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No models, for example, attempt to forecast the way in which sharply
decreased adult longevity may reshape economic rationality and thus the
decisions of firms, household and individuals. Most economic theory,
rooted firmly in the logic of developed economies, is based on the
principle that individuals rationally consider future expectations,
which in many ways is based on their anticipated lifespan. De Waal
points out that over the past century, most people in developed
societies—once they have reached their teens—could expect to live into
their 70s. But when adult lifespan becomes highly uncertain,
individuals' rationale to invest time and resources in their education
or training, or to save and invest is less rational. Rather people's
emphasis turns to spending and consuming, to liquidating assets to pay
for health care and to enjoy their short lifespan.36 As de
Waal puts it:
Why save for a
future that does not exist? ... Just as a doubling of longevity would
entail major structural transformations of developed economies, a
halving of adult lifespan in much of sub-Saharan entails a structural
change in the region's economies that make it impossible for it to
follow existing models for economic development.37
Budgets and taxes:
increased demands and decreased supply
Existing levels of HIV infection mean that Southern African societies
will experience drastically increased levels of severe illness.
Resultant increasing demands for access to government clinics, medical
stocks, and available hospital beds threaten to push the region's
limited public health systems to, and past, their limits. As governments
increase health spending to cope with the increasing demand for medicine
and hospital beds, they will be faced with a growing wage bill to
replace dying nurses and doctors from an increasingly scarce labour pool
and growing expenditure to assist families caring for orphans. For most
countries in Southern Africa, public spending on HIV/AIDS related
matters threatens to consume their entire health budget, or increase the
overall national budget.
Evidence, albeit often anecdotal and episodic, is beginning to
accumulate that suggests these impacts are already occurring. In South
Africa, government reports have admitted that substantial increases in
AIDS patients are steadily displacing other patients.38 In
South Africa's industrial heartland, Gauteng province, Soweto's Chris
Hani Baragwanath Hospital, the country's largest, has seen a 500%
increase in HIV patients since 1996. One half of all beds in the
province's public hospitals are occupied by AIDS patients.39
Yet the country's health system is unable to meet these increased
demands. A 2002 survey of AIDS affected households in four South African
provinces found that 40% to 60% of people living with AIDS had never
been admitted to a hospital.40 Just 16% of eligible
households were able to obtain a state grant.41 South African
government estimates predict the number of orphans rising from the
present 150,000 to two million by 2010, far outstripping the capacity of
the existing welfare system.42
What potential impacts will these rising demands on national budgets
have on the region's multi-party systems? Economic policy makers will
come under increasing pressure to devote increasing shares of the
national budget to public health and welfare expenditure for AIDS
orphans and the families or institutions who care for them. Significant
shifts have already occurred. In 1997 public health spending on AIDS
exceeded 2.5% of GDP in seven of 16 sampled African countries, an
extremely high proportion since total health spending accounted for only
3% to 5% of GDP in these countries.43 As of 1998, 12% of
South Africa's national budget went to health, and 21% of provincial
budgets have been allocated specifically to HIV/AIDS related
expenditure.44 The total proportion of the South African
government's budget devoted to AIDS will increase by 22% (R1.4 billion
to R1.8 billion) between 2003 and 2004.45 Yet according to
South African government reports, even with present levels of real
growth in future health budgets, the health system will not be able to
keep pace with increased demand for services.46
In Zambia, government AIDS spending rose from US$1.7 million in 1990 to
US$12.9 by 1995, and is expected to rise to US$21 million by 2005.47
Zimbabwe spends almost half of its health budget on treating AIDS
patients.48 This is expected to rise to almost two-thirds by
2005.49 In Malawi, senior government health officials have
publicly expressed their concern that half of their health budget will
soon have to be devoted to treating AIDS patients.50
Regardless of whether or not they decide to provide drugs that reduce
mother-to-child transmission, or anti-retroviral therapies, countries
with any form of public health system will ultimately have to confront
these costs. Nattrass and Jolene Skordis conclude from a costing of
mother-to-child transmission drugs in South Africa,
unless the
government is planning to deny hospital care to children with HIV/AIDS
(which would be unconstitutional in South Africa), it costs the
government more to let the children contract HIV from their mothers, get
sick and die, than it does to save them.51
While relatively
wealthy countries like South Africa or Botswana may be able to
redistribute expenditures between budget sectors, or embark upon
limited, disciplined deficit spending, the poorest countries in the
region will be forced to increase their dependence on foreign
assistance. International donors already account for approximately
two-thirds of HIV/AIDS budgets in low and middle income countries across
the world, largely accounted by overseas development assistance.52
As of 1996/97, sub-Saharan African governments are contributing an
average of just 9% of all HIV/AIDS spending in their countries.53
Even in South Africa, which is significantly better able to support its
own efforts, a 2000 Futures Group International study found that it
still received around half of its total HIV/AIDS funding from external
sources.54
HIV/AIDS may consequently increase the reliance of Southern African
states on international donor funding. Zimbabwe's foreign assistance
needs have reportedly already increased by 27% because of AIDS.55
Such increased demand for health related donor assistance may crowd out
other development assistance funds that countries badly need.56
And if widely known, such dependence on donor funding may reduce the
recipient government's popular legitimacy because of the conditionality
with which donor funds usually come.
Because HIV/AIDS has a disproportionate impact on the most productive
part of the labour force, it will disproportionately reduce the numbers
of those most able to contribute to the national treasury through
payroll taxes. Thus, at the same time that the HIV/AIDS pandemic raises
public demands for increases in public health expenditures, increased
levels of death and illness will simultaneously reduce the tax base from
which governments finance their budgets.
How will governments pay for increased budgetary demands in the face of
a decreasing tax base? If they choose deficit financing, they will crowd
out the private investment that could otherwise increase employment and
growth. If they choose expenditure switching, they will crowd out
government investment in infrastructure or development programmes (e.g.
housing, education or land redistribution) that might otherwise help
reduce inequality and build public confidence in democratic government.
