AIDS in Namibia

Soc. Sci. Med. Vol.41, No. 2. pp. 277-284, 1995

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AIDS IN NAMIBIA ROSS A. SLOTTEN Department of Family Medicine, St Joseph Hospital, Chicago IL 60657, U.S.A. and School of Public Health University of Illinois at Chicago, Chicago IL 60680, U.S.A. Abstract--The purpose of this article is to examine the AIDS epidemic in Namibia, a country for which little data currently exists. An examination of published and unpublished literature about the historical, socioeconomicand health factors as well as an analysis of updated data from other sub Saharan countries presented at the IXth International Conference on AIDS in Berlinmay shed light on the pandemic as it relates to Namibia. Despite inadequate data, it is clear that the AIDS epidemic has already reached Namibia, though the country has not been afflicted as ,severely as some of its neighbors. Because of 75 years of apartheid, the new government is faced with a formidable array of problems, both in health care and in the economic domain. The strategieslacingadopted to confront the AIDS epidemicwill take years to evolve, a period of time the nation can ill-afford if it is to wrest control over a virus that is relentlesslyspreading into susceptible populations. Key words--AIDS, Namibia, Africa

INTRODUCTION Since the first reports in 1981, AIDS has been spreading inexorably across the African continent from its epicenter in the central regions. Today, no African nation remains untouched. Those that have not been severely affected are not necessarily less vulnerable, only less affected. The purpose of this article is to focus on a country in the early stages of the AIDS epidemic. Namibia, formerly Southwest Africa, is such a country. By examining the historical, socioeconomic and political setting, as well as the health conditions of the people, it is possible to demonstrate what makes Namibia especially vulnerable to the AIDS virus. An understanding of these factors may provide insight into developing strategies for arresting the progression of this disease before it reaches levels comparable with those in neighboring countries.

GEOGRAPHY/DEMOGRAPHY Namibia is located in the southern part of the African continent. It is bounded on the south by the Republic of South Africa, on the east by Botswana, on the west by the Atlantic Ocean, and on the north by Angola and Zambia. The current population is approx. 1.5 million. There are 11 ethnic groups, each with its own language. Owambo is the most commonly spoken language [l], but English is now the national language, having replaced Afrikaans. Eight-eight per cent of the population is black, 5% white, the remainder mostly "Coloureds" [2]. Sixty per cent of the population lives in three northern districts: Caprivi; Kavango; and Owambo. Population density is very low compared with most sub Saharan nations, at 2.06 people per square kilometer [3]. Windhoek, the

capital, in the central region of the country, is the largest city, with 150,000 people.

HISTORICALBACKGROUND The history of Namibia has been characterized by the displacement and migration of indigenous peoples. The first known inhabitants were the Bushmen, who populated most of southern Africa I0,000 to 25,000 years ago. Over the last several hundred years various tribes, moving in from the north, put pressure on these aboriginal peoples, driving them into more inhospitable territories such as the Namib and Kalahari deserts [4]. The Portuguese were the first Europeans to set foot on Namibian soil in 1484, but the Germans had the most profound impact. In 1884, Namibia formally became a German colony and was known as German South West Africa. During the time of annexation, the Herero and Nama peoples were the largest tribes, inhabiting the most desirable land, which the Germans gradually expropriated between 1893 and 1903. This expropriation led to many battles, culminating in the intentional genocide of 60% of the population [3, 5, 7]. To this day, the Hereros and Namas have not recovered their original numerical strength. By 1907, the Germans had consolidated their power, instituting a system of apartheid. Initially the territory was divided into two sections, the most arable portion being allotted to whites. In the north and northeastern regions, reserves were created, nominally controlled by traditional rulers. Laborers were recruited from these reserves to work on farms and in mines. Pass laws were implemented to maintain segregation. After World War I, Germany lost its African colonies. The League of Nations mandated the territory of South

