6. The Impact on Household Livelihood Strategies

As emphasised above, various research initiatives have shown that HIV/AIDS first affects the welfare of households through illness and death of family members, which in turn leads to the diversion of resources from savings and investments into care (Cohen, 1993; HSRC, 2001a; Rugalema, 1999a). The HSRC has argued that it is expected that the premature death of large numbers of the adult population, typically at ages when they have already started families and become economically productive, can have a radical effect on virtually every aspect of social and economic life (2001a: 13). This is clearly indicated by an increase in the number of dependents relying on smaller numbers of productive household members and increasing numbers of children left behind to be raised by grandparents or as child-headed households.

According to LoveLife (2000), once a household member develops AIDS, increased medical and other costs, such as transport to and from health services, occur simultaneously with reduced capacity to work, creating a double economic burden. Cohen (1997) and Ayieko (1998) have undertaken case studies showing that households with an AIDS sufferer frequently seek to keep up with medical costs by selling livestock and other assets including land. Members who would otherwise be able to earn or perform household and family maintenance may then be spending their time caring for the person with AIDS. An example was cited in a recent study where a son with a sick mother in Zambia reported that he spent more time looking for money to make ends meet by working in the field and doing casual jobs, and in addition having to contribute an average of three hours a day towards caring for his mother and staying up part of the night attending to her needs (Balyamujura et al, 2000: 21).

This emphasises an impact of HIV/AIDS illness and death, which often results in the re-allocation of livelihood tasks amongst household members. Rugalema (1999a) reports that intensive use of child labour increases as a major strategy typically used by the afflicted household during care provision. Children may be taken out of school to fill labour and income gaps created when productive adults become ill or are caring for terminally ill households members or are deceased. Drawing from another study in Tanzania, Rugalema confirms that the illness affects time allocation, puts pressure on children to work, divert household cash and the disposal of household productive assets (1999b). HIV/AIDS is therefore an impoverishing process that leads to other problems such as malnutrition, inaccessibility to health care, increased child mortality and hence intergenerational poverty.

It is important to recognise that the impact of HIV/AIDS on rural households is not equal: the poorer ones, especially those with small land holdings are much less able to cope with the effects of HIV/AIDS than wealthier households who can hire casual labour and are better able to absorb shocks. Du Guerney has raised the question as to who benefits from the sales of assets by farm-households attempting to cope with the long drawn-out effects of HIV/AIDS (2001a: 9). In his view, the number of occurrences evident could lead to significant changes in the socio-economic structures of villages, redistribution of wealth and of land. HIV/AIDS infection ultimately stretches the resources of an extended family beyond its limits as both material and non-material resources are rapidly consumed in caring for the infected.

Baier (1997) and Cohen (1998) have drawn attention to the manner in which HIV/AIDS can cause affected households to become socially excluded, thus diminishing their ability to cope with further crises. Similarly, extended family networks sometimes collapse, not least due to pressure of having to support orphaned children (Halkett quoted in Aliber, 2001). Moreover, it has been argued that in KwaZulu-Natal, South Africa, HIV/AIDS has forced a change in household composition, severely weakening and often breaking the young adult nexus between generations (Marcus, 2000: 19). This, in turn, exacerbates an already existing social crisis of care, which worsens as the epidemic progresses. It is a social context that is unlikely to withstand the weight of need that HIV/AIDS related deaths generate and many, especially children and the aged, face economic and social destitution (Marcus, 2000: 19).

It is increasingly clear that as a result of HIV/AIDS causing significant increases in morbidity and mortality in prime-age adults, increasing negative social, economic and developmental impacts will occur. As clearly indicated, the economic impact at the household level will be decreased income, increased health-care costs, decreased productivity capacity and changing expenditure patterns. Major survival strategies developed in response to the epidemic may include the altering household composition the withdrawal of savings and the sale of assets, the receipt of assistance from other households. Following death the impact breaks out of the household and into the community in the form of increasing number of dependents such as orphans.

