The African State and the AIDS Crisis

Amy S. Patterson

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780815397427
• eBook ISBN: 9781351147866
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Politics
• Index: Politics & International Relations

This edited volume analyzes African state responses to the AIDS epidemic. Institutionally weak, limited in resources and lacking power in the international system, the African state has been characterized as inefficient, corrupt and illegitimate. The volume questions how aspects of the African state have affected policy responses to AIDS. It highlights how African states must initiate, develop and/or implement the long-term policy solutions necessary to combat AIDS. It employs empirical studies from the international and national arena to illustrate why some African states have been able (and willing) to address AIDS while others have not. Contributions analyze how international actors, civil society organizations, state ideology, patriarchy and state capacity have influenced policies to fight AIDS. Examining AIDS policies through the prism of African state development and linkages to domestic and international actors, this book provides a nuanced understanding of the variety of responses to AIDS in Africa.

Chapter 1
Introduction: The African State and the AIDS Crisis

Amy S. Patterson

In July 2004, the Joint United Nations Program on HIV/AIDS (UNAIDS) reported that over the previous year, roughly five million adults and children were newly infected with the human immunodeficiency virus (HIV) that causes the acquired immunodeficiency syndrome (AIDS). An estimated 25 million adults and children are thought to be living with HIV/AIDS in sub-Saharan Africa. In the same period, over two million adults and children in the region died because of AIDS (UNAIDS 2004). This volume examines the role of the African state in addressing this crisis. Through the chapters, the book questions how the African state, which is usually seen to be institutionally weak, limited in resources, and lacking in international power, has responded to AIDS. The work broadly defines a state to include institutions, territory, laws, bureaucratic and military apparatus, and ideology (Englebert 2000,4).

As Boone and Batsell (2001) argue, political scientists have been noticeably absent from much of the analysis of AIDS in Africa.¹ Yet, because power, resources, ideology, and institutions shape policy making on HIV/ AIDS, any responses to the epidemic are intensely political. Through the contributions of African, American, and European scholars, this book examines the nexus between the African state and the AIDS epidemic. It questions how African state power in the international system, state dependence on donor resources, democratic and economic transitions, ideology, political culture, and state-civil society relations shape Africa's fight against HIV/AIDS. The chapters draw on several case studies to demonstrate the complexity and diversity of variables shaping the interface between AIDS and the African state.

The AIDS Epidemic in sub-Saharan Africa

The AIDS epidemic in Africa is characterized by its magnitude and its potential long-term impact on society, politics, and economics. With over 30 per cent of the people living with HIV/AIDS globally, southern Africa is the region most affected. As of 2004, HIV prevalence rates were approximately 37 per cent in Botswana and Swaziland, roughly 21 per cent in South Africa, and 24 per cent in Zimbabwe (UNAIDS 2004). The prevalence rates in East and Central Africa were not as horrendous, but roughly 13 per cent of citizens in the Central African Republic were estimated to be HIV positive. In West Africa, AIDS has manifested itself in a variety of ways. Senegal's HIV rate remains approximately 1 per cent, reflecting the country's early HIV-prevention and awareness programs. However, in an alarming trend, HIV prevalence among sex workers in Dakar and small cities has risen recently. In 2004, HIV prevalence rates were between 3 per cent and 4 per cent in Burkina Faso and Ghana, while the situation in Cote d'Ivoire and Nigeria was graver, with rates over 10 per cent in some parts of those two countries (UNAIDS 2003a, 8-12; UNAIDS 2004). In a hopeful sign, prevalence rates among 15 to 24 year old pregnant women in some cities have declined. For example, HIV rates fell to 8 per cent in Kampala in 2002 from 30 per cent a decade earlier; prevalence in Addis Ababa declined from 24 per cent in 1995 to 11 per cent in 2003. Despite the variation in HIV prevalence rates and some signs that the epidemic has reached its peak in some countries, 'The epidemic in sub-Saharan Africa ... remains rampant' (UNAIDS 2003a, 4).

