Theme IV : Roles and approaches for an effective response

This paper is concerned with the demands made by the HIV/AIDS pandemic on leadership in Africa. The crisis of HIV/AIDS is quite simply the largest challenge facing the African continent today. It has been said, quite rightly, that combating HIV/AIDS requires the same level of commitment, vision and leadership as fighting a war of independence. This paper examines what sort of commitment, vision and leadership will be required. It concludes: even more is required.

Very often, analyses of the challenges of combating HIV/AIDS concern themselves in substantial detail with the bio-medical, public health, educational and care requirements of effective response, and then conclude with an appeal for ‘political will’ or ‘leadership’ to make these policy requirements a reality. This paper starts where these analyses stop. This requires a wide-ranging, comparative analysis that looks at actual and possible responses to HIV/AIDS at a very high level of generality, in the context of other examples of leadership and social mobilization from around the world.

The paper considers leadership in its broadest sense. It identifies both the elements of agency required and the structures within which leadership can operate. Structural constraints include both wider political and social systems, and opportunities for social mobilization and public policy formulation and implementation.

The challenges of responding to HIV/AIDS are perhaps even greater than recent public debates would lead one to believe. The leadership challenges posed by HIV/AIDS have been compared to fighting a war of liberation. The comparison might however mislead: the leadership characteristics required for containing HIV/AIDS are very different from those demanded of a political leader seeking national liberation. And the task itself is rather more difficult: the cultural and political resources that can be brought to bear on the issue are more limited, and the demands for wide-ranging social, attitudinal, and political change is more considerable.

However, some remarkable progress has already been made. The speed with which the issue of HIV/AIDS has become a priority for continental and international public policy in Africa is unprecedented. The challenge is to build on this emerging political commitment, and ensure that the energies of leadership, public policy and social movements are channeled in effective and sustainable ways.

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Leadership Challenges of the HIV/AIDS Pandemic in Africa

The HIV/AIDS pandemic in Africa poses extraordinary leadership challenges. The level of death and dislocation threatened by the pandemic is worse than any natural disaster or war that Africa has faced for a century if not longer. Some have said that the level of mobilization required is equivalent to that needed to fight a war of national liberation. This comparison highlights the parallel with Africa’s greatest and most inspiring leaders, who achieved independence from the European empires. It recalls Africa’s most epic struggles, which mobilized entire nations within a single political, social, cultural and moral movement, and which also generated an unprecedented level of unity of purpose and vision across the entire continent. The fight against HIV/AIDS cries out for the best that Africa can offer: a struggle and commitment comparable to continental liberation from tyranny.

HIV/AIDS, however, is an ‘invisible enemy’ and its characteristics make it particularly difficult to tackle. The challenge of HIV/AIDS is particularly wide-ranging. Its unique pathological characteristics make it mysterious to laypeople. The period between infection and the development of full-blown AIDS is so long that HIV/AIDS can be spread unwittingly and become well-established in a population before there is any awareness that it is a threat at all. Moreover, the long latency period encourages silence as it works against people making the causal link between sexual relations years ago and the onset of symptoms. Its mode of transmission—predominantly sexually-transmitted—is intimate and makes it the subject of many taboos and culturally imposed silences. Also, unlike previous pandemics, where the death of those infected was a matter of days, and thus the medical cost per individual was small, HIV/AIDS requires years of expensive drug cocktails to keep it at bay. There are serious hurdles facing any government or organization that tries to make the pharmaceutical multinationals provide drugs at an affordable price to Africa. And the origins of the disease itself are so obscure and controversial that it is the subject of myth making, and an arena for extraneous agendas and debates, in which a wide range of prejudices can be manifested. Critics have even gone so far as to argue that even talking about HIV/AIDS stigmatizes Africa, echoing some of the early, frankly racist, theories about how and why the disease appears to have originated in Africa. One of the first challenges for Africa is to face the reality of the pandemic in the continent.

The HIV pandemic in Africa also has unique characteristics. The strain of HIV prevalent in the continent, especially in eastern, central and southern Africa, is particularly virulent. However, ‘becoming infected with HIV is not a random medical event. More perhaps than any other major health threat, it demonstrates the extent to which disease is in fact embedded in the social, political, economic, cultural, behavioral and medical experience of individuals’ (Van Der Vliet, 1996: 118). Moreover, vulnerability to HIV/AIDS ‘stems from lacking the power to control one’s circumstances… the power to affect the outcome of the epidemic is intimately tied into the social, political, economic and cultural purposes of those in control’ (op cit, p. 132). Africa is the continent worst-affected by AIDS, containing more than two thirds of the world’s people living with AIDS. ‘In the West, the fact that the epidemic has affected most directly marginalized populations (drug users, homosexuals, the poor) helps to explain the lack of a timely response. Globally, Africa is analogously marginalized’ (Fredland, 1995: 9).

Africa is the continent least well-placed to respond to the crisis of HIV/AIDS. It is the poorest continent with the worst health and educational infrastructure. It has the weakest civil society, and the political leadership in many countries is marked by patrimonialism, corruption, authoritarianism and even militarisation and criminalisation. Africa is subject to a high degree of disruption, with mass displacement due to war and disaster, and mass migration in search of employment and opportunity. This raises a central tension in formulating how to tackle HIV/AIDS in Africa—the relationship between necessary short-term action and the need for more profound change. No problem can be seen in isolation. Yet with HIV/AIDS, the connection to broader questions of poverty and power is particularly stark (Collins and Rau, n.d., Baylies, 1999: 389). The absence of any medical ‘magic bullets’ or immediate technical fixes demands that responses involve a wide range of moral social and economic challenges. As Fredland underlines, ‘broad scale medical problems have politico-economic roots and … any solution must be related to attacking these larger problems and not just medical occurrences’ (1995: 5). This has led some to stress the importance of dealing with the broader issues of poverty, under-development, and gender inequality, at the expense of addressing the issue of HIV itself. However, as Van Der Vliet (op cit, p. 6) points out:

The problem with seeing AIDS as essentially a product of poverty and socio-economic conditions is that prevention and cure must then be postponed till Utopia—or something approaching it… Long term, socio-economic, upliftment may well curb the epidemic, but AIDS is happening in the short term. Leaders are needed who can enable people and communities to devise appropriate strategies for coping with AIDS, rather than using it as a political football.

The leadership challenge is thus to make inroads into tackling underlying causes such as poverty and gender inequality while simultaneously taking specific steps to target HIV/AIDS.

Major Moral Challenges

The ‘safe sex’ message, if universally adhered to, would stem the rampant spread of HIV/AIDS. The primary building block where change must occur remains with the individual. Individual behaviour, however, is contingent on social and cultural factors as well as ‘biomedical factors such as condom availability and health services which facilitate or retard behavioral change’ (Van Der Vliet, 1996: 121). Moreover, there is often a huge gap between what people know to be the best course of action, and what they actually do, and this gap is sustained by the social and economic pressures to which people find themselves subjected. This subsection will briefly review some of the main challenges facing those wanting to develop a comprehensive campaign to combat HIV/AIDS.

1. Gender relations.

HIV in Africa is predominantly transmitted by heterosexual activity. One of the groups greatest at risk is young women they are infected at significant younger age than men (WHO 1994). In Africa, over 20% more women than men are living with HIV. The dangers that women face from the AIDS pandemic have been described as a ‘triple jeopardy’ (Panos Institute, 1990). HIV and AIDS potentially threatens women as individuals, mothers and carriers. A Ugandan study has showed that deaths from HIV/AIDS, especially of the mother, leads to reduced farm inputs and family labour, lower agricultural production, reduced schooling for children, and higher malnutrition (UNDP, 1995).

The challenge of gender interacts with the problem of poverty. Women are generally poorer than men, especially if they are heads of households. The combination of poverty (in extremis, desperation for income that dictates extremely short time horizons) and inequality (relative powerlessness when confronting husbands, boyfriends, employers and others) compounds the fundamental problem of gender relations.

A number of elements in gender relations in Africa need urgent attention if there is to be a realistic chance of containing the pandemic.

Sexual violence. The level of rape in many parts of Africa is appallingly high. South Africa in particular is notorious as the country with the highest rate of rape in the world. Rape in Africa is often a crime committed with complete impunity. Women and girls are coerced into sex by criminals, by policemen and soldiers, by teachers, by employers, by government officials—in fact by men in almost any position of authority. Rape is particularly common in wartime, and in fact is sometimes even used as a weapon of war. However, sexual violence is disturbingly common in ‘normal’ circumstances too. It is routine in many schools for female students to be pressured into having sexual relations with their teachers in return for good grades. Male students may believe that their female counterparts are ‘fair game’ and engage in mass rape. Members of the uniformed services, particularly when armed or in positions of arbitrary power, very often coerce women and girls to have sexual relations.

