Fertilizer subsidies in Malawi: An HIV/AIDS Prevention and management strategy?

Malawi is one of the poorest countries in the world and its economy is agrarian. More than half of the population survives on smallholder farming and lives in poverty and a good section of that is described as ultra poor. Chinsinga and O’brien, 2008 agree as they say “the economic reality is grim, 52% of the population are poor defined as per capita income of less than US$0.40/day. At least 22% live on less than US$0.26/day and are classified as ultra poor.”

Agricultural production is the sole source of food provision to the population. While tobacco, coffee and tea are the main cash crops, maize is the crop that is regarded as “food” for many Malawian families. However, the agricultural sector is vulnerable to so many shocks including adverse weather and soil nutrient depletion and these render the sector, the mainstay of the economy and food provision for the country, immensely unreliable at times. The rainy season, running from about November to March supports and sustains only one growing season (Chinsinga and O’Brien, 2008). Any individual, family or community coming out of that growing season with inadequate maize or any of the cash crops is left open to hunger and starvation as there is no tangible and stable social welfare system in the country, considering its small and low economic base, to come in handy for the people in times of lean harvests. Livelihoods stagger when this happens; and Malawi has had its fair share of chronic hunger stretching across all the three governments Malawi has had since independence in 1964. Adverse weather conditions and the ever-skyrocketing prices of inorganic fertilizers have played their role in this.

MALAWI, AND THE HIV, AIDS-POVERTY CYCLE.
Malawi is a small country in the sub-Saharan region of the vast continent of Africa. This region has the greatest burden of disease in the world, even more so the burden of HIV and AIDS. Malawi alone is home to close to one million people living with HIV and AIDS; representing, of the 13,000,000+ people in Malawi, 14.1% of those aged between 15 and 49 (UNAIDS, 2008).

As can be deduced from this, the impact of HIV on any sector in Malawi is devastating and agriculture has not been spared. It can be argued that the loss of labour and manpower, owing to HIV, is considerably significant so as to stand independently as a factor in the low food and cash crop production in Malawi at present. Additively, the low economic growth of the country, the inability to respond to shocks of different sorts because of poverty and the constant state of food-insecurity have a significant bearing on the wild-fire-like spread of HIV – and these factors, in a compounding fashion, render the population infected with HIV susceptible to quicker and aggressive progression to AIDS; so Malawi on the whole, is caught up in a serious, devastating vicious cycle of poverty, HIV and AIDS. Save the Children UK and Oxfam, 2002 agree as they say, “there is a clear-cut two-way relationship between HIV, AIDS and food insecurity in southern Africa; the pandemic is being driven by the very factors that cause malnutrition: poverty and inequality.” (Refer to Box Two for more information).

ANTRETROVIRAL THERAPY (ART) IN MALAWI.
Of all the people living with HIV and AIDS in Malawi, more than 200000 are in need of ART. Chimzizi and Harries, 2006 indicate that 170000 people, in 2006 stood in need of ART. The 170000-mark must have been passed by now and looking at Malawi’s Ministry of Health (MOH) figures of people requiring ART (Box one), it is projected that by the year 2010, 245000 people will have been started on ART but this too will be falling far short of the required need and demand if one considers that 90000 people become eligible for ART every year (Harries, Makombe, Libamba, Schouten and Lungu, of MOH, 2006).

ART demands on the body tissues and systems may be immense and the need for adequate food and nutrition may be of paramount importance as one gets treatment. ODI, 2006 augments this as they subtly intimate that evidence is emerging to the effect that adherence to treatment and the benefits from it are linked with access to food and nutrition. If one has no food, taking of medications may not count as much.

As Malawi grapples with the ever-growing need for ARV therapy, the need to prevent further infections becomes even more important and food security needs to be prioritised. It is a challenge to do this amidst other critical issues of poverty, gender inequalities, less-than-satisfactory political governance, a fragile and an immensely understaffed health care delivery system; but one that needs to be embarked on with diligence and all the political will that it deserves.

THEORETICAL UNDERPINNINGS TO HIV AND AIDS MANAGEMENT: MIXED TEHORIES (Barnett and Whiteside, 2002 and Campbell, 2003)
It has got to be appreciated in the final analysis that HIV and AIDS have got two major sides that need to be approximated together properly for comprehensive management strategies and if people-centred tangible results are to be realised. There is a biological dimension to HIV as well as a socio-economic one; the two so far, seem to have taken different routes and directions. There are theoretical perspectives that would aid in a holistic approach to HIV and AIDS management and this paper exemplifies two: - the Social Cohesion approach as advanced by Barnett and Whiteside and the integrated approach to prevention: Health promoting communities as articulated by Catherine Campbell. Barnett and Whiteside argue that for a long time HIV prevention strategies have concentrated on individuals and the risks they take as they engage with society – almost completely ignoring the context within which the risky indulgencies take place. They further argue that susceptibility and vulnerability to acquiring HIV and progression to AIDS and dying from it are directly related to the social cohesion and amount of wealth any society has.

