Politics and Policy of HIV/AIDS

Alex de Waal has written an incisive new book called AIDS and Power. De Waal raises a number of difficult questions about the adequacy of the present approach to HIV/AIDS. One of the main questions de Waal grapples with is why AIDS has had such a limited political impact in Africa. Given the scale of the epidemic, he is surprised by public opinion data from a 2002 Afrobarometer survey that found that AIDS is not a particularly high priority for African publics. De Waal also is skeptical about the adequacy and the form of AIDS treatment and prevention programs.

Part of his book is a lament about the pitiable state of African health systems. He writes that the key obstacle ” to any control-based public health response to AIDS is that few if any African states have the capacity and legitimacy to implement a ‘normal’ public health response to HIV/AIDS of the scale and intrusiveness required” (53). De Waal once wrote how AIDS might threaten the stabiity of African governments, but much of this short book is about how AIDS is being managed by African governments in ways that may do little to lessen the impact of the disease but much to weaken its political importance. Chapter 4 is titled “How African Democracies Withstand AIDS” while Chapter 5 is titled the “Political Benefits of AIDS.” He writes how Uganda’s leader Yoweri Museveni has used the myth of his government’s successful response to AIDS as a way to stay in power and divert attention from the country’s misadventures in the Congo. He also raises the more difficult question about whether prevention programs like Uganda’s did or can work.

Echoing Helen Epstein’s work, de Waal writes that “It is sobering to reflect on the fact that Africa’s best-known ‘success-story’ began before the inflow of international aid for AIDS, before the national AIDS policies were adopted…” (118) He notes how difficult it is to know since prevention efforts would ultimately require data on HIV incidence, the rate of new infections. However, that is not easy or cheap to track so instead we’re reliant on tracking prevalence levels which may go down because people die before passing the disease on, not because prevention efforts succeeded. Moreover, prevalence levels may not go down in the future if more and more people are kept alive on ARV therapy.

The delivery of this ARV therapy is another subject of concern. Since most African governments are too poor and incapable of delivering these services themselves, we have what de Waal calls “Sub-Saharan Africa’s biggest-ever service delivery operation” that is being implemented by a “multiplicity of new actors.” De Waal suggests this is an important moment, “we are on the brink of an unparalleled life-controlling intrusion into African societies, and we just don’t know what it will look like” (115). It is unclear if the voluntaristic, NGO model of service delivery can work at scale or if more coercive efforts will be needed.

He is afraid that these service delivery models will be co-opted by the neo-patrimonial systems of governance that prevail in Africa, with service delivery being chanelled to the political allies of the powerful. In this, de Waal issues a warning, “Across Africa, people suspect that coercion is lurking, and retain a deeply embedded resistance to external citadels of expertise and their projects of extending bureaucratic power. The future AIDS response may be part of a project of liberalization-through-aid, but equally it could become another doomed-to-fail foreign intrusion or a prop to authoritarianism, an ally of the war-making approach to AIDS efforts” (121). While this book raises a number of deep and valid concerns, it is less clear how donors and Africans themselves should navigate this uncertain path. De Waal is both supportive and critical of the arrival of these new resources and actors, but he has left answers to his concerns for other books and other writers.

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Filed under: Politics and Policy