Economic pressures on women contributing to a high rate of commercial sexual activity. The economic crisis that afflicts Africa compels a wide range of young women to become commercial sex workers. These include the wives and partners of migrant workers, students, unemployed young women, single mothers who have been forced to drop out of school or leave employment (often their status as single mothers arising from reluctant sexual activity or rape). Also, refugees, young widows (some of whose partners have died of AIDS) and workers in insecure occupations such as waitresses, food sellers, barmaids and domestic work. Economic disadvantage puts women at special risk: it pressures them to enter unequal relationships with older men, it diminishes their negotiating power within relationships, it reduces their power to object to partners’ infidelities, and it forces many into commercial sex work itself.

Short of commercial sex work, many women and girls enter into multiple sexual relationships in order to obtain some financial security from boyfriends and ‘sugar daddies’ (Manjante et al., 2000).

Powerlessness of women with respect to use of condoms. Women who are aware of the dangers of HIV infection are frequently unable to insist that their partners use condoms. Men—particularly those who have dangerous occupations such as soldiers, construction workers and miners—may believe that their self-worth and masculinity is bound up with a disregard for risk, and they may insist on ‘skin to skin’ contact. The poorest commercial sex workers are those least able to insist on protection. Men may regard a partner’s request for using protection as an accusation of infidelity. In addition, many women want to become pregnant and bear children, so they do not want to use any form of contraception. The Total Fertility Rate (number of live births that a woman can expect in her lifetime) in Africa in 1998 was 5.4. Cultural attitudes to fertility make it imperative for a woman to prove she is fertile by having a child. Men must also prove their virility by having children. This is all additional to the proscription on contraception by among others the Roman Catholic church (very recently slightly modified with the admission that condom use can be justified in some circumstances) and the problems of simple lack of availability of condoms, unreliability of condoms, and their expense which can be prohibitive for the poor. Lastly, there is a lack of female-controlled methods of barrier contraception, such as the female condom, available in Africa.

Domestic violence. Women who are victims of domestic violence—which is disturbingly common across Africa—are least able to influence their partners’ behaviour. Rape within marriage is not uncommon. Female victims of domestic violence have reduced status and bargaining power within their relationships, which can be crucial when it comes to their partner’s extra-marital sexual activities, or the use of condoms.

Polygamy, early marriage and sexual activity of girls. In many African societies, whether Christian, Moslem or following traditional religions, polygamy is deeply entrenched. In many societies men prefer to take very young women as their wives, including second and subsequent wives. Any girl old enough to be potentially fertile, and many who are not even that old, are considered eligible for marriage. There are strong social and financial incentives towards early marriage. Men have also acquired a preference for younger sexual partners because they believe them less likely to be HIV positive. In some countries there is even a belief that sex with a young virgin can be a cure for the infection. The level of defilement of underage girls is high in many countries. Child sex abuse is present but almost always a taboo subject. (Zimbabwe’s programme of ‘child-friendly courts’ is a welcome initiative in this regard.)

This is a depressing catalogue of the powerlessness of women. It forces us to question the implicit assumption in most western-initiated approaches to sex education and encouragement of condom use, namely that most sexual acts are consensual. If the contrary is true, that the norm in parts of Africa is non-consensual sex, or at least sex in the context of very unequal power relations between men and women (‘partners’ would be a euphemism in this context), then much education about sex and HIV transmission becomes of limited relevance.

Africa’s political leadership is overwhelmingly male. There is a marked lack of women in senior positions in government, business and (to a lesser extent) civil society. Equally problematically, there is dominant masculinity in African forms of government. Many leaders are military men, for whom ‘masculine’ modes of behaviour—giving commands, taking decisive action, using violence—are indicators or their power, authority and legitimacy. Many civilian leaders are also obliged to incline towards these militaristic modes of authority, not least in order to keep their generals in check. The political sphere in Africa is a domain of ‘hegemonic masculinity’, in many cases tending towards the cult of machismo. ‘Hegemonic masculinity’ means much more than men wielding power over women: it is the way in which characteristically masculine and macho manifestations of power are embedded in society, and accepted by both men and women.

In these circumstances it is not difficult to understand why political leaders do not consider the systematic restructuring of gender relations and the empowerment of women to be a priority. In some cases they may espouse these values in some speeches and even in some actions, but they lack the motivation and structures to turn these commitments into reality.

Changing gender relations in Africa is a demanding task. But we can also identify important social and cultural resources that can be brought to bear on the challenge. Africa’s customary laws and traditional social structures commonly give more authority and freedom to women than has been recognized: these traditions need to be recognized and revived. Women’s organizations are strong and growing across the continent, and there are powerful local, national and international coalitions for the promotion of women’s rights. Lastly, we must also recognize that the reality of HIV/AIDS is itself giving a new momentum to mobilization around gender issues.

2. Transparency

Facing up to a problem is a pre-condition of it being tackled. HIV/AIDS can only be effectively combated where it is not considered secret, but it is openly discussed. This is stressed by Van Der Vliet: ‘Information, despite the problems in translating knowledge in to behaviour, remains the sine qua non of individual empowerment; until individuals have a clear, complete, unvarnished picture of the disease, and how it can be avoided, appropriate behaviour modification is impossible’ (1996: 124). Free and open public discussion is an essential prerequisite for any effective anti-AIDS programme. However, there are many reasons why the necessary public debate and transparency is rare in the African continent.

Governments refusing to admit the extent of the HIV pandemic. This is now generally a thing of the past, as most governments are ready to admit that they are confronted with the disease. But the problem persists in certain countries. In addition, some governments prefer to obfuscate the issue by disputing the level of HIV infection, or the link between HIV and AIDS. Very often, the question of the level of HIV infection in a particular society is considered unimportant, because the government cannot see any effective way of responding to the problem (Fredland, 1998: 592). This stands in the way of undertaking good epidemiological studies of HIV, which in turn is a major impediment to effective public health measures. Early attempts by some western analysts to blame HIV on supposed African deviant practices were very unhelpful in this regard.

Armies and police forces generally have among the highest levels of HIV among any groups. But the armed forces are reluctant to admit the level of HIV positivity among their members. This is for several reasons.

It is seen as a national security threat: if a very high level of HIV is known to exist among the armed forces, the enemies of the state may take solace.

Easy sex is one of the unstated perks of military service, and this would become more problematic if the true level of HIV among soldiers were known.

Governments in Africa rely very heavily on their armed forces for survival, and to admit the extent of HIV would cause demoralization and a crisis of confidence.

Many African armies are serving outside their frontiers, either involved in neighbours’ wars or in peacekeeping missions. Admitting levels of HIV among these soldiers would have international repercussions. Lastly, armies are obliged to provide health care for their members and the financial implications of providing HIV and AIDS treatment for so many soldiers could be crippling to defense or national budgets.

There is good evidence that, particularly in eastern and central Africa, the armed forces are some of the major elements in transmitting HIV. In the absence of good information and open discussion about this fact, there is little chance of instituting effective measures of control.

There is a real fear, both within Africa and internationally, that the HIV pandemic may cause chaos and disorder in the continent. By attacking the most important age groups and occupational categories, the pandemic has the potential to become a major security threat within Africa, and also more widely, affecting the national security even of the USA. Is this a real threat? Is it just scaremongering, in the tradition of much western fear-fascination with Africa that has long predicted the doom of western civilization based on supposed African ‘barbarity’? Exaggerated prejudices about Africa and inflated fears about the impact of the pandemic can only be addressed by full openness.

Discomfort in talking about sex, gender relations, commercial sex and homosexuality. Effective measures to promote public education about HIV involve dealing with these issues in a practical way, without traditional conservative moralizing that condemns these activities as immoral in themselves. Experience with HIV containment indicates that there is very little to be gained by regarding sexual activity, commercial sex, homosexuality etc. as wrong in themselves and seeking to control HIV by promoting restrictive sexual morality. Currently there is a wide gap between sex as it is talked about, and sex as it is practiced: this gap needs to be closed.

Fear. Everyone is frightened of disease, especially new, fatal and mysterious diseases. The dominant messages concerning HIV/AIDS have centered on fear. Public education aimed at frightening people into protecting themselves as individuals may not be the most helpful, on several counts.

These messages are not relevant to those who are already HIV positive or fear that it is inevitable that they will become so. For such people, the message should be one of communal responsibility, not to spread the virus any further.

For people who are already living under many different threats (destitution, hunger, violence, displacement), the fear of succumbing to AIDS at some point in the future is likely to be much less salient than for people (as in many western countries) who do not live with such fears.

Both African tradition, protection of the community rather than the individual may be a more culturally appropriate message. Community-based approach may be also more practical and effective response in societies where certain groups (e.g. young women) have very little scope for individual action to protect themselves.

The public education agenda for HIV/AIDS containment is in significant part an agenda for free expression and open debate about sensitive and highly charged issues. Breaking the taboos and demonstrating that these issues must be talked about openly is one of the most important tasks for political leadership.