INSTITUTIONAL
IMPACTS OF HIV/AIDS ON DEMOCRACY
Democracy is a system of rules and procedures by which free and equal
people elect representatives to make decisions for them, and a system of
rules and procedures by which those representatives make decisions. A
consolidated democracy is one in which these rules are widely known, and
predictable—where the processes of democratic governance become a matter
of habit.
These rules are given effect through political institutions—such as
legislatures, executives, courts and regulatory and security
agencies—which both embody and enforce these rules. To work effectively,
these institutions require people with sufficient skills, expertise and
resources to develop sufficient political autonomy and power to fulfil
their functions, whether to make laws, oversee the executive, prosecute
criminals, or deliver public services impartially. In this sense, the
development of a strong and effective state is a necessary, though
certainly not sufficient, condition for the consolidation of democracy.
There is little reason to believe that state employees across Southern
Africa are more immune to HIV infection than the rest of the population.
While the greatest number of infections and deaths are projected to
occur in the unskilled and semi-skilled part of the workforce, skilled
and highly skilled sectors will nevertheless be hit heavily. In South
Africa, HIV infection rates have been projected to peak at 23% of
skilled and 13% of highly skilled workers by 2005. By 2015 this will
result in a skilled workforce that is 18% smaller, and a highly skilled
force that is 11% smaller.57 Thus, the pandemic is likely to
devastate large portions of policy-makers, national legislators, local
councillors, election officials, soldiers and civil servants—including
doctors, nurses, teachers, ambulance drivers, fire-fighters and police.
South African government reports conclude that AIDS will have become the
leading cause of death among public servants by 2002, resulting in an
estimated 250,000 deaths in the public service by 2012, or 23% of the
present workforce of 1.1 million employees.58
According to media reports, HIV/AIDS has resulted in the death of a
senior presidential advisor, a sitting cabinet minister, and an
influential legislative back-bencher in South Africa's ruling party. In
Zimbabwe at least three cabinet ministers have succumbed to AIDS.59
At the local council level, a 2002 analysis of Durban's (eThekwini)
metropolitan council records over a 21-month period shows sharp
increases in the extent of councillor absenteeism because of illness
(from less than one in the first half of 2001, to over four in mid
2002), as well as in the proportion of total absenteeism due to illness
(from less than 5% in the first half of 2001 to 37% in late 2002).60
The Parks, Recreation and Culture Department reported a 32% turnover in
personnel in the previous six months. The electricity department
estimated that they experience four to five employee deaths and two
medical boardings per month over the past two years double their
previous rates.61
Besides killing increasing numbers of public servants and elected
officials, the pandemic could severely damage the process of political
institutionalisation in several ways. A shrinking proportion of civil
servants, policy-makers and legislators will be at their jobs long
enough to develop the specialised skills, expertise and professionalism
needed to do their jobs.
It will be increasingly difficult for legislatures, ministries and
government agencies to pass on the skills that they do have. There will
be fewer experienced officials available to train younger personnel in
key formal skills (such as programme design, budgeting, cost/benefit
analysis, monitoring and evaluation, and personnel management), or pass
on more informal standard operating procedures or norms such as
ministerial accountability, bureaucratic neutrality and official ethics.
Identifying training needs and grooming replacements is likely to be
made more difficult by the stigma of AIDS which means that civil
servants may leave work and die with little warning.
In South Africa, government reviews have concluded that the country is
not training enough nurses and teachers to cope with current demand, and
pointed to similar problems looming in the police and justice system.62
In Zambia and Malawi, deaths among doctors and nurses have exceeded the
rate at which replacements can be trained.63 In Durban, fire
department managers have noted that while it takes three months to train
a fire-fighter, it takes years to create one with enough skills to pass
knowledge onto younger members through informal training.64
When asked about their ability to co-ordinate and plan the recruitment
and planning or replacements, several city managers related stories of
processing applications for medical boarding on a Friday only to find
out the following Monday that the person had died over the weekend.65
Where civil servants endeavour to deliver public services according to
rational principles of need or merit, the rapidly changing demographic
impacts of the HIV/AIDS pandemic will make it difficult to anticipate
demand accurately and plan the types, amounts and locations of services
to be supplied. National and local governments may invest in services
that end up under-utilised because of an unanticipated fall in demand,
or they may face unanticipated demands because their ability to supply
has fallen faster than the decline in the overall population.66
For example, the managers of Durban's municipal subsidised housing
programme admit that they know little about how HIV/AIDS will affect
patterns of household formation. South Africa awards subsidies to
households, not individuals. Thus, even if it were possible to make
relatively accurate projections of decreases in eligible individuals, it
would be difficult to predict changes to the number of potentially
subsidised households. The pandemic may reduce demand for housing if
splintered families combine into new households; but it may also
increase demand if families splinter and scatter into new, smaller
households, or if it spurs increased urban migration. The increase in
orphans also places new challenges on housing planners who must find new
ways to increase the capacity of communities to absorb these children.67
All this is particularly worrying since the region's nascent democracies
lack strong political institutions. The dominant characteristic of
political institutions across the region, and indeed most of sub-Saharan
Africa, is one of neo-patrimonialism whereby 'strong man' political
leaders use patronage to gain and maintain political loyalty. Patronage
relationships shape the behaviour of legislators and civil servants as
much as any legal-rational principles of a bureaucratic state.68
A civil service characterised by a high degree of staff turnover and
growing proportions of inexperienced personnel will be even less likely
to develop and enforce institutional boundaries and autonomy.
Conversely, such a civil service is more likely to succumb to patronage
or corruption payoffs by a neo-patrimonial executive branch, party
officials or business people.
