Academic journal article Harvard International Review

The Politics of a Health Crisis: Why AIDS Is Not Threatening African Governance

Academic journal article Harvard International Review

The Politics of a Health Crisis: Why AIDS Is Not Threatening African Governance

Article excerpt

Africa's HIV/AIDS epidemic has engendered many nasty surprises. In the 15 years after the continent's first AIDS cases were reported on the shores of Lake Victoria in the early 1980s, the virus spread further and faster than any epidemiologist predicted. Early predictions stated that it was impossible for more than 10 percent of the adult population to become infected; this ceiling, however, was soon broken as infection rates reached 20 percent, 30 percent, and even 40 percent in some populations, at which point the lifetime chance of a teenager contracting and dying from the disease became almost a complete certainty. Life expectancy crashed in a manner unprecedented for a peacetime population, with some southern African populations seeing expected longevity plunge from about 60 years to fewer than 40.


Scholars of historical calamities observe that one disaster often portends a second calamity. Economists have projected that the loss of national income due to AIDS could send some economies into a tailspin--described as "Adam Smith in reverse" by Malcolm McPherson of Harvard's Kennedy School of Government. Management specialists expected that loss of skilled workers would result in essential services such as schools and clinics, not to mention army and police forces, grinding to a standstill. Drawing upon studies of how the rural poor survive famines, I coined the term "new variant famine" in 2002 to describe the vicious interaction between drought and AIDS which was unfolding in southern Africa at that time. I argued that households hit by the disease would be unable to cope with the extra demands of a food crisis and would be plunged into indefinite destitution. Political scientists feared for Africa's stability. How could democracy function when, as one Kenyan nurse protested, "All the voters will be dead?"

Some of these fears are indeed materializing. Others still loom. But some have been proven unfounded or at least exaggerated. Foremost among the dire predictions that have not come true is the expectation that the epidemic would cause a governance crisis, leaving conflict, repression, and anarchy in its wake. Africa has these ills aplenty, but AIDS has not been indicated in their etiology.

Marginalization of AIDS in African Opinion

Since 1999, the University of Cape Town has conducted public opinion surveys in a growing number of African countries. These "Afrobarometer" surveys are a rich source of data on what ordinary citizens think. They have revealed a simple but surprising fact about public opinion: namely that AIDS is never at the top of the list of issues of concern for a population. That position is occupied by unemployment, poverty, famine, and crime, depending on the country in question. Although "health" occasionally comes in at number two, AIDS very rarely breaks into the top three, or even top five issues, though in some countries, notably South Africa, it has been climbing the ladder of concern.

AIDS occupies a commensurately marginal place in African political life. No African government has been overthrown because of its AIDS policies. No election has been decided on this issue. In fact, in South Africa, the ruling African National Congress (ANC) was reelected with an increased majority in 2004 despite President Thabo Mbeki's notorious denial that HIV causes AIDS. True, South Africa has seen street protests over access to treatment, but the Treatment Action Campaign (TAC), which organizes them, has no counterparts elsewhere in the continent. Furthermore, its agenda is reform and not revolution. Surprising as it may seem to AIDS activists from elsewhere, many TAC leaders remain loyal ANC members. Their dispute with Mbeki is not the insurrectionary fervor of the ANC toppling apartheid, but rather one wing of the new political establishment struggling to bring its errant colleagues back in line.

Why is it that a disease which will kill one in six adult Africans and more than half of adults in the continent's southernmost six countries is not the subject of overwhelming political passion? The demographer John Caldwell noted that life expectancy in many African cities is comparable to that in France during World War I--and has been over a much longer period than those four years of war--but while France was traumatized by the death of so many young men, political life in Africa continues in a remarkably normal way; democracy is actually spreading.