The last year has seen significant breakthroughs in public debate on HIV/AIDS in Africa. A series of international conferences has highlighted the issue. This does not automatically translate into widespread transparency about the issue, but it is an important start, and creates an environment in which governments are better able to acknowledge the realities they face.

Diplomatic niceties, including the protocol of international conferences concerning Africa, militate against exposing the shortcomings of specific governments and institutions. It is considered unseemly to name names. This is, to say the least, unfortunate. Many millions of lives could have been saved if leaders of all types had been willing to say openly that specific named leaders were failing to act, or were denying reality or showing no interest in facing it.

3. Stigmatization of, and discrimination against, those with HIV/AIDS.

‘How the disease is constructed in the public mind will profoundly influence the relative powerlessness of the infected.’ Van Der Vliet, 1996: 6

People living with HIV/AIDS are among the most important actors in any programme to contain the pandemic. If HIV/AIDS is portrayed as something to fear then it becomes something to run away from. Denial is the worst response. Similarly, if people living with HIV/AIDS feel compelled to keep their status a secret, or are terrified of that status or become bitter and angry, then they are unlikely to take actions to prevent them passing the infection to others, and may even deliberately try to spread the virus. On the other hand, if people living with HIV/AIDS are confident that they will be respected, cared for and treated, they are more likely to act in a responsible way. People with HIV/AIDS are also the best people to carry the message about HIV prevention: they speak with an authority and immediacy that no others can match.

However, in many African countries, HIV positive status and AIDS carry with them a heavy stigma and fear. This is a powerful disincentive to action. Aspects of the necessary response include the following:

Care agenda. Those with AIDS must be treated with respect and kindness, accepted in the community, counseled and given solace. This is a classic task for religious hospices and the extended family. This task is hindered by religious attitudes that blame the victim and ignorance about how the disease is transmitted. The very high prevalence of the disease, and the fact that it affects many educated and elite people, has meant that a number of leaders have publicly acknowledged close family members who have HIV or AIDS. (Very few have admitted to being HIV positive themselves.) This has helped begin to change social attitudes and promote greater sympathy in some countries.

The care agenda also extends to the dependents of those who die from AIDS, especially orphaned children. These victims of the disease also require support, respect and kindness.

Treatment agenda. In industrialized countries there are now treatment regimes that mean that people with HIV/AIDS can live a near-normal life for extended periods. Unfortunately (because of the practices of pharmaceutical companies) it costs $4,000-6,000 to provide a year’s course of antiretrovirals and the associated tests and consultations. (Panos Institute, 1990). This treatment is extremely expensive and it is far beyond the means of Africa’s overstretched health services to provide AIDS treatment to even a small minority of those affected by the virus. As Caroline Bylies points out, this presents a ‘danger that the global solidarity based on a common affliction which characterized the position towards AIDS in the early nineties, could diminish’ (1999: 390). Until there is at least a minimal level of treatment available that can improve the quality of life of people living with HIV/AIDS, there is little chance that the stigma of AIDS and the behaviour of those with HIV/AIDS can be improved. The task of obtaining cheaper and more accessible treatment is a challenge that African leaders cannot address alone. This requires a partnership with aid donors and international pharmaceutical companies examining viable alternatives for Africa.

An additional element to the treatment agenda is how it interacts with the prevention messages in public education campaigns. Prevention campaigns that focus on generating fear, by saying that contracting HIV makes death inevitable, only serve to stigmatize those living with HIV/AIDS. This in turn militates against people going for testing. Improving the status of those with HIV/AIDS, and lessening the fear of the disease, will in fact assist with prevention.

Protection agenda. The very minimal requirement for a state is to protect the rights of those with HIV/AIDS who choose to ‘come out of the closet’ and declare their status, in some cases as a prelude to social activism on the issue. But there are unfortunate instances of conspicuous failure of leadership on this issue, for example cases in which individuals have publicly admitted their HIV+ status, only to be victimized by vigilantes, who have escaped punishment. A basic civil rights agenda for people with HIV/AIDS is the very first step for political leadership on the issue of the pandemic.

People living with HIV/AIDS must not be written off, as though they are dead already. Treatment should not be seen as a waste of resources. Protecting the rights of those with HIV/AIDS, providing them with treatment and care, is intrinsically related to removing stigmatization and discrimination, which in turn promotes prevention.

There is a need for a domestic political agenda in African countries to overcome the stigmatization of those living with HIV/AIDS and to encourage and promote care and treatment. Leadership on these issues must operate at different levels.

A number of factors are forcing change in social attitudes towards people living with HIV/AIDS. Perhaps the most significant is the sheer number of infected individuals. In most central and southern African countries, everyone has family members and friends who are living with HIV/AIDS or who have fallen victim to it. When a disease touches the lives of all, stigmatization of the affected becomes more and more difficult. In addition, public education, the efforts of health workers and NGOs, and the public statements of national leaders, are all gradually changing attitudes. Those whom it is most important to influence: teenagers and young adults, are the most amenable to attitude change. (But by the same token, it is even more important to understand youth cultures in Africa, a much under-studied area.)

4. Religious attitudes and practices.

It is very unfortunate that HIV/AIDS is so intrinsically wrapped up in questions of personal morality as interpreted by religious authorities. It is very easy for those with a particular religious bent to see HIV as some sort of curse or vengeance from the creator. HIV can be an encouragement to the worst forms of hypocrisy and misguided piety. ‘Leadership’ on the issue by religious authorities, and secular authorities who have devout religious beliefs or who try and gain legitimacy from association with religion, can often be exactly the worst form of leadership, impeding effective action instead of promoting it.

We can identify several major challenges.

Roman Catholic Church and teachings on contraception. The Roman Catholic Church is proving unable to revise its teachings with sufficient alacrity to take account of the problem of HIV/AIDS. This is a challenge not only to Roman Catholic church leaders across Africa but also to political authorities that have to cooperate with them, without provoking unnecessary antagonisms. Van Der Vliet describes how ‘at a landmark conference on "The role of religion and moral behaviour in the Prevention and Control of AIDS and STDs," held in Cairo in September 1991, leading Muslim and Coptic Christian theologians "rejected safer sex education and condoms and affirmed that early marriage and marital faithfulness are more appropriate weapons against HIV infection"’(quoted in Van Der Vliet, 1996: 43). Only very recently, in September 2000, has the Vatican adjusted its position on the use of condoms. In a highly significant change in applied doctrine, the Roman Catholic Church has consented to the view that the use of condoms in some circumstances should be permitted, specifically referring to the prevention of HIV transmission as such a circumstance.

Christian and Moslem teachings on personal morality. As mentioned above, it is very tempting for many religious leaders to see HIV as some form of divine retribution, and use the pandemic as a weapon to bolster their campaigns for certain forms of personal morality. These teachings may have some value in themselves and may in certain places be able to prevent high levels of HIV from occurring in certain communities (for example small and relatively closed communities following particular religions). But they cannot change the social and sexual behaviour of entire countries.

Unwillingness of religious authorities and religiously-inclined political leaders to talk about sex. ‘There is in much of Sub-Saharan Africa some gap between sex as it is practiced and sex as it is discussed. Islam and Christianity have compounded that problem and deepened the silence’ (Caldwell, 1992: 1179). In some Moslem countries for example it is virtually impossible to talk about sex in public, except in very traditional moral terms.

Traditional religious beliefs and practices. In many countries, traditional beliefs coexist with Islam and Christianity; often believers in Islam and Christianity also follow traditional beliefs in other aspects of their lives. Some practices may hinder the containment of HIV/AIDS, such as polygamy, early marriage, some scarification or circumcision practices that may mingle the blood of different individuals or use unsterilised instruments, and even in some cases ritual prostitution.

For obvious reasons it is very difficult for religious believers and leaders, and political leaders in countries marked by high levels of religious beliefs, to be independent and objective about the health implications of religious beliefs and practices. The challenge before leaders is to ensure that the practical changes in attitude and behaviour can be accomplished without stretching existing belief systems to breaking point. Some debate and controversy will be inevitable, but too much bitter controversy can be counterproductive. Leadership can play the essential role in providing legitimacy to new forms of discourse and dialogue.

Africa’s cultures and traditional religions can play a positive and helpful role. Africa has strong traditions of tolerance and inclusion, of the duty to care for both relatives and strangers. African chiefs traditionally do not inherit their position: they need to be approved by acclaim or consensus, and they maintain their status by their generosity to their communities. Such qualities are essential for the containment of the AIDS epidemic, at least as important as any medical and public policy advances. Stressing these positive cultural resources that Africa brings to the containment of HIV/AIDS will be a very important contribution to the continental struggle against the disease. To emphasize grassroots resources should not be seen, however, as an alternative to action from governments, pharmaceutical companies and the international community for whom it is an attractive option to make the affected groups bear the costs themselves (Baylies, 1999: 387).

