The politics of a health crisis: why AIDS is not threatening African governance.

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.

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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.

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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?