AIDS in Africa: Coping with Crisis

AIDS in Africa

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In the fifteen years after Africa’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 estimations were that it was impossible for more than ten per cent of the adult population to become infected. This ceiling was soon broken, hitting 20 and then 30 per cent, with some populations even pushing 40 per cent, at which point the lifetime chance of a teenager contracting and dying from the disease is almost 100 per cent. Life expectancy crashed in a manner unprecedented for a peacetime population, with some southern African populations seeing expected longevity plunge from about sixty years to less than forty.

Scholars of historical calamities observe that one disaster often portends a second one. What else might AIDS bring in its wake? Economists projected that the loss of national income due to AIDS could send some economies into a tailspin – “Adam Smith in reverse” is how Malcolm McPherson of the Kennedy School at Harvard described it. Management specialists expected that loss of skilled workers would result in essential services such as schools and clinics—not to mention armies and police forces—grinding to a standstill. Drawing upon studies of how rural people survive famines, I coined the term “new variant famine” in 2002 to describe the vicious interaction of drought and AIDS unfolding in southern Africa at the time, arguing that households hit by the disease would be unable to cope with the extra demands for coping with 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”?

Many of these fears are indeed materialising. Others still loom. But some have been proven unfounded or at least exaggerated, diminished to manageable proportions. Foremost among the dire mis-predictions has been that 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 isn’t indicated in their etiology.

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 to a population. That position is occupied by unemployment, poverty, famine and crime depending on the country in question. Although “health” occasionally makes it 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, and in South Africa, the ruling African National Congress were returned 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 which organises them has no counterparts elsewhere in the continent. Also, 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 their errant colleagues back to the right path.

Why is it that a disease that will kill one in six adult Africans, and more than half in the continent’s six southernmost 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 One, and has been over a much longer period than those four years of war. But while France was traumatised by the death of so many young men, political life in Africa continues in a remarkably normal way. Most notably, democracy is actually spreading.

A large part of the answer to this conundrum lies in denial. From the earliest days of AIDS, some individuals have struggled with the reality of infection with a sexually transmitted disease for which there is no cure. This remains common. But collective denial—as happens when an entire society refuses to contemplate a disturbing reality—is a level beyond. As Stanley Cohen notes in his analysis of the ways societies deny their culpability for genocide, one often finds the construction of an alternative reality in which people attempt to keep key social and moral frameworks unchanged. A severely AIDS-impacted community in southern Africa faces a similar challenge: how to maintain a social order based on lineage and ancestorhood when so many people are dying of a “bad” disease with their life-cycle 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 neighbours 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 encourage protection against HIV are based on a straightforward and rather paternalistic model of public education. The same simple messages are broadcast on all possible media. But for publics accustomed to state-controlled media, and therefore used to screening out official commands to be more patriotic and vote the president in (again), exhortations from on high to abstain or be faithful are unlikely to make much of an impact. More effective is to make AIDS the subject of popular debate by keeping it in the news and stirring controversy. People trust a high-quality and independent media. People talk about the news, 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 which is overcoming denial.

A second explanation for the persistence of political normality is that, unfortunately, we have yet to see the worst. AIDS is a long wave event: 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 further.

Nonetheless, AIDS is causing a number of visible problems for African governments, both authoritarian and democratic. Many of the problems facing functioning democracies are being studied in an ongoing research project by Kondwani Chirambo at the University of Cape Town. These include the need to update voters’ rolls more regularly to ensure that deceased voters are removed and the need for special voting facilities for the sick and their carers. An increased number of by-elections due to more MPs dying puts financial strains on first-past-the-post electoral systems and, in African political systems, also advantages the incumbent because the ruling party is better able to find the resources necessary to mount by-election campaigns. But these are manageable problems, not an overwhelming crisis.

But this could get worse. Cautiously, I added the last word “yet” to the title of my book AIDS and Power: Why there is no political crisis – yet. Arguing that the prediction of doom has yet to be refuted (if, indeed, it is refutable) fails to do justice to the intriguing complexity of what is going on.