5. Addressing Youth.

Youth are the group most at risk of contracting HIV. The highest incidence of new HIV infection among women is among late teenagers; among men it is in the twenties. There can be no effective response to HIV/AIDS in Africa that does not tackle the challenge of responding to the needs of youth. This is an agenda that is remarkably under-developed. To a large extent, even the most basic questions about youth in Africa are not understood by those who make public policy, lead their countries, or mobilize social movements.

Rather than outlining issues and potential actions, this subsection can do no more than identify several of the key questions that need to be investigated. Any investigation of these issues should be participatory, involving youth themselves in all aspects of research and recommendation. By these means, it should be possible to chart an agenda.

Some of the key issues involve:

What do we mean by youth? In much of Africa, the term ‘youth’ has come into popular use because of the absence of educational and employment opportunities for young people, so that ‘youth’ are people living in economic uncertainty. By the same token, they are a category waiting to be mobilized. ‘Youth’ can refer, in different contexts, either to those who are fighting for a cause (exemplifying courage and righteousness), or those who are involved in crime and anarchy (gangsters, people to be feared). Either they are heroes or villains (Seekings, 1993). In either case, there is a strong link between ‘youth’ and violence, and attempts to organize youth will tend to follow one or other stereotype. If we can overcome these stereotypes and understand the real complexities of young people, we can begin to design and implement programmes that can reduce their risk of contracting and spreading HIV.

What cults and organizations exist among young people themselves? In much of Africa, there are strong organizations, some traditional, others new but informal or even clandestine, based on mobilization of people in age groups. These include the traditional age grades of many societies, youth cults, students’ societies, football clubs and others. Most are exclusively male: much less is known about young women’s organizations. Some, such as some student societies, street gangs and sports clubs, have a collective agenda that includes seeking ready sex. This is an area that has only recently become the focus for social science research, and the agenda for how to influence these groups has yet to be developed. Mobilizing the youth leaders themselves will undoubtedly be a crucial component in ensuring that such organizations become allies in the struggle against HIV/AIDS.

What do we know about risk-taking? Among young men (in particular) there is often a sub-culture of engaging in risky activities, simply because they are fun and because those who excel can gain great esteem among their peers. Dangerous sports would not exist if it were not for the thrill of risk-taking. Research on driving cars shows that as cars are made safer, people drive them faster—seeking a certain level of excitement or danger. Some occupations are also inherently risky (e.g. soldiers, miners, construction workers on high buildings), and those who practice them gain a sense of self-worth and masculine identity from these jobs. For such people, engaging in ‘unsafe’ sex may be seen as either irrelevant (because there are other greater risks in their lives) or as part of their entire high-risk lifestyle.

What do we know about orientation towards the future? For many young people, especially in poor and insecure parts of Africa, the future is bleak and uncertain. It seems unlikely that they will enjoy the same life chances as their parents or grandparents. The central message of HIV prevention is based on self-control today in order to enjoy a brighter future. If the future is universally dark, what salience does such a message have? They ask, ‘Why should I change my behaviour when I see little hope for improvement in life’s opportunities?’ (Collins/Rau: 29). Many young people, faced with a high likelihood that they will become infected with HIV, may merely revise their life expectations downwards, anticipating ten years of adult life instead of 20 or 30.

What do we know about youth cultures of resistance? There is always the danger, when authority is addressing youth, that any messages will be subverted and precisely the wrong lessons will be learned. If their parents are acting in a certain way and encouraging the youth to conform, we can predict that many of the youth will choose to do precisely the opposite. Advertisers have learned much about how to reach youth consumers; how much of this expertise can be transferred to the issue of HIV/AIDS?

This broad analysis of youth is dispiriting. However, the fact that so much of Africa’s male youth is organized, to a greater or lesser degree, in societies, cults and clubs, provides opportunities for positively influencing behaviour that may be lacking in more atomized or individualistic societies. Moreover, what little research has been done into youth aspirations suggests that, even under the most adverse circumstances (e.g. Sierra Leone), African youth tend to hope for a very conventional future of education and employment (Richards, 1996).

Poverty

The challenge of HIV/AIDS cannot be addressed outside the context of the poverty that prevails across Africa. This is a challenge both to Africa, and to the international community. As the discussion in this paper develops it will be evident that it is impossible to overcome the AIDS pandemic without far-reaching social and economic change across the continent.

The HIV/AIDS pandemic not only causes poverty: it is also caused by it (Collins/Rau: 7). Many cultural characteristics that prevail in African societies can be traced back to poverty and the need for material support, and many of them include a sexual component that allows of the transmission and spread of HIV/AIDS. In the following discussion only a few can be mentioned.

Poverty often means ignorance. Access to information is often limited for those who do not have the means to travel to urban settings or trade centers. If there is an HIV campaign at all then it may not reach people in remote regions and places. Or they may simply not understand the education messages that are purveyed. No electricity and a very bad or non-existent infrastructure prevent information from traveling. In many cases, infection with HIV can occur out of sheer ignorance about HIV and how it is transmitted.

Protection can be costly: the poorest simply do not have the option to make the right choice. Under conditions where a glass of clean water is luxury, spending resources on condoms or on breast milk substitutes in order to prevent mother to child transmission is not even an issue. If a decision has to be made whether to walk ten miles to the next trading center to buy a condom or whether to buy a fish from the neighbour to feed the family, the outcome is obvious. Poor people often do not have the choice to protect themselves.

Poverty entails being unable to manage risk. Even where people know exactly how HIV is transmitted and the risks that they are running, many have no real option but to run the risk. The parallel with environmental degradation stands out: poor people across Africa engage in environmentally destructive practices, not from ignorance, but from lack of alternative sources of income. Poverty forces them into short-term behaviours that undermine their long-term prospects. So it is for many poor youth in Africa, especially young women: their entire lives consist of uncertainty and risk, playing off one set of immediate pressing concerns against another, less visible and less immediate risk.

Poverty drives women to unprotected sex. As mentioned above, female poverty is a major factor that drives women, young and old, into risky behaviour, including commercial sex work and dependence on multiple partners or ‘sugar-daddies’. There is research that indicates that the poorer the sex worker, the less likely she is to ask for or insist on using a condom. Competition among commercial sex workers means that those who demand safe sex may be forced out of the market. (It should be stressed: the problem here is not commercial sex work as such, because this can be ‘safe’, but unprotected commercial sex work. The key factor in the latter is poverty.)

Poverty contributes to migration, which is a major risk factor for HIV. A different association between poverty and the spread of HIV occurs when men have to leave their families for far away places where they have better job opportunities. These migrant workers, being deprived of their wives, have the tendency to engage in casual sex in the locations where they find work. Not only is the transmission rate amongst people working and living around these workplaces (e.g. mines) particularly high, there is also a very high risk of husbands returning home to their families and infecting them. There are many aspects to life among migrant workers’ communities that predispose towards risk of contracting HIV. Among them are overcrowded all-male dormitories, forcing men to seek casual sex outside; boredom, predisposing men to drink alcohol and engage in casual sex; large numbers of men patronizing relatively few commercial sex workers, who are likely to become HIV positive and transmit the infection; and macho risk-taking culture that is averse to ‘safe sex.’ In many ways, soldiers serving in armies are similar to migrant workers. Many conscripts chose a military career because of poverty. Far away from home, and under very harsh circumstances, casual sex is tempting.

Poverty contributes to work in the informal sector, which can also be a risk factor for HIV. Lack of employment opportunities in the formal sector have contributed to a flourishing informal sector in many African countries. Informal economies are based on trade, including smuggling and providing services to traders. One of the few African economic sectors that is booming is based on long-distance trading. Informal economy activities tend to be insecure, and to congregate together.

Lastly, poverty is closely associated with factors such as undernutrition, susceptibility to other diseases (including STDs) and risk of harmful traditional practices such as female circumcision. These are all in themselves risk factors for HIV transmission, especially for women. There is what has been called ‘a synergism of plagues’.

Inequalities

Clearly, poverty predisposes to vulnerability to HIV. However, equally important is the structure of poverty, or—to use different language—the inequalities built into impoverishment in Africa. Poverty and inequality are the membranes over which the AIDS pandemic has spread throughout Africa

Individual poverty does not always correlate closely with risk. For example, the category of men most at risk from HIV includes many who are relatively well-educated and well-off. They are not the poorest. What renders them at high risk of HIV is their readiness to engage in multiple sexual liaisons. Their ability to do this arises from the pronounced inequality that is a feature of African societies and economies; they can easily exploit vulnerable women. In a sense, they too are indirect victims of poverty.

Impoverishment has also forced many Africans, poor or less poor, into new forms of economic activity and social interaction. These in turn have become the continental arteries for the HIV pandemic.

There is much evidence that links migrant labour, armies’ garrisoning, and truck routes with the spread of HIV. There are parallels here with how the development schemes of earlier decades contributed to the spread of certain diseases. For example, the Gezira scheme in Sudan created a problem of schistosomiasis, and the Volta River dam in Ghana accentuated the problem of river blindness. Similarly, the economics of labour mobility in contemporary Africa has been a major social vector of HIV transmission. We may blame individual behaviour, but changing social and economic conditions have put that behaviour in a new and very different, dangerous context (Schoepf, 1991).

