The “activist State”: Botswana’s voluntary’political response to southern Africa’s epidemiological crisis
Although in the 1980s and early 1990s, sero-prevalence rates were already extremely high in East Africa (including Uganda, Rwanda, Burundi, and Kenya), by the end of the 1990s the epidemic was peaking in southern Africa (Republic of
South Africa, Botswana, Swaziland, Zimbabwe, Namibia, Mozambique). From then on, the highest HIV/AIDS rates would be concentrated in this part of Africa. At that time, one out of five adults infected with HIV/AIDS was living in southern Africa.
Botswana has often been presented as a model of economic success (Benkimon, 2001). Once the AIDS sero-prevalence rate in Botswana passed the symbolic 30%, a rate unheard of until then,2 the State’s leaders began to mobilise in an unprecedented manner. It should be recalled that when Botswana declared Independence in 1964, it was one of the poorest countries in the world. Over the next 40 years, it became one of sub-Saharan Africa’s “richest” countries, with an estimated GDP per capita of USS3.500. During the same period, the international community praised its political stability. Botswana has been based on a two-party democratic system since 1966 (Medard, 1999), long before the rest of the continent liberalised its political regimes, beginning in the 1990s.
Botswana’s first AIDS case was diagnosed in 1985, the year screening tests became available. Starting in 1987, the Health Ministry established two plans recommended by the WHO Global Program on AIDS. It displayed a high-quality epidemiological surveillance programme, attached to a high-performing health system. Nevertheless, the prevention efforts did not meet expectations, and the sero-prevalence rates exploded. The most commonly cited explanatory factor was the mobility of diamond mine workers. Paradoxically, the good quality roadway infrastructure and the ease with which workers could travel weekly between their family home and the diamond sites partly explains why they became sick. Low condom use and contact with sex workers in the diamond mining area were thought to explain the dynamics of the Botswana’s epidemic, which official moralising discourse barely affected (Eboko and Nemeckova, 2009).
Until the mid-1990s, the AIDS epidemic did spur the involvement of political leaders. This changed after 1998, when Festus Mogae, a former deputy of the party in power and executive at the International Monetary Fund, was elected President. His mandate coincided with national and international media reports on Botswana’s AIDS epidemic. He became the country’s first important figure to declare a national AIDS emergency and to take control of the fight against AIDS as the president of the National AIDS Council (NAC) (Chabrol, 2002). The AIDS programme was structured around the African Comprehensive HIV/ AIDS Partnership (ACHAP), a platform established in 2000 in collaboration with the Bill and Melinda Gates Foundation and Merck. The ACHAP partnership was preceded, accompanied, and then replaced by a series of agreements that provided the basis for a coalition of international actors in the AIDS field in Gaborone, the capital. Among them were BOTUSA (an agreement between the Botswanan government and the Centers for Disease Control - CDC in Atlanta), the Botswana Harvard Institute, and Secure the Future (the Botswanan government and Bristol-Meyers Squibb) (Chabrol, 2002).
The programme for access to ARVs, called MAS A (which means “dawn" or “new beginnings” in Tswana language of southern Africa), was launched in 2002.
From the start, the Botswanan authorities made ARV treatment free and available to eligible patients who were Botswanan citizens (Chabrol, 2002). In promoting access to HIV/AIDS treatment, political mobilisation thus achieved a major goal. But between 2002 and 2005, the number of patients on ARVs and the acceptability of the screening promoted by public health authorities nevertheless failed to meet the expectations of the country's leaders.
At this point. President Festus Mogae took an exceptionally symbolic and media-sawy step. In November 2005, Botswana Television (BTV)’s audience witnessed a new episode in both the country’s spectacular fight against AIDS and the relationship between politics and the citizenry. On live TV, President Festus Mogae underwent an HIV/AIDS screening test. This gesture heralded the willingness of high-level state health authorities to provide something of a salutary shock in favour of a massive screening campaign and the powerlessness of the same State to persuade the public to accept what had been offered: free and comprehensive multiple-drug treatment for patients afflicted with HIV/AIDS (Eboko, Enguéléguélé and Owona Nguii, 2009).