Campbell, on the other hand, argues that prevention should look beyond biomedical and behavioural approaches. She advances the school of thought that HIV prevention – probably including management of effects – should be perceived and viewed as social and development endeavours. She argues that prevention should be strategized in such a way that an enabling environment for prevention is created other than persuading individuals to change their behaviour. She articulates that HIV should be viewed as a BIO-PSYCHO-SOCIAL problem – all three aspects should be brought together and operate in unison to register the successes that are sought (Campbell and Williams, 1999).

Malawi is a country that can easily be described as a socially cohesive society but with very low wealth – and according to Barnett and Whiteside such an environment offers enablement to a high HIV and AIDS epidemic like the case of India (Barnett and Whiteside, 2006). Malawians still practice a sense of belonging to what can be described as the traditional extended family set-up and this has provided, over the years, invaluable source of social capital on which people relied for several problems including ill-health. However HIV and AIDS are ripping through this social fabric so much that the system itself can palpably be seen to be getting fatigued as a direct consequence. More and more people have become ill from HIV, this is happening amidst excruciating poverty, immense gender inequalities etc and the epidemic seems to just have found a proper breeding ground to thrive (Chatterji, Murray, London and Anglewicz, 2004).

FOOD INSECURITY: ITS ROLE IN THE HIV AND AIDS-POVERTY CYCLE (Refer to Box Two)
Malawi is a low-wealth country meeting fully one aspect of the Barnett and Whiteside theory for an enabling environment for the HIV spread, thrive and flourish. Poverty leads to all sorts of shocks onto people’s livelihoods including food insecurity and this alone supports a fertile environment for the spread and flourishing of HIV. IPFRI, 2004 agree as they say “HIV/AIDS and food and nutritional insecurity may become increasingly entwined in a vicious circle – HIV/AIDS heightens vulnerability to food insecurity which in turn may heighten susceptibility to HIV infection.”
There are so many ways in which this can happen and one of them is that people, particularly women, will go to great lengths to acquire food for their families and the chances of indulging in risky behaviour e.g. transactional sex become very high (Swidler & Watkins 2006). Further to this an under-nourished body is incapable of sufficiently fighting off infection and an encounter with HIV may render a malnourished body significantly vulnerable to acquiring the infection and in a spiralling fashion, progress into AIDS becomes quick and almost inevitable.

A PERSUASIVE CASE FOR FERTILZER SUBSIDIES IN MALAWI
Malawi’s population has shifted from slightly below 4,000,000 in 1964 (at independence) to more than 13,000,000 in 2008. The land has remained the same and cultivation has been in almost the same fields, year in and year out. The dwindling sizes of land tenable to anyone Malawian and the inevitable depletion of soil nutrients, renders the agricultural sector, the mainstay of food production in the country, vulnerable to inadequacies leading to a population on a risky course of food insecurity (Chinsinga and O’brien, 2008). One of the strategies available to make sure Malawian families have adequate food is to try and ensure optimal production of food items, particularly maize, on these small-sized farms with dwindling soil nutrients as well as in the backdrop of a shrinking labour force in a severely income-unequal society (Refer to Box Three).

When the current government came to power in 2004, one of the things the President told and promised Malawians was to bring food to their plates. Despite serious resistance and misgivings from the World Bank, IMF, The US and Britain, the Malawi Government (MG) was determined to bring the fertilizer subsidies back – looking at it as the only way that would ensure adequate food production thereby bringing about the much needed food security to families and households. Bingu wa Muntharika, the President of Malawi, declared “as long as I am president, I do not want to be going to other capitals begging for food” (New York Times, 2007).

This may have been done HIV and AIDS-blind however, the policy seems to have worked for three years running. Malawi produced enough food supplies in the 2005/2006, 2006/2007 growing seasons and the indication is that the harvest for the 2007/2008 growing season will be pretty good too. The benefits in regard to HIV/AIDS management may be accruing.

IMPLICATIONS FOR HIV AND AIDS MANAGEMENT.
Adequate food provision as part of a response to HIV and AIDS is in tandem with article 28 (refer to Box 4) of the United Nations General Assembly Special Session (UNGASS) and governments need to respond and meet the demands of the article. The MG’s fertilizer subsidy policy is a defining policy in increasing the likelihood of sustained adequate, food production and provision for most Malawians and once they can be assured of food, day in and day out that will probably be a huge precondition for economic growth as more and more people may be able to participate in economic activities after food-needs are assured because food is a basic need that everybody will first try to secure before they can do anything else. This is and will be a recipe for increased household wealth and with the already long and deep running social cohesion, the conditionality for a more positively aggressive fight against HIV and AIDS may ensue – as Barnett and Whiteside do contend that high social cohesion and high wealth, more often than not results in a decreased HIV and AIDS epidemic. Increased household wealth, combined with the social cohesion will provide an enabling environment for individuals, families, households and larger communities to be more resilient to the devastating effects of HIV and AIDS as well as being in a position to negotiate new ways of preventing acquisition of the virus.