Structural Adjustment and HIV

The correlation in time between the AIDS pandemic and the austerity measures imposed on Africa by international financial institutions is striking. In the last twenty years, Africa has suffered severe cutbacks in basic services including education and health. In the meantime, economies have been restructured, with growing unemployment, migration in search of work and food, and informal economies and export-oriented trade have grown. Inequality has grown. All these factors have intensified the conditions under which Africa’s youth are obliged to seek sustenance by migration to cities, abandonment of traditional social ties, petty trade, commercial sex work, etc. And at the same time, the capacity of public service provision to contain the pandemic has suffered.

Perhaps equally importantly, structural adjustment programmes have entailed a new, tougher language of economic development in Africa. International donors have placed the primary and overwhelming responsibility for economic failures on African governments themselves. International focus on basic survival and social security has been conspicuously weak: these tasks have been largely delegated to relief NGOs, rather than lying at the center of international assistance policies.

Options: Is Comprehensive Change Necessary?

This limited account indicates that poverty and inequality increase the likelihood of some sections of the populace engaging in frequent unsafe sexual intercourse. Comprehensive responses to the AIDS pandemic entail helping to stitch the African social fabric back together again, making it possible for millions of the poorest, especially women, to survive without engaging in regular unsafe sex, and making it possible for all Africa’s young people to think positively about the future, and therefore believe that it is meaningful for them to protect themselves. If AIDS is the only disaster that threatens, it is likely that individuals and communities will take action against it. But when AIDS is only one disaster among many, it is not the highest priority.

Africa cannot wait for sustainable and equitable socio-economic development before it begins to combat the HIV/AIDS pandemic. There must be individual behavioral change; individuals and communities must protect themselves. But those who seek to change individual behaviour in Africa must also be aware that the challenge of HIV/AIDS can only be met in the broader context of combating poverty. Equally importantly, those who try to change individual behaviour must refrain from placing blame for the pandemic on supposedly ‘irresponsible’ behaviour: these actions take place in a context which leaves many of the afflicted with little choice but to gamble with their lives.

Need for Dialogue

‘Leadership in the fight against AIDS must be indigenized’ (Fredland, 1995: 14). The question of traditional religions leads on to the equally important issue of localism. In any issue as sensitive and intimate as HIV transmission, very local belief structures and practices are extremely important. Language is a key issue. Public education messages are most effective when transmitted in local languages. This demands a level of local connectedness and awareness that is very difficult for an outsider, even from another part of the same country, to achieve.

No single formula can fit all cases perfectly. While the general shape of public education about HIV/AIDS is clear, the particularities must be tailored to very specific requirements. As Zaffiro underlines, ‘any successful AIDS policy design must incorporate relevant cultural difference in local concepts of disease, contagion, treatment, and cure’ (quoted in Fredland, 1995: 14). Each community needs to find its own mechanisms and idioms for responding. ‘Thus the "safe sex" message is not, ipso facto, adequate. AIDS education runs counter to many traditional notions which lack scientific bases and therefore must be completely integrated into a group’s consciousness if it is to be effective’ (Fredland, 1998: 564). How is one to impart the message, to teenage girls, that it is essential to insist on using a condom during first sexual intercourse? An intrusion into one of the most intimate moments of a girl’s life requires extraordinary sensitivity that no public policy formula can hope to achieve.

HIV/AIDS is also a major challenge because societies do not appear well equipped with the cultural resources for response. The cultural archive of African societies contains responses to many historical epidemics and famines. Strategies include moving away, isolating those who are infected, conserving resources, waiting, responding to the loss of life by increasing fertility. But none of these responses works for HIV/AIDS: Africa needs to develop a new cultural repertoire to deal with this challenge. This cannot be imposed, it cannot be formulated as part of a public policy initiative, it must emerge from national debate.

As mentioned above, when HIV/AIDS is seen less as a conventional epidemic, and more as a multi-dimensional social and political challenge, Africa’s appropriate cultural resources become much more formidable. Traditions of care, obligation, hospitality, inclusion, socially-responsible leadership, solidarity of youth, etc., can all be mobilized in support of a wide agenda for combating HIV/AIDS.

Effective response to the challenge of HIV/AIDS therefore depends upon an open dialogue with all able to contribute. Leadership at national and international political levels, effectiveness in developing and implementing public policy, must be combined with ability to allow and promote free expression and debate, and sensitivity to very local and particular concerns.

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What is Leadership?

This paper attempts to keep terminology to the minimum: the aim is not to test sociological hypotheses but to explore possibilities for social change. But we need to identify several major concepts:

Leadership: What can it do?

Leadership is a position of power and authority, with corresponding responsibility, over an organized institution, collectivity or community. For leadership to be more than simply presiding over an inert group or organization, it must also have the component of agency: the ability to affect change (or, to resist change).

Responsibility includes the Latin work respondere, or the English ‘responding’. Leadership is thus not a matter of isolated action and existence but leadership always, by definition, requires a group of people it responds to. There is never leadership without the led. To cater to and maintain the led is what constituted leadership.

Leadership is also a form of guidance towards a particular goal, leaders have an impact on the way their constituency sees and responds to the world. Thus they help to define public opinion. In this process, they shape what is possible amongst the led, and what is impossible. This feature, unfortunately, is often misused for example when constituencies are manipulated into ethnic antagonism, discrimination and potential violence. We are all aware of the power of leaders to instigate unrest. In the struggle against HIV/AIDS leaders are challenged to use this capacity to influence their people in a positive way – to create a national, social environment that hinders the spread of the pandemic and cares for PLWA.

High-level leadership, especially political leadership, has several forms of agency:

Formal power within a system. State power, namely the authority to instruct government machinery to carry out instructions, is the prime example, but power within parties and the legislature in general is also important. (The special constraints of public policy will be examined below). In addition, power can be exercised through the legal system of the state.

Power over discourse. Leaders have the capacity, through their statements and actions, including symbolic actions, to shape debate and dialogue. Even when their formal power is limited, they can use their access to the media and stature in society to influence what people talk about.

Moral authority. Arising from leaders’ power over discourse is their ability to shape morality, to determine what is acceptable and what is not. This can sometimes be more important than formal power, especially so in countries in which traditional hierarchies are important, and there is respect for authority.

These forms of agency are at the same time responsibilities. Leadership can be exercised in positive or negative ways, to promote change, to block it, or to promote obstructive measures. Role models can play a key role in transforming attitudes. But leaders can also serve as negative role models, promoting fear, fatalism and stigmatization.

In defining leadership, we also need to distinguish the time frame and scope of the leader’s ambitions:

Strategic leadership for building a movement. This is the long-term leadership that is required to set high goals and work purposefully towards them.

Tactical leadership: what we do today. This is the leadership that facilitates an immediate response to a pressing problem.

If leadership is crucial, ‘leaderism’ must be resisted. As Horace Campbell argues, many prevailing European styles of leadership and communication stifle imagination and creativity (Campbell, 1996: 222). This emphasis on the ‘great leader’ that has become common across Africa can often be a handicap to effective mobilization. A principal weakness of ‘leaderism’ has been the stress that is put on ‘the importance of the speaker and organizer and the passive participation of the listener’ (Campbell, op cit.). In short, there is a mechanical model of leadership, in which authority and knowledge is vested exclusively in the leader, and the followers are merely expected to follow the leader’s instructions and parrot his words.

In the context of HIV/AIDS, ‘leaderism’ can be disastrous. There is a need for people to internalize the reasoning behind the measures proposed or advocated by the leadership. Directives issued from on high will fall on barren ground and not take root. Effective leadership does not arise from an all-important individual who attempts to know and do everything himself, but from the ability of a person with authority and responsibility to engender in others confidence in their own leadership abilities. This is most effective when it is accompanied by an enabling environment in which the leadership qualities of others are supported and can have concrete expression.

Leadership in Africa

Leadership in Africa has regularly been decried by social scientists especially ‘Afro-pessimists’. One thesis is the ‘criminalisation of the state’, which argues that many African leaders are uninterested in any form of legitimacy, and are simply plundering the resources of their countries and exploiting whatever illicit opportunities arise to enrich themselves (Bayart, Ellis and Hibou, 1998). A second thesis argues that legitimacy in African political systems derives from patronage, so that African states are marked by dispensing patrimony, the ‘recycling’ of elites, and the use of state resources for the consolidation of power through unproductive investment in social and political networks (Chabal and Daloz, 1998).

It would be futile to deny that these depictions do not contain some truth. Leadership in Africa has not been marked by major successes. Africa has struggled to maintain the same level of economic and social development as it had at independence four decades ago, while political institutions have often been in states of decay. At independence, many African leaders enjoyed high stature and respect, but few succeeded in maintaining that over succeeding years. Subsequently, first in the 1980s and again in the 1990s, a ‘new leadership’ was hailed in Africa, but again hopes were disappointed. Africa’s ‘democratization wave’ toppled many authoritarian and military regimes, but democracy remains fragile.