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West Africa to Great Britain, which in turn entrusted the land to South Africa [3, 7]. The League dictated that South Africa "promote to the utmost the material and moral well-being and social programs of the inhabitants of the territory" [7]. Instead, South Africa ruled Namibia as it did its own country, consolidating the powers of the white minority and exploiting the majority for the benefit of the few. South Africa ruled Namibia formally between 1920 and 1966. In 1964, the South African government created 11 'self-governing' homelands, establishing separate legislative assemblies and executive councils. Except for the government of the white population, these assemblies and councils were unable to generate significant amounts of revenue with which to govern. The firmly entrenched labor system separated families for long periods of time, because women were not permitted to accompany their husbands into white areas. Those blacks who lived in towns were forced to live in segregated townships [3, 6, 7]. In response to this political situation, the South West African People's Organization, or SWAPO, was founded in 1960 [7]. Although there had been a long history of resistance to the colonial administrations, SWAPO was the most organized and had the greatest support among the black population. In 1966, the United Nations finally terminated South Africa's mandate, but South Africa continued to rule illegally [3, 6, 7]. Over the next 23 years, SWAPO was engaged in a low-intensity guerilla war with the government of South Africa. SWAPO leaders were forced to operate outside their country. At first, its military arm was headquartered in Zambia, from which incursions were made into the Caprivi strip. Operations were moved to Angola, in 1972, when the Portuguese dictatorship collapsed and the new administration suddenly divested itself of its colonies. Cuba poured in thousands of troops into Angola in support of the communist-inspired government [3, 6, 7]. The South African army utilized Bushmen as scouts, because of their superb tracking skills and their willingness to fight against people toward whom they harbored a long historical resentment [8]. As a result, the border of Angola and Namibia became a battleground between South African troops, the SWAPO guerrillas and the Angolan army. This battleground was disruptive to the local people, who were dislocated and often the victims of violence by the warring parties [3, 6, 7]. The war and the deteriorating economic condition of the homelands led to massive urban migration throughout the 1970's and 1980's. These tremendous movements of peoples were exacerbated by drought, the worst of the century. Shanty towns sprang up around the major cities. A severe housing shortage forced many people to inhabit the same cramped quarters. When South Africa finally agreed to cede power, in 1989, the country was further burdened with the repatriation of nearly 41,000 exiles from all over the world [3, 6, 7]. On 21 March 1990, Namibia

became a sovereign state. Democratic elections took place that same year and Sam Nujoma, the leader of SWAPO, became its first president.

CONSEQUENCES OF SOCIALUPHEAVAL A strong association between the occurrence of protracted wars and HIV-transmission has been noted [9]. Protracted wars have been occurring throughout sub Saharan Africa for decades. Almost all of the nations of southern Africa have been or are currently embroiled in such wars. These wars have devastated rural economies, displacing massive numbers of people, who are subjected to physical and psychological violence. The translocation of peoples provides opportunities for HIV to spread into less affected populations. By inference, Namibia is as vulnerable to the spread of AIDS as nations elsewhere in Africa, because of the social upheaval of the last decade. This volatile situation has been compounded by the high rate of unemployment, estimated at 40% [3]. The conditions of the Bushmen have become more challenging since independence. These people have lost their traditional way of life but are no longer supported by the South African army. According to one source, they are fearful of retribution from their adversaries who now govern the country. Their future is uncertain [8]. There are some interesting parallels to the situation in Namibia in another African country. At the IXth International AIDS conference in Berlin, Basset described the Zimbabwean experience and that society's vulnerability to HIV infection [10]. Zimbabwe, which became independent in 1980 after a protracted war, is suffering from the consequences of a prolonged economic crisis, which has resulted in an increase in the cost of living and unemployment. The conditions for this crisis were created long ago by the prior colonial administration, which left people landless, forcing them to migrate for jobs. Women and children generally remained in the crowded, impoverished rural areas. Men, separated from their families, often acquired 'town wives,' whom they supported through their work in addition to supporting their wives back home. With the current economic downturn, this system has eroded. Multipartnering has become common. Men frequently make no commitments and no longer have any long-term financial obligations to their sexual partners. Single women, lured to the cities, having been driven from home by the drought in the 1980's, often become 'low-volume' sex workers, adopting prostitution as a strategy for survival. Lush describes a similar set of circumstances in his eye-witness account of events leading up to Namibian independence [6]. Economic hardship and profound political changes, then, coupled with the injustices of a patriarchal society, the resultant lack of empowerment of women and attitudes about sex have become powerful determi-

AIDS in Namibia nants of HIV transmission in this part of the world [10]. The people of Namibia are vulnerable to HIV infection for o t h e r r e a s o n s . Although the World Bank h a s classified Namibia with "middle income" countries [3, 1l], this categorization is deceptive. The white population enjoys a standard of living comparable to that of Europe and the United States, with high median incomes, a life expectancy of 69 years and low infant mortality rates, 21/1000 [7], but indicators for the black population as a whole demonstrate that black Namibia is similar to its neighbors in terms of life expectancy at birth, illiteracy rates, infant mortality rates, etc.

