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War and The HIV/AIDS Epidemic

in the Great-Lakes Region of Africa

By Raïs Neza Boneza


Bio Other articles in this series...

Transcend Africa Network: Report on Refugees


Africa in the Face of the Development of Others


International Migration and Development Revisited


Ghettoization or Globalization Of African Literature


Great Lakes Region of Africa - Burundi


Sudanese Internal Displaced People


Rwanda: Conflict, Genocide and Post Genocide


Child Rights Associations/Youth Movements in Rwanda


Assistance, Bi-lateral Cooperation and Humanitarian Interventions

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1. Introduction: Background of the region

Almost thirty conflicts have raged annually since the end of the cold war; many of them in Africa. The Great-lakes region of Africa is one of the volatile epicentres of violence and conflict. It has experienced from the last decades Holocaust and genocides. The complexities of the conflicts in that region have been found largely incomprehensible or with not enough interest for the international community until more than 4 million victims were lost in the conflict (Boneza 2005). The countries of Burundi, the Democratic Republic of the Congo, Kenya, Rwanda, Tanzania and Uganda compose the East and Central regions of Africa and together they are the Region of the Great Lakes. Although they are all separate entities, they are bounded by the many diverse and similar ethnic groups as well as historical legacy of colonialism that has planted the torment experienced today in the area.

The Great Lakes Region of Africa’s main plagues are: poverty, political instability, armed conflicts and the HIV/AIDS pandemic. The troubles will hinder any development endeavour if appropriate measures are not taken quickly in order to reduce the poverty, put an end to insecurity and armed conflict, and control HIV/AIDS. Internal armed conflicts that some countries in the sub region have faced have resulted in the massive and prolonged displacement of the populations. "A titre examplatif", the number of displaced people owing to the wars that broke out in the DRC since 1997 to 2003 amounts to 3,000,000. The forced spatial mobility has resulted in a splitting and recombining of families. The affected population came mainly, on the one hand, from the East and North East of the DRC.

The main purpose of this paper is to present the provisional results of the study on the effect of conflicts on the health vulnerability toward for displaced persons. With a focus on the HIV/AIDS pandemic. The study of the effect will deal essentially with the scenarios of the diffusion and propagation of the HIV/AIDS. We shall seek to bring to the fore the men/women vulnerability differential in the different areas under investigation. The study rests on the analysis of documents published on the HIV/AIDS pandemic.

2. Armed Conflicts and the emergence of new diseases

Armed conflicts have long been associated with disease outbreaks by creating the necessary conditions for epidemics explosion: destruction of infrastructure including water supply and sanitation facilities, displacing civilians and creating refugees who are often driven in overcrowded and unsanitary settlements. As in the 40’s, the World War One (WW1) may have been responsible for the great flu pandemic of 1918 that killed at least 40 million people(1) The authors of a report published in The Lancet when reviewing past mortality and morbidity reports from the early part of 20th century found evidence in the years preceding the 1918 pandemic of sentinel outbreaks at training camps and barracks in the UK, where many young soldiers were succumbing to a pneumonic like illness and rapidly dying after a short time.

The barracks with their dormitory-like buildings were ideal for dissemination OF air-borne disease. When these young men were sent off to the war front, there they came in contact with hundreds of thousands of other soldiers, allowing the virus to spread, change and mutate and become even more virulent. The frontlines had all the conditions of refugee camps, with hundreds of thousands of young men living in squalid unsanitary, overcrowded camps, ideal areas for the spread of disease. When the soldiers left the frontlines and returned home, they came back carrying more lethal forms of the bug and re-introduced it into the civilian population.

As for Great-lakes, Armed conflicts have killed for the last decades more than 7 millions and brought suffering to millions more and setback development. The genocide in Rwanda in 1994 and the war that followed to drive out the Hutu supposed perpetrators forced them into the jungles of neighbouring Democratic Republic of Congo (DRC) and created a huge refugee crisis.