However, these statistics only tell part of the story. In most countries, HIV rates in urban areas are higher than in rural areas, reflecting the migration of individuals into areas where they may lack social connections and often face economic insecurity. Without networks of family and friends to discourage risky sexual behavior, individuals are more vulnerable to contracting HIV. Yet, there are exceptions to the urban concentration of AIDS, such as the rise of HIV prevalence in small southern Nigerian cities and the similar urban and rural HIV prevalence rates in Swaziland (UNAIDS 2003a, 12). Additionally, areas with high cross-border trade and migration (and sex workers to serve these traders and migrants) often have higher HIV prevalence rates. For example, HIV prevalence is highest along Ghana's eastern border (GAC 2003). AIDS also has a gender bias in sub-Saharan Africa, where women are at least 1.3 times more likely to be infected with HIV than men. In 2004, UNAIDS reported that 57 per cent of those infected in sub-Saharan Africa were women (UNAIDS 2004).

AIDS is closely linked to inequality and poverty. Over 95 per cent of the HIV-positive individuals globally live in the developing world, with over two-thirds of these individuals living in sub-Saharan Africa. With an average life expectancy of 46 years, a gross national income per capita of $460, and a mortality rate of 171 deaths per 1,000 children under five years old, sub-Saharan Africa is the most impoverished region of the world. Poverty has led to reliance on foreign aid and indebtedness. In 2001, the region received $13.9 billion in foreign development assistance, while it owed $202 billion to bilateral and multilateral lenders. In the majority of sub-Saharan African countries, at least 50 per cent of the population lives below the national poverty line (World Bank 2003). These factors contribute to what Barnett and Whiteside (2002, 73) term 'risk environments', or social and economic environments in which an infectious disease can rapidly develop into an epidemic. Poverty increases an individual's vulnerability to HIV infection by decreasing access to good nutrition; by limiting access to health care such as prenatal care, HIV testing, and treatment for sexually transmitted infections (STIs); and by necessitating migration for employment. Poverty also makes it more likely that women will engage in survival sex to provide for their children and themselves (Whiteside 2002).

The neoliberal economic policies encouraged by the World Bank and International Monetary Fund have compounded the link between AIDS and poverty. By requiring a reduction in state employment and privatization of national industries, these policies contributed to unemployment. Unemployment is one factor in the risk environments for HIV, if men are forced to migrate far from their families to find jobs and women must turn to survival sex to feed their children. Neoliberal policies also have encouraged the introduction of user fees for education and health services, a factor which has made it more expensive for citizens to access these services. Yet primary health care is essential for preventing the spread of HIV, through HIV testing, prenatal care, and treatment for STIs.

Another consequence of the decline in state spending on health and education is that African states must rely more on international donors and nongovernmental organizations (NGOs) to provide basic human services. Reliance on these external actors has two consequences. First, the development of comprehensive AIDS policies has been made more complex, because NGOs and donors are outside the control of the state and may challenge state policies. For example, Medecins sans Frontières (Doctors without Borders) began to import generic drugs for AIDS patients into South Africa, despite state objections to the plan. While such actions are certainly important for providing individuals with access to needed medicines, they do illustrate the lack of coordination in AIDS programs and policies in Africa. Second, because of the large amount of funding they provide for AIDS programs, international organizations have played a key role in designing many state AIDS programs and decision-making institutions throughout Africa. For example, as Chapter 5 demonstrates, the Ghana AIDS Commission developed from consultations among UNAIDS, the UN Development Fund, and the US Agency for International Development; its initial funding came from the World Bank and the UK Department for International Development.

