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Weakening Immunity: HIV/AIDS and the State

Publié le 1 décembre, 2007 | Pas de commentaires

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What is the effect of HIVS/AIDS on the state? Civil society can be considered the ‘immune system’ of the state in that it is a pre-requisite for sustaining democracy and is an integral requirement for combating HIV/AIDS. What emerges is a recursive crisis, where any state that fails to cope with the epidemic will see its capability to fight it as well as its ability to maintain democracy wither away.

AIDS, Mozambique
Elektra Noelani Fisher,
AIDS, Mozambique, 2005
Certains droits réservés.

The AIDS virus has a remarkably devastating effect. It slowly destroys the body’s ability to defend itself from infection, eventually undermining the body as a whole. Death does not come from the disease, but always from some other, opportunistic virus that takes advantage of the weakened state of the body. HIV/AIDS does precisely the same thing to a state. It undermines civil society – the ‘immune system’ of the state – leaving the state weak and vulnerable to ‘infection,’ and eventually to state collapse. This seems a strange comparison, but the role of civil society in permitting democratic regimes to persist and its role in contributing to the strengthening of democratic institutions is well documented, suggesting that an active and able civil society may very well be the equivalent of the state’s immune system1

Obviously, HIV/AIDS does not attack the immunity of the state in quite the same manner, but it is no stretch of the imagination to see that a country’s experience with HIV/AIDS is strikingly similar to that of an individual. This article seeks to extend this metaphor, looking at the effect of HIV/AIDS on the systemic level. HIV/AIDS affects civil society in a unique way, undermining it both quantitatively and qualitatively, and the success of AIDS policies depends heavily on civil society. Ultimately the problematic question is: if a state cannot cope with HIV/AIDS, will they find their ability to fight the disease and their ability to remain democratic, compromised?

HIV/AIDS & Civil Society

AIDS kills infected individuals, but deaths from AIDS are not isolated instances; they manifest themselves in the larger context of society. The broader ramifications can be seen in two reductions in the ability of civil society to perform two functions: one, a quantitative reduction in number, the other a qualitative reduction in abilities.

Simply and quantitatively put, deaths from AIDS remove both current members and potential members from any given organization. While it may not be the most significant result, the loss of rank-and-file members and its effects cannot be overlooked2. Most organizations are heavily dependent on activists and specialized volunteers, who are willing to give their time and energy to carrying out the necessary, every-day work of the organization. Seemingly minute tasks like letter stuffing, distributing pamphlets and canvassing are all critical for the success of many organizations. While the people who normally perform these activities are arguably more replaceable than a specialist, replacing a committed volunteer is difficult, and it involves clearly more than simply filling the slot with any new person. Furthermore, the death or incapacitation of family members or close ties can also remove an individual from participation in civil society. The growing responsibility to care for the sick is difficult to measure, but it would not be unreasonable to expect participation to decrease in proportion to increased burdens of care3.

However deleterious a reduction in numbers may be, it is merely a nuisance in comparison to the qualitative changes that occur when members of civic organization are removed from participation. Organizations are not mere collections of individuals; they produce value that surpasses any individual or their mere aggregation. Durkheim, in The Division of Labour in Society, differentiates between two types of solidarity: mechanical and organic. Mechanical solidarity was the connection that arose from being a part of a society. Crucially, despite forming an important part of the social organization, individuals were easily replaceable. If a group of gatherers failed to return, they were simply replaced by whoever was around. This is not the case with organic solidarity. Once labour was divided and relations of dependence emerged, it was no longer possible to simply replace one individual with any another. Roles became specialized. A blacksmith needed to be replaced with a blacksmith, and if one was not available, the society suffered as a consequence.

Modern civic institutions are clearly not mechanical in nature. Their reliance on specialized individuals and differentiated skill sets makes them inherently organic. Any loss of membership is a loss of a specialized individual, a fund-raiser or a public relations specialist, and they are not easily replaced. These losses place institutions into worse situations, not only in terms of the role of the lost member, but as a whole.

As HIV/AIDS removes members from organization, the organization suffers not only the loss of rank-and-file members, but the loss of specialization, of human capital and human networks4. Critically, the loss of human capital is forward-reaching and has more than just an immediate impact. Ultimately, the loss of key members negatively affects the future of the institution, producing a downward spiral that may not be easily escaped.

Civil Society: The Immune System of the State?