However, we must also point to the resilience and legitimacy of the state in Africa. There has not been wholesale collapse of states or redrawing of national boundaries. There is a remarkable ability of national political leaders to acquire legitimacy from their positions despite the apparently artificial nature of the state.

The weakness of the state in Africa, and the limits of governmental power, mean that leadership in the continent is a complex affair. Later in this paper we attempt a typology of African states, identifying the extent to which social mobilization is possible in different contexts.

Leadership operates at many levels. In the African context, there are leaders at all levels of social and political organization; local chiefs and administrators, religious leaders, party leaders, national leaders, and international leaders. All need to be involved and allowed to make their own particular contribution in the fight against HIV/AIDS. To caution against ‘leaderism’ is not to deny that at times it can take individuals of exceptional vision and caliber to provide a spark and harvest the potential for change. Different contexts require different kinds of leadership. These include:

National political leadership: this has the prime responsibility for initiating and promoting change. In Africa, many political leaders have national power that exceeds that of their counterparts in western countries. This can be seen in several respects:

Government and state leaders have moral authority; they have often managed to obtain a high level of legitimacy, acquiring the status of paramount chiefs.

States can operate in a highly hierarchical manner, enacting top-down directives and campaigns. Examples include directives for combating illiteracy, or agricultural production, in many countries.

National institutions can achieve high levels of mobilization, for example party mobilization for elections. In these cases, cadres fan out across the countryside reaching every village, ensuring that all possible voters are mobilized.

All of the above can translate into effective action against HIV/AIDS. In several countries in Africa (e.g. Uganda and Senegal) there are positive examples of this.

Religious leadership: religious leaders combine access to and influence with huge constituencies, with the ability to take a stand on important social issues that will change people’s behaviour. Religious leaders can have the power to encourage social responses to HIV/AIDS such as caring for sick people and orphans, renegotiating gender roles, social inclusion of PLWAs, fighting against stigma and human rights abuses.

Community leadership: community leaders, including local political leaders, local chiefs, administrators etc. have a responsibility towards the people with whom they live on a daily basis. Their relationships, as well as their influence, can be personal and intimate, as well as exercising authority. Their scope of intervention and guidance can thus concentrate on the day-to-day struggle of households where they can encourage equality, care and respect, but also on local decision-making and politics.

Bureaucratic leadership: salaried civil servants, national and international, can make a huge difference. Often, one of the biggest challenges for leaders is not transmitting their message, or inspiring their followers, but making large and complex bureaucracies, prone to inertia and infighting, actually deliver a policy. Far too often, policy initiatives get lost in the bureaucratic maze, so well satirized by the British TV programme ‘Yes, Minister’, in which a senior civil servant routinely reverses every initiative that comes from his ministerial boss. If salaried civil servants decide to make the system work, they have great power in their hands to effect change.

Trade union leadership: based on notions of solidarity and equality, trade unions have the capacity, especially through peer education, to educate workers about protection and to act as a safety net for those who have been infected with HIV.

Education sector leadership: teachers have major influence on their pupils, not only while they are studying but throughout their lifetimes. Throughout Africa, teachers are revered and respected, and thus have enormous responsibilities with regard to their students. Bearing in mind that youth are the age group with the highest levels of HIV infection, teachers find themselves in a pivotal position.

Cultural and social figures: in all countries, cultural figures and celebrities (singers, artists, poets, sportspeople, newscasters, royalty) have important influence far beyond any formal powers they may enjoy. They can be role models and opinion formers, and can serve as the most effective messengers to spread attitude and behavioral change. In particular they have the possibility of reaching certain groups that are otherwise resistant to messages about changing sexual behaviour.

Voluntary and grassroots leadership: the leadership of social movements and voluntary organizations is the most difficult to define and reach, but can be the most influential. Community-based organizations and NGOs can be flexible, rapid, innovative and effective; they can find unexpected solutions to problems. In Africa today, where so much responsibility for coping with adversity falls upon communities themselves, this level of leadership is among the most important. Being voluntary in nature, NGOs have the possibility to select themselves what aspect of the HIV/AIDS crises to focus on, and what strategy to deploy. Driven by nothing but concern, their impact can be tremendous and vital.

Military leadership: armies are the most hierarchical and obedience-oriented institutions, and ‘leadership’ in its most formal sense is found among the officer class. However, military leaders are usually not selected for their ability or readiness to address issues such as the sexual behaviour of their troops. Given the importance of responding to the crisis of HIV in the military, this will call on military leaders to acquire new leadership skills.

International leadership: all of the above forms of leadership are also reflected, in differing ways, at the international level. International influence can be exercised on many levels: on national political leaders, improvement of development, empowering of marginalised groups and encouraging of gender equality.

Leadership, however, is constrained by structures, including the wider economic, political and cultural environment in which the leader operates. Leadership is also influenced by the constituency being served, the political and organizational arrangements in place and the nature of the tasks needing to be tackled. This suggests that leadership is a complex relationship rather than the property of an individual. Instead of reeling off a list of supposedly universal traits that the ‘good leader’ must possess, attention must be paid to the context in which acts of leadership must be performed. An understanding of both leader’s agency and structure is necessary: each determines the other.

Public policy formulation and implementation

Political leadership in a modern society, especially when it includes issues such as public health, requires public policy. We can identify four main aspects to this:

Policy formulation: the process of identifying a policy;

Obtaining policy consensus: building a constituency in support of the policy and announcing the policy initiative to the public;

Policy implementation: ensuring that the public service and ancilliary organizations can actually carry out the stated policy, and not see it subverted, neglected or undermined;

Consistency and commitment: ensuring that the policy is implemented for long enough and with sufficient energy to actually work. This implies mechanisms for monitoring and accountability.

Policy also operates at different levels. Some of the most effective policies have originated as initiatives at a community or NGO level, and have then been replicated, adapted or scaled up, to become national programmes. Less often, an international policy initiative has been the initiator of major public policy change which has been implemented at national and local level according to a blueprint.

At a general level, we can identify some of the preconditions for effective public policy measures against a major social ill:

A set of technical and/or policy measures that a state can utilize to effectively tackle the specific social ill. There has to be a package that works in the most basic technical manner. In the case of HIV/AIDS, there is a core package that is known to work, but there is no single simple remedy, and the different components of successful policy vary according to place and time. Leadership is required to help identify and reproduce successful responses to the crisis: this requires flexible and creative thinking.

Mechanisms to ensure that the technologies and/or policies are adequately utilized, backed by legislation, administrative commitment or other specific forms of sanctioning. There have to be mechanisms for ensuring that institutions function, and political processes for accountability. In the case of a simple remedy (e.g. releasing food stocks in the case of impending food scarcity) this is a relatively easy requirement. In the case of HIV/AIDS it is far more complex, with many different components required. Some of the challenges of integration, mainstreaming and scaling-up HIV/AIDS responses are outlined below.

An ethical consensus which rules that this specific social ill is unacceptable. The policy must be acceptable to the target group and the general public. This is especially important when the policy involves trying to change attitudes and behaviour. This is particularly the case for a challenge such as HIV/AIDS, in which widespread social mobilization is an essential prerequisite for successful action.

We can identify several challenges to ensuring that a sound public policy idea becomes workable within the context of national or international policy-making (Collins/Rau: 43ff).

The need to integrate HIV/AIDS prevention and care programmes with existing sectoral activities, including businesses, NGOs and government programmes. This can facilitate the most effective use of resources, it can routinise HIV/AIDS activities within existing programmes, it can be efficient for clients (especially marginalised target groups), and it can help to overcome stigma and discrimination against PLWA. Integrating HIV/AIDS programmes across social mobilization and public service systems is perhaps the greatest challenge (see below).

The need to mainstream HIV/AIDS prevention and care into normal bureaucratic activities such as planning, budgeting and evaluation. This is a particular challenge to national leadership, at a political and bureaucratic level, and also to the leadership of aid institutions. Bureaucracies are institutions that are often jealous of their operational independence and are resistant to taking on board cross-cutting initiatives. However there are some encouraging signs of change, often in the middle ranks of institutions.

The challenge of scaling-up effective initiatives to cover a wider area or wider population. This requires leadership skills to identify what should be scaled up and promote it, which in turn requires flexibility in policy implementation. (Aid bureaucracies are among those needing to attend to this lesson.) Experts naturally prefer to work from professional blueprints rather than from grass-roots experience of what works: changing this mindset is one challenge needing to be faced. Scaling-up also requires a general capacity for implementation among state institutions, which entails reversing years of neglect and austerity.

