AIDS and Power: Why There is No Political Crisis - Yet

One in six adults in sub-Saharan Africa will die in the prime of his or her life of AIDS. AIDS and Power explains why social and political life in Africa goes on in a remarkably normal way, and how political leaders have successfully managed the AIDS epidemic so as to overcome any threats to their power. Partly because of pervasive denial, AIDS is not a political priority for electorates, and therefore not for democratic leaders either. AIDS activists have not directly challenged the political order, instead using international networks to promote a rights-based approach to tackling the epidemic. African political systems have proven resilient in the face of AIDS’s stresses, and rulers have learned to co-opt international AIDS efforts to their own political ends. AIDS and Power concludes that without political incentives for HIV prevention, this failure will persist.

7 Responses to “AIDS and Power: Why There is No Political Crisis - Yet”

1. Tony Barnett:

January 23rd, 2007 at 11:31 am

Since the publication of his important book “Darfur: famine that kills,” first published in the 1980s and republished in a revised edition in 2005, Alex de Waal has taken a critical and original attitude to many African issues. Indeed, Darfur reoriented thinking about the nature of food aid and famine relief for a whole generation of people working in the famine relief business. Now, in his new book, AIDS and Power, he has engaged with a very serious debate–the question of whether the HIV/AIDS epidemic really presents a threat to state stability and security in Africa or anywhere else.

The question is important because a number of influential commentators have suggested that the epidemic would have serious and adverse implications for state functioning and might even constitute a threat to security. Thus in 2003, the Pretoria-based Institute for Security Studies predicted that the severe social and economic impact of HIV/AIDS, and the infiltration of the epidemic into the ruling political and military elites and middle classes of developing countries may intensify the struggle for political power to control scarce state resources. Such dynamics, even singularly, have the potential to lead to political instability. Some of the more extreme predictions have come from within US administrations. For example: “AIDS, other diseases, and health problems will hurt prospects for transition to democratic regimes as they undermine civil society, hamper the evolution of sound political and economic institutions, and intensify the struggle for power and resources.”, and also an early assessment from the National Intelligence Council.

In AIDS and Power, Alex de Waal shows that the situation is much more complex. Above all he concludes that: “. . .the HIV/AIDS epidemic itself does not threaten African political systems. Governments and institutions are designed to handle threats to their survival, and HIV/AIDS has turned out to pose a political threat no greater than familiar pathologies such as hunger and homelessness. AIDS has been politically domesticated.” Similar conclusions are accumulating around this question, for example in the recent paper by Feldbaum, Lee and Patel and in a 2006 report to UNAIDS .

2. Alan Whiteside:

January 23rd, 2007 at 4:31 pm

The first draft of AIDS and Power contained many ideas that need to be developed and refined. I read it and spent an afternoon talking to Alex de Waal, author about it. I wondered how on earth he was going to turn this mass of material into a coherent book, especially in the impossible time constraints he seemed to have set himself. Plus, and in parallel, life was continuing with a move from living under the Blair regime to the Bush regime, (albeit in the little haven of liberal democracy of Boston), pand there was Alex’s engagement in the Dafur peace process. To his credit Alex managed to produce, with a little bit of help from his friends, an immensely readable and deeply interesting book.

It is also rather depressing. A few months ago a book I was involved in co-editing came out (Anne C. Conroy, Malcolm J Blackie, Alan Whiteside, Justin C. Malewezi and Jeffrey D. Sachs (eds) Poverty, AIDS and Hunger Breaking the Poverty Trap in Malawi, Palgrave, Basingstoke, 2006). Although my co-editors desperately try to find good news for the catastrophic little country that is Malawi, it was clear they battled. The book was originally to be called the ‘Perfect Storm’ as it describes the co-incidence of over exploitation of the country, rising population, political misrule, donor dependence, climate change and AIDS. In AIDS and Power Alex articulately sets out to explain why social and political life in Africa go on in a remarkably normal way. I think he is right in that life goes on, the question is what is normality? Again personal experience kick in. As a South African I have expected to talk about crime at dinner tables for many years now. What is new is that we now talk of death and orphaning in the same way. This is not normal. The orphaning is cumulative, this too is not normal.

AIDS and Power is a useful start, but it really must be a case of watch this space. Read it in conjunction with Peter Gill, Body Count, Profile Books 2006 and William Easterly, The White Man’s Burden’ Oxford 2006. At the end of this the choice is reach for the Prozac or become a revolutionary.