HIV/AIDS threatens at least two political institutions which are
intrinsically important for the development of young democracies. The
first is the set of institutions responsible for organising and
conducting regular free and fair elections, the irreducible minimum of
democratic government. The loss of non-partisan supervisory officials,
combined with the complicated voter registration procedures of Southern
Africa's multi-party systems, will increase opportunities for voter
fraud. Increased deaths may necessitate more regular vetting of voters'
rolls. Alternatively, increasing death rates will increase opportunities
for governments to utilise 'ghost voters' to inflate vote totals.
Increasing proportions of ill voters may also necessitate more, or more
strategically located, polling places and greater use of absentee
ballots to enable the ill to vote.69
Thus, better electoral administration skills may become more necessary
at the same time that electoral commissions begin to lose skilled
personnel. Moreover, the funds necessary to register voters, maintain
voters' rolls and hold free and fair elections may be crowded out by
increasing shares of national budgets going to health care or
anti-HIV/AIDS programmes.70 These prospects may threaten to
damage popular perceptions of the impartiality of elections.
Countries with specific types of electoral systems may come under
additional pressures. Increased deaths among Members of Parliament (MPs)
and local councillors in constituency based systems will increase the
number of by-elections. A steady flow of by-elections may increase
government sensitivity to shifts in public opinion, but may also be
financially unsustainable. Countries may be forced to abandon
constituency representation in favour of party list proportional
representation systems. While the list system provides for the swift and
cheap replacement of sick or dead legislators it also removes a
fundamental linkage between governors and the governed.
The second set of key democratic institutions theatened by HIV/AIDS
includes national, regional and local legislative bodies, the sine
qua non of representative democracy. Legislatures best represent
constituent views when they develop institutional autonomy vis-à-vis
the executive. This is usually achieved through the development of a
seniority system that encourages the accumulation of skills in the use
of legislative procedures and rules, as well as substantive
specialisation and expertise in specific policy areas to enable informed
oversight of executive policy. Such skills help create stronger and more
autonomous parliamentary portfolio committees. This applies to both
elected members as well as parliamentary researchers, administrative
assistants and clerks. Rapid membership turnover due to AIDS illness and
death threatens these processes.
CULTURAL IMPACTS OF
HIV/AIDS ON DEMOCRACY
Democracies require democrats. They require citizens who believe
democracy is preferable to all alternatives, and who give life to the
democratic processes by obeying the law, participating in democratic
life, refraining from supporting elites who could endanger or end
democratic processes, and who are willing to stand up and defend
democracy if it is under threat.71
As noted earlier, democracy as a political regime uniquely recognises
and is designed to maximise human agency. But the unique combination of
the characteristics of HIV/AIDS attacks this sense of human agency.
First, because it disproportionately affects large numbers of younger
age cohorts, it results in a drastically reduced adult lifespan. Second,
the combination of its scope and its incubation period means that at any
given moment, a large proportion of society will be living under a death
sentence. Third, the length of the incubation period means that many
people will live under this 'death sentence' for a prolonged period.
Fourth, at least in Southern Africa, HIV infection and the onset of AIDS
illness imposes significant economic burdens on individuals and their
households in the form of increased medical costs, the prospect of
losing a wage earner, as well as significant burial costs.72
Finally, given that few people can be confident about the HIV status of
current or prospective sexual partners, the uninfected are also likely
to experience a sense of helplessness and lack of control over their
future. For example, where national prevalence is 15%, and this rate
applies throughout a person's lifetime, more than half of today's
15-year-olds will die from AIDS.73 Given the lack of any
clear, positive message of hope to uninfected people in those age groups
about how they can confidently avoid infection over an extended period
of time, a large number of teenagers and young adults may conclude that
they have little hope of avoiding this death sentence themselves.
Akin to de Waal's arguments about the need to revise traditional
assumptions about homo economicus, we also need to consider what
such a sharp reduction in adult life expectancy means for our
assumptions about the behaviour of homo politicus. It is likely
to recalibrate the context of citizens' rational decision making, in
particular reducing the incentives for co-operative behaviour and
increasing incentives for opportunistic behaviour.74 Thus,
the pandemic not only damages the human body, but may also 'damage' the
'body politic'.75 This is likely to have several important
political consequences.
Decreased citizen
support for democratic government
At its most extreme, HIV/AIDS may turn citizens into authoritarians
because mounting death and sickness drives them, in desperation, to try
any set of political entrepreneurs who promise to offer a
solution, whether they use democratic means or not. These could, for
example, be political or religious movements who seek to place the blame
for the pandemic on personal immorality, religious transgressions,
minority groups, or external forces.76 Such a scenario could
become more likely if the region's democratic governments are widely
perceived to be incapable of preventing the pandemic from growing,
caring for its victims or preventing a sharp deterioration in quality of
life.77
More likely, the pandemic may reduce the importance which people attach
to democracy because of more urgent priorities such as simple survival.
The degree to which democratic versus authoritarian government matters
to someone infected with a fatal disease, or whose life is burdened with
caring for such people, or who believes they have little prospect of
avoiding infection, is an open question.
Decreased citizen
participation
HIV/AIDS may also reduce overall levels of public participation in
democratic politics. Mounting AIDS deaths and illness will reduce the
absolute number of citizens able to vote or participate in public life.
But the question also arises whether the 'death sentence' imposed on the
infected, or the threat of infection facing the uninfected will reshape
the usual incentives to becoming involved in public affairs. Moreover,
the burden of caring for ill family members or friends is likely to
reduce those people's time and resources available to participate in
public affairs. For example, many countries in the region require people
to obtain multiple forms of identification to register to vote, which
places both the ill and caregivers at a disadvantage.78
However, it is also possible that some counter-trends will occur. As
medical research brings down the costs of anti-AIDS medication, or comes
closer to developing an AIDS vaccine, the infected and their loved ones
might be galvanised into a strong and active constituency to demand that
their governments make these drugs widely available. Though it is
composed of a relatively small number of activists, South Africa's
Treatment Action Campaign (TAC) may be one example of a broad social
movement.
