delineate on the various intervention programmes and media campaigns launched over the years.

In the conclusion to the book the editors deduce that "the outlook is gloomy, but there are steps which can be, and in some cases already are being, taken to mitigate these impacts. Participation is essential if responses are to be appropriate and implementable. Children, non-governmental organisations (NGOs), community-based organisations (CBOs) and all levels of government need to be involved in the development, implementation and monitoring of interventions."

Significantly, the book's well-researched portrayal of the HIV/AIDS epidemic is reinforced by the editors' attempt not to see the epidemic in isolation. Where innumerable authors have faltered in seeing HIV/AIDS as an isolated event, and not as part and parcel of South Africa's peculiar social, historical, and cultural composition, the editors of Impacts and interventions conclude that "serious consideration needs also to be given to the underlying problems in society, which have lead to these problems and in some ways the impacts." "Why, the editors ask, "are so many adults and children living in poverty? Why are the health, welfare and education systems already so strained? Why has the socio-economic and political environment allowed, and at times promoted, the spread of HIV? Why does macro-economic policy constrain public spending in the midst of a disaster?"

The editors close the book with a call to action: "The time for action to reverse these impacts more effectively is now." In effect, South Africa's next generation is in need of saving, and the time for it is now. In this rescue attempt Impacts and interventions is a commendable study.