For example in the D.R.Congo Ebola virus was first isolated in 1976. Further outbreaks have occurred in Democratic Republic of the Congo (1995 and 2003), Gabon (1994, 1995 and 1996), Uganda (2000), and Sudan again (2004). A new species was identified from a single human case in Côte d'Ivoire in 1994, Ivory Coast Ebola virus (ICEBOV). In 2003, 120 people died in Etoumbi, Republic of Congo, which has been the site of more outbreaks, including one in May 2005.

The hypothesis here is that refugees driven into the jungles of the Congo, or soldiers fighting in the DRC, will invade the habitat of the natural host of the Ebola virus (to date the host is still unknown, but is presumed to be a monkey or a wild animal), or even worse will be exposed to even more hitherto unknown lethal diseases that will escape into the general human population.

In West Africa, researchers are alerting people to an increase in outbreaks of haemorrhagic fevers, possibly due to increased contact between man and animals especially monkeys that may be the reservoir for Ebola. Liberia and Sierra Leone are two countries that have just come out of civil wars that created large numbers of refugees displaced into the surrounding jungles. Some epidemic diseases are making resurgence due to wars in Africa and putting people at risk. Also there has been some reappearance of epidemical diseases such as typhus Burundi in 1997 after an absence of twelve years associated with the civil war that broke out in 1993. Typhus is spread by lice and epidemics are associated with high density populations such as in refugee camps (2).


3. HIV/AIDS and War in the region

In the last decade, countries in the Great Lakes Region were considered the epicentre of the epidemic because of the high prevalence rates and the socio-economic impact on the populations. During this period the Great Lakes Region also faced unbearable years of turmoil, war and armed conflict across borders. There was mass movement of armies, displacement and migration of entire communities from one.


3. a. Uganda case


In 1979 the Uganda / Tanzania war had contributed to the spreading of HIV/AIDS in Uganda. Geographers at Cambridge University, UK suggested the spread of AIDS could be traced back to the route the fleeing soldiers of Idi Amin’s defeated army took in 1979 while being pursued by Tanzanian soldiers. They concluded that the ethnic base and reported spatial pattern of AIDS is significantly related to the ethnic composition of the defeated Uganda National Liberation Army (UNLA) in 1979. In this instance war enabled the escape of the virus out of South West Uganda as the soldiers seeded it along the route from the South to the North of Uganda.  This could help explain the spread of AIDS from the South to its secondary focus in the North of Uganda (3).

Since the epidemic began, more than 60 million people have been infected with the virus worldwide. HIV/AIDS is one of the leading killers in Africa, where there are now more than 28 million people infected (4). In 2002, a meeting held in New York, hosted by UN High Commissioner for Refugees and the Women's Commission for Refugee Women and Children, and discussed the effects of war on the spread of disease. The meeting was seeking to address the concerns in light of earlier U.N. Security Council resolutions (including Resolution 1308) on the role of conflict in the spread of the disease (5).


Adult (15-49)

HIV prevalence rate


(range: 2.8%-6.6%)

Adults (15-49)

Living With HIV

450 000

(range: 300 000-730 000)

Adults and children (0-49)

Living with HIV

530 000

(range: 350 000-880 000)

Women (15-49)

Living with HIV

270 000

(range: 170 000-410 000)

AIDS deaths

(adults and children)

in 2003

78 000

(range: 54 000-120 000)









Source: 2004 Report on the global AIDS epidemic

The last decade Uganda government has proven a strong national commitment to awareness and health promotion about HIV/AIDS resulting in an average 18% decline in the prevalence rate in the early 1980s to its current stagnation around 6%.


3.b. Rwanda


Rwanda emerged from years of a mass displacement, war and genocide facing an AIDS epidemic threatening the 8.1 million Rwandan inhabitants.

Amnesty International UK Media Director Lesley Warner said:

"Sexual violence against women was a huge component of the 1994 genocide. Women’s bodies and minds were mutilated, humiliated and scarred on a scale that defies belief. It is an outrage that most of these women are not receiving adequate healthcare."

In 1994 the Rwandese people suffered some of the most horrific violence of the twentieth century as up to a million people were killed during the genocide committed by the interahamwe militia, and reprisal killings by the Rwandan Patriotic Army.