AIDS is particularly troublesome for civil society, that much is clear; but does this translate into a larger problem for the state? Earlier, civil society was described in terms of an immune system. If this is the case, then any unchecked AIDS problem is weakening the state and will eventually provide ample opportunities for infection, disease and death. Does the metaphor hold?
If one is speaking of democratic regimes, then the answer is a resounding ‘yes.’ Without participation in governance, there is no democracy; and this participation necessitates more than simply casting a ballot5. Often, the importance of civil society can be seen in the roles of political parties and independent media6, but its most valuable function is to contribute to the stability and consolidation of democracies7. Democracy requires civil society in order to be tenable, but AIDS contributes to its withering away.

This problem becomes even more pronounced when examined in light of recent arguments concerning the critical role of civil society in handling crises8. Consider the case of South Africa, which was faced with a debilitating AIDS problem. When contrasted with the relative success of some other African states in handling the disease (most notably Uganda), the failure of South Africa is alarming.

A Losing Battle: The Case of South Africa

South Africa’s experience with HIV/AIDS can be described, at best, as a losing battle. Using antenatal HIV prevalence as a measure, from 1990 to 2002, the rate of pregnant woman infected with the virus rose from 0.55% to 27.60%9. The rise occurred in the midst of the government’s attempts to handle the disease. There are many reasons for South Africa’s failure, from President Mbeki’s particular philosophy on the disease, to the structures of the institutions which emerged after apartheid. Indeed, institutional legacies play a key role in explaining South Africa’s failings. For South Africa, the form of government institutions is extremely important as the shift from apartheid to democratic rule occurred almost simultaneously, with the recognition of HIV/AIDS as a threat that needed to be addressed. This transition to democracy was characterized with modest institutional change and a high degree of continuity. Specifically, the change came in the form of the establishment of a “quasi-federal political system to satisfy minority political interests,” whereas the continuity can be seen in the negotiated protection of civil servant jobs10.

Both of these factors had profound effects on how social policy would be shaped in the following years. As Schneider and Stein note, “the new government thus inherited the apartheid administration intact. This administration was concerned much less with social delivery than with maintaining a political system of divide and rule.11” In South Africa, the quasi-federal system put in place was particularly disastrous as it fragmented leadership ability, creating more potential points for conflict. The coordination of action and the division of responsibility amongst several spheres of government were thus significantly complicated by the new federal structure12.

Thus, institutionally, the South African government was more likely to pursue policies that its bureaucracy was capable of handling. The effectiveness of the bureaucracy allowed it to focus on syndromic treatment of HIV/AIDS, a method that relies on generalized assessments, which then allows for a larger number of treatments at a lower cost. Interestingly, it has been noted that this method was unavailable to Uganda, one of the rare success stories in the region, precisely due to its undeveloped health bureaucracy13.

Regardless, the result was a solution centralized in nature, top-down in execution and, most importantly, non-participatory. The South African government effectively shut out civil society from participating fruitfully in handling the HIV/AIDS epidemic. South Africa had numerous organizations on the ground working to combat the disease, and while some government links existed with community organizations, the links were few and far between. According to one survey, only 40% reported receiving any funding, while the figure dropped to zero for faith-based organizations14. The community level response has thus been largely independent and unofficial, and the fact that only two-fifths of the community organizations are receiving government funding at all suggests that they are not taken seriously as a viable partner15.

A Surprising Success: The Case of Uganda

In contrast to South Africa, Uganda’s experience in tackling HIV/AIDS was relatively positive. In 1990, Uganda had an antenatal prevalence rate of 30.81%, but by 2002 that rate had fallen to 8.30%16. Uganda’s success is also attributable to many factors (Museveni’s leadership, the acceptance of medical expertise, etc.), but what is recognized as being exceptionally successful in Uganda was the focus on personal networks, which had the effect of stressing the personal risk of the disease, convincing many that AIDS was not something that only happened to other people17. And it was the government’s commitment to engage with multiple sectors, as well as to enlist a large number of national participants into battling the disease, that ultimately allowed them to implement personal networks into the solution18. Such a decentralized approach to handling the epidemic necessitated the involvement of civil society groups, local faith-based organizations and people living with HIV/AIDS. Their impact was invaluable due to their direct contact with effected communities19. Civil society and local NGO groups played an instrumental role in helping to bring about the behavioral change witnessed in Uganda. As one observer commented, Uganda’s approach was “community-based, face-to-face, and culturally appropriate. Strong nongovernmental organizations (NGO) and community-based support led to flexible, creative, and culturally appropriate interventions that worked to change behavior.20

