On a windswept plateau in the Lesotho highlands, Southern Africa, a grandmother steps out of her rondavel to begin morning chores. She looks out at the wide expanse—clear blue sky above, parched land below—and then begins tending to her home keyhole garden, a circular raised structure with a pie-shaped slice cut from the middle. She fills the basket in the middle of the garden—a compost pit—with wash water and food scraps before pulling weeds that are growing between the new plant shoots breaking the surface of the moist, nutrient-rich soil. Soon she will have spinach, peas, and beans to feed the children that she cares for. Most of them are AIDS orphans. Keyhole gardens and other home gardens are part of the arsenal of interventions to mitigate the devastating effects of food insecurity (i.e., the inability to obtain food of enough quantity and quality in socially acceptable ways 1) and HIV and AIDS in Lesotho and elsewhere.2,3
The Global Food Crisis and HIV/AIDS
In 2008, the World Food Program (WFP) cited the increase in world food prices as the biggest challenge in its 45-year history, calling the impact a “silent tsunami” that threatened to plunge millions into hunger.4 Today, more than one billion people are estimated to be undernourished worldwide, reflecting an increase of nearly 75 million since the beginning of the global economic recession and food crisis of 2008.5 The causes and consequences of the global food crisis are complex and beyond the scope of this column.6 However, in the developing world, especially in Sub-Saharan Africa (SSA), there is a synergism between the global food crisis and HIV/AIDS that intensifies both problems.
The term “syndemic” refers to the interaction among linked health problems under conditions of poverty and structural inequalities including gender inequality. As the Centers for Disease Control and Prevention states, looking at the way in which health problems reinforce each other allows for a better understanding of these syndemic relations, and facilitates the creation of effective interventions.7,8 Nowhere is the example of a syndemic more evident than in SSA, where multiple epidemics work together against the survival of individuals, households, and communities. Given the widespread occurrence of famine and drought along with the HIV/AIDS pandemic and the high cost of food associated with the global food crisis, public health initiatives must adopt a multidimensional approach that addresses sustainable food production, poverty reduction and elimination, and disease mitigation through a reduction in high risk behaviors such as transactional sex9 (i.e., the exchange of sexual favors for basic necessities such as food and shelter).
Lesotho: The Case for Sustainable Food Production and Disease Mitigation
The Kingdom of Lesotho, a small landlocked nation completely surrounded by South Africa, encompasses a largely mountainous terrain that has been highly eroded through the years due to deforestation, overgrazing, and drought. To say the least, agriculture is risky business in Lesotho.10 As of early 2009, Lesotho was importing 70 percent of its food, and was heavily dependent on international food donations.11 Agricultural productivity has also decreased due to the absence of able-bodied workers. Up until the 1990s, large numbers of adults, mostly men, were absent in Lesotho—working in mining and agriculture in South Africa. More recently, work in apparel production has drawn many women from their rural villages to the lowland factories in Lesotho. Far from home and often renting small cement block flats, women have little land to grow food or social capital to support such efforts. More devastatingly, the country's workforce has been dramatically depleted by HIV/AIDS, which is believed to cause more than 30,000 deaths annually in a country of 2.1 million.12 Initiatives to individually address HIV/AIDS prevention, treatment, and food insecurity have met with varying degrees of success. However, we believe that such efforts would be more successful if they addressed the problem as a syndemic, that is, if they try to mitigate HIV/AIDS and food insecurity through small-scale sustainable food production and nutrition education, poverty reduction, and behavioral changes aimed at reducing risk. The latter can be achieved through enhanced HIV/AIDS education and awareness, open discussion of protective measures, provision of condoms, and the promotion of abstinence and being faithful to one's partner, combined with income generation opportunities for women—for example through the sale of surplus vegetables—that empower them and reduce their dependence on men.
Home Gardens: Improving Food Security and Nutrition
Home gardens are being promoted in Lesotho and elsewhere as a way of increasing dietary diversity (i.e., variety of foods). Dietary diversification encompasses a variety of approaches with the goal of increasing the production, availability, and access to micronutrient-rich food, which improves nutritional status and immune function. This is critical in resource-poor countries like Lesotho where diets are monotonous and carbohydrate-dense, and where AIDS and other infectious diseases such as tuberculosis are highly prevalent.
Catholic Relief Services13 (CRS), along with other organizations in Lesotho, has taken action to respond to the HIV/AIDS-food insecurity syndemic by implementing sustainable agriculture programs and irrigation schemes. One such program is the Lesotho Homes with Urban Gardens (HUG) project, implemented to expand food security programming from rural areas into peri-urban areas—areas in rural settings that are undergoing urbanization. Targeting poor households, the CRS HUG project focuses on home gardens as a means to mitigate the impact of rising food prices on urban households, and to increase access to food. The project assumes this will be accomplished in two ways. First, households will gain direct access to the fresh vegetables their gardens produce, which in turn may ease the burden of food costs in proportion to income. Second, the production and sale of surplus vegetables may provide a secondary source of income for program households. CRS's efforts center around the use of two types of gardens that are designed to absorb and retain water, and to yield large amounts of vegetables throughout the year: keyhole gardens and trench gardens, each of which offers special advantages and presents special challenges.14 Further, because the keyhole garden is a raised structure, it minimizes the amount of physical work required to take care of the garden. Therefore, it is ideal for households where the elderly, children, and individuals affected by HIV/AIDS are responsible for food production.
Today, more than one billion people are estimated to be undernourished worldwide, reflecting an increase of nearly 75 million since the beginning of the global economic recession and food crisis of 2008
We and one of our graduate students have been fortunate to be able conduct research15 with CRS on the HUG project and will continue to work toward the development of multidimensional interventions that not only address the problem of sustainable agriculture but also aim to mitigate the impact of HIV/AIDS through poverty reduction, nutrition education, prevention, and the empowerment of women through the enhancement of income-generating opportunities. We believe that only by taking this multifaceted approach can we get at the roots of this devastating syndemic.
For more information about food insecurity and HIV prevention see the Food and Agricultural Organization (FAO) of the United Nations,16 the World Bank,17 and the International Food Policy Institute.18
DAVID HIMMELGREEN is a biological anthropologist with special interests in nutrition, growth, HIV/AIDS, and food insecurity; he has research experience in Lesotho, India, Costa Rica, and the United States.
NANCY ROMERO-DAZA is a medical anthropologist with expertise in HIV/AIDS, substance abuse, and reproductive health; she has worked in Lesotho, Costa Rica, and inner cities in the United States. Both Himmelgreen and Romero-Daza are Associate Professors in the Department of Anthropology at the University of South Florida.