Neoliberal policies have sought to incorporate Africa into the global economy by liberalizing trade and encouraging foreign investment in the continent. Donors have increasingly focused on 'trade not aid' through legislation such as the US African Growth and Opportunity Act of 2000. To get the lower tariffs on textiles, agricultural products, and clothing that the legislation promises, African states have had to join the World Trade Organization and accept its related treaties. Though Africa's share of global trade is minimal, these trade agreements have had a disproportionate impact on the continent's ability to fight AIDS; the ability of African states to provide access to patented medications to treat AIDS and the opportunistic infections that accompany it has been hampered. Likewise, because of the focus on trade, African states have had to court international investment through promises of cheap, nonunionized labor. As Whiteside points out in Chapter 6, this type of foreign investment may increase the risk environments for the spread of HIV/AIDS.

The AIDS epidemic directly threatens African states. Without comprehensive, well-organized efforts, the epidemic will decrease life expectancy, decimate military forces, and challenge state efficiency. Economically, the epidemic threatens the advances in development that the continent has made since independence. The illness affects households, as families must sell assets such as land and livestock or use savings to pay for the increased costs of medicines and funerals. In the long term, households may be unable to recover because of these losses (Rugalema 2000). As the southern African humanitarian crisis illustrates, AIDS kills farmers, prevents adults from passing down knowledge on food production to future generations, and leaves families without labor, seeds, or savings which will carry them through periods of drought (New York Times, 19 November 2002). In several southern African countries, 60 per cent to 70 per cent of farms have suffered labor losses as a result of HIV/AIDS (UNAIDS 2003b). The outcome is that six million people in southern Africa needed food aid in 2003. Since 2002, food shortages have affected 14 million people in Lesotho, Swaziland, Malawi, Zambia, Mozambique, and Zimbabwe (UN Integrated Regional Information Network, 1 December 2003).

Because of the loss of productive labor in society, many scholars believe that AIDS will have a detrimental macroeconomic impact. For example, Botswana's economy may be 24 per cent to 38 per cent smaller in the next 25 years because of HIV/AIDS (Whiteside 2002). AIDS will cause governments to divert state expenditures from poverty alleviation and other social services to health care, and more specifically, to hospitalization of those with AIDS. The long-term cost of this diversion may negatively affect education, teacher training, and primary health care, at just the time when these services are most needed for African countries to prepare for the future and to prevent new HIV infections (Brown 2004). In 2003, economists at the World Bank and Heidelberg University predicted that because of HIV/AIDS, incomes in South Africa will halve over the next three generations and child labor will be ubiquitous by 2080. Because of the erosion of the country's intellectual capacity, South Africa faces an inescapable descent into economic backwardness (Bell, Gersbach, and Devarajan 2003).

Furthermore, the AIDS epidemic threatens to erode the ability of the state to provide order and security in society. Though admitting that data on HIV prevalence rates in African militaries is fraught with problems, Elbe (2002) illustrates the high levels of HIV infection among African militaries, with Angola and Malawi near 50 per cent; Zambia, 60 per cent; Zimbabwe, 55 per cent; and South Africa, 15 per cent to 20 per cent. AIDS is the primary cause of death among Congolese soldiers. These rates will have implications for staffing decisions and military preparedness, and they will necessitate additional military resources for recruiting and training soldiers to replace those dying of AIDS. In Chapter 8, Ostergard and Barcelo illustrate that the realization that AIDS may decimate the Ugandan military caused President Yoweri Museveni to reframe AIDS as a security issue. Likewise, the estimated 11 million African children under 15 years old who have lost at least one parent to AIDS will challenge the state's ability to promote security. By 2005, nearly one million South African children will be AIDS orphans. AIDS orphans are more likely to be depressed, to use drugs, and to be involved in crime (Schötenich 1999; Segendo and Nambi 1997). Lacking positive socialization experiences, these young people may contribute to societal instability; they may challenge the state's legitimacy, if it cannot address this growing problem. In 2001, the United Nations General Assembly Special Session on HIV/AIDS agreed that by 2005 all countries should work to implement comprehensive national programs to protect and support children affected by AIDS. Despite this pledge, almost no African country has a national orphan policy in place (UNAIDS 2003a).

