Gamula, Swaziland — The village of Gamula is about as far from the center of power as it is possible to be in this Kuwait-sized country of a million people. Hunger is everywhere, in the bloated bellies of children and the anxious exhaustion of adults.
Yet at a community-run care center near Swaziland's southeastern border, Roster Dlamini and two neighbors hold a fragile line against the collapse that threatens a nation battered by years of drought and the worst Aids epidemic in the world. Every day, in between trying to coax seedlings out of the cracked earth, the women cook for more than 100 orphans, dispensing the only nutrition and the only emotional support they are likely to get.
Swaziland's National Emergency Response Council on HIV/Aids (Nercha) estimates that 60,000 children have already lost parents, giving rise to a new socio-economic phenomenon - the child-headed household. There are at least 15,000 households without an adult and with children as young as eight caring for siblings.
Mrs. Dlamini says that the hours spent lighting the fires and cooking donated grains and legumes in the three-legged black pots, sheltered from the dry wind by a round fence of lashed branches, continues the traditional practice of caring for those who can't care for themselves. Surrounded by children who cling to her skirts, she somehow finds the energy to keep coming back, even though she herself has no means of support.
But with a national adult HIV prevalence rate nearing 40 percent - and nearly 50 percent among young women in some areas - traditions have withered. Famine and disease have eroded the African resilience that has always amazed visitors. There is no bounce-back from a crisis of this magnitude.
Only the fortified corn-soy blend supplied by the World Food Programme and the unpaid work of people like Mrs. Dlamini keep tens of thousands of Swazi children alive. And worse lies ahead.
Figures from Unicef, the United Nations children's fund, suggest that 50 people are dying daily, while 55 more are getting infected. By the end of the decade, an estimated 120,000 children will be orphaned - 12 percent of the entire population.
As illness continues to spread, the work of unpaid caregivers becomes increasingly untenable. In addition to tending a generation of children, women across the country are caring for the sick without the most rudimentary protection of gloves or disinfectants.
The glimmer of hope in Swaziland is that despite continuing stigma and denial, the scope of the emergency is being openly discussed and government has begun to act to confront it. Vocal organizations of people living with Aids have sprung up, media are beginning to report the crisis, an aggressive program to provide treatment with anti-retroviral drugs is being rolled out, and Nercha, despite some internal misgivings, has decided to press the case for paying people like Mrs. Dlamini for their work.
The misgivings stem from worries that a bad precedent is set by paying volunteers who are simply acting on Swazi values of caring for their neighbors. There are also doubts that international funders will support the plan. Nercha's national coordinator for care and support, Sibusiso Dlamini, fears that giving money to community volunteers will lead to abuses and corruption.
Stephen Lewis, UN Secretary-General Kofi Annan's Special Envoy for HIV/Aids in Africa, discussed the issue with Nercha staff during a recent visit to Swaziland. He told Dlamini that his concerns were understandable. But in a country where 66 percent of the people live on less than a dollar a day, the envoy said, failure to compensate the women who provide the care perpetuates the poverty and dependence that fuels much higher rates of HIV infection among women than among men.
Nercha's director, Dr. Derek Von Wissell, says Swaziland's application for the fourth round of grants from the Global Fund to Fight Aids, Tuberculosis and Malaria includes a request for a monthly salary of 200 lilangeni, about U.S.$30, for each of 10,000 workers - an annual total of about $3.5 million.
The plan has the backing of Swaziland's prime minister, Absalom Themba Dlamini. Interviewed in Washington, DC, where he came to advocate the extension of the African Growth and Opportunity Act that provides trade preferences for African exports, he said the move is in line with the government's campaign to mobilize local responses to HIV. We have a saying, he said, that "if you have trained one woman, you have trained the whole community." Similarly, if you provide a woman with sustenance, the whole community is supported.
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Health policy experts say that the fight against HIV demands integrated strategies that combine an array of interventions. Clearly, compensation is a big issue, and it goes beyond just the caregivers, says Dr. Helene Gayle, a member of the Global Fund board and Director of the Bill and Melinda Gates Foundation's HIV, TB and Reproductive Health program. "There is the general question of livelihood for people with HIV, many of whom suffer a continuing revenue deficit."
Gayle points out that the distribution of life-saving anti-retroviral medications, in isolation, doesn't solve that problem. "As drugs start arriving, and people who were too sick to work begin receiving treatment, they may become physically able to return to their jobs, but in some cases those jobs may not be waiting."
In this arena, as in others, the burdens fall most heavily on those least able to bear them - the poorest of the poor. Professionals like doctors, teachers and administrators are more likely to be able to return to equivalent positions than the majority of people who are unskilled workers. Therefore, Swaziland's proposal to pump income into destitute rural areas through compensation for caregivers is only a first step - but one with implications far beyond its borders.