The UN estimates that between 250,000 and 500,000 rapes were committed. Gang rape was common, especially at check points set up by the interahamwe, and there were many incidences of women being abducted and held for long periods as sex slaves. Of the women who survived these attacks, 70% are estimated to have been infected with HIV. Most reportedly still suffer from severe trauma and have little hope of receiving adequate medical care or compensation.

source: unaids2003 report


3.c. Democratic Republic of the Congo ( DRC): Rape is a more powerful weapon than bullets

The DRC is the size of Western Europe. Amin Shah, global issues 2003, said: Described by some as Africa's First World War, the conflict in the DRC (formerly known as Zaire) has involved seven nations.

There have been a number of complex reasons, including conflicts over basic resources such as water, access and control over rich minerals and other resources as well as various political agendas. This has been fueled and supported by various national and international corporations and other regimes which have an interest in the outcome of the conflict.

· Since the outbreak of fighting in August 1998,

o At least 3.3 million people, mostly women, children and the elderly, are estimated to have died because of the conflict, most from disease and starvation

o More than 2.25 million people have been driven from their homes, many of them beyond the reach of humanitarian agencies.

· These shocking figures would usually be more than enough to get media attention the world over.


In the East, where 90 percent of vital infrastructures such, health, education, and roads have decayed due to war. Many reprisals (such as rapes) were thrust upon the population (with a big majority of women and children as victims).

Armed forces from Rwanda and Uganda had by 1997 a higher prevalence of HIV/AIDS in their homeland than in DRC has occupied that region. Therefore sexual aggression has been the major vector in spreading AIDS in the region. In the Congo, rape was a more dangerous weapon of war than bullets. Experts estimate that some 60 percent of all combatants in the DRC are infected with HIV/AIDS. According to UNICEF, combatants of all armed groups in the DRC have committed rape and other forms of sexual violence, with such abuses reported to be "widespread and systematic" in eastern DRC.

The WCASV (Women of the Coalition against Sexual Violence), an organization based in US (Washington), stated that the reasons behind this extreme violence were psychological, political and ideological and added: … Sexual violence against women is a deliberate attempt to humiliate the Congolese people and the entire nation. Neighbours of D.R. Congo covet its immense wealth. In the "war against women" combatants use the "weapon" of women’s bodies and their reproductive capabilities to spread the HIV/AIDS virus, and to give birth to non-Congolese - "foreigners’ ".…

Political progress in D.R. Congo since the end of 2002 includes the ratification of various peace agreements, the creation of a transitional government and the official reunification of the country. Despite these steps the security of the eastern part of the country continues to cause concern.

At the beginning of 2003, the UN Security Council condemned all forms of sexual violence against women during armed conflict as weapons of war. However sexual violence against women and deliberating HIV/AIDS contamination remains widespread. Each actor in the conflict has participated in these atrocities: militants from the Rwanda supported Rassemblement Congolais pour la Démocratie (Congolese Rally for Democracy - RCD), Rwandan and Burundian military, Mayi-Mayi and Interhamwe militias, and Burundian rebels loyal to the Forces pour la Défense de la Démocratie (FDD) and the Forces Nationales de Libération (FNL).


5. Consequences of the epidemic on the region development

Doctor Chinua Akukwe (former Vice Chairman of the National Council for International Health (NCIH), Washington) argue that The HIV/AIDS crisis in Africa is the most devastating disaster to befall the continent. The ultimate responsibility for managing and eventually conquering this menace that threatens to destroy the social and economic sinews of African societies lie with Africans. He explained, adding: The HIV infection is like a stealth bomber that moves at supersonic speed, with major direct and collateral effects. There are two important direct effects of the infection: The infective status which is infinite and, the deteriorating health status during the AIDS stages of the disease. Once an individual becomes HIV positive, that person is theoretically, and for all practical purposes, capable of transmitting the infection to another individual. At least 90% of all infected individuals worldwide are unaware of their high risk status because of their robust physical appearance. These individuals may continue to propagate the disease, unwittingly. Thus, it is not surprising that in many parts of Africa, robust or "healthy" looking individuals are not seen as at risk of transmitting the virus. The second direct damage is the deteriorating health status that invariably incapacitates the individual during the AIDS phase of the disease, with multiple opportunistic infections. This is the stage that many relatives begin a whispering campaign on the cause of the individual’s illness