State Actions on HIV/AIDS

Given the potential economic, social, and political challenges of the epidemic, what have African states done to fight HIV/AIDS? For many state leaders, the initial response to the news that AIDS existed inside their territories was denial. For example, Kenya's President Daniel arap Moi stated that the foreign press was conducting a hate campaign against his country when it reported in 1985 that Kenya had 20 AIDS victims (Fortin 1987). The King of Swaziland only declared the HIV/AIDS epidemic a national disaster in 1999, after the UN Children's Fund published a report in the Times of Swaziland on the likely long-term negative impact of AIDS on the society (Daly 2001). As Furlong and Ball illustrate in Chapter 7, the apartheid regime in South Africa tried to downplay AIDS by portraying it as a disease that only infected 'deviant homosexuals'. On the other hand, President Museveni of Uganda admitted the presence of HIV/AIDS in his country when he came to power in 1986. He cooperated with the World Health Organization's Global Program on AIDS to develop comprehensive prevention programs. He also publicly discussed the disease, urging abstinence and monogamy. Low-Beer and Stoneburner (2004) maintain that part of the reason that Uganda's anti-AIDS efforts were effective was because the government provided a space in which local groups, faith-based organizations, neighbors, and friends could discuss the disease and educate one another.

Policy responses to HIV/AIDS can fit into three overall categories: prevention, care and support, and treatment. Most African states, international donors, and NGOs have focused on prevention, through messages about abstinence, monogamy, healthy living, and compassion for those with HIV/AIDS. Prevention also encompasses setting up centers for voluntary counseling and testing, providing treatment for STIs, providing drugs that decrease the transmission of HIV from mother to child, and developing peer education programs for sex workers, young people, and others at risk. Care and support activities include orphan care, food and housing support for family members affected by HIV/AIDS, school fee support for AIDS orphans and other family members affected by the disease, and palliative care. In 2002, the Lancet reported that through the implementation of a variety of prevention, care, and support efforts, by 2010, 45 million new infections globally could be averted (Stover et al. 2002). However, on a continent with high levels of poverty and underdeveloped health-care services, such programs are conspicuously absent. UNAIDS (2003a, 4) reports that a mere 1 per cent of pregnant women in heavily affected countries have access to services for prevention of mother-to-child transmission. In 2004, UNAIDS found that only 8 per cent of out-of-school youth have access to education on prevention in sub-Saharan Africa (UNAIDS 2004,11).

African states also have been unable to provide their citizens with antiretroviral (ARV) treatment, the combination therapies that directly attack the virus in the body. Of the roughly 25 million HIV-positive Africans, only about 50,000 had access to ARVs in 2003. The first ARV (AZT or zidovudine) was developed in 1987 and belongs to a group of drugs termed nucleoside reverse transcriptase inhibitors. These drugs slow down production of the reverse transcriptase enzyme and make HIV unable to infect new cells and duplicate itself. The more powerful class of drugs...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of Figures
• List of Tables
• List of Contributors
• Acknowledgements
• 1 Introduction: The African State and the AIDS Crisis
• 2 AIDS and Patriarchy: Ideological Obstacles to Effective Policy Making
• 3 Patterns of Mobilization: Political Culture in the Fight Against AIDS
• 4 AIDS, Politics, and NGOs in Zimbabwe
• 5 AIDS, Democracy and International Donors in Ghana
• 6 The Economic, Social, and Political Drivers of the AIDS Epidemic in Swaziland: A Case Study
• 7 The More Things Change: AIDS and the State in South Africa, 1987-2003
• 8 Personalist Regimes and the Insecurity Dilemma: Prioritizing AIDS as a National Security Threat in Uganda
• 9 Weak and Ineffective? African States and Recent International AIDS Policies
• 10 AIDS, Pharmaceutical Patents and the African State: Reorienting the Global Governance of Intellectual Property
• 11 Pursuing African AIDS Governance: Consolidating the Response and Preparing for the Future
• Index