Here’s how the global response to AIDS in Africa has made me think more deeply about democracy

In commemoration of World AIDS Day on December 1, Kim Yi Dionne writes about democracy and AIDS interventions in Africa, drawing on her book, Doomed Interventions: The Failure of Global Response to AIDS in Africa (Cambridge University Press, 2018).

What are the first five things that come to mind when you think of Africa? At the beginning of every academic term I teach African politics, I ask my students to write a list in response to this question. Typically, more than half of them will have AIDS on their list.

American college students are not exceptional in their responses. My extended family’s imagination of Africa involves war and disease, especially AIDS. When asked by a stranger what I do for a living, if I tell them that I have written a book on AIDS intervention in Africa, the most frequent response I get is one of pity for the imagined African suffering of AIDS.

In the West, many imagine Africa as a place suffering from AIDS. And while Africa has shouldered the largest AIDS burden of all other world regions—two-thirds of the world’s HIV-positive people live in Africa—there are many more Africans who are HIV-negative than HIV-positive.

AIDS has hit hardest in the young democracies of East and Southern Africa and a significant chunk of the funding for AIS interventions is spent there. Yet these interventions do not reflect the opinions or ideas of their “intended beneficiaries.”

In my book, Doomed Interventions: The Failure of Global Responses to AIDS in Africa, I study the opinions and priorities of both HIV-positive and HIV-negative Africans, the primary population to whom AIDS interventions are targeted.

My book shows that African citizens and key decision-makers in the global community diverge on how AIDS interventions should be prioritized vis-à-vis other pressing policy issues. Judging from data on donor spending, AIDS is exceptional, especially if you compare it to other health issues. AIDS has been a top priority for donors, who spend large sums on AIDS, especially considering the higher death tolls from other diseases.

The figure below compares AIDS to malaria both in number of deaths and in amount of foreign development assistance. Though malaria is just as deadly as AIDS (and in some years, more deadly), AIDS funding far outpaces malaria funding.

Disease burden and official development assistance (ODA) for HIV and malaria in sub-Saharan Africa. 

Sources: Organisation for Economic Co-operation and Development and Institute for Health Metrics and Evaluation.

Note: OECD has no data on malaria funding prior to 2000.

At the same time, survey data I collected in Malawi along with public opinion data collected by Afrobarometer in 20 African countries show that Africans give relatively low priority to AIDS when compared to other pressing issues like access to clean water or agricultural development. I found that while HIV-positive people were more likely to rank AIDS interventions higher on their policy priority list than HIV-negative people, AIDS interventions remained a relatively low priority.

Malawian citizens and their fellow Africans did not rank AIDS a relatively low priority out of ignorance. Unfortunately, the Malawian villagers and headmen interviewed in the course of my research know all too well the tragedy of the AIDS epidemic. They have lost friends and family to AIDS.

When there is a misalignment of priorities, whose preferences should take precedence? Doomed Interventions raises an important question about power: Does AIDS intervention in Africa simply demonstrate the power of donors and the weakness of citizens?

Writing Doomed Interventions has made me think a lot about democracy. In the book’s conclusion, I ask “What are the implications for democracy in African countries experiencing a generalized AIDS epidemic?” As young democracies in southern Africa—where AIDS has hit hardest—grapple with their many development challenges, the external push for prioritizing AIDS may provide short-term benefits to power brokers in the form of earmarked aid, but leaders risk future dissatisfaction from citizens by overlooking matters more important to them.

One more “democratic” approach I offer is to learn about the issues citizens prioritize. Indeed, the Pan-African Afrobarometer network, now collecting public opinion survey data in more than 30 African countries, regularly asks nationally representative samples of people their opinions on what issues are important to them. Parties interested in improving the human condition can look to such resources for more information or as models for how to learn citizens’ opinions and priorities.

The current approach of most interventions to improve the human condition—interventions designed from afar usually providing financial support to African governments to intervene—is decidedly undemocratic as it often ignores the opinions of citizens and also provides governments a source of revenue unattached to its citizens’ assessments of government performance.

Rather than rely on the Western imagination of what Africa is and what Africa needs in shaping interventions meant to improve the human condition, there are opportunities to actually ask Africans their own opinions and ideas and experiences in improving their condition. Doing otherwise erodes any existing mechanisms of accountability and representation.

Kim Yi Dionne is an Assistant Professor of Political Science at the University of California Riverside. She is also an editor of The Monkey Cage, a blog on politics and political science at The Washington Post, and a co-host (with Rachel Beatty Riedl), of Ufahamu Africa, a podcast about life and politics on the African continent.