HEALTH CARE SYSTEM--BURDEN OF THE PAST

Namibia's health care system has contributed to the difficulties the country faces in terms of AIDS and other health care issues. From 1915 until 1990, health care delivery was modeled after South Africa's system. According to Gottschalk (after Savage) [12], the provision of health in South Africa and Namibia centered around four key features: a curative rather than a preventive approach; a system organized for white and urban needs; a weakly developed primary health care service; and the domination and control of medical care by the white minority. These features were firmly entrenched by the mid 1960's [3]. Hospital-based health care was excellent, directed towards a minority of the population, though in theory, people of all races could receive top-notch curative services. Windhoek State Hospital provided care comparable to that in Europe and the U.S. Regional and district hospitals were uniformly of high quality. Those who benefited, however, lived in urban areas or in rural areas with access to transportation. Those with treatable medical and surgical conditions also benefited. The system was not equitable because it could not reach 70% of the population, which was geographically and economically isolated. Little preventive health (:are was provided [3, 7]. For ex~,mple, some pediatric wards were filled with children suffering from the sequelae of measles because few children had been immunized [13]. Since independence, the situation has not changed substantially [3, 13], though various health and economic indicators remain deceptive. There is one physician per 5008 Namibians and 5.6 beds per 1000 people, well above the WHO recommendation of 2 beds per 1000 for sub Saharan Africa [3]. The government currently spends proportionately the same amount of its GDP on health care as Japan, 4.5% [3]. Yet most physicians are hospital based and live in Windhoek. Maldistribution is significant, with Windhoek and Oshakati Hospital (in the north) employing most of the doctors and 50% of the nurses [3]. The budget for tertiary services makes up 37% of total health spending, while community health services

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Table I. Morbidityand mortalityrates in Namibia[3, 13, 15, 16] 295/100,000cases of tuberculosis 281/100.000 cases of measles

473/100.000cases of malaria 1/3 ofchildrenstunted(32% rural.23% urban,42% in the northeast) 6% of childrenseverelymalnourished 12% low birth weight 58/1000infantmortalityrate (varies,up to 100/1000in someregions) 85/100,000 under-5mortalityrate 372/100,000maternalmortalityrate 311 reported AIDScases

only make up 43% [3]. In some regions, hospital beds are less than half occupied and others are more than 100% occupied. Health care outlays for whites have been almost twice as much as those for blacks in Owamboland, the only figure documented [13]. Despite the relatively large amount of money poured into the health sector, rates of disease are very high (see Table 1). Diarrheal and acute respiratory diseases cause significant morbidity and mortality, but exact numbers are not yet known [13]. According to the World Bank, there are essentially two reasons for the discrepancy between the health budget and health indicators [3]. Firstly, the system emphasizes curative health care, with benefits for the few at the expense and to the neglect of the majority. Secondly, the country is vast relative to its population, so delivery of services is expensive. The democratically elected government inherited a system which has serviced the white minority but has not addressed the needs of the rest of the population, which for the most part is impoverished, illiterate, poorly educated, undernourished, inadequately housed and lacking in running water and basic sanitation. Prior to independence, "there was virtually no meaningful national health policy and strategic plan for development of health services" [ 13]. Furthermore, the new government's efforts have been hampered by lack of data. Data that do exist have been limited and have tended to be segregated meticulously along ethnic lines. In fact, records of gender, age, income status, etc. were never collected systematically by the previous colonial administration [14]. Reliable statistics for a variety of diseases did not exist, though inferences could be made from what was available (see Table 1). A scan of the medical literature reveals only 6 articles pertaining to health problems in Namibia [4, 17-21]. These focus on particular groups of people or regions but do not address health conditions in the country as a whole. Even without accurate data, one trend is particularly alarming. Although only 24 STD cases were officially reported in 1989/90, a review of outpatient and hospital records in the south and central parts of the country revealed 15,487 people treated for STDs, a rate greater than 1000 cases per 100,000 [13]. The relationship between STDs and HIV has been well-documented and was powerfully reiterated at the 1993 International Con/erence on A I D S in Berlin [22].

