Looking at Boyd is like staring into the bottom of a well. His eyes are small and dark, impenetrable. I ask him: What is it like to care for orphans? What is it like to live in a village in the Zambian bush? What is it like to be poor? My words are like arrows shot into the ocean, pointed and tiny against the vast waves.
The adult (aged 15-49) HIV prevalence rate in Zambia is 14.3 percent, according to the country’s 2007 Demographic and Health Survey—the seventh highest prevalence rate in the world. Anti-retroviral therapy was introduced in 2004, and 120,000 people now receive treatment in no small part because of the vast sums of money PEPFAR has poured into the country—more than $269.2 million in FY2008 alone. (The entire budget of Zambian Ministry of Health in 2008 was $317.5 million.)
PEPFAR has been criticized for devoting too much money to a single disease and for channeling aid mostly through international NGOs, circumventing the government. One afternoon I asked Dr. Ben Chirwa, Director General of the National HIV/AIDS/STI/TB Council, if Zambia’s battle against the epidemic is too reliant on donor funds.
“AIDS is a global problem,” he said. “It is beyond what any one government can do.”
What about the Washington economist who termed ballooning U.S. funds for AIDS treatment an entitlement that is unsustainable?
Boyd showed me around his compound—the hut where he stores food, his two goats, a checker board carving in the dirt where his children play games. I ask what he would do without RAPIDS.
The U.K gives about two-thirds of its aid to Zambia directly to the government, more than any other bilateral donor. The idea is to help build the accountability and capability of the state so it can provide for its citizens. Aid to an NGO that buys HIV/AIDS medicine will save lives today, but working with the government to improve its drug distribution system (one of the things DFID is doing) will help all Zambians access essential medicines over the long term.
When Joy first arrived in Zambia, before anyone knew who she was, she visited a remote village called Kazuni in Southern Province. She shared a mud hut, walked to the river to get water, burned her fingers cooking nshima, laughed around a crackling fire with the women who were hosting her.
Night comes early in Lusaka. In the dark sounds are amplified. The rustle of leaves, dogs barking down an alley, a car engine trying to turn over.
Sometimes it feels like you’re being swallowed up, pulled under by a rip tide. The enormity of need. The limits of what we can do.
*This is adapted from a piece I wrote in 2009 for the Center for Global Development.