A damaged civil
society
The level of public participation in a democracy is not determined
solely by the choices of ordinary citizens. Mass participation in the
political system is also facilitated by civil society organisations and
interest groups who mobilise, channel and structure public participation
between elections. Civil society across Southern Africa is weak.
However, it could be further weakened because the types of people who
form the backbone of most civil society organisations may be especially
susceptible to HIV infection: while they tend to be better educated,
they also tend to be younger, more mobile, and often spend time away
from their home office during the course of their work. It is estimated
that a medium to large civil society organisation with 30 staff and 80
volunteers, based in South Africa's KwaZulu-Natal province, will lose
one to two employees and one to two volunteers annually by 2009 to AIDS,
totalling 19 staff and 22 volunteers by 2021. By 2009, this would mean
the loss of 158 days of staff time and 212 days of volunteer time
annually due to AIDS related illness.79
Many organisations may be particularly vulnerable since lost staff
members take with them unique skills that took many years to develop.
The loss of long-term staff members or volunteers is likely to be
particularly devastating. As the director of a KwaZulu-Natal democracy
promotion organisation pointed out, such staff possess experience vital
to understanding the culture, traditions and dynamics of the communities
where they work, and have build up mutual trust and understanding with
communities, churches and traditional leaders; relationships that are
the very strength of these organisation.80
The pandemic may thus reduce overall levels of public participation in
democratic processes by inhibiting the capacity of those civil society
organisations who organise and channel political activity.81
Some evidence of this dynamic may be found at the societal level in an
Afrobarometer survey of seven Southern African countries. It found that
countries with the highest measured levels of severe illness (due to any
cause) also have the lowest overall levels of attendance in local
community meetings and participation in local service and welfare
groups. This relationship persists even after controlling for levels of
poverty. This may reflect the fact that AIDS has already resulted in the
death of critical proportions of those who organise and drive community
meeting or local welfare groups.82 And at the organisational
level, a survey of 59 KwaZulu-Natal civil society organisations found
that three-quarters reported some form of AIDS-related impact on their
organisation. One-third of the Durban-based organisations noted
absenteeism or loss of staff members to HIV/AIDS.83
The 'uncivil'
society
Finally, the pandemic may have important effects on the 'civility' of
society, decreasing popular compliance with the law, and increasing
violent protest, social intolerance and criminal activity.
Individuals or households who suffer an AIDS illness, or have lost a
wage-earner to severe illness or death, will be less able to pay local
taxes or rates, or for public services such as electricity or user fees
for schools or health clinics. Moreover, HIV infection may reduce or
totally remove any incentive to do so, especially if payment is required
after services have been provided rather than before. In contrast, the
incentive would appear to dictate getting whatever you can for as little
money as possible. De Waal notes: "Those who feel they have nothing to
lose cannot be deterred by a judicial system that imposes custodial
sentences, or even the death sentence."84
Another impact on political culture may come from the tendency of people
infected with HIV or ill with AIDS to be lonely and depressed. Such
conditions often lead to hopelessness and apathy, and even frustration
and aggression, which could result in the non-compliance with laws or
even political violence.85 Paradoxically, falling prices of
some anti-retroviral drugs may aggravate and inflame these simmering
frustrations because firms, and eventually governments will be in the
position of deciding who does and does not receive life prolonging
drugs. The crucial period will occur after it becomes affordable
to provide anti-retroviral treatment to some employees and citizens, but
before it becomes possible to provide them to all. During this period
firms will have an incentive to provide limited drug therapy for their
most highly skilled workers. If done widely enough, and for a prolonged
period, this could reinforce class divisions and inequalities between
different socio-economic classes in society.86 Even if firms
are able to provide drug therapy for all their employees, in the context
of high unemployment levels, this could still fuel class-based conflict
between those with a decent job and everyone else who either works in
the informal sector or is unemployed.
The wide-scale private sector provision of anti-retroviral treatment for
employees may increase the pressure on governments across the region to
also provide drug therapy to public sector employees and citizens not
covered by their employers.87 If resources are limited,
governments will be confronted with decisions about where, and for whom,
to prioritise access to drug therapy. As with firms, governments may be
tempted to use skills and education as criteria of eligibility for
treatment, to protect its investments in training and education.88
Alternatively, governments may be tempted to prioritise the allocation
of life-extending drugs to its supporters. While such possibilities
might seem outlandish, the government of Zimbabwe, under the presidency
of Robert Mugabe, has shown itself quite capable of manipulating the
distribution of food aid to favour its political supporters. In Zambia,
applicants for management positions in the mining industry are screened
for HIV, and in Botswana prestigious study-abroad scholarships are
restricted to HIV-negative applicants.89
Regardless of whether or not governments actually do this, the
perceptions of politically expedient preferences in the provision of
anti-retroviral drugs may be bolstered by the fact that South Africa's
highest HIV rates are located in KwaZulu-Natal, political heartland of
the opposition Inkatha Freedom Party, or that Zimbabwe's non-Shona
population suffer higher HIV infection rates and have less adequate
heath care than the largely pro-government Shona population. Or, that
Namibia's Herero and Damara populations have less access to government
resources and health care.90 Even with the best of
intentions, the uneven distribution of existing health care systems may
advantage certain groups and areas. For example, while Botswana has an
extensive primary health care system by Southern African standards, only
one out of every 12 pregnant Batswana women receive
mother-to-child-transmission treatment, most of these live in urban
areas.91
Thus, political decisions around AIDS treatment hold the potential to
aggravate tensions and political conflict between workers and
unemployed; urban and rural populations; or between different ethnic
groups.