Added to this, as Catherine Campbell may argue, food security alone brings about a social state that is more stable and more productive in many ways – women for example, whose vulnerability to acquiring HIV increases with food insecurity, will be in a better position not to engage in activities that make them susceptible to acquiring the virus e.g. transactional sex. It can further be argued that food-secure families would be in a much more strong position to revisit gender relations which may lead to a reconstruction of the gender roles in a positive way and Catherine Campbell argues that this is important in the fight against HIV and AIDS.

Further to this the general population at large will be healthier and as it is medically true, well nourished bodies are more resilient at fighting off infection.
Further to this, with a good section of the population on ART and there is evidence that for those that are already on ART, adherence and benefits from the treatment are optimal if the nutritional needs are adequately met and continually catered for (ODI, 2006).

CONCLUSION
The conclusions of the Durban Conference on HIV/AIDS, Food and Nutrition Security (Box FIVE) cover in subtle terms it can be argued, what Barnett & Whiteside and Catherine Campbell advance as areas that need to be looked into as approaches to preventing and managing HIV and AIDS are concerned. The environment has to be one that disables the conditions that allow for the spread and proliferation of HIV and where AIDS has already taken its toll, the environment has to be that which facilitates resilient responses by individuals, families, households and communities. Good governance, for example, works well for the people in enabling them to participate in wealth creation and bringing about social development – key areas of contestation by Barnett & Whiteside and Campbell that have the capability of strengthening, in a positive way, the fight against HIV and AIDS and its effects on populations and their social and human development.

The Malawi nation, through its political leadership, to bring about food security by employing fertilizer subsidies, should stay this course for both, food security in its own right and as an important precondition to stabilize households, families and communities rendering them an opportunity to participate better in the fight against HIV and AIDS. And for those on ART, a well nourished body is more resilient to battling off OIs and better food renders ART more effective; there also is a cost saving benefit for households; even more so for the national economy (ODI, 2006).
Further to this, it is important for the government of Malawi to look at the sustainability of the programme in the long term. Some donors do not support subsidies to farm inputs and as time goes by, even those that sympathise with the programme may become fatigued. In this regard, it is of paramount importance to look at how Malawians themselves can fund the fertilizer subsidies as donors assist with other areas; even more important is the fact that Malawi should be diversifying its economic growth strategies and activities. With food-secure families, having started in 2006, there has to be a plan, forecast and drive to let Malawians own the programme.

The grey areas of the programme also need to be addressed and meticulously policed. Some quarters argue that the programme is highly politicised which may work to its detriment. It is also highly rumoured that some corrupt politicians take advantage of the situation; they buy the subsidised fertilizer in large quantities and sell the commodity at huge profits, sometimes even smuggling the commodity to neighbouring countries like Zambia (Afrol News/The Chronicle, 2008). Accountability may be the catch word here with all the whole-marks of answerability and enforceability (World Bank (WB), 2004).

Added to all this Malawi needs concerted efforts to work on its inequalities in the fields of gender as well as wealth distribution. Gender inequalities alone bring an avalanche of problems including the spread of HIV and the entrenchment of poverty. Working for a more gender equal Malawi will bring with it benefits in terms of social and food security alongside resilient participation in fighting off HIV. And as the WB 2006, purported, Malawi is one of the most unequal countries in terms of wealth distribution. It would be to the nation’s advantage, as it tackles its myriad problems, to look at this issue and work on strategies of wealth creation and redistribution. This will serve well as a precondition for resilient fights against HIV and AIDS and its effects. Catherine Campbell puts up a persuasive case in support of strategies that change people’s circumstances and she intimates that programs to prevent HIV infection and AIDS must seek to bring about change to the community as a whole and not just within individuals particularly in circumstances where the social and economic dimensions that divide people, thereby making them unequal, are precisely the same forces that increase their shared risk of HIV infection. This, in definite terms, puts up a case for change in peoples circumstances, socially as well as economically.

Malawi should position itself for a long time of excruciating morbidly and mortality caused by HIV and AIDS as a good percentage of the population is already infected and affected, however good policies have to be in place and especially those that help to break the vicious cycle of poverty and HIV and AIDs; the adequate and affordable provision of fertilizer is one of those policies that can aid in this fight. Malawi should stay the course because if it does it will be positively contributing to the achievement and fulfilment of Millennium Development goal six. (Refer to box 6).

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