This action falls under what I have called the “strategic State”. Although the same concept has been used to analyse States in the West, it is applicable to Botswana in that "The strategic State can be understood as a discourse in both the analytic and prescriptive sense [...]. The reality of the strategic State and its representation mutualise each other” (Chevallier, 2007, p. 184).
As a leader, Festus Moge was a vector of the “activist” and "strategic” State. He harnessed power for precise ends, favouring a dynamic - the process of awareness-raising. screening, and therapeutic and social care - which eventually resulted in care for people infected with HIV/AIDS. Three years after his “spectacular” television appearance, Mogae made a presentation at the opening of the 2008 International AIDS Conference, in Mexico City. He declared, without fanfare, that more than 90% of infected pregnant women were being cared for under the Prevention of Mother to Child Transmission (PMCT) programme. With the same modesty, he added that more than 80% of treatment-eligible patients in his country were on ARVs - a record for sub-Saharan Africa. The limits of this model lie in the weak collective mobilisation of associations. Hence, the difference between Botswana and Uganda models, and the poorer results for prevention in Botswana.
From “passive adherence” to a “therapeutic revolution”
The “passive adherence” to international guidelines (1986-2000)
Passive adherence is the style followed by most African States (e.g. Côte d’Ivoire and Burkina Faso) when they formally adopted the international recommendations of the WHO’s Global Programme on AIDS, between 1986 and the end of the 1990s. Two main criteria underlie this positioning: an absence of political leadership and the subordination of AIDS associations to health personnel and international development agencies present in a particular country. The disconnect between civil society actors and AIDS public policy is one of the first effects shown in social science research.
The dominance of associations by "medical oligarchies from ambivalence to therapeutic action
In most of the above-cited countries, biomedical professionals, particularly those in charge of AIDS, served as an entry point for traditional pharmaceutical companies. They were able to play on the visibility they had gained in the international AIDS field in the 1980s and 1990s to join transnational networks that included the pharmaceutical companies. Through their strategic positioning between the local level and the international level, they were transformed into what I call "biomedical oligarchies” (Eboko, 1999a).
Before the discovery of ARVs, most of the African countries discussed here established a separation of power by delegating the responsibility for fighting against AIDS to doctors, by way of the national programmes (PNLS/NAC). In this context, the political space was occupied by the doctors responsible for implementing the programmes recommended by the WHO’s GPA, specifically its short-term programs (STP1 and STP2). In various examples I studied, the heads of state and heads of govermnent were barely involved with the media, even when the national programme was directly under the President or Prime Minister. Even when Senegal’s President Abdou Diouf solemnly exhorted his counterparts at a top summit meeting of African leaders in Dakar to take charge of the fight against AIDS in their own countries, his call had little effect.
A relative political and collective apathy clearly distinguishes “passive adherence" from “active participation” models like the "activist State". Most countries discussed here used the AIDS issue as a modality for their transactions with international partners and organisations. In these cases, although development agencies and UN organisations declared AIDS to be a “national priority”, the countries themselves exerted a certain degree of inertia. Burkina Faso, for example, fell into an "epidemic of silence" about the fate of its children (Desclaux, 1997); it has been characterised as “A State against public health" (Desclaux, 1995). In Cameroon, a similar situation was stigmatised as an "acquired political immunodepressive syndrome”, a formulation that could apply to most of sub-Saharan Africa (Eboko, 2000).
In all of these cases, African political authorities engaged double-talk, for example, through adherence to discourses on the danger of AIDS and absence from “active participation”. In fact, some groups that mobilised in favour of political change and democracy in Africa were noticeably absent from the public fight against AIDS, in keeping with the broader double-dealing that characterised African authorities.