280

Ross A. Slotten EPIDEMIOLOGY OF AIDS IN NAMIBIA

Saharan Africa is only 10-30% complete [9]. Very few seroprevalence studies have been conducted in Namibia, or at least published. The only published account was in 1988 [17]. In this study, 708 sera were analyzed from East Caprivi Strip. By both ELISA and Western Blot, 2.6% were positive. These same data were cited by the U.S. Bureau of the Census to estimate seroprevalence rates in 'low risk' populations in Namibia [24]. From these scanty data one can only conclude that HIV infection exists in Namibia, but at an unknown frequency. Though the numbers are relatively small, the potential problem in Namibia is enormous. Since the social, economic and medical systems in Namibia resemble those of South Africa, with whom it was intimately involved for 75 years, a stochastic model for South Africa might apply to Namibia. By this model, it is projected that 29% of the adult black population could be infected by the year 2000, a staggering rate [32].

Although, as Jonathan Mann has said, "the HIV pandemic is composed of thousands of smaller epidemics differing in time, place, scope and populations affected" [23], it is difficult to separate Namibia's epidemic from the epidemics in neighboring countries. The relatively fluid borders between Angola, Zambia and Namibia, the long-term relationship with South Africa, and a socioeconomic setting similar to Zimbabwe's, suggest some sort of interface and overlap. The epidemic in Africa has continued its relentless spread outward from its epicenter in East and Central Africa [22]. Each year countries with previously low prevalence rates report increasing incidence of HIV infection. In those countries already severely affected, there is no sign of a plateau in incidence rates [22]. The Center for International Research of the U.S. Census Bureau, with support from the Africa Bureau and the Office of Health AIDS Division, Agency for International Development (AID), has compiled seroprevalence NATURAL HISTORY OF AIDS IN NAMIBIA rates from existing data for many countries around the When did AIDS reach Namibia? The first reports of world, including southern Africa [24]. The quality of AIDS in South Africa came in 1981, but from white data varies from country to country because surveys male homosexuals [18]. As late as 1985, it was of HIV seroprevalence have not been based on still possible to state that AIDS was not endemic in national samples and may be biased by sample size, South Africa and Namibia [18]. At that time, in tiny non-representativeness, geography and testing [24]. In non-representative samples from Johannesburg and a recent study from Botswana, among adults in major the Caprivi Strip, seroprevalence was 0. Yet in 1986, urban areas, seroprevalence rates over 18% in the only one year later, four cases of full-blown AIDS were sexually active age groups have been recorded [25]. reported from Namibia [6, 31], which demonstrates Surveys conducted in several South African regions that the virus was present before 1985. As previously reveal a dramatic rise in seropositivity over the last mentioned, seroprevalence in East Caprivi by 1988 several years [26-28]. Data from Angola are poor was 2.6%, suggesting rapid penetration into that because of the ongoing civil war. Indirect evidence region. might be obtained from the prevalence of HIV To identify HIV positive individuals in Namibia, infection in Cuban soldiers who served in Angola ELISA testing is performed twice on sera, without during the war with South Africa. If the data are to be Western Blot confirmation [31]. Although ELISA tests believed, only 0.025% of Cubans who have lived have high sensitivity, their specificity is not as good, outside of Cuba (presumably including soldiers) were with a significant false positive rate when seroprevafound to be HIV-positive [29], but doubt has been cast lence is low [33]. Performing multiple assays on on that assessment [30]. reactive samples has been shown to improve specificity The importance of truck drivers as a source of HIV [34], but it is not clear if multiple assays are used in infection in Namibia has not been elucidated. Namibia Namibian laboratories. Unfortunately, the Western shares borders with countries having high prevalence Blot is too expensive to perform and is not done rates of AIDS and a map of Namibian customs and commonly [31]. In a report from the AIDS conference, immigration points shows possible commercial entry single ELISA testing is almost as sensitive as repeat sites, but does not prove a relationship. testing, but only in populations where seroprevalence The number of AIDS cases reported to WHO from is high [35]. Levels of HIV seropositivity have Namibia by 12 December 1992 was 311 [25]. This is a probably not reached those of many other sub Saharan cumulative number, with 189 cases having been countries, so reliance on a single ELISA test might be reported between 1979 and 1989 and 122 cases unwise at this time. thereafter. The last report submitted to WHO was The spectrum of AIDS-indicator diseases or on 20 March 1992. As of May 1993, approx. 4400 HIV-related problems in Namibia is unknown. cases of both HIV infection and AIDS had been Presumably tuberculosis is a significant problem, since documented [3 l]. its prevalence rate is high (see Table 1). One might As elsewhere in the world, the true number of HIV expect a rise in rates of streptococcal pneumonia if infections in Namibia is unknown but the number HIV seroprevalence increases. In Zimbabwe, S. reported is felt to be "the tip of the iceberg" [16]. It has pneumoniae is the most common cause of lobar been estimated that AIDS case reporting from sub pneumonia [36]. This potentially treatable bacterial