6.1 Coping Strategies - or simply surviving?

In the face of the extreme impact of HIV/AIDS, Balyamujura et al refer to three categories identified by UNAIDS in which strategies to cope with the epidemic can be divided (2000). These strategies have been elaborated in table four below. UNAIDS suggest that individuals and households undergo processes of experimentation and adaptation when adult illness and death impacts whilst an attempt is made to cope with immediate and long-term demographic changes (1999). Several factors will determine a household’s ability to cope including access to resources, household size and composition, access to resources of the extended family, and the ability of the community to provide support (UNAIDS, 1999). The interaction of these factors will determine the severity of the impact of HIV/AIDS on the household.

TABLE FOUR: Household Coping Strategies

Source: UNAIDS (1999)

Rugalema (1999a) has, however, challenged the usefulness of the concept of “coping strategies” put forward by UNAIDS and others (see Topouzis, 1999). The central point of this argument is that the concept is of limited value in explaining the household experience in the context of HIV/AIDS and may divert policy-makers from the enormity of the crisis. Rugalema agrees that AIDS-induced morbidity and mortality has an immense impact on rural households^[6] but questions whether the observed effects should be defined as “coping strategies” (1999a: 4). He argues that any meaningful analysis of coping behaviour must include the real and full costs of coping.

Rugalema posits several reasons why the concept is of limited use and explores alternative ways of conceptualising the impact of HIV/AIDS in more detail. Firstly Rugalema defines the concept as being essentially concerned with the analysis of success rather than failure of the household as it implies that the household is managing or persevering. This ignores evidence that households often dissolve completely with survivors joining other households. This runs contrary to a concept of strategy intended to avert the breakdown of the household unit.

Secondly, he argues that households do not act in accordance with a previously formulated plan or strategy but react to the immediacy of need, disposing of their assets when no alternatives present themselves. Decisions are not based on the importance or usefulness of the asset to the household as saving lives is deemed more important than preserving assets. Rugalema argues that more evidence is emerging that even land, the “most important agrarian asset”, may not be spared in the quest to ‘cope’ with illness (1999a: 11). Indeed, a recent study on the impact of HIV/AIDS on female microfinance clients in Kenya and Uganda, found that there was a clear sequence of “asset liquidation” among AIDS caregivers in order to cope with the economic impact - first liquidating savings, then business income, then household assets, then productive assets and, finally, disposing of land (Donahue et al, 2000). This last resort of disposing of land has profound consequences for people losing their economic base. Walker asserts that such people are likely to be those with fewest options and those who are most vulnerable (2002: 8).

Thirdly, Rugalema indicates that coping strategies tend to be defined as short-term responses to entitlement failure giving the impression that it involves few additional costs thereby obscuring the true cost of coping. In Tanzania, Rugalema found that short and long-term costs included curtailing the number and quality of meals that a household could afford which resulted in poor nutrition with obvious implications for health. Another household option was the withdrawal of children, mostly girls, from school in order to utilise their labour and save money, which, amongst other things, had ramifications for future literacy levels and the child’s participation in the modern economy. The positive gloss accorded to coping invariably ignored long-term costs that fundamentally jeopardise recovery of a household let alone sustainability.

In summary, Rugalema argues that reference to coping strategies may make sense in circumstances of drought or famine but not for the impact of HIV/AIDS, which not only changes communities and demographic patterns but also agro-ecological landscapes with long-term implications for recovery. The fact that AIDS kills the strong people and leaves behind the weak undermines the capacity of households and communities, especially in the long-term. It is therefore important to further differentiate the household according into their various possible members with an emphasis on the power relations between people forced to respond to the compounding impact of HIV/AIDS on their livelihood strategies.

6.2 Women and HIV/AIDS

There are a number of interlocking reasons why women are more vulnerable than men to HIV/AIDS, which include female physiology, women’s lack of power to negotiate sexual relationships with male partners, especially in marriage, and the gendered nature of poverty, with poor women particularly vulnerable (Walker, 2002: 7). Inequities in gender run parallel to inequities in income and assets. Thus women are vulnerable not only to HIV/AIDS infection but also to the economic impact of HIV/AIDS. This is often a result of the gendered power relations evident in rural households (Waterhouse and Vifjhuizen, 2001)^[7], which can leave women prone to the infection of HIV. With increasing economic insecurity women become vulnerable to sexual harassment and exploitation at and beyond the workplace, and to trading in sexual activities to secure income for household needs (Loewenson and Whiteside, 1997).