3. John R. Talbott:

February 21st, 2007 at 6:32 pm

I just returned from two months in Botswana where I was trying to learn more about the country’s reaction to HIV/AIDS. At first, I thought I had gotten off the plane in the wrong country. I knew that one third of the adult population was infected, and yet there was little mention of the illness on TV or on billboards. I asked my cab driver if Botswana people used condoms and he told me married couples did when they wanted to avoid pregnancies, a use I must admit I had utterly forgotten about.

How can a country that is one third infected with a deadly virus function normally? This is one of the key points of Alex de Waal’s new book. Experts have not only been wrong about how destructive the virus will be to political institutions, they have been dead wrong about how to contain it. To date, much of the effort has been on treatment with little energy or thought applied to not only prevention but cessation of the virus. Part of the fault lies with the international aid community whose NGO’s are poorly organized to lead a thorough fight against such a devious foe. NGO’s piecemeal approach to care will never be sufficient to successfully defeat such an infectious virus unleashed on the general population. Someone has to organize a wide-ranging long term well planned effort with all parties accountable.

I was shocked that most everyone I spoke with had a brother or sister or child who had died from the illness. My immediate reaction was to ask if they had ever thought of marching on their government plaza. Maybe because of a history of paternalistic chiefs or maybe because of their dominant one party system of democracy, the idea never struck them.

4. Peter Baldwin:

February 26th, 2007 at 10:32 am

Americans have, on average, among the lowest life expectancies of any industrialized nation. Why? In part, because they are obese, smoke and are overly sedentary. The CDC reported in 2004 that as many as 400,000 deaths annually were related to obesity. Is it likely that a political movement will arise that will topple our elected government for failing to prevent widespread adiposity?

We are perched on the cusp of an accelerating warming trend, largely due - it would appear - to human activity. The US is among the worst offenders on a per capita basis in the developed world. We do not use energy particularly efficiently and this may help precipitate major change and even catastrophe within our children’s lifetimes. Is it likely that a political movement will arise toppling our elected government for failing to treble gasoline prices, ban SUVs, mandate nonincandescent lighting, and whatever else it will take to reduce our carbon output?

The answer in both cases is, of course, no. And the reason is that neither issue is seen as touching the fundamentals of our political system and, indeed, the first isn’t even seen as a political issue at all. Both involve behaviors that we like and are unlikely to give up except by some combination of encouragement, hectoring, persuasion, pricing and possibly regulation. We like stuffing our faces and driving big, overpowered, air-conditioned cars. We are unlikely to revolt because the authorities don’t prevent us from indulging ourselves. Quite the contrary, we are much more likely to protest when and if they try to do something about it.

Illness, especially illness that is largely dependent on voluntarily adopted behaviors, has never been the source of political action. Even illness that is as purely transmissible as possible, and thus largely outside the control of the individual, has rarely, if ever, been a political problem in the modern world. In 1918, the influenza pandemic was the result, not the cause, of political turmoil. One of the few instances of political unrest associated with disease was the antivaccinationist controversies of late 19C Britain, which brought massive protest to the streets of Leicester and other cities. The protesters, however, were not objecting to governmental inaction. On the contrary, they were those deluded fools who resisted the authorities’ implementation of the single most effective allopathic medical intervention ever created: vaccination. Their descendants, incredibly, still populate North London and contribute to the letters column of the Guardian.

AIDS is especially prevalent in Africa and has become a heterosexual epidemic there in large measure because of particular forms of behavior. Both men and women are more likely than elsewhere to have multiple ongoing sexual relationships. The avenues of transmission are thus more smoothly paved than other parts of the world where either actual monogamy (even where some men get small local monopolies) or serial monogamy (the developed world) holds sway. Of course, there are background factors that help explain why only in Africa has AIDS become a heterosexual epidemic: the economic necessity that force men to migrate to cities and work, leaving women behind; the patriarchal attitudes that condemn women to dependence on their husbands and families; the economic distress that impedes basic sanitation and the like. But there are lots of places that suffer from similar problems without having succumbed to AIDS to the same extent. Ultimately, AIDS is not a disease caused by poverty, gender disempowerment or social dislocation. Its epidemic spread is caused by transmissive behavior, either drug injection or, more importantly in the African case, sex of certain sorts.

De Waal’s central problem is: Why has the AIDS crisis not caused a major political upheaval in Africa? It seems to me that the real mystery is, why would one expect it to do so in the first place? AIDS is the result of behaviors that are enjoyed, considered natural and obvious, and whose enforced removal or change would be resisted–much like overeating and slothful energy usage in America.