Building trust

There are major problems with the implementation of public policy in Africa, based on Africa’s unique historical experience. Since colonial days, lack of voluntariness and insensitivity to local realities have routinely undermined trust in public policy. This has left a deep legacy of distrust in governmental interventions. Ordinary African citizens routinely suspect that any initiative from a government department or international agency may have a hidden agenda, or may be a passing fad that will soon be superceded. For many ordinary people and low-level bureaucrats alike, the established modus operandi is to try and survive despite public policy initiatives, paying lip service to them and going through the motions of implementing them, but in fact either ignoring them or subverting them. Africa is littered with development or environmental programmes that failed because local people quietly undermined them from within.

This problem exists for some public health programmes as well. During the 20^th century, many draconian policies were enforced in Africa in the name of public health, including the forcible bulldozing of shantytowns and relocation of their inhabitants, and the movement of villages to contain tsetse flies. The ethics of some colonial medical practices have also been questioned. Leaving aside the current debate about whether the origin of HIV can be traced to the use of infected chimpanzee livers as a culture for developing polio vaccines, it is evident that some European medical scientists relaxed their ethical standards when operating in Africa. In Apartheid South Africa there is a disturbing and sometimes bizarre history of medical experimentation conducted with the aim of finding pathogens that will selectively attack Africans. Our point here is not whether these allegations are true, but that many Africans have deep suspicions of national health policies. For example, some may fear that advocating condom use is the West’s means of limiting Africa’s population.

Again, this discussion brings us back to the challenge of leadership. For some leaders, implementing public policy is seen as a mechanical affair of consulting experts, drawing up blueprints, issuing directives, and calling on civil servants to implement what is required. The reality of HIV/AIDS in Africa is that leadership has also to establish a substantial level of mutual trust between the leader and the target group. The trust has to be mutual, so that (a) the target group trusts the messages from the leadership, and does not ignore or subvert them, and (b) the leadership trusts the target group to develop and implement their own responses to the crisis.

Health policy needs a positive environment

Public policy against HIV/AIDS has its limits. Whether HIV/AIDS programmes can make a significant difference in the absence of more general and elementary changes in Africa’s predicament can itself be questioned. The success of campaigns based on condom promotion, sex education and the provision of information is hugely dependent on the existence of basic factors such as adequate infrastructure, gender equality and literacy. Actual resources are also key. There is no point in knowing that condoms prevent HIV transmission if condoms are not readily available. Sometimes, African heads of government are encouraged to commit the political will to change the factors conducive to the spread of HIV/AIDS, but with little indication of ‘how countries would achieve the wealth and independence to develop in these areas’ (Klouda, 1995: 482). Poverty is not only the background to the AIDS pandemic in Africa, it intrudes into every aspect of the spread of the disease and efforts to combat it.

To ignore primary factors such as poverty and lack of governmental capacity in drawing up HIV/AIDS programmes is, argues Klouda, like attempting ‘to put windows in a house before the walls are built… The vast majority of programmes stay fiddling with the windows, benefiting a few individuals who already have the walls, but leaving the vast majority of the poorest and marginalized unprotected’ (1995: 470). Yet if this is accepted, the question then becomes, where will the ‘walls’ come from and when? In the absence of a profound and instant shift in the global economic order, we may be in for a long wait. In the meantime, HIV/AIDS continues to ravage Africa. The magnitude of the changes that need to occur to contain HIV/AIDS does not mean that they should not be undertaken. The opposite is the case. Yet if it must be stressed that HIV/AIDS is symptomatic of more general problems, this can be a double-edged sword. Those who argue that to take HIV/AIDS specific measures is to whistle in the wind, can merely provide a recipe for inertia. Tackling HIV/AIDS cannot wait for the end of poverty, inequality and exploitation.

Organization or movement for social progress or emancipation.

This concept encompasses NGOs, grassroots organizations, civil society organizations, trade unions, political parties, and other forms of social organization that involve the voluntary association of individuals. This is, self-evidently, a movement to remedy a perceived social ill and bring about social change for the better. It is the practical manifestation of the impulse for social change or emancipation, the popular counterpart of leadership.

We can try to identify several different kinds of movement, including:

Power-seeking political mobilization (by a party or faction seeking political power).

Ideological political mobilization (in pursuit of an ideological agenda).

Social engineering (the use of state power to influence behaviour or enforce change). (Voluntariness in this case may be limited.)

‘Primary’ social mobilization (mobilization of constituents in pursuit of their interests).

‘Secondary’ rights activism (professionalised activism by human rights specialists).

Once again, we find that the circumstances in Africa are unpropitious for the emergence of truly effective movements for social change and emancipation. One of Africa’s tragedies has been that the emergent mass movements of the 1940s and ‘50s, which succeeded in obtaining independence for most African countries, did not subsequently translate into wide social movements for civil rights, democracy and development. There are many reasons for this. Among them we may note the way in which in rural areas, most ‘primary’ mobilization was in the form of resistance against external intrusion, rather than for obtaining social progress in specific areas. We can also note the importance of ethnic mobilization, which in some cases has been hitched to emancipatory political programmes but in many others has simply become a vehicle for seeking power. Of particular significance also is the prevalence of armed struggle and the widespread use of violence as a means of achieving political goals. While this continues, mass non-violent social mobilization is extremely difficult.

Among civil leadership, we can identify two contrasting modes of operation with regard to governments.

Adversarial. This is the type of activity most commonly associated with human rights organizations and protest movements. They document the failures of government, criticize them with the aim of embarrassing those in power (‘mobilizing shame’), and thereby effecting change.

Programmatic engagement. This is the activity more commonly undertaken by implementing NGOs, that work with government structures to deliver services, to discuss policies, and to effect internal reform and capacity building within existing systems.

Western human rights NGOs are often criticized in Africa for focussing on adversarial activities to the exclusion of programmatic engagement. In some cases this may be a fair criticism. However, in the case of the HIV/AIDS pandemic, it is clear that there is room for both types of activity. Most NGOs and community-based organizations will focus on programmatic engagement, but the selective use of adversarial methods—‘naming and shaming’—is also necessary. There are many, among national and international leaders, who have signally failed their people, and there is nothing to be gained by refusing to confront them with their failures and its consequences.

The basic triangle of concepts—leadership, public policy, and social mobilization—which will be elaborated later in this paper, provide the props for exploring the potential for effective leadership measures, public policy and social movement against HIV/AIDS in Africa.

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Public Policy Measures Against Disease

This section examines, comparatively, cases of public policy measures to combat epidemic diseases, famine and poverty. HIV/AIDS has no exact parallels in the history of medicine, and even the closest models (such as TB and syphilis) are inexact. Each case that follows is a model that has attractions and disadvantages for the case of HIV/AIDS.

The eradication of smallpox. The conquest of smallpox in the 1970s is one of the greatest public health achievements of all time—if not the greatest. One of the greatest scourges and causes of death in the world was eliminated completely. This was achieved by a coordinated worldwide international public health campaign. It was facilitated by a relatively simple technological package: a single-dose immunization that could be 100% effective, made possible because of the nature of the disease. Smallpox was solely a human disease, so that elimination from human hosts meant total elimination. In addition, the disease could be progressively eradicated: the elimination from a single country or region, followed up by careful monitoring and quick response when new cases were detected, meant that the campaign could bring major progress even before reaching its ultimate goal. Because a one-off total eradication campaign was possible—and was achieved—it was not necessary to supplement the technical package (immunization plus monitoring) with public education or attitude change.

The eradication of smallpox was a monumental achievement of public policy. However it was one of the least complex political and social challenges for international public health. It is also a misleading model for the eradication of many other diseases, among them AIDS, because it implies that success can come through a technical, bio-medical package alone. The vaccine model of ‘solution’ for disease also ignores the 23 million Africans already infected with HIV, and the millions more who will become infected before any vaccine becomes available and universal vaccination is provided.

The elimination of cholera and other waterborne infectious diseases from industrialized cities in Europe in the 19^th century. This is an interesting and instructive case highly relevant to the political history of HIV. Cholera was effectively eliminated from northern European cities well before any effective treatment was found. It was eradicated by public health measures. But this was not achieved without a struggle. One particular struggle was the valiant and ultimately successful attempt by the pioneer epidemiologist John Snow (1813-1858) to establish that cholera was waterborne, and carried by contaminated water supplies. Following an outbreak of cholera in an area of London in 1854, Snow demonstrated statistically that cholera was far more prevalent in streets served by one particular water company than in streets, otherwise similar, served by others. With the removal of a single water pump around which cases were concentrated, incidents of cholera declined immediately (Porter, 1997: 413). Water companies that failed to ensure strict separation between waste and clean water were marked by high levels of cholera transmission; those that effected good hygienic practices were marked by low cholera levels. Snow’s efforts were vigorously opposed by the water companies, which took the extreme measure of suing him for libel in the courts. Snow fought and won. His findings contributed to the construction of new sanitary infrastructure. They succeeded in changing public policy. His efforts demonstrated an important link between moral courage, social activism, the rule of law, and the conquest of an epidemic disease.

