THE POLITICS OF AIDS IN AFRICA

Copyright Indiana University Press Spring 2009

Patterson, Amy S. 2006. THE POLITICS OF AIDS IN AFRICA. Boulder, Colo.: Lynne Rienner. 226 pp. $52.00 (cloth); $19.95 (paper).

Patterson's book is published in the series "Challenge and Change in African Politics." Patterson claims that the fight against HIV/AIDS has not received the attention it deserves in African politics. Political centralization, neopatrimonialism, low capacity, and instability have slowed down the fight. Central to the study, which analyzes AIDS and politics in South Africa, Swaziland, Uganda, and Zimbabwe, is the idea that the magnitude of the problem, the growing inequality on the continent, and cultivation of open responsible institutions by African states and all groups in the international community, would go a long way toward implementing a solution. Patterson structures the first two chapters on discourses on the decline of the African state and unsuccessful democratic transitions and analyzes approaches to combating HIV/AIDS-approaches that include an open dialogue and campaign against the disease by President Museveni of Uganda; centralization in the case of Zimbabwe; the right discourse, but contradictory actions by the King of Swaziland; and Thabo Mbeki's pronouncements that have questioned whether HIV causes AIDS and have raised doubts about generic drugs. Despite the fact that South Africa is an open society, in which activists have taken up the cause, South Africa has achieved little because the ruling party, the African National Congress, has centralized the fight against the disease. Patterson uses the available literature on political thought and HIV/AIDS to provide insights into the political behavior and operations in the selected countries, and the result is an insightful book, which demonstrates that the fight against AIDS ought to involve all sectors of the political community, and political leaders at the highest level ought to take charge in creating and implementing policies that would strengthen the fight.

In chapter 3, Patterson works with the postulate that democratic states promote health. She examines this idea through several themes, namely that citizens in African countries want their governments to prioritize AIDS and have organized through civil society to have governments take action in fighting it. It is thought that governments often to respond to such demands because they fear that if they do not respond, they would see an adverse effect during elections. Furthermore, democratic institutions are avenues for promoting the fight against AIDS, and democratic governments respond to citizens' views. The critical analysis of political action in the four countries demonstrates that contrary to these political assumptions, AIDS has not been a major issue in elections, and governments have not taken the risk of budgeting money to fight the disease. Most of the money actually used to fight the disease has come from outside donors. Patterson argues, "with the exception of South Africa, democratic institutions such as legislators, judiciaries, and local governments have played a minor role in AIDS policy development" (p. 91).

In chapter 4, Patterson analyzes the role played by civil society groups in the fight against AIDS, and highlights why some AIDS organizations are strong and some influence policy. What emerges in this chapter is careful description and analysis of well-known AIDS organizations, like the Treatment Action Campaign (TAC) in South Africa, and other organizations in Ghana and Zimbabwe. The strength of an organization depends on adequate financial resources, the capacity of its members, its leaders, and its internal structures. By all four of these criteria, TAC in South Africa is probably a strong AIDS organization, one of the few on the continent. The influence an organization can have in the fight against AIDS depends on several factors, including the political system, which is democratic in the organizations studied, except the Zimbabwean AIDS organization, which is autocratic because of Robert Mugabe's domination. The other factors are the political culture in the country that supports AIDS activism, the building of national and international coalitions, and the relationship the organization has with the state. Here, some organizations, like the AIDS organization in Zimbabwe, have been captured by the state, while some cooperate with and confront the state.

In chapter 5, Patterson analyzes the work of donor agents by focusing on two major programs, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), formed in 2001, initially the brainchild of Jeffrey Sachs and Kofi Annan, Secretary General of the United Nations. The other program is the President's Emergency Plan for AIDS Relief (PEPFAR), announced by President Bush in his State of the Union Address to Congress. The U.S. Congress approved PEPFAR in 2003. This move by the White House came after criticism that the United States was not doing enough in the fight against the disease. Patterson argues that the two programs and agencies have approached AIDS in different ways. PEPFAR has approached HIV/AIDS as an emergency, giving the impression that something can be done to "fix" it quickly. GFATM does not see HIV/AIDS as an emergency, but neither approaches the fight against HIV/AIDS in a way that would provide resources for dealing with broader issues of AIDS, such as poverty, conflicts, human rights, gender inequalities, and governance. Structurally, PEPFAR has a complicated setup, which follows mandates laid down by the Congress when it appropriated the necessary funds. For example, PEPFAR works largely through U.S. faith-based organizations, the United States Agency for International Development (USAID), the United States Centers for Disease Control (CDC), and other agencies approved by the United States through embassies in recipient countries. PEPFAR requires that participants in the program use drugs approved by the U.S. Food and Drug Administration (FDA), and use those funds mostly on abstinence programs. This approach has been criticized because it ignores national plans, and many FBOs do not have the capacity to absorb large amounts of money. Additionally, PEPFAR does not give African governments much say in the structure and operation of PEPFAR. The GFATM has a more flexible structure, requires that recipients create national committees, and makes its grant to governments. Patterson argues that donors have to make a long-term commitment to fighting AIDS, and African governments must demonstrate a long-term commitment and be accountable to those affected by the disease.

In the final chapter, Patterson argues that institutions are crucial in the fight against AIDS. The establishment of those institutions is the responsibility of the political leaders who must assume leadership in the fight against AIDS. "AIDS is a public policy problem; how we address the disease is the outcome of political decision making. Politics is about some people convincing others that one policy idea or resource allocation should be accepted over another" (p. 178). Therefore, the state and public organizations must work together with political actors taking an active role in the fight against HIV/AIDS.

Patterson's book is well documented, with several graphs, and she demonstrates an exemplary mastery of the political issues. It is unclear whether, for this book, Patterson (who has lived in Senegal, but does not mention it here) was in Africa, but she indicates that her students gathered most of the material in the United States, and they have not studied the fight against AIDS on the ground in Africa. Regardless of that, in reading the book, one has the impression that one is following things as they happen, especially in chapter 5, where a large number of Patterson's sources are U.S. newspapers. That aside, Patterson not only reports what newspapers publish, but offers critical perspectives on the issues she discusses. All involved in the fight against AIDS will find Patterson's analysis of PEPFAR and its limitations helpful because the control of PEPFAR lies very much with the U.S. government, U.S. embassies, agencies with strong U.S. connections, and FBOs. Scholars and politicians weary of international relations cannot miss the fact that even with amounts that are quite generous, PEPFAR promotes U.S. products and personnel, and for that reason it has not departed from prevailing practices in the foreign-aid industry. Though Patterson does not speculate on how long the fight against AIDS would take, her criticism of treating the pandemic as an emergency demonstrates that African government and their leaders ought to engage in long-term planning if they want to make gains against the pandemic. Patterson's book is very accessible, and it will be useful to all involved in the fight against the HIV/AIDS.

[Author Affiliation]

Elias K. Bongmba

Rice University