Between a Rock and a Hard Place

Whether the engagement of civil society is a cause, effect or unnecessary condition of a successful AIDS policy is up for debate. However, in addition to the support offered by the Ugandan case, there is a strong connection suggested between the engagement of civil society and success in ameliorating crises (see Hsu, et al.) independent of these two cases. Herein lies the conundrum: civil society is crucial for democracy, while AIDS eats away at civil society. Add to this that AIDS may be best handled by employing an approach that utilizes civil society and the logical conclusion is frightening: Any state which is unable to properly combat AIDS will witness a reduction in its ability to combat AIDS. Not to mention the fact that they will see their democratic foundations withering away as well.

South Africa does not seem able to combat AIDS effectively. It has been suggested that their problem is more structural than anything else, couched deeply in the legacies left from apartheid21. This suggests that these institutional legacies have shaped the democratic institutions in very particular ways that lead to the structural preference of some approaches over others. It has been suggested that Uganda’s success rested on its government’s ability to act unfettered, pursuing the best response without political constraint22. If these two arguments prove true, then some reconsideration is needed.
South Africa embraces democracy, and the AIDS crisis affects civil society, the means to that end. Civil society is also the means to handling the AIDS crisis. Thus, if the crisis is not handled effectively, South Africa will find itself in a situation where democracy has crumbled, civil society has been decimated and thus, the means to both of their ends gone. It is clear that the only way out of the crisis is to address it head-on, and this may mean abandoning democracy in the short run, in the interest of securing it in the long run.

Uganda’s authoritarian approach proved successful in combating HIV/AIDS, suggesting that perhaps it is necessary for South Africa to consider stepping out of the shackles that democracy has provided, and to pursue a more centralized, even authoritarian, structure of government in respect to the management of HIV/AIDS. Better by choice than by default, since their very democracy may depend on it.


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2. Hsu, Lee-Nah. Building Dynamic Democratic Governance and HIV-Resilient
societies. UNESCO, 2005: 705.
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5. Schaeffer, Frederic Charles. Democracy in Translation: Understanding Politics in an Unfamiliar Culture. Ithaca, N.Y.: Cornell University Press, 1998: 118.
6. Sandbrook, Richard. “Transitions without Consolidation: Democratization in Six African Cases.” Third World Quarterly 17.1 (1996): 69-87.
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8. Hsu, Lee-Nah. Building Dynamic Democratic Governance and HIV-Resilient Societies. UNDP South East Asia HIV and Development Program, 2004.
9. UNAIDS/WHO Epidemiological Fact Sheet: South Africa, 2004. Available at: http://data.unaids.org/Publications/Fact-Sheets01/southafrica_en.pdf
10. Schneider, H. and Joanne Stein. “Implementing AIDS policy in post-apartheid South Africa.” Social Science and Medicine 52 (2001): 2.
11. Ibid.
12. Schneider and Stein. op. Cit.: 4.
13. Parkhurst, Justin O. and Louisiana Lush. 2004. “The Political Environment of HIV: lessons from a comparison of Uganda and South Africa.” Social Science and Medicine 59 (2004): 1919.
14. Birdsall, K. and Kevin Kelly. Community Responses to HIV/AIDS in South Africa: Findings from a multi-community survey. Johannesburg: Centre for AIDS Development, Research and Evaluation, 2005: 8.
15. Birdsall and Kelly. op. cit.:52.
16. UNAIDS/WHO Epidemiological Fact Sheet: Uganda, 2004. Available at: http://data.unaids.org/Publications/Fact-Sheets01/uganda_en.pdf
17. Hogle, Janice A. ed. What Happened in Uganda: Declining HIV Prevalence, Behavior Change, and the National Response. USAID, 2002: 10.
18. Hogle ed., op. cit.: 4.
19. Uganda AIDS Commission Secretariat. 2002. HIV/AIDS in Uganda: The epidemic & the response, p. 9. Available at: http://www.aidsuganda.org/pdf/hiv_aids_impact.pdf
20. Hogle ed., op. cit.:4-5.
21. Schneider and Stein, op. cit.:2-4.
22. Putzel, James. “The Politics of Action on AIDS: A Case Study of Uganda.” Public Administration and Development 24(2004): 19-30.

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