I’m Erika Larson.
I want to get sick so the doctor will give me a grant, and my children will have healthy food. Even if I die, my children will be better taken care of.
These words were spoken by Zolile, one of over 4.8 million HIV-infected South Africans. Her story illustrates the perverse incentives of the South African disability grant program that offers $130 per month to those with a CD4 count of 200 or below. Because grants expire after six months, patients have stopped taking medicine to remain sick in order to receive the grant and feed their families. Selwyn Jehoma, Deputy Director-General of South Africa’s Social Security Department is investigating yet another possible problem the program has created. “There’s another area that we’ve investigated: we’re asking ourselves ‘Are people leaving children with family members for the provisions for a foster care grant. And why are they doing this? Given there is a lack of income and they can’t support their own children, and obviously one would like to look at support systems.” In a country where unemployment soars to nearly 40%, HIV patients are confronted with a desperate choice: a choice between personal health and the well-being of their family.
Decisions like those of Zolile suggest not only inadvertent problems with the welfare program, but consequences of South Africa’s poverty. Destitution increases vulnerability to HIV. Migrant laborers, sex workers, disempowered women, and low education have augmented the spread of the epidemic. In turn, HIV compounds impoverishment. Affected households earn only 50-60% of the income earned by non-affected families. Low incomes, further drained by medical bills and funerals, do not adequately finance nutritional food, thereby increasing the chances for opportunistic infections. South Africa’s dilemma demonstrates that the vicious cycle between poverty and HIV has yet to be broken.
Though solving the problem seems unfathomable, there are alternatives to the disability grant program. When asked about other options, Dr. Peter Hess, Professor of Economic Development at Davidson College, drew from the success of Mexico’s educational conditional cash transfer program. For South Africa, a program would mobilize community health workers to test patients’ CD4 counts before and after medication, measuring their regime adherence and rewarding them for continuing drug therapy. Conditional cash transfers not only lighten the heavy bureaucracy, but also provide a space for positive incentives and community involvement, both essential components to sustainable development.
These South African songs are reminders not only of a profound culture, but also resilient religious and civil societies. Like Brazil, South Africa can draw on both churches and NGOs to create a comprehensive approach, fusing both top-down epidemiology and bottom-up development.
Though President Mbeki’s denial of HIV as the cause of AIDS has created an unredeemable lag in tackling the HIV issue, South Africa can find hope in policies that address HIV, poverty, and malnutrition. By engaging the expansive, young population through education and open dialogue, South Africa can harness one of its most important assets, its people.
Though it may be easy to criticize South Africa, we should ultimately examine our own choices. Have we, as an international community, failed to recognize the link between HIV and poverty? The moral imperative to address AIDS lies beyond science—it can be found in stories like that of Zolile, narratives that are reminders of what it means to be a part of global community.