Rudolf Virchow also made such links when investigating a typhus epidemic among a suppressed polish minority in Prussia in 1847. As Porter explains, Virchow stressed how ‘epidemics were symptoms of a general malaise; they mainly affected oppressed groups. The answer was thus not medicine, but "political medicine": education, freedom and prosperity. "The improvement of medicine would eventually prolong human life," he proclaimed, "but improvement of social conditions could now achieve this result more rapidly and more successfully"’(Porter, 1997: 415).

It is arguable that the shortage of good epidemiology of HIV in Africa reflects the interests and biases of institutions that have little positive interest in promoting complete transparency. An epidemiologist with the courage of Snow, working in Africa in the 1980s, might have been able to slow significantly the spread of the disease by identifying key agents of transmission such as the military and exposing the dangers of impunity for crimes of rape.

The campaign against polio. The attempt to eradicate polio has become one of the more controversial international public health decisions of the later 20^th century. Polio is a disease that has ravaged many across the world, and has been effectively eliminated in industrialized countries within living memory. A campaign to eliminate polio is a worthy goal. However, it is also a complex disease that is extremely difficult to eradicate entirely. Because it has non-human hosts, it requires constant re-vaccination of every new generation: unlike smallpox it cannot be eliminated once-for-all. In addition, the disease is more dangerous the older the infected person. Therefore, once vaccination has been started, it becomes even more important to maintain constant programmes of vaccination, for fear that an even worse outbreak of the disease should occur.

It is interesting to contrast the attempt to eradicate polio with the failure to institute any comparable campaign against measles. Like smallpox, measles is a disease that has only a human host, and is therefore potentially eradicable. The vaccine against measles is also effective and simple. Measles takes many lives across the developing world, and in many respects is a greater public health menace than polio. However, it was not chosen as a priority for eradication, perhaps because measles does not have the same profile as polio in western countries, from where funds for the campaign have been sought. The case also demonstrates the shortcomings of a market-based global health system to develop the appropriate medical technologies for poor parts of the world.

The comparison with the disparity of research resources focussed on strains of HIV prevalent in Europe and America compared with those prevalent in Africa is obvious if inexact. The lesson here is the importance of allowing the precise needs of African countries to take their proper proportion in relation to the demands of obtaining resources and public support elsewhere in the world. The limited market ‘demand’ of Africa for appropriate drugs must be bolstered by international public policy.

Strong leadership has made it possible for effective mobilization and public policy measures to reduce the incidence of polio across the world, eliminating it in many countries. The absence of any such leadership or public policy initiative concerning measles has been a notable absence.

The containment of leprosy. Leprosy is a mysterious disease: its mode of transmission remains unclear; it is slow-onset, highly-stigmatised and feared, and the reasons for its disappearance from large parts of the world are unknown. The control and containment of leprosy is a very complex task, including public education to remove or at least reduce the stigma, ensuring high rates of patient compliance in drug-taking (making sure that patients continue to take medication for months after symptoms have disappeared to ensure no relapses, and that drug resistance does not emerge), care for those disabled or scarred by the disease, and maintenance of monitoring and case-identification systems in health services. The medical challenges posed by leprosy are minor compared with the challenges of changing attitudes and behaviour. Even after decades of patient public education, negative attitudes towards leprosy and widespread rejection and ostracisation of leprosy sufferers remains widespread. The fact that the disease is continuing to spread (very slowly, it is true) is discouraging to those who are optimistic about changing health-related behaviours. On the other hand (with a few notable exceptions such as the late Princess of Wales) there have been very few high profile figures ready to associate themselves with the campaign against leprosy. Leprosy sufferers have suffered from a lack of political leadership ready to try to change wider social attitudes.

The conquest of famine in India during the 20^th century, in comparison with the failure to do so in Africa, is an interesting case that illustrates the potential for social mobilization under effective leadership. Civil and political liberties are used to enforce, a state obligation to protect basic economic rights, founded on a national political consensus that famine is completely unacceptable. This case can only be understood in its specific historical context.

In the last decades of the 19^th century, a coalition of Indian farmers and labourers, nationalists, and foreign sympathisers with the nationalist cause, succeeded in shaming the British government over the extent of poverty and famine in India. Mass starvation in the subcontinent was, they said, an indictment of Britain’s supposed mission to bring civilization to the world. Fearful of the security threat posed by destitution and restlessness, and the loss of legitimacy arising from the nationalist critique, the British Raj first instituted the famous Famine Codes, and then reformed them to make them more effective. Intended as no more than an administrative obligation, famine prevention and relief quickly became adopted as basic rights by Indians themselves, so that when in 1943 the British allowed a devastating famine to strike Bengal, the loss of legitimacy for the imperial regime was devastating. The fact that famine prevention usually worked so effectively made this failure all the more striking. The hungry masses themselves would not have been a major threat, and neither would the nationalist leaders as a class—but the combination was profoundly threatening.

One of the important achievements of the anti-famine coalition in India was to change the moral terms of the debate. For most of the 19^th century, the British insisted that the Indian poor starved because of their own moral shortcomings: they were idle, failed to plan for the future, and had too many children. By changing the debate from one centred on the supposed moral inadequacies of the victim, to be one of combating a wider social ill, it became possible to develop effective public policy and political commitment. This has clear parallels with the challenge of HIV a century later.

Post-independence governments in India have feared that famine would destroy their credibility and electability. They have proved responsive to press exposure of impending famine and inept or inadequate relief, and have been ready to support expensive but effective anti-famine programmes. As Sen has described, the Indian political system ensures that both the informational and the incentive factors are present for famine prevention. This is a classic ‘political contract’ against a social ill.

In many parts of Africa, there has been a comparable political contract that ensures that states are obliged to provide food for townspeople. But that obligation has rarely been extended to rural areas, and in fact urban food security has often been maintained to the detriment of rural food security. For various reasons, comprehensive anti-famine political contracts in Africa have been elusive. These reasons include the less visible and less politically threatening nature of rural African famines, the traditional nature of political authority in rural areas, the failure to politicise famine in a consistent way, the internationalisation of responsibility for response to famine, and the lack of civil and political liberties in many African countries. The rural food insecure do not tend to identify with one another and mobilize around the issue of food: instead they tend to seek individual security within local networks of patronage and local economic niches.

The difficulty of mobilizing rural constituencies in Africa around generic issues (rather than around locality-based demands) is highly relevant to the challenge of HIV/AIDS. Mobilization and protest require that people hold the state accountable for HIV/AIDS prevention and care. It is highly unlikely that rural people with HIV/AIDS in Africa will come together as a constituency to press for their common interests; it is more probable that they will continue to seek individual solace where they can, in the context of the extended family or local charitable efforts. The fact that the wealthiest can afford treatment also reduces the pressure on such people to identify themselves as HIV positive and to identify their common interests with poorer people living with HIV/AIDS.

The struggle against poverty in India. Let us contrast the success of the anti-famine political contract in India with the failure to develop a wider political contract against poverty. As Prof. Amartya Sen and others have pointed out, India’s success in eliminating famine contrasts sadly with its failure to reduce the extent of chronic poverty that afflicts the subcontinent. Why is this? We can identify several possible reasons. Each of them has some relevance to the difficulties of mobilizing a coalition in support of the issue of HIV/AIDS:

Lack of visibility. Famines in India are highly visible: there are mass movements of people to cities, mass destitution on the streets. But poverty is less visible. Urban poverty is likely to be a higher-profile issue than rural poverty, because (a) some of the urban poor can be seen sleeping on the streets, (b) there are negative public health implications of large-scale urban destitution and (c) urban poverty is usually ugly (and prosperous city dwellers like their cities to look clean and attractive). Making rural poverty visible is notoriously difficult.

HIV/AIDS is an extraordinary epidemic, in that it can affect a huge proportion of the adult population of a country, and yet remain all-but ‘invisible’. Because of the slow onset of the disease, the way in which it disguises itself (particularly as TB), and the stigma attached to it, there can be little visible sign that a country is being ravaged by the pandemic. It is not like an epidemic of cholera or a famine. It takes an effort of political will to make the issue visible. This can either follow from an act of bold leadership or from social mobilization by affected people and their friends.

The sheer level of HIV/AIDS infection in many countries will, tragically, make the disease visible. Fortunately, the level of national and international attention generated by recent national, regional and international conferences and media campaigns has undoubtedly broken through the visibility barrier in much of Africa.

Lack of ‘separability’. It is easier to mount a campaign or develop a public policy focussed on a single, separable issue. But poverty is so complex, so multi-faceted, that it is difficult to identify what aspects to prioritise and tackle.

Is the abolition of poverty, like the abolition of war, simply too vast to be practicable for a social movement or a political contract? There are good arguments for believing that this may be the case. Social mobilization requires visible issues, simplification of issues, possibilities for tangible progress, etc. Poverty is probably too huge and complex an issue to allow for these measures.

In addition, in most societies, the concept of poverty is so heavily laden with religious and cultural baggage that it may