More significant is the third part of the explanation, namely, that African governments are expert at managing multiple crises and even turning them to their advantage. There’s a rich literature on ways in which 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. The devastation caused by AIDS—the numbers of people lost, the trauma and the impoverishment—is in some ways little different from the impact of misgovernment over the years. Africa’s big men have learned that disorder can be a political instrument – that where the social and political infrastructure is limited, opposition cannot sustain sufficient organisation 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 AIDS epidemic but has turned it to his political advantage. Just how and why Uganda managed to turn the corner in reducing HIV prevalence some ten 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 efforts of Uganda’s civil leaders were instrumental – notable among them the singer Philly Lutaaya who, in an act of conspicuous personal courage, played his last tour visibly sick with AIDS and enjoined 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 liberation movements in power—before becoming 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 into 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 $10 million in total.

Second, Museveni banked 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 actually prevent an epidemic were, of course, much less visible. The AIDS 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 tailor credit for his country’s success in reducing HIV to the donor of the moment. To evangelical Christians he emphasises abstinence and fidelity; to AIDS activists he jokes about the number of condoms his country needs; to European ministers of development cooperation he stresses the integrated national AIDS program located in his own presidential office. 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, a piece 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 are targeted to different groups. In the capital city, he has provided a circumscribed liberal space of uncensored newspapers and resurgent university life – and has encouraged condoms. In the rural areas, there is an exercise in tight administration through a hierarchy of “resistance councils,” and puritan moral standards including campaigns against condom use are enforced, sometimes with coercion.

The centralised control of the national program in the presidency is less the 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, incidence is sharply rising.

There's a forth and final reason for African governments' apparent ability to survive the AIDS crisis – one which is, oddly enough, quite 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 is more or less what has happened. Every African army that can do mandatory testing does so, and most of them summarily decommission those found to be HIV positive.

But, surprisingly, 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 organisations are active in AIDS work such that legislation formally grants rights to people living with HIV and AIDS. A remarkable number of senior leaders speak frankly about the disease and, year on year, the number of functioning democracies in Africa has increased and indicators of civil and political liberties are rising.

The reason for this encouraging conjunction of circumstances is that the leadership in AIDS programming has lain with an international network of activists who have succeeded in penetrating—and indeed in many cases building—international institutions. The epidemic struck at a time of democratic transition and globalisation and so, because the existing institutions, most notably the World Health Organisation, were so slow to respond to the AIDS epidemic, a new architecture was set up.

New organisations like 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, voluntary testing, the rights of people living with HIV and AIDS (PLWHA), and the participation of PLWHA in making policies that affect their lives including representation on the boards of UNAIDS and the Global Fund. This has been resoundingly successful.

Africa’s AIDS activists are globally networked and are part of this international phenomenon. While Uganda’s first AIDS activists focused on mobilising their local communities, the subsequent leaders of the movement have cultivated ties with international non-governmental organisations, multilateral institutions and donors. While they may not get through the front door of national ministries in their own capital cities, they are invited to meetings in Paris, Geneva or Washington DC by Médecins Sans Frontières, 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 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 analyses of the impact of aid dependence conclude that governments become less accountable to their citizens the more they rely on foreign aid. During the Cold War, this was one of the major raisons d’être for aid, to keep loyal governments in power whatever their citizens thought about it. Well-intentioned aid, for example for famine relief, has too often had a similar effect of immunising a government from the pressures of its citizenry, providing band-aids to problems whose solutions demand policy changes. The prospect of aid-for-AIDS dependence could be frightening indeed: 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 has meant that new tracks of accountability have emerged leading to new pressures for respect for 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 spectre 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 organised (PLWHA, health professionals), and the responses are concrete and measurable. But the scale and expense of treatment needs meant 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 on AIDS treatment by the end of 2005 were not met, but the scale-up of treatment is nonetheless impressive. Most importantly, the tenfold increase in funding for AIDS that has been unlocked has changed entirely the landscape of possibility for global health efforts.

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 less easy to grasp; the constituencies are less easy to identify and mobilise; and the measurement of success is much more difficult. The key lesson of the last five years is that getting the political engineering right is the key to success. Overcoming AIDS and its dire consequences is a task for social and political scientists as much as for physicians and epidemiologists.

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