AIDS in Namibia infection has also been responsible for an unacceptably high mortality rate, 8%, in a study of adult community-acquired pneumonias associated with HIV in Nairobi [37]. Diagnostic procedures to identify opportunistic pathogens are not routinely performed because of cost, yet even if opportunistic infections could be diagnosed, drugs for treatment are too expensive and generally unavailable. Retrovir, a mainstay of therapy in the U.S. and Europe, is not frequently used [31]. Not every person suspected of infection is tested for HIV in Namibia, once again cost being the primary factor, even though by Western standards, ELISA testing is inexpensive. Screening has been performed in an unlinked anonymous fashion [31]. This term, 'unlinked anonymous', is defined as a method for screening blood collected for other purposes, such as for syphilis screening, in such a way that identifying information is removed prior to that screening. If a result is positive, the donor can not be traced [38]. At what frequency and in what context unlinked anonymous testing is performed in Namibia was not clear. Interestingly, WHO reports that 100% of donated blood in Namibia is screened for HIV. Zimbabwe is the only other country on the continent with a similar blood donor surveillance record [3911.In what manner a seropositive donor is notified and how that person is counseled are also unclear. Although Namibia's surveillance procedures for blood donation meet high standards, the risk of HIV infection through transfusion is relatively insignificant because most Namibians do not receive treatment in hospitals [131]. When HIV-testing can not be performed and a patient is suspected of having AIDS, the WHO-Bangui clinical definition is used [31] (see Table 2 [40])As pointed out by de Kock et al. this definition is problematic because it can have a low sensitivity and specificity. In one example, the sensitivity was only 59% and specificity 90%; positive and negative predictive values were 74 and 81%, respectively 'E41]. Without serologic confirmation, cases are missed and even over-diagnosis is possible. For example, HIV-negative patients with tuberculosis may fulfill the clinical definition for AIDS [41]. Table 2. WHO clinicalcase definitionof AIDS in Africa AIDSin an adultis definedby the existenceof at leasttwo majorsigns associatedwithat leastoneminorsignin the absenceof knowncauses of immunosuppression Major signs

--Weight loss > 10% bodyweight --Chronicdiarrhea > 1 month --Prolongedfever > 1 month(intermittentor constant) Minor signs

--Persistentcough > 1 month ~eneralized pruriticdermatitis --Recurrent herpes zoster ~ropharyngeal candidiasis --Chronic progressiveand disseminatedherpes simplexinfection ~eneralized lymphadenopathy The presence of generalized Kaposi's sarcoma or cryptococcal meningitisare in themselvessufficientfor the diagnosisof AIDS