Another dimension of 'uncivility' may arise not amongst the infected,
but in the form of public intolerance targeted at stereotyped 'high
risk' groups such as homosexuals, truck drivers, orphans, sex workers,
miners or released prisoners. South Africans, for example, already tend
to be intolerant of disliked social groups, political opponents and
foreigners.92 Given the fear created by the HIV/AIDS
epidemic, governments may succumb under popular pressure to deny
political and economic rights to perceived 'high risk' groups.
Alternatively, local groups may take it upon themselves, using terror
and intimidation, to force HIV-positive people out of their schools and
communities.
A 2002 survey in South Africa revealed that a tenth of AIDS-affected
households had faced hostility or rejection from their community. Many
reported being chased away, refused help, or confronted with uncaring
attitudes by health care workers.93 A three-country study of
41 schools in Botswana, Malawi and Uganda found AIDS orphans were
subject to insensitive treatment by teachers and administrators at
schools. However instances of deliberate discrimination were quite rare.94
Finally, some analysts are concerned that HIV/AIDS may contribute to
lawlessness by orphaning large numbers of children across the region
over the next two decades.95
Without AIDS, orphans in developing countries around the world comprise
an average of 2% of all children aged 15 and under.96
According to the United Nations Children's Fund (UNICEF), however,
orphans exceed 20% of the under 15 population in Congo-Kinshasa, Malawi,
Rwanda, Uganda, Zambia and Zimbabwe. A large part of sub-Saharan
Africa's unusually high proportion of orphans has usually been
attributed to political conflict. As of 1999, however, UNICEF estimated
that just under one-third of all orphans in the sub-continent were AIDS
orphans.97 Within Southern Africa, USAID estimated the total
number of maternal or double orphans, as of 2000, at 2.9 million, or 8%
of all children 15 and under, of which 65% were AIDS orphans.98
UNICEF projects the total number of maternal and double AIDS orphans to
increase to 14 million across sub-Saharan Africa by 2010. Particularly
sharp increases in the orphan population are expected in Botswana,
Central African Republic, Lesotho, Mozambique, Namibia, South Africa,
Swaziland and Zimbabwe, amounting to 30% to 40% of all children.99
In Southern Africa, USAID expects the total number of orphans to
increase to 5.5 million by 2010, by then accounting for 16% of all
children 15 and under, of which 87% will be AIDS orphans.100
In South Africa, a Medical Research Council report estimates that a
third of children born in 2002 will be orphaned by 2015, with a total of
around 1.9 million orphans under 15 and three million under 18.101
All orphans suffer the trauma of losing parents, and of higher levels of
impoverishment, exclusion and abuse. The education of orphaned children
is often one of the first casualties if extended families suffer losses
of income.102 Demographic and Health Surveys from 15
sub-Saharan African countries in the 1990s found that 'out of school'
rates of orphans aged 10 to 14 were on average 19% higher than
non-orphans.103 A Botswana, Malawi and Uganda study of
schools in high prevalence districts found that orphans, especially
double orphans (i.e. those who lost both their parents), were
considerably more likely to interrupt their schooling than other
children.104
But AIDS orphans are likely to suffer even higher levels of trauma as a
result of watching parents endure prolonged, often painful periods of
illness and depression prior to death. Social stigmatisation may produce
even higher levels of discrimination and maltreatment.105
This may lead to higher levels of crime and other anti-social behaviour
over the next two decades as this growing, and disproportionately large,
share of children move through the 15 to 24 age range; the years of
greatest propensity to commit crime.106 British and South African
studies of children or young adults who had committed violent crimes,
found that above average proportions of them had been orphaned,
abandoned or rejected by parents or guardians.107
CONCLUSION
Democracy is the preferred political system in the world today. It is
the only political regime that is based on, and designed to maximise,
human equality and freedom. Southern Africa was not immune from the
'Third Wave' of democratisation that swept the world in the 1980s and
1990s. Beginning in 1990, multi-party systems with regular elections
emerged in Namibia, Zambia, Malawi, South Africa, Lesotho, Mozambique
and Tanzania. Recent political changes suggest that Angola may not be
far behind.
However, in none of these countries can democracy be characterised as
consolidated. 'Strong man' presidents and firmly entrenched ruling
parties threaten political pluralism in the face of weak legislatures,
weak party systems, and weak civil societies. Yet with the important
exception of Zimbabwe, civil and political rights, and reasonably free
and fair elections persist in most of these newly democratised states.
HIV/AIDS, however, threatens to block and even reverse democratic
development across the region. Lost incomes, increasing health costs,
shrinking tax bases, increased labour costs and decreasing productivity
all conspire to threaten the economic growth necessary to sustain
democratic practice in poor countries. Increasing death and illness in
cabinets, legislatures and government ministries threatens the
institutionalisation that young democracies need, to create the strong
and effective states that give effect to the rules of democracy. Sharply
decreasing adult life expectancy, and increasing proportions of people
living with effective death sentences, removes incentives for large
sections of the populace to participate in democratic politics or comply
with the rules of the democratic state. Stigma, discrimination and
conflict over scarce resources threaten to increase political conflict
and criminal behaviour.
However, almost all of what has been outlined here is based on the
assumption that in Southern Africa, HIV-infection is akin to a death
sentence. Two developments may force a revision of these assumptions and
all the projections based thereon. First, sharply decreased costs of
anti-retroviral drugs. Or, increased political will by national leaders
across the region to provide such drugs to their citizens may
significantly mitigate the economic, social and political consequences
of HIV infection. Second, bold and imaginative prevention campaigns may
convey to the uninfected how to avoid infection, thus reversing the
cycle of gloom and despair.
Finally, much of what is presented above is based on logic and
conjecture, rather than fact. Little is known about why or how children,
citizens, elites and institutions infected, affected or threatened by
HIV/AIDS change their social and political behaviour. Clearly, much more
research is needed. The spread and extent of the pandemic across the
southern African region and within individual countries should provide
sufficient evidence to support comparative cross-sectional and
longitudinal research by inquisitive and dedicated researchers. This
paper has been written in an attempt to lay out a research matrix into
which prospective research can be slotted, and hopefully entice
researchers to translate conjecture into testable hypotheses.