As a result, women have experienced the greatest losses and burdens associated with economic and political crises and shocks (Collins and Rau, 2001: 19) with particularly severe impact from HIV/AIDS. The epidemic exacerbates social, economic and cultural inequalities (economic need, lack of employment opportunities, poor access to education, health and information), which define women’s status in society (IFAD, 2001: 10). Collins and Rau have considered a number of the linkages between gender inequalities and HIV/AIDS (2001: 21):

• Breakdown of household regimes and attendant forms of security: Decades of changes in economic activity and gender relations have placed many women in increasingly difficult situations (Rugalema, 1994). HIV/AIDS has accelerated the process and made “normal” sexual relations very risky. Women whose husbands have migrated for work are afraid of the return of the men knowing that they may be HIV-infected. Although poorly documented, the range and depth of women’s responsibilities have increased during the era of HIV/AIDS. More active care giving for sick and dying relatives have been added to the existing workload. Children have been withdrawn from school, usually girl-children first, to save both on costs and to add to labour in the household. Thus HIV/AIDS is facilitating a further and fairly rapid differentiation along gender lines.

• Loss of livelihood: Whether women receive remittances from men working away from home, are given “allowances”, or earn income themselves, HIV/AIDS has made the availability of cash more problematic.

• Loss of assets: Although poorly documented, fairly substantial investments in medical care occur among many households affected by HIV/AIDS. These costs may be met by disinvestments in assets. Household food security is often affected in negative ways. Furthermore, in many parts of Africa, women lose all or most household assets after the death of a husband.

• Survival sex: Low incomes, disinvestments, constrained cash flow - all place economic pressures on women. Anecdotal evidence and some studies indicate that these pressures push a number of women into situations where sex is coerced in exchange for small cash or in-kind payments (ICRW, 1996: 6-7).

Women frequently carrying a double burden of generating income outside the home and for care giving as well as maintaining family land (Loewenson and Whiteside, 1997). In this regard, women are responsible for caring for sick members of the household, for childcare, as well as being heavily involved in generating money and supplying food for their households through agricultural production. Further, the burden of caring for people living with HIV/AIDS and for orphans falls largely on women. Thus, it has been argued that the illness and death of a women has a “particularly dramatic impact on the family” in that it threatens household food security, especially when households depend primarily on women’s labour for food production, animal tendering, crop planting and harvesting (IFAD, 2001: 11).

In rural areas, women tend to be even more disadvantaged due to reduced access to productive resources and support services. Indeed, the World Bank has suggested that “low income, income inequality, and low status of women are all fairly highly associated with high levels of HIV infection” (Ainsworth cited in IFAD, 2001: 11). UNAIDS has also reported that some traditional mechanisms to ensure women’s access to land in case of widowhood contributes to the spread of the HIV infection (2000 cited in HSRC, 2001a: 14). Baier has shown that women who are widowed due to HIV/AIDS sometimes lose rights to land, adding to an already precarious situation (1997). In some contexts, if a widow does not marry her husband’s brother she loses access to her husband’s property (HSRC, 2001a; IFAD, 2001: 10). The issue of AIDS and inheritance is therefore particularly important when discussing the impact of HIV/AIDS on women. Many customary tenure systems provide little independent security of tenure to women on the death of their husband, with land often falling back to the husband’s lineage. While this may, traditionally, not have posed problems, it may create serious hardship and dislocation in the many cases of AIDS-related deaths.

6.3 Children and HIV/AIDS

HIV/AIDS impacts on children in two major ways: as a disease that kills their parents (and/or other adult guardians) leaving them as orphans^[8], and as a disease that infects them as well. In 2000, 90 percent of the 11 million orphans left by the global HIV/AIDS epidemic were children living in Sub-Saharan Africa, even though only a tenth of the world’s population lives in the region (Fourie and Schonteich, 2001: 38). By 2010 the Southern African region is expected to have 5.5 million maternal or double orphans, approximately 16 percent of all children under the age of 15 years, of which 87 percent will be orphaned because of the HIV/AIDS epidemic (USAID, 2000).