5. Pieter Fourie:

February 27th, 2007 at 1:33 pm

Since HIV and AIDS first made headlines in the early 1980s Political Scientists in South Africa and elsewhere have been remarkably reticent to view the pandemic as a topic for serious study. There are several possible explanations for this: the associated behavioural aspects may seem to fit more comfortably with Epidemiology, Anthropology or Sociology; in this country the local epidemic’s nexus with culture, race and gendered realities made it too much of a political hot potato to start with; and the main discourse until recently seemed to be driven mainly by ‘numbers’ epistemic communities such as Economics, Demographics or Actuarial Science, who are most concerned with conclusions regarding sectoral or aggregate impact analyses.

However, at the turn of the millennium this changed dramatically: the United Nations Security Council declared AIDS a global security threat, passed resolutions to that effect, and since then a sweeping narrative has been constructed to securitize the pandemic. Enter Political Science. Emboldened by the context and funding opportunities created in the wake of 9/11, AIDS took its place alongside analyses of other health threats, terrorism and weak states as the key longer-term threats to global stability. The tacit and increasingly explicit premise has been that the pandemic would in itself become a vector for state fragility. This master narrative has concluded that AIDS will ‘reverse Max Weber’, erode states’ monopoly on violence, undo economic development gains and emasculate government capacity to such an extent that it would be only a matter of time until states with mature epidemics implode altogether.

In this book, Alex does what few have done before him: he moves beyond the assumed polemic, separates ideologically infused doomsaying from the available empirical evidence and bases his conclusions on what we actually know about the impact of AIDS. What he finds is surprising and deeply counter-intuitive: for now there simply is no evidence to suggest that AIDS by itself is causing political crises. This is not simply fringe-talk–note the two qualifiers in the sentence above: ‘for now’ indicates that we are only 25 years into the AIDS pandemic, which is a long-wave event that will probably take around 130 years to fully manifest. The second qualifier, ‘AIDS by itself’, emphasizes the exceedingly complex nature of this pandemic: it is nigh impossible to separate AIDS from other socio-political factors as an independent variable when drawing conclusions about long-term impact.

We simply do not yet have a sufficient understanding of the dynamics associated with the pandemic to draw definite conclusions about what AIDS by itself is or is not doing within broader global and domestic political contexts. Alex thus warns that the pandemic is even more insidious and complex than previous analyses would have it. These are early days for Political Science’s interaction with HIV and AIDS. Most importantly, we should guard against the push by proponents of the ‘Geneva consensus’ to come to definitive conclusions about AIDS, as this will foreclose more granular and nuanced analysis as the pandemic manifests in different contexts, and at different levels of analysis.

Broadly speaking there are two kinds of useful books that are written about AIDS. The first include those that serve to clarify the master narrative, pointing out syntheses in thinking and showing readers where the main discourse is heading. These books are valuable in that they simplify the hugely contested (and therefore exceedingly political) discursive environment. The great majority of AIDS watchers and analyses fall into this category. The second kind of book is much rarer: it challenges existing discourses, introduces novel ways of viewing the pandemic and may, at bottom, lead to Kuhnian revolutions. Alex’s book falls into the latter category, and my prediction is that it is set to become the progenitor of significant and fascinating new conversations within the larger global AIDS ‘dialogue’.

6. Francoise Nduwimana:

March 5th, 2007 at 4:19 pm

Alex de Waal’s book provides an extraordinary occasion to enhance our analytical skills on AIDS in Sub-Saharan Africa. His greatest contribution in this regard is his home based perspective, which questions the responsibility of African leaders, and therefore, emphases on both internal and endogenous factors for the African failure to address AIDS.

First, I underscore his efforts to analyze the various forms of what he qualified as “denying AIDS”, from an anthropological perspective, and his attempt to include gender dimensions. I also share many of his critiques on the limited democratic development in African countries.

Second, his contribution presents entry points for further research. While reading his book, some questions grew in my mind. They include:

  1. Even if the book borrows from the Afrobarometer surveys, the analysis is heavily centered on the South African experience, which could be interpreted by many as a particular case. For example, TAC is the only social and activist movement the author referred to as a civil society mobilisation and answer to the AIDS crisis. For evident reason that the author himself pointed out, the recent history of the liberation of South Africa leads us to understand why TAC hasn’t chose the confrontation strategy.