Endnotes
An earlier version
of this paper was presented to a University of Natal Health Economics
and AIDS Research Unit (HEARD), University of Cape Town Democracy in
Africa Research Unit, and Institute for Democracy Governance and AIDS
Programme Workshop on 'Democracy and AIDS in Southern Africa: Setting
the Research Agenda', Cape Town, 22-23 April 2002. For proceedings, see
<www.uct.ac.za/depts/cssr/daru>.
See for example, A
Hamoudi and J Sachs, The Economics of AIDS in Africa, Centre for
International Development, Cambridge, MA, undated; S Freudenthal, A
Review of Social Science Research on HIV/AIDS, Unpublished paper,
Sida/SAREC, November 2001.
For an examination
of the political implications of economic impacts, see W Parker, U
Kistner, S Gelb, K Kelly and M O'Donovan, The Economic Impact of
HIV/AIDS on South Africa and its Implications for Governance: A
Literature Review, USAID, Washington DC, 2000, p 1. For projections
on the impact of HIV/AIDS on security forces and regime stability, see L
Heinecken, Living in Terror: The Looming Security Threat to Southern
Africa,
African Security Review 10(4), 2001, pp 7-18; R B Cheek, Playing
God With HIV: Rationing HIV Treatment in Southern Africa,
African Security Review 10(4), 2001, pp 19-28; P Fourie and M
Schönteich, Africa's New Security Threat: HIV/AIDS and Human Security in
Southern Africa,
African Security Review 10(4), 2001, pp 29-44. For initial
evidence on impacts in the education sector, see P Bennell, K Hyde and N
Swainson, The Impact of the HIV/AIS Epidemic on the Education Sector
in Sub-Saharan Africa, Centre for International Education,
University of Sussex Institute for Education, Sussex, February 2002.
A recent literature
review concludes that while there is a growing, though unorganised, body
of theoretically informed speculation about the impact of HIV/AIDS,
there is virtually no body of substantive evidence. See R Manning,
AIDS and Democracy: What Do We Know?, Paper presented to a
University of Natal Health Economics and AIDS Research Unit (HEARD),
University of Cape Town Democracy in Africa Research Unit, and Institute
for Democracy Governance and AIDS Programme Workshop on 'Democracy and
AIDS in Southern Africa: Setting the Research Agenda', Cape Town, 22-23
April 2002.
T Barnett and A
Whiteside, AIDS in the Twenty First Century: Disease and
Globalisation, Hampshire and New York, Palgrave Macmillan, 2002, p
48.
R Pharaoh and M
Schönteich, AIDS, Security and Governance in Southern Africa: Exploring
the Impact,
ISS Paper 65, January 2003, p 1.
Barnett and
Whiteside, op cit, p 48.
No author, AIDS and
Violent Conflict In Africa, Peace Watch 8(4), United States
Institute of Peace, Washington DC, June 2001.
A Sen, Democracy as
a Universal Value, Journal of Democracy 10(3), 1999, pp 3-17.
A Przeworski, M
Alvarez, J Antonio Cheibub and F Limongi, Democracy and Development:
Political Institutions and Well-Being in the World, 1950-1990,
Cambridge University Press, Cambridge, 2000, p 47.
L Diamond,
Introduction, in: L Diamond & M Plattner (eds) Democratization In
Africa, Johns Hopkins University Press, Baltimore, 1999.
See L Diamond, Is
the Third Wave Over?, Journal of Democracy 7(3), July 1996, pp.
20-27;and R Joseph, Africa, 1990-1997: From Abertura to Closure,
Journal of Democracy 9(2), April 1998, pp 3-17.
A Karatnycky, The
Freedom House Survey, Journal of Democracy, 13(1), January 2002,
pp 99-112; R Mattes and A Leysens, Southern Africa, in: E Kolodziej (ed)
A Force Profound? The Politics, Power, and Promise of Human Rights,
University of Pennsylvania Press, Philadelphia, (forthcoming), 2003.
Przeworski et al, op
cit, pp 117-122.
J Linz and A Stepan,
Towards Consolidated Democracies, Journal of Democracy 7(2),
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S M Lipset, Some
Social Requisites of Democracy: Economic Development and Political
Legitimacy, American Political Science Review 53(1), 1959, pp
69-105.
Przeworski et al, op
cit, chapter 2.
In using Przeworki
et al's results to assess life expectancy of southern Africa's
democracies, an important caveat is in order. No country in continental
southern Africa would qualify as a democracy under Przeworski et al's
criteria, which include at least one turnover in government. However, I
am proceeding on the basis that had they coded Botswana as a democracy
in their data set of countries from 1950 to 1990, the results would have
been essentially the same, and thus can be used to assess the life
expectancy of regular elections and multi-party competition.
Przeworski et al, op
cit, chapter 2.
L Diamond and J
Linz, Introduction: Politics, Society and Democracy in Latin America,
in: L Diamond, J Linz, and S L Lipset (eds.), Democracy in Developing
Countries: Latin America, Lynne Reiner, Boulder, 1989, pp 1-58.
Przeworski et al, op
cit, chapter 2.
Ibid, pp 109-111.
World Development
Report, 2000/2001, Oxford University Press, Washington D.C., 2001, pp
274-275.
The Gini index
measures inequality over the entire distribution of income or
consumption. A value of 0 represents perfect equality, and a value of 1
perfect inequality.
Przeworski et al, op
cit, pp 120-121.
World Development
Report, 2000/2001,
op cit, pp 282-283.
A Whiteford and D E
Van Seventer, Winners and Losers: South Africa's Changing Income
Distribution in the 1990s, WEFA, Johannesburg, 1999, pp 3 and 11-19.