AIDS Denialism

To answer this conundrum, we must first look at denial. From the earliest days of AIDS, individuals have often refused to face the reality that they are infected with a sexually transmitted disease for which there is no cure. Indeed, personal denial remains common. But collective denial--the refusal of an entire society to contemplate a disturbing reality--is something more. As Stanley Cohen notes in his analysis of how societies deny their culpability for genocide, this reality is due to the construction of an alternative reality in which people struggle to keep key social and moral frameworks unchanged. A severely AIDS-impacted society in southern Africa faces a similar challenge: how can a community maintain a social order based on lineage and ancestry when so many people are dying of a disease which leaves the lifecycle incomplete and who will therefore struggle to attain the status of "ancestor"? One response is to ensure that the deceased is provided with a lavish funeral, entertaining all the neighbors and relatives who were unable to receive largesse during the lifetime of the departed. Across Africa, poor households struggle to pay for expensive burials, even in the age of AIDS, when death is so common. Could the explosion of sorcery accusations in many African cities be related to the need to give meaning to such pervasive misfortune?

Most attempts to overcome AIDS denialism and to compel people to protect themselves against HIV are based on a straightforward and rather paternalistic model of public education. The same simple messages are broadcasted through all forms of media. For a public accustomed to state-controlled media, and therefore used to screening out official pronouncements to be more patriotic and vote the president in (again), exhortations on abstinence or fidelity are unlikely to make much of a dent. Instead, concerned officials should make AIDS the subject of popular debate by keeping it in the news and stirring controversy. People trust a high-quality and independent media. What is in the news is what people talk about, and what they talk about with their friends and families influences how they act. An unpublished study by Jacob Bor of Harvard University shows that there is a strong correlation between the quality of the press in a country and the extent to which its citizens think that AIDS is an issue for public policy. It is open and democratic debate that is key to overcoming denial.


AIDS as a Long-Term Phenomenon

A second explanation for why political normality persists is that we have not seen the worst. AIDS is a long-term phenomenon. Just as the peak of AIDS deaths occurs eight or ten years after the steepest increase in HIV prevalence, so too does the impact of AIDS on the social fabric lag behind even further.

Nonetheless, AIDS is causing a number of visible problems for African governments, both authoritarian and democratic. Kondwani Chirambo has been studying many of the problems facing functioning democracies in an ongoing research project at the University of Cape Town. These problems include the needs to update voters' rolls more regularly, to ensure that deceased voters are removed, and to construct special voting facilities for the sick and their caretakers. An increased number of by-elections due to more MP deaths puts financial strains on first-past-the-post electoral systems. In African political systems, such strains advantage the incumbent because the ruling party is more capable of finding the resources necessary to mount by-election campaigns. But these are manageable problems, not an overwhelming crisis. It is possible, however, that AIDS-related political problems may get worse. But arguing that no prediction of doom is yet refuted (or indeed refutable) fails to do justice to the intriguing complexity of what is actually going on.

African Government Political Engineering

More significant is the third part of the explanation, which is that African governments are experts at managing multiple crises and even turning them to their advantage. There is rich literature on how regimes of all political complexions have thrived despite famine, crime, unemployment, and all manner of social disasters that would have destroyed the legitimacy of a Western government. Even democratically-elected rulers have little to fear from AIDS. Governments in Zambia and Kenya may be voted out of office, but political crises brought on by AIDS, or by their mishandling of the epidemic, will have little to do with it.

The devastation caused by AIDS--the number of people lost, the trauma, and the impoverishment--is, in some ways, little different from the impacts of misgovernment over the years. Africa's leaders have learned that disorder can be a political instrument--that where the social and political infrastructure is limited, opposition cannot sustain sufficient organization to unseat a ruler who floats above the turmoil and deprivation. Why should HIV/AIDS be any different?

Uganda's President Yoweri Museveni has been particularly masterful. He has not only presided over Africa's first national generalized AIDS epidemic, but also has turned it to his political advantage. Just how and why Uganda managed to turn the corner in reducing HIV prevalence some 10 years before any other country in sub-Saharan Africa remains a mystery. Perhaps it was the unique trajectory of this early and atypical epidemic, which began in the rural areas and spread to the cities, just as a return to peace meant that many urban dwellers were returning to the newly prosperous countryside as schools reopened and agriculture boomed. Quite likely, the national struggle against HIV/AIDS has been strengthened by the efforts of Uganda's civil leaders, notably singer Philly Lutaaya, who in an act of conspicuous personal courage played his last tour while visibly sick with AIDS, enjoining his audiences to stand together to fight the disease. Newly installed in power at the head of a revolutionary government, professor-turned-guerrilla-turned-president Museveni also led a remarkably energetic administration in his first few years--a characteristic of a liberation movement in power, before it becomes mired in the limitations of a centralist ruling style.

