Interview with researcher Paul Harvey on humanitarian aid and HIV

Paul Harvey is a researcher with the Humanitarian Policy Group (HPG) of the UK-based Overseas Development Institute. He talked to Plusnews about some of the issues raised in his study for the HPG, "HIV/AIDS and Humanitarian Action", and the implications for humanitarian relief in Southern Africa. QUESTION: How do you target food aid - how do you reach people who are believed to be living with HIV/AIDS and are vulnerable? ANSWER: I think it comes back to needing to be clear about what you are trying to do. As you look at what has happened in Southern Africa in the last couple of years, there are different things that different agencies have tried to do. So, if you're providing food aid as part of a broad response to what's perceived as a crisis, say in 2002/3, that 12 million people are at risk of starvation, according to the vulnerability assessment committee, and a perceived need for food aid in response to that - now that's a big traditional food aid programme in response to a humanitarian crisis. There you are clearly wanting to target based on traditional indicators of vulnerability. The sense, then, in which HIV/AIDS is an issue, is the extent to which it is contributing to vulnerability, and the usefulness, or not, of the various proxy indicators that have been used as one mechanism for identifying vulnerability, along with all the other ways of identifying people who are poor and in need of assistance. Q: What are these proxy indicators that are traditionally used? A: Chronic illness, orphans - being an orphan or looking after orphans, recent death - those are the main ones. While it's fine to some extent, these indicators are one aspect of explaining whether people are vulnerable or not - people who have chronic illness in the household or are looking after orphans may be more likely to be vulnerable. But, equally, perfectly healthy people can be looking after orphans and have people ill, so there's a need to look at the other aspects of vulnerability, which aid agencies were doing with their targeting. But there is a risk - if you just focus on the proxy indicators, you miss other aspects of vulnerability. So that's AIDS and targeting in relation to a generalised crisis. But there is a separate question about if you are deliberately trying to target, specifically, people living with HIV/AIDS as part of a programme, where they are the specific target group - say, for instance, food as part of a home-based care programme - then the challenges are completely different, because you're not looking at broad proxy indicators for vulnerability, you're looking at specifically trying to identify people with HIV/AIDS in a situation where it's stigmatised [to be HIV-positive] ... There are very different targeting challenges, depending on what your programme is actually trying to do; whether it's a short-term response to food shortages within a district for whatever reason, or it's a long-term programme, in a sense, of welfare support to people, as another example. Q: How has HIV/AIDS changed traditional responses to vulnerable people? What you've got at the moment is this sort of - I hesitate to use the word 'transition' - but ... it's after the traditional humanitarian response. You have this slightly unclear situation in which things were started as an emergency response in 2002/03 and, depending on where you are in this enormously complicated picture, you've got six different countries at least, and different dynamics within all those countries as to where they are in terms of crisis. So you had these initial emergency responses, which are now continuing because there continues to be very real needs - but exactly what those are, is unclear. Is this an ongoing emergency response, or is it becoming, in a sense, a long-term welfare response? For aid agencies there are very difficult questions about exit strategies, particularly raised by HIV/AIDS, because you start providing food as part of your home-based care project - because of the perceived [crisis] in 2002/03 and the food shortages related to that - but the needs of the people on a home-based care programme don't necessarily go away with a better harvest, so it's very difficult to exit from that. But, on the other hand, it's also very difficult to get long-term funding for potentially decades, or however long it's needed. So you've got these aid agencies involved in these programmes because they need to be there, but an unclear transition into what these programmes are becoming, and a dialogue going on with the donors about whether there's going to be ... interest in continuing to fund these programmes in the long term. Q: Is there a question over the appropriateness of some of the assistance – food-for-work programmes when people are weak because of AIDS - and the types of food in the food baskets? Were agencies a bit unprepared? A: We, as the broad humanitarian system, were probably late about really focusing on the issue of HIV/AIDS... In interviews with aid agencies over what they did in 2002/03, and the ways in which HIV/AIDS was incorporated into their response, it was clear that a big learning process was going on, and also that there are lots of other questions. There is a need for much better analysis and monitoring; there are big question marks. We are not yet at the stage where we can say that 'You should do this because of Y', because the evidence is just not there. For instance, with food-for-work programmes there is obviously a logical case that if people are laid up [bedridden] because they are sick, or because they are caring for sick people, they are less able to participate in public works. But how real those constraints are on the ground is unclear. If you talk to agencies that are running food-for-work programmes, they are saying, 'Yes, we're aware this is a