281 PRESENT AND FUTURE DIRECTIONS

Namibia's campaign against AIDS is tied closely to its approach to health care in general. As pointed out, Namibia has an excellent medical infrastructure, which is oriented towards curative rather than preventive health, a system more suited for countries in the developed world, less suited for the needs of the developing world. The inadequacy of the system was recognized long before independence. In fact, representatives from SWAPO attended the Alma Ata Conference on primary health care in 1978 and, in association with WHO, began formulating a health care policy as early as 1980 [7]. The U.N. study, completed in 1986, focused on the most pressing health issues. Interestingly, the control of STDs and AIDS was not listed as a priority, nor even mentioned in the analysis [7]. The Constitution reflects the concerns of the new country's founders regarding health care. In Article 95, section 'j', it mandates that "the state shall actively promote and maintain the welfare of the people by adopting, inter alia, policies aimed a t . . . consistent planning to raise and maintain an acceptable level of nutrition and standard of living of the Namibian people to improve public health" [42]. Although the methods are not delineated specifically, the intention is clear: to redress the injustices of a system which neglected the basic public health of the majority of its citizens. Early on, the planners have set out to alter the health care system radically, though gradually. Regulation, not abolition, has been the initial goal, while a national strategy is developed. This strategy's ultimate goal is to improve health care for all Namibian citizens, in consonance with WHO's goal of Health for All by the year 2000 [16]. However, the task is complicated by the tremendous social changes occurring in Namibia and must reflect the transforming needs of a population rapidly shifting from rural into urban areas. The yearly growth rates in urban and peri-urban regions is estimated at 7-11%, with approximately one-third of citizens living in cities in 1992 as compared with 25% a decade before [14]. Melbar describes Namibia as possessing the characteristics of a country in the initial phases of a demographic transition [14], a term used to describe changes accompanying the shift from a traditional to a 'modern," economically developed society [43]. In theory, such changes should eventually lead to reductions in fertility rates, infant and child mortality, etc., objectives towards which the current leaders clearly aspire. In the World Bank's overall assessment of Namibia, it was noted that a substantial increase in health care spending is unnecessary if the system is reoriented to preventive health care. This is fortunate in light of the troubled economic situation. Namibia has taken some initial auspicious steps. The cumbersome bureaucracy inherited from the colonial administration has been streamlined by the elimination of regional authorities

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Ross A. Slotten Table 3. Strategiesimplementedby Ministryof Health and SocialServices[13] I. Expandedprogramon immunization(EPI). adoptionof WHO/EPIguidelines 2. Controlof diarrheal diseases(CDD) program 3. Establishmentof oral rehydrationtherapy(ORT)corner in clinics 4. Cholerapreparednessguidelines 5. Controlof acute respiratoryillnessesprogram--tobe implementedin 1993 6. Maternal/childhealth care/familyplanning 7. Completionof micronutrientsurvey 8. Essentialdrug list compiled,but not yet approved 9. Developmentof nationalguidelinesfor AIDS preventionand control 10. Establishmentof health informationsystem

and the creation of a central administrating body, the Ministry of Health and Social Services (MOHSS). " . . . MOHSS has moved in a forceful, organized and coherent fashion in restructuring the health care system towards primary health care . . . " [3]. A directorate for primary health care has been developed and a national PHC committee established to formulate new policies. Some of the strategies have already been implemented (see Table 3). The importance of the programs noted in Table 3 can not be overemphasized. In a report from the World Bank on 6 July 1993, life expectancy at birth has soared and the number of children who die before their fifth birthdays has dropped dramatically in developing countries which have instituted these basic public health measures [44]. The establishment of a health information system has been prioritized in Namibia because, as Minister Nickey Iyambo indicates, the MOHSS needs "denominators to calculate the rates and r a t i o s . . , to measure the improvements in health we are determined to achieve" [16]. These measurements will take time. A few initial surveys have been undertaken. Examples are a national household survey performed in conjunction with UNICEF in 1990, a situation analysis of children and mothers, a maternal/child health baseline health survey and an AIDS awareness survey [45] and a demographic and health survey, referred to in this paper. A population census was completed in 1991. A national household survey of larger scope is planned for the second half of 1993. Some improvements in health conditions have already occurred. In a national immunization survey conducted in 1990, only 21.6% of children sampled had been fully vaccinated with BCG, 3 OPVs, 3 DPTs and measles, as recommended by WHO [45]. By 1992, 57% of children between the ages of 12 and 23 months had been fully vaccinated, while 71.3% had been partially vaccinated by age 1 and only 5% had received no vaccinations [46]. Two-thirds of mothers had received one tetanus toxoid during pregnancy to prevent neonatal tetanus (though two are required in previously unimmunized women)J46]. Because of the previous apartheid administration and delayed recognition, Namibia has lost ground in its efforts to combat AIDS. In 1992, < 1% of women used condoms, regardless of age, marital status or educational level [46]. No data for condom use by men are available.