Whatever finally emerges from a full examination of the social epidemiology of AIDS in Uganda (a topic about which the Ugandan government discourages independent analysis), two things are clear; the first is that the Ugandan response and its success pre-dated any significant foreign spending on AIDS in the country. Incidence was reduced while national AIDS expenditures were less than US$10 million in total. Second, Museveni took the credit. Aid donors and public health activists needed an African "success story," and Uganda was not only Africa's first one, but for a long time, it was the only one. Cases such as Senegal where public policies had helped prevent an epidemic were, of course, much less visible. The AIDS-response industry needed Uganda, and Museveni needed their money and political endorsement, especially as he had no intention of relinquishing power. Speaking to foreign audiences, the Ugandan president is ready to credit his country's success in reducing HIV to whatever a particular donor is most interested in promoting. To evangelical Christians, he emphasizes abstinence and fidelity, to AIDS activists, he jokes about the number of condoms his country needs, and to European ministers of development cooperation, he stresses the integrated national AIDS program established by his administration. In return, the world has paid little attention to his government's single-party rule, military adventurism, and corruption.

Uganda's AIDS program is, in fact, an expression of Museveni's left-wing militarism. Like his fresh and radical plans for restructuring provincial governance to help his country emerge from the trauma of genocidal violence under his predecessors, Museveni's approach to AIDS was refreshingly frank and energetic. As with international audiences, his different policies targeted different groups. In the capital city, he provided a circumscribed liberal space of uncensored newspapers and resurgent university life--and also encouraged condoms. In the rural areas, there was an exercise in tight administration through implementation of a hierarchy of "resistance councils" and puritan moral standards, exemplified in the anti-condom campaigns, some of which were enforced with coercion. The centralized control of the national program in the presidency is less a vision of a comprehensive and coordinated program--Museveni has never in fact signed the most important pieces of legislation developed by his talented health administrators--than a determination to keep personal control of a crucial national asset. The Ugandan AIDS program has as much to do with the president's ambition to stay in power for life as with "best practice." AIDS has served Museveni extremely well in his quest for regime stability. Whether his regime in fact warrants the "success story" label is another matter: the last two years of HIV surveillance show that after fifteen years of decline, the incidence of the disease is sharply rising.

International Civil Society Activism

The fourth and last reason why African governments have stayed afloat and democracy has not been threatened under the onslaught of AIDS is indeed the most surprising and heartening. Left to their own devices, most African leaders would have followed the Cuban model of AIDS policy--compulsory testing and a denial of rights to those infected. Where such approaches have been possible, for example in armies, this model has more or less been adopted. Every African army that can do mandatory testing, does so, and most of them summarily decommission those found to be HIV positive. But national AIDS programs for the general population have not followed this path. True, stigma and discrimination persist, but official policies are consistently liberal. Civil society organizations are active in AIDS work. Legislation formally grants rights to people living with HIV and AIDS. A remarkable number of senior leaders speak frankly about the disease. And, year by year, the number of functioning democracies in Africa has increased and indicators of civil and political liberties are rising.