  2. Then my question becomes: “Why the author didn’t complete the assessment with structural external factors of the AIDS crisis?” as did Stephen Lewis in his book, “Race against Time”? De Waal seemed to confirm that, by focusing too much on the right to ART, Aids activists have abandoned the crucial issue of prevention. This is questionable. The overall experience is that African countries have developed very strong and proactive prevention programs. In many countries, media, women movement, youth associations, stars, artists etc., play a key role in prevention campaigns. However, these initiatives do not reach the envisaged results. Such outcome should then lead to the structural interpretation of this failure. Thus one could see that the root causes go beyond the lack of will from African leaders. For instance, the questionable position of President Museveni (Uganda) with respect to the ABC model, and the controversial position of the South Africa President Thabo Mbeki should not be generalized to all African countries.

  3. The author’s main question is why such unprecedented disaster has not yet led to a political crisis? One could question the meaning of “political crisis” in the book, because it seems to be limited to the capacity of citizens regrouped or not in organizations to keep the issue of HIV/AIDS on the political party platforms or government priorities. Moreover, according to the author, so long as Aids is not included in electoral contests, there is little chance to overcome it. While I agree with the fact that African leaders should be more committed to addressing the disease and be accountable to citizens on that matter, there is no evidence based demonstration that putting AIDS in the debate and framework of electoral process will lead to positive results. . The problem is much more complex and both citizens and politicians are aware that overcoming AIDS will require time, substantive and sustainable resources, international commitment, and decisive political will for structural changes.

  4. I totally share de Waal’s disappointment with respect to the persistent difficulties of citizens to see AIDS considered as a priority by politicians. Further research may look at the psycho-social dimensions of denying AIDS. Moreover, it would be useful to examine the extent to which the use of metaphor language has influenced the resistance to talk openly about AIDS.

  5. Finally, de Waal has attempted to include gender dimensions. However, he did not enough explore the anthropological, sociological and political dimensions of gender relations. To his question: “why there is no political crisis yet?” one should add, “Who is mainly affected by the AIDS crisis, its factors, its causes as well as its consequences? Who is caring for the orphans and sick persons? Who is paying the biggest tribute to the society?” De Waal agreed that “Without publicly audible complaint, rural women bear burden of the disease shifted onto them by others” (page 91). I would strongly suggest a deeper research on Gender, Aids and Power. I think that it is time to seriously analyse the extent to which anthropological and sociological gender relations intervene in the practices of politics, which tend to exclude women’s perspectives in addressing major challenges such as the one posed by AIDS. If overcoming AIDS is inconceivable without more political will, it is also right to say that it is impossible without changing political practices, which include those women perspectives. In addition, changing political practices is not just a matter of gender parity. It requires fundamental changes in the role of States and governments vis a vis to citizens, which could be achieved if donors and governments agree on the fundamental needs of people. May be the Afrobarometer surveys should, in the future, target politicians, national leaders and donors, and ask them, what they intend to put on their agenda in terms of socio-economic and political priorities? If they point out AIDS as the top priority, then the next questions would be How concretely are you going to proceed for overcoming AIDS? Do you think that women are part of the solution?

Let’s dream of the answer, hoping that it will be structural as well as articulated on gender balanced power.

7. Ann Swidler:

March 6th, 2007 at 5:33 pm

Wow! This is a courageous–even radical, fascinating, and frustrating book. It is as if the drive that propelled Alex de Waal’s HIV/AIDS activism–his impassioned, clear-eyed, indignant humanitarianism–has run headlong into a bog of muddy, difficult evidence. The fascinating and courageous part of AIDS and Power is that de Waal takes this evidence seriously, even though it flies in the face of the doomsaying that has been the stock and trade of AIDS advocates for a decade. The frustration is that, seeing that expectations about AIDS-induced collapse and chaos haven’t (for now, as Pieter Fourie notes) proved true, he doesn’t quite take the next step.

Alex de Waal deserves real credit for recognizing these unsettling realities–unsettling because the global AIDS community has been shouting that the sky is falling. But what else can we learn from his insights?

None of the Existing AIDS-Prevention Approaches Have been Shown to Work

In at least two places de Waal acknowledges what the AIDS establishment has almost never dared say: he notes that holding politicians accountable by measuring success and failure in AIDS prevention “assumes, of course, that AIDS ‘best practices’ actually work–an assumption with rather little evidence to support it” (pp. 109-110). Later he puts this disturbing thought even more strongly: “Governments and institutions don’t know how to reduce HIV infections and are not subject to political pressures and incentives to make them learn…. We know very accurately the effects and side-effects of ARVs but we have no idea whether decades’ worth of AIDS education messages have any impact at all” (p. 122).