potential issue, but in practice we haven't found that participation is constrained', because the household is sufficiently flexible that they can get labour from somewhere if they need to get the benefits - so they can pull in the random cousin from somewhere. A lot of our interventions in Africa are premised on a nice neat household, but anybody who's worked in Africa knows that a household is a very flexible and often quite nebulous construct. I think food-for-work is one example where agencies working on the ground are seeing in practical terms the flexibility of the household, and that labour constraints might not be that big a problem in reality. And, yes, there's a need for caution, but I think where we are at is being able to say that these are the possible issues we need to look out for in thinking about how we design our programmes, or how we monitor and access their effectiveness when we implement them, but I'm not sure we can get hard and fast rules. The literature on HIV/AIDS and food security is centred around the idea of labour constraints and the household, and that is creating adaptations to what people are doing ... for instance, shifting from one type of crop to cassava, which is less labour intensive. So, in providing seed packages, aid agencies are thinking about whether the standard seed package needs to be adapted in the light of HIV/AIDS-related vulnerabilities, and there are various ways of doing that: you can add cassava to the package, or you can add vegetables to the package, which are easier to grow for somebody sick tending a home garden. Again, these are all perfectly plausible, but actually not yet evaluated to an extent that we can say, 'Yes, this is the appropriate seed package for an area where there is 25 percent AIDS prevalence'. Q: There's been a lot of discussion about the need for a new development model; a new development paradigm. What, in your view, does that mean? A: If linking relief and development were straightforward, then we'd have been doing it much better for the last 10 years, because we've been talking about it at least for that long. There are good as well as bad reasons for the need for a distinct humanitarian aid delivery mechanism, that is, in some sense, different and distinct from development ... I think HIV/AIDS both creates new challenges to the way in which the broader international system is structured, and also reinforces existing needs. To start with the humanitarian [approach], which, in a sense ... is what we've really been talking about - it's the challenge of mainstreaming the need to take into account HIV/AIDS–related vulnerabilities across different cycles and sectors. But then you get into this ... potentially mind boggling and circular argument about terminology: what's an emergency and what's development, and what do these different concepts mean? But if you take the fact that problems related to HIV/AIDS are probably going to be around for decades, that's clearly a long-term challenge, and that creates a need for the development system - for want of a better word - to take on those challenges. In relation to the focus of my report [www.odihpn.org], which is emergencies and humanitarian action, I highlight a few - one of which is disaster preparedness and mitigation issues – but the development system remains oddly premised on the idea of progress, and oddly reluctant to accept the fact that periodic crises are inevitable, whether they are relating to drought, conflict, or vulnerabilities related to HIV/AIDS, or the interaction between all three of them. So, to take Malawi in 2002 as an example, it is utterly predictable that there will be periodic drought in Southern Africa, and that the drought in 2002 was going to recur at some point and create a crisis. And yet the development assistance system in Malawi in late 2001 and early 2002 was singularly ill-equipped to notice there was a crisis going on and respond to it. And, to the extent that HIV/AIDS and its impact on food insecurity means that crises are likely to be triggered more easily, that just reinforces the fact that that isn't good enough. There's a need for greater investment in disaster preparedness and mitigation. It's not a new issue, but HIV/AIDS makes it doubly important to be taken on board... It also reinforces the need for the broader development system to take on board the need for long-term welfare, and for social protection, and for safety nets, which, again, is not a new problem. I come back to Malawi because I know it best, but in a country were 80 percent of the population are poor - and of that number another percentage are what they call 'ultra-poor' - there's clearly already a need for a safety net for some of those people; and that this level of destitution and inability to participate in any kind of development process, for the weakest members of society means that in an ideal world, there'll be some kind of safety nets; and that's reflected in PRSPS [poverty reduction strategy papers developed by governments] and development terminology these days, but is rarely reflected in reality. Lip service is paid to it, but it doesn't happen - except to an interesting extent in Malawi, in relation to the starter-pack programme [in which farmers were provided with small quantities of free seed and fertiliser]. Q: Which was under attack by donors if I'm not mistaken? A: Well, indeed, and there's an academic debate going on about the extent to which, in the current crisis, the scaling back of the starter pack scheme was a factor. But there is a series of vulnerabilities related to HIV/AIDS that suggests to me a need for welfare. A grandmother that's looking after eight orphans - it's wrong to expect her to participate in productive [ventures]; that you only need to provide relief for a limited period and, somehow, that household will become productive. And