AIDS is erasing progress by shortening life expectancy. Millions of people are dying young or in early middle age. Average life expectancy in Sub-Saharan Africa is now 47 years, when it could have been 62 without AIDS. The HIV/AIDS epidemic is bringing additional pressure to bear on the health sector. As the epidemic matures, the demand for care for those living with HIV rises, as does the toll amongst health workers. HIV/AIDS strips family assets further, this impoverishing the poor.



Conflict and war has been and continues to be an important factor in the spread of disease in Africa. While unresolved conflicts continue in regions such as the Democratic Republic of Congo, the emergence of new and deadly diseases still remains an extremely grave threat. Presently, the conditions for a rapid propagation of HIV/AIDS in the principal East Urban centre of the Congo and in the whole country are put together. Zones with a weak prevalence are not free from infection, bearing in mind the dominant mode of the HIV infection (heterosexual relationships) and

Poverty. The most affected groups are individuals whose age ranges between 15-40 years (8.4%).

Conflict resolution in Africa is not just a matter of national or regional concerns but is also of global interest. As the examples of the spread of the ‘Flu’ epidemic in the early part of the 20th Century and epidemics which occurred in time of war, these have the ability to spread far beyond the confines of areas of conflict in a relatively short time to threaten millions all over the world. The New Partnership for Africa’s Development (NEPAD) has given conflict resolution in Africa priority as a necessary prerequisite for sustained development in Africa.

Disease surveillance efforts need to be prioritized in the countries involved in conflicts. More funding and support is required from the international community to develop underdeveloped surveillance facilities in Africa. At the same time more efforts should be made to prevent war and end the conflicts currently raging in Africa.

The actions to be undertaken are as follows:

Information about HIV/AIDS, chiefly the transmission modes. Popularisation agents could be recruited among people exercising a prominent influence in the village communities and the urban zones (village chiefs, leaders of religious groups);

Facilitate access to ARV and other medicines against opportunistic diseases;

Free access to condoms;

Rationalizing disarmament, demobilization and reinsertion campaigns of ex-combatants;

Giving a sense of responsibility without any ambiguity whatsoever the National Centre for the Campaign against HIV/AIDS;

Avoid the profusion of centres of decision in the management of the fight program.

Disease surveillance efforts need to be prioritized in the region. More funding and support is required from the international community to develop underdeveloped surveillance facilities in Africa. At the same time more efforts should be made to prevent war and end the conflicts currently raging in Africa. Actions should be taken in favour of the youth in cities and the countryside primarily. Actions in favour of women and ex-combatants and soldiers should be envisaged at the level of the sub-region if they are to be sustainable bearing in mind the mobility of the populations.


UNAIDS (2002) Report on the Global HIV/Aids. UNAIDS, Geneva

UNAIDS: Report on the global AIDS epidemic. 4th Global Report. 2004

World Health Organization (2002): HIV/AIDS: Epidemiological Surveillance Update for the WHO African Region. WHO.

Loretti A: Armed conflicts, health and health Service in Africa; Med.Conl.Survival,1997, Jul-Sep,13:219-28

JS Oxford, A Sefton, R Jackson, RS Daniels and NPAS Johnson. World War 1 may have allowed emergence of "Spanish Influenza", The Lancet, Volume 2, Number 2, 2002

  Raoult D, Ndihokubwayo JB, et al, Outbreak of typhus associated with Trench fever in Burundi, Lancet, 1998, Aug 1;353-8

JHS Kiwanuka Ssemakula. HIV/AIDS & the Health Care System in Uganda, MPH Thesis, Dundee University, 1992

UNAIDS, AIDS Epidemic Update, December 2001

UNFPA Press release, Expert Meeting Examines Impact of Armed Conflict on HIV/AIDS Epidemic, 18 April 2002