The reason for these encouraging developments is that the leadership in AIDS programming has allied with an international network of activists who have succeeded in influencing--and, in many cases, building--international institutions. The epidemic struck at a time of democratic transition and globalization. Partly because the existing institutions, most notably the World Health Organization, were so slow to respond, a new architecture was set up. New organizations, such as UNAIDS and the Global Fund to Fight AIDS, TB, and Malaria, have had their agenda set in significant part by civil society activists. That agenda has included a major focus

on human rights, including the right to privacy and voluntary testing. These organizations have also advocated protection of the rights of people living with HIV and AIDS (PLWHA), and participation of PLWHA in making policies that affect their lives, through, for instance, representation on the boards of UNAIDS and the Global Fund. This has been resoundingly successful. Some public health specialists would even argue that it has been too successful--an approach centered on individual rights may be more appropriate for the gay communities of North American cities than for the general population of an African country, where predatory sexual behavior by males is the driving force behind the epidemic. Respect for some of these personal freedoms in Africa merely becomes a cover for perpetuating gender inequities that deepen the vulnerability of women and girls to HIV. The global governance of the AIDS pandemic is liberal, both in its epidemiological individualism and its stress on civil liberties.

Africa's AIDS activists are globally networked and are part of this international phenomenon. While Uganda's first AIDS activists focused on mobilizing their local communities, the subsequent leaders of the movement have cultivated ties with international non-governmental organizations, multilateral institutions, and donors. While they may not get through the front door of the national ministries in their own capital cities, they are invited to meetings in Paris, Geneva, and Washington by Medecins Sans Frontieres, UNAIDS, or the Bill and Melinda Gates Foundation. Finding that the gates of foreign citadels are open to them, and that these geographically distant but more sympathetic institutions have the power of the purse over African governments, activists compel African leaders to take notice.

This is a circuitous accountability, which has the potential to turn the aid encounter into a force for human rights and political liberalism. Most political science analysis on the impact of aid dependence concludes that decreased governmental accountability is associated with increased reliance on foreign aid. During the Cold War, this was one of the major raisons d'etre for aid--to keep loyal governments in power whatever their citizens thought about it. Well-intentioned aid, famine relief for example, has too often had the similar effect of immunizing a government from the pressures of its citizenry and providing band-aids to problems that demand policy changes. The prospect of aid-for-AIDS dependence could be frightening, with entire nations relying on the largesse of foreign donors for the drugs that keep millions of their citizens alive. But thus far, the way in which the international aid apparatus has become more transparent and accessible means that new tracks of accountability have emerged, leading to new pressures for respect of rights.


The entrenchment of civil society and human rights is an unsung victory for the global AIDS community. This is neither an even nor an assured success; there are still huge problems of denial and stigma to overcome, but this activist revolution has come further and faster than we would have imagined a decade ago. And there is no question that this has had wide ramifications for the protection and promotion of democracy in Africa. The specter of AIDS-prompted governance regression has not occurred.

Activism's greatest successes have been in the field of treatment. In retrospect, there are reasons that make treatment access the obvious locus for a breakthrough in activist effort: there are constituencies that stand to benefit and can be organized (PLWHA, health professionals), and the responses are concrete and measurable. But the scale and expense of treatment means that even five years ago, the level of today's access to anti-retroviral therapy was considered an impossible challenge in poor countries. Targets for three million people in the developing world to be on AIDS treatment by the end of 2005 were not met, but the scale-up of treatment has nonetheless been impressive. Most importantly, the tenfold increase in funding for AIDS has changed entirely the landscape of possibilities for global health efforts.

Future Challenges as a Political Task

The next big challenges for AIDS--prevention of HIV infection and care for the sick and orphans--present greater difficulties. The political incentives for action are harder to grasp, as the constituencies are less easy to identify and mobilize, and measurements of success are much more difficult to obtain. HIV incidence is nowhere monitored so it is perhaps unsurprising that reducing it has not, in reality, been a priority for governments or international agencies. The main lesson of the last five years is that astute political engineering is the key to success. Overcoming AIDS and its dire consequences is as much a task for social and political scientists as it is for physicians and epidemiologists.

ALEX DE WAAL is program director at the Social Science Research Council and a lecturer on the Department of Government, Harvard university. He is the author of AIDS and Power: Why There is No Political Crisis--Yet.


Although it kills one in six African adult, AIDS has not had the sociopolitical consequences that academics expected. A partial explanation for this is provided by the consolidated results of 15 independent surveys conducted in South Africa, shown above. Of those asked to list Africa's most important social issues, only 12% mentioned AIDS, and many more respondents named crime and employment as problems.


Afrobarometer 2002

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