With assistance from WHO, Namibia implemented a short term plan to combat AIDS in February of 1990 [16, 31]. On 4 July 1990 President Sam Nujoma inaugurated the National AIDS Program in a speech to the nation. At the same time a theater group presented a well-attended play about AIDS to the public [31]. An extensive educational program was developed, including distribution of pamphlets, display of posters and presentations by the media. One ad carried by the Namibian Broadcasting Corporation on television was explicit in urging the use of condoms and emphasizing general vulnerability by showing a map of the country with people of all ethnic groups crowded within its boundaries [47]. The efficacy of these programs is hard to gauge. However, since a significant number of people are illiterate, or speak only one language, and access to television and radios is unknown [3], one wonders how informed the populace can be about the threat of AIDS. Also of note, an examination of the national telephone directory did not reveal an AIDS hotline number for concerned people to call [48]. The government has taken some novel approaches to educating its people about AIDS. Recognizing the particular vulnerability of women to AIDS, a workshop for women and AIDS was held in the town of Swakopmund. The president and his wife attended. Additionally, Namibia is one of nine sub Saharan African nations which have received money from the Global Programme on AIDS for development of a collaborative anti-AIDS effort by women's organizations and NGOs [39]. The government also gathered together 72 traditional healers who were educated about the reduction of HIV spread through the use of such techniques as scarification [49]. If black Namibians utilize traditional healers as frequently as South African blacks (up to 80% in one study [50]), involvement of this group is critical to the national AIDS control efforts. In December of 1991, Namibia developed its medium-term plan (MTP) for AIDS. These guidelines follow the recommendations of WHO and are in the process of enactment. Included are policies regarding testing and screening, care and management and support of those with HIV, use of condoms, infections control procedures, blood safety, etc. [51]. In February of 1992, a resource mobilization meeting was held to obtain financial support for the MTP from various national and international organizations.

AIDS in Namibia CONCLUSION The N a m i b i a n government has made great strides in its efforts to improve the health care of its populace. Namibia is in a unique position, politically and historically, to reorient its public health programs towards primary and preventive health care. Democratic elections have given the new administration a mandate for change. Already, the government has shown great ingenuity in confronting the AIDS epidemic by involving traditional healers and women in designing methods for AIDS prevention. Further empowerment of these groups can have a significant impact on the epidemic. Unfortunately, 75 years of apartheid have perpetuated a formidable array of health problems. Reorientation of the health care system is not enough to improve the health status, of Namibians. Without significant improvement in the economic domain, it will be difficult to redace morbidity and mortality rates and the vulnerability to AIDS. Recently hospital fees were raised, which caused a public outcry [52]. The raising of fees was justified by government officials as a method to encourage people to use clinics rather than the significantly more expensive hospitals [53]. But changing old habits is difficult. Furthermore, the gap between government expenditures and government income is high, 46%, which will require either large cutbacks or more taxes [54], not a positive trend for dealing with a problem as serious as AIDS. The worldwide effort against AIDS is flagging, one of the themes of the I X t h International Conference on A I D S . Dr Michael Merson, the director of W H O ' s Global Programme on AIDS, believes that the world must spend 10-20 times more than what it does to combat AIDS, 1.5-2.9 billion dollars annually by his estimation [22]. However, financial support appears to be declining [9]. Countries like Namibia are dependent upon the support of organizations like W H O and the NGOs. The success of their programs hinges on s ach support. The future regarding AIDS in Namibia is ominous. An observer of South Africa prophesizes that, in South Africa, " . . . AIDS will knock the bottom out of health budgets" [55]. There is no reason to expect the situation to be different in Namibia. Already, hospital beds in other sub Saharan countries are being occupied by patients with HIV-related problems. For example, at the University Teaching Hospital in Lusaka, Zambia, 40-60% of the beds are occupied by people with AIDS [39]. In Botswana, 42% of hospitalized patients with tuberculosis are HIV-positive, stressing the need for improving home therapy in order to decrease the hospital burden [56] and the nosocomial spread of this disease, which is more virulent in the HIV-infected individual. As Namibia formulate,; its national strategy for health care, struggling to guarantee health care and equal access for all, and seeks out funding from shriveling sources for the implementation of its AIDS guidelines, the HIV virus

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continues its relentless spread into susceptible populations. These strategies will take years to evolve, a period of time the country can ill-afford if it hopes to wrest some control over what is rapidly becoming one of the greatest worldwide public health crises of this century. Acknowledgements--Special thanks to Dr S. Boadu of

the National AIDS Campaign Program in Namibia and Ms Joy de Beyer of the World Bank, who provided helpful information and documents for this paper. I would also like to thank Dr Judith Levy for her advice and constructive criticism. REFERENCES

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