yet, that's what a lot of development thinking remains premised on, and there's a reluctance to say, actually, that she should have an entitlement to welfare - whether you call it a pension, or food aid, or whatever is appropriate. Q: To put government back into the equation, where does the state fit, and how does it work for many governments constrained by cost-cutting policies under structural adjustment? A: It's a debate that needs to happen and I don't have the answers. Humanitarian aid is premised around, in a sense, the assignment of responsibility, and acting as an instrument of last resort... The role of humanitarian agencies is to step in when the state is unable to meet its obligations. But there is a need to be clear that responsibility for the welfare of its citizens does still lie with the state, and to think then about what the role of humanitarian and development agencies is in situations where the state is increasingly unable to meet the needs of its citizens, and whether [humanitarian actors] play a role, in a certain sense, of substituting [for the state], or whether they play a role in trying to regenerate the capacity of the state to meet those responsibilities. Obviously, once you get into that sort of argument there are all sorts of difficulties that you get into around corruption and governance questions, and those have to be taken on board aid agencies if they perceive a renewed need for long-term welfare, related in part to vulnerabilities relating to HIV/AIDS - thinking about who's the most appropriate; what is the most appropriate system and body for delivering that welfare, needs to be part of the debate. In a sense, in 2002/03 the debates were marginalised for a variety of reasons, one of which was the centrality of Zimbabwe and the political situation there, meaning that any sort of engagement with government was deeply problematic for donors. And in Malawi, perceived donor concern over the sale of the strategic grain reserve, and perceived concerns over the capacity of government to deliver relief, led, again, to a marginalisation of government within the relief process. I know the other countries less well, but the relief response was largely international organisation-led, and so, in looking at the longer-term needs, there's a need to think carefully about where and how government [can] be brought back into the equation. Q: Where do you see donor thinking right now? After all, in Southern Africa you don't see the dead bodies, for example, like you saw in traditional famine in Ethiopia in the 80s. A: There's a host of really complicated issues and it's difficult to know where to start. One of them is around the idea of preventative relief, that - obviously from the donor and humanitarian agency perspective - it's better to provide food aid before people start starving to prevent that from happening and, certainly, that's the policy of both the donors and the agencies - and that's why there was such a generous response to the threat of famine in 2002/03. However, sustaining political support for that, which is what donors have to do within their own countries, is difficult. It's a much harder sell for a development minister of the UK to keep on selling, year on year, the need to have a relief response in Southern Africa or Ethiopia to prevent the potential famine, than it is to sell the need for a response because people are already dying... There's a tendency on the part of humanitarian agencies to blame donors sometimes for a lack of response. When the people sitting in CIDA [the Canadian development agency] want to be able to respond, they often have a similar analysis of some of the issues; they have constraints in terms of needing to take their political masters with them, and their political masters have constraints in needing to take their publics with them. It's to do not only with donor perceptions with what the problem is, but to do with Western governments and Western public perceptions of what the problem is, and the political saleability of a prolonged engagement with a long-term crisis. Q: Has there been a kind of a normalisation of an unacceptable level of mortality as regards HIV/AIDS? A: There's certainly a risk of that. The normalisation argument comes from south Sudan or Somalia, that if things are bad enough for long enough you just come to accept it, and in Sudan and Somalia through the 90s, rates of malnutrition and mortality that would once have triggered a crisis response were almost being redefined as normal, and as a baseline from which, if they went up further than that, there [was] a need for a response. The way in which you can look at the argument in Southern Africa is not in terms of acute malnutrition and mortality - there's difficulties of data, but the broad picture seems to be that levels have remained reasonably stable. But if you look at other indicators relating to long-term crisis there's a risk of normalisation going on; that the levels of mortality and morbidity relating to HIV/AIDS and other issues - and it's very hard to disentangle mortality related to HIV/AIDS and mortality related to food security, for instance - then, yes, it's accepted as part of the background noise. And I think this is where, as humanitarians, we have a responsibility to raise the alarm bell. In our engagement with the wider development system - whether at the World Bank level or IMF level, or in donor discussions with governments about budget support - to be making noise about the levels of mortality and suffering that are unacceptable. So, whether it's relating to the fact that 50 percent of the population in Malawi doesn't have access to health care ... although this is a long-term problem and has been going on for a long time, that doesn't mean that it's okay. And there are many other examples of things that are unacceptable that you could draw on.