M Over, The
Macroeconomic Impacts of AIDS in Sub-Saharan Africa, Technical Paper
3, World Bank, Washington DC, 1992, cited in: Parker et al, op cit, p19.
K Quattek and T
Fourie, The Economic Impacts of AIDS in South Africa: A Dark Cloud On
the Horizon, ING Barings, Johannesburg, April 2000, p 21.
Arndt and Lewis, in:
Parker et al, op cit, p 17. Parker et al note a recent trend toward
cautious optimism, however, citing cross national studies that find no
evidence of slower growth in economies where HIV/AIDS is advanced (Bloom
& Mahal, 1995). Indeed, modelling the impacts of HIV/AIDS is so
difficult because the disease is different from other epidemics. Parker
et al, op cit, pp 10-12.
N Nattrass, AIDS,
Growth and Distribution in South Africa, CSSR Working Paper 7,
Centre for Social Science Research, University of Cape Town, Cape Town,
March 2002, p 5.
Ibid, p 1.
Ibid, pp 12-21; C
Kennedy, From the Coalface: A Study of the Response of a South
African Colliery to the Threat of AIDS, CSSR Working Paper 5, Centre
for Social Science Research, University of Cape Town, Cape Town, April
2002.
B Beresford, The
Cost of Doing Nothing, Mail & Guardian, 17 to 23 May 2002.
Nattrass, op cit, pp
6-12.
A de Waal,
Modelling the Governance Implications of the HIV/AIDS Pandemic in Africa,
AIDS and Governance Discussion Paper 2, Unpublished draft, March 2002.
Ibid, p 9.
L Ensor, AIDS To
Outstrip SA's Future Health Budgets, Business Day, 10 October
2001.
Cheek, op cit, p 22.
B Beresford, Failing
to Deliver, Mail & Guardian, 11 to 17 October 2002.
L Clarke, Study
Highlights Ravages of HIV/AIDS, Sunday Independent, 3 November
2002.
No author, New
Priorities Needed, Business Day, 10 October 2001.
Heinecken, op cit, p
10; Cheek, op cit, p 20.
No author, Comparing
Thailand, Brazil, South Africa, Botswana and Uganda, Budget Watch,
Idasa, Cape Town, November 2002, p 8; No author, Focus on Brazil,
Thailand, Uganda, Botswana?, Budget Watch, Idasa, Cape Town,
November 2002), p 2.
Proceedings,
Democracy in AIDS in Southern Africa: Setting the Research Agenda, op
cit.
Ensor, op cit.
Cheek, op cit, p 22.
Heinecken, op cit, p
10.
Cheek, op cit, p 21.
G Hiwa, Malawi
Ministry of Health, cited in: Cheek, op cit, p 22.
N Nattrass and J
Skordis, Paying to Waste Lives: The Affordability of Reducing Mother
to Child Transmission of HIV in South Africa, CSSR Working Paper 4,
Centre for Social Science Research, University of Cape Town, Cape Town,
December 2001, p 2. Also see Nathan Geffen, Nicoli Nattrass & Chris
Raubenheimer, The Cost of HIV Prevention and Treatment Interventions
in South Africa, CSSR Working Paper 28, Centre for Social Science
Research, University of Cape town, Cape Town, January 2003.
Focus on Brazil,
Thailand, Uganda, Botswana?, op cit, p 2.
Ibid, p 4.
Ibid, p 4.
L Bollinger, J
Stover, R Kerkhoven, G Mutangadura and D Mukurazita, The Economic
Impact of AIDS in Zimbabwe, POLICY Project, Washington DC, 1999, <www.tfgi.com/Zimbabwe.doc>,
cited in: J Youde, All the Voters will be Dead: HIV/AIDS and
Democratic Legitimacy and Stability in Africa, International
Foundation for Electoral Assistance, Stockholm, 2001, p 26.
Youde, op cit, p 27.
Quattek and Fourie,
pp 1, 7 and 10.
No author, AIDS
Could Cripple Public Service, Business Day, 29 June 2001; Youde,
op cit, p 19.
Youde, op cit, p 8.
R Manning, The
Impact of HIV/AIDS on Local Democracy: A Case Study of the eThekwini
Municipality, KwaZulu-Natal, South Africa, CSSR Working Paper,
Centre for Social Science Research, University of Cape Town, Cape Town,
forthcoming, 2003, pp 25-26.
Ibid, pp 11 and 22.
L Ensor, Treasury
Sounds the Alarm Over AIDS, Business Day 10 October 2001.
Cheek, op cit, p 22.
Manning, op cit, p
20.
Ibid, p 22.
Ibid, pp 12-13 and
18-19.
Ibid.
M Bratton and N van
de Walle, Democratic Experiments In Africa, Cambridge University
Press, Cambridge, 1997.
See E Costarelli,
HIV/AIDS, Democracy and Citizenship, Electoral Institute of Southern
Africa, Johannesburg, pp 8-10.
Youde, op cit, pp
10-20.
R Mattes and H Thiel,
Consolidation and Public Opinion In South Africa, Journal of
Democracy 9(1), January 1998, pp 95-110.
In South Africa
average household expenditure on health is approximately 4% of total
income. However, a survey of 771 AIDS affected households in four
provinces found that they were spending on average a third of their
income on health care, rising to over half of all income in rural
households. Half of the families had paid for a funeral in the previous
twelve months, usually consuming more than three months income. The vast
majority of households were poverty stricken with an average household
income of under R1,000 per month. Two-thirds reported that they had lost
some income due to AIDS. See B Beresford, Families Tipped Into
Destitution, Mail & Guardian, 27 September to 3 October 2002; and
B Beresford, Failing to Deliver, Mail & Guardian, 11 to 17 October 2002;
and L Clarke, Study Highlights Ravages of HIV/AIDS, op cit.