What are we to make of this? In part de Waal is pointing to the difficulty of measuring HIV national-level HIV incidence–the proportion of a population newly infected–to assess whether prevention approaches have worked. (Indeed, it is only now, with the advent of simpler HIV tests that accurate estimates of HIV prevalence are emerging; measuring incidence for representative national samples would require very expensive, cumbersome longitudinal surveillance in which large, representative samples are tested repeatedly to track new infections.) But HIV incidence is sometime measured in random clinical trials of particular prevention interventions. And those careful trials–as well as larger patterns of prevalence–show remarkably few successes and an astounding number of failures.

Prevention approaches like “safe sex” and condom use, which proved effective in high-risk communities that used moral solidarity (as in gay male communities) or public-health and police surveillance (as with Thai or Senegalese sex workers) to achieve near universal condom use, have failed miserably to halt or even slow HIV infection in generalized sexual epidemics like those in Africa (see Hearst, Norman and Sanny Chen (2004), “Condoms for AIDS Prevention in the Developing World: Is It Working?” Studies in Family Planning 35(1): 39-47; and Kajubi, Phoebe, Moses Kamya, et al. (2005), “Increasing Condom Use Without Reducing HIV Risk: Results of a Controlled Community Trial in Uganda.” JAIDS Journal of Acquired Immune Deficiency Syndromes 40(1): 77-82). De Waal correctly notes that Botswana, wealthy and well-governed, where political leaders have taken the fight against AIDS seriously and followed the advice of the international public health community, has thus far had no success in reducing HIV prevalence.

Other interventions that seem logical, or even essential, to activists and public-health experts from the Global North also have very mixed or negative records of success in careful clinical trials when actual HIV incidence is the measured outcome: This includes programs to empower women or to supplement their incomes (perhaps not surprising given that wealthier countries and wealthier strata within countries have higher HIV prevalence [see Shelton, James D., Michael M. Cassell, et al. (2005) “Is poverty or wealth at the root of HIV?” The Lancet 366: 1057-1058]); the provision of Voluntary Counseling and Testing; and mixed records even for interventions that biological and epidemiological evidence suggest should work, like treatment of STIs to prevent HIV transmission. Frequently one study shows strong positive results, but many later studies of the same intervention have null or even negative findings.

In a devastating sentence, well worth reading twice, de Waal says, “The prematurely achieved and unobjectionable consensus that is the stock-in-trade of international agencies is an obstacle to the kinds of inquiry and debate that are necessary” (p. 122, my emphasis). Years ago James March and Johan Olsen developed the “garbage can model” of organizational decision-making. They observed that organizational actors, rather than defining problems and seeking solutions, often had favored solutions already available, and then those solutions were tacked on to available problems. In response to the AIDS crisis, activists and funders from the Global North have promoted their own favored solutions: human rights; empowering women; condoms and reproductive choice; abstinence and sexual restraint; drugs and the quest for a vaccine or microbicide (or even revolutionary social movements of the sort we children of the sixties admire), assuming that what has been so important for us, like growing equality for women or the ability to make choices on the basis of full information that VCT promises, must also be critical in preventing HIV.

There have been successes, but a hard truth–that de Waal’s bold book only begins to explore–is that thus far most public health research and most activist intervention has been powered more by our own moral imaginations than by the systematic search for effective prevention approaches. Those like Daniel Low-Beer and Rand Stoneburner, who have carefully studied the Ugandan case, keep pointing out that partner reduction–the “zero grazing” and “love faithfully” campaigns–played the most important roles in bringing down HIV prevalence in Uganda. And for years, several researchers have been pushing the international public health community to take seriously the overwhelming body of evidence that male circumcision is a powerful factor explaining existing variations in HIV prevalence (see Halperin, Daniel T. and Robert C. Bailey (2000), “Viewpoint: Male Circumcision and HIV Infection: 10 Years and Counting.” The Lancet 354(9192): 1813-1815). Now that three randomized clinical trials have shown a protective effect of male circumcision of about 60% for female-to-male transmission, and an additional protective effect reducing male-to-female transmission even when a man is HIV positive, there are indications that the public health community is about to move forward on adding male circumcision to the array of intervention options. But I would hazard that neither promoting fidelity (”zero-grazing” is precisely the strategy that would reduce the concurrent partnerships that are now thought to be so central to Africa’s generalized heterosexual epidemic) nor promoting male circumcision fires the moral imagination of AIDS activists, or even public-health officials, in the ways that promoting human rights, or safe sex, or the empowerment of women does. So if Alex de Waal’s important book is to stimulate a major rethinking of our stance towards the AIDS epidemic in Africa, we have to reconsider our own social imaginations as well.

Aids and Power Book Cover