Orphans are by tradition absorbed into the extended family. However, the impact of HIV/AIDS on the extended family is more acute than in any way experienced before, which has resulted in the system of absorbing orphans breaking down where it existed in the past (Foster et al, 1998). The United Nations Children Fund (UNICEF) has concluded that Africa’s age-old social safety net for orphans, in the form of deep-rooted kinship systems and extended family networks, is unable to cope with the strain of HIV/AIDS and soaring numbers of orphans in the most affected countries (1999, cited in Schonteich, 2001). HIV/AIDS has accentuated the impact of urbanisation and labour migration, which have been destroying such extended family structures.

According to Fourie and Schonteich studies that have been conducted on the plight of orphans and their caretakers have shown that families that foster children in Kenya usually live below the poverty line, and that orphan households in Tanzania have more children, are larger, and have less favourable dependency ratios (2001). Research commissioned by the Nelson Mandela Children’s Fund found that South African AIDS orphans are being ostracised by their communities and exploited financially by relatives who had taken them in, primarily to receive a state grant (Thompson, 2001).

These problems are unlikely to be short-term phenomenon. The HIV/AIDS epidemic has transformed the issue of orphaning from a sporadic, short-term problem caused historically by war, famine or disease, into a long-term chronic problem that will extend at least through the first third of the twenty-first century (Schonteich, 2001: 2). This is because the increase in orphan rates lags behind HIV infection levels by about ten years, the time it takes the average person who contracts the virus to die from full-blown AIDS. HIV/AIDS is also decimating the next generation of caregivers with severe implications for the offspring of today’s generation of orphans, who will not have grandparents to care for them (Walker, 2002: 8).

6.4 The Elderly and HIV/AIDS

As clearly illustrated above, the HIV/AIDS epidemic has immense ramifications for the structure of households with prolonged emotional and financial responsibilities of child-raising for grandparents. Large numbers of orphans have been left in the care of their grandparents across Southern Africa. Research in South Africa has reported that by 2015, if nothing changes, nearly one in every three children aged 15 to 17 will have no mother (Pretoria News, 4 April 2002). Du Guerny has argued that the role of the elderly in rural development in the context of the HIV/AIDS epidemic has been neglected (2001). He has attempted to examine under what circumstances the elderly can play in rural areas of developing countries. Drawing on the UNGASS Declaration, du Guerney argues that the elderly can play a crucial role, not just in care giving, but in ensuring the food security of millions of affected rural farm-households (2001b).

The population projection with HIV/AIDS scenario by US Bureau of Census highlights changes in sex and age structure from the perspective of elderly at the national level, particularly for Botswana and South Africa, two of the worst affected countries. Du Guerney has argued that the population pyramids for these countries suggest that:

• In 20 years time a significant number of 60-69 year olds will be dead (HIV mortality peaks around 30-34 years for women and 40-44 years for men),

• The surviving younger elderly of 60 years or more will have a role as care and subsistence of older ones.

• Number of children will decline significantly over 20 years,

• Due to change in sex ratio for adults, female age group, middle age and young elderly will have a burden of care and housework and this will force changes in division of labour (2001b).

In Botswana more rapid ageing is seen in rural areas than in urban areas. This is also reflected in South Africa as a result of younger working age people migrating from rural communities and older people often returning (du Guerny, 2001b). In countries such as Kenya, infection rates tend to be higher in densely populated areas, which are the most productive agricultural areas. With this spread of HIV/AIDS, it can be concluded that there will be fewer young adults who will be able to carry out essential tasks. Therefore the elderly will increasingly be required to do such tasks. Du Guerney concludes that the elderly are a largely invisible resource in the context of HIV/AIDS, requiring assistance and empowerment in order to fulfill its indispensable potential in areas of crisis. Thus the rural elderly have a potential to play a pivotal role of holding together farm households, ensuring food security and survival of orphans.