Fourie and
Schönteich, op cit, p 31.
De Waal, op cit, p.
9.
A Whiteside and D
FitzSimons, The AIDS Epidemic: Economic, Political and Security
Implication, Conflict Studies 251, Research Institute for the
Study of Conflict and Terrorism, May 1992, p 26.
De Waal, op cit, p
8.
J Brower and Chalk,
The Security Implications of Infectious Disease and Its Impact on
National and International Institutions and Policies, in America's
Real Achilles Heal: The Threat of Infections Disease to National and
International Security, RAND, Santa Monica, 2002, p 6, cited in:
Manning, op cit, p 14; Youde, op cit, p 5.
Youde, op cit, pp
10-20. For a discussion of ways to empower HIV-affected people to vote,
see E Costarelli, op cit, pp. 8-10.
R Manning, The
Impact of HIV/AIDS on Civil Society: Assessing and Mitigating Impacts:
Tools & Models for NGOs and CBOs, Health Economics and HIV/AIDS
Research Division, University of Natal, Durban, 2002, pp 14-26.
Manning, The
Impact of HIV/AIDS on Civil Society, op cit, pp 16 and 29.
D Gordon, Plague
Upon Plague: AIDS and Violent Conflict in Africa, cited in: Manning,
AIDS and Democracy: What Do We Know?, op cit.
A Whiteside, R
Mattes, S Willan and R Manning, Examining HIV/AIDS In Southern Africa
Through the Eyes of Ordinary Southern Africans, CSSR Working Paper
11, Centre for Social Science Research, University of Cape Town, Cape
Town, 2002, pp 36-37.
Manning, The
Impact of HIV/AIDS on Civil Society, op cit, p 1, pp 10-11.
De Waal, op cit, p
8.
R Shell, Halfway to
the Holocaust: The Economic, Demographic and Social Implications of the
AIDS Pandemic to the Year 2010 in the Southern African Region,
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2000, pp 19-20. On the relationship between frustration and violence,
see T R Gurr, Why Men Rebel, Princeton University Press,
Princeton, 1970.
Nattrass, op cit, p
1.
De Waal, op cit, p
10.
Cheek, op cit, pp
24-25.
Ibid.
Ibid, pp 25-27.
Ibid, p 24.
J Gibson and A Gouws,
Overcoming Intolerance in South Africa: Experiments in Persuasion,
Cambridge University Press, Cambridge, 2002; R Mattes, C Africa and H
Taylor, Intolerance and Intimidation in South Africa, Opinion '99
Series 2(9), Idasa, Cape Town, 1999, <www.idasa.org.za>.
For South Africans' attitudes toward ordinary and skilled immigrants,
see R Mattes, D Taylor, D McDonald, A Poore and W Richmond, South
African Attitudes To Immigrants and Immigration, in: D McDonald (ed.),
On Borders: Perspectives On International Migration In Southern
Africa, St. Martin's Press, New York, 2000), pp196-218; and R
Mattes, J Crush and W Richmond, The Brain Gain and Legal Immigration to
Post-Apartheid South Africa, Africa Insight 30(2), October 2000,
pp 21-30.
Beresford, Families
Tipped Into Destitution, op cit; Beresford, Failing to Deliver, op cit.
Bennell, Hyde and
Swainson, op cit, p xi.
Fourie and
Schönteich, op cit, p 38.
Ibid.
S Hunter and J
Williamson, Children on the Brink: Strategies to Support A Generation
Isolated by HIV/AIDS, UNICEF/USAID, New York, June 2000, cited in:
Bennell, Hyde and Swainson, op cit, p 48.
Cited in Fourie and
Schönteich, op cit, p 38.
Bennell, Hyde and
Swainson, op cit, pp 66 and 68.
Cited in Fourie and
Schönteich, op cit, p 38.
J A Smetherham, 33%
will be AIDS Orphans by 2015, says MRC Report, Cape Times, 18
June 2002.
Cited in Fourie and
Schönteich, op cit, p 38.
The Progress of
Nations,
UNICEF, New York, 2000, cited in: Bennell, Hyde and Swainson, op cit, p
58.
Bennell, Hyde and
Swainson, op cit, p 59.
Fourie and
Schönteich, op cit, p 39.
M Schönteich, Age
and AIDS: South Africa' Crime Time Bomb?,
African Society Review 18(4), 1999; Fourie and Schönteich, op
cit, p 40.
Fourie and
Schönteich, op cit, p 40. However, for a recent comprehensive review of
the evidence supporting current thinking about the social and political
impact of growing numbers of AIDS orphans, see Rachel Bray,
Predicting the Social Consequences of Orphanhood in South Africa,
CSSR Working Paper, Centre for Social Science Research, University of
Cape Town, forthcoming, 2003.
ABOUT THIS PAPER
Across Southern
Africa HIV/AIDS threatens to block and even reverse democratic
consolidation. Lost incomes, higher healt and labour costs, shrinking
tax bases and decreasing productivity undermine the economic growth
necessary to sustain democratic government in the countries of Southern
Africa.
Sustainable democracies require a professional civil service and strong,
viable and autonomous courts, legislatures, executives and electoral
systems at national and local levels. AIDS related death and illness
among cabinets ministers, legislators and public officials threaten the
political institutions that are necessary to give effect to the rules of
democracy. Sharply reduced adult life expectancy, and increasing
proportions of people living with AIDS, remove incentives for large
sections of the populace to participate in democratic politics or comply
with the rules of the democratic state.
ABOUT THE AUTHOR
ROBERT MATTES is
associate professor of Political Studies, and director of the Democracy
in Africa Research Unit in the Centre for Social Science Research,
University of Cape Town. He is also cofounder and co-director of the
Afrobarometer, a regular cross-national survey of citizens' attitudes to
democracy, markets and civil society in selected African countries..
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