The best of times, the worst of times
From Griffith REVIEW Edition 17: Staying Alive
© Copyright Griffith University & the author.
Written by Peter Browne
Download the complete article PDF
Peter Browne's biography and other articles by this writer
Behind the Princess Marina Hospital, not far from the centre of Gaborone, are the two small buildings that house Botswana's largest anti-retroviral therapy clinic for people with HIV/AIDS. Alongside the red-brick blocks of the main hospital complex, these prefabricated buildings seem modest and temporary, but it was here that Botswana's ambitious HIV/AIDS treatment program – the first national scheme in Africa – was launched in early 2002. Over the past five years, the number of clinics across this sparsely populated country has grown exponentially, and there are now thirty-two sites, each with up to four satellite clinics, serving a national population of 1.8 million.
Botswana is one of the few African countries in which the urgency and scale of the government's response to HIV/AIDS match the size of the problem, according to Alex de Waal in his recent book, AIDS and Power (Zed Books, 2006). And the scale of the problem is enormous: an estimated quarter of the adult population live with HIV/AIDS, and life expectancy – which had been predicted to reach the age of seventy by the year 2010 – has fallen to below forty.
On this warm, still afternoon, the day's consultations are over and the clinic is beginning to wind down. The main corridor is lined with people waiting for their turn at the dispensary counter. It has been another long day: the clinic opens at 7.30am but people start queuing at dawn to see one of the six doctors who assess patients and monitor their treatment. Waiting for me near the end of the corridor is one of those doctors, Kenalemang Mmeko, who has worked at the clinic for a year after training in Grenada and placements in the United States and Britain. Of the two hundred patients who pass through each day, he usually sees about thirty. Nationally, with free treatment provided by a partnership between the government, the Gates Foundation and Merck pharmaceuticals, those figures translate into over seventy thousand recipients out of a potential group estimated at 110,000. Although that coverage is proportionally the highest in Africa, the aim is to get to everyone.
Cultural attitudes have stopped some people from using the program, or even from being tested. "Initially people preferred to try traditional medicine," says Mmeko, "but they saw that people kept on dying. They also saw that the people who were on anti-retrovirals were doing well." Numbers certainly rose enormously as the clinics spread across Botswana, but a range of factors – denial, lingering supernatural beliefs, the fear of stigma – meant that many people still weren't having a test. The government redoubled its efforts, introducing HIV tests as part of routine medical examinations and pregnancy tests. Activist groups mounted a concerted campaign to make sure that women were aware of the availability of tests and treatment.
Mmeko, who has been at work since early morning and was on call the previous night, is starting to look like he'd rather be home in bed. He quickly describes the standard routine – how people come in first for tests, then two weeks later to discuss the results and map out the treatment, then another week later to check on any side-effects and fine-tune the dose. This eventually settles down to three-monthly visits if all goes well, and monthly visits if the viral load hasn't fallen. With a shortage of medical staff still a problem for the program – around a fifth of Botswana's health-care professionals died of AIDS between 1999 and 2005 – long waiting times at the dispensary can make the treatment process difficult for people with jobs.
Mmeko says the latest figures show a fall in the rate of new HIV infections. This is consistent with the findings of the latest large-scale survey of HIV/AIDS prevalence in Botswana, supervised by the World Health Organisation, which found a fall of three percentage points among pregnant women, especially younger women, between 2003 and 2005. If this is accurate – and measuring the impact of HIV/AIDS in a country like Botswana is not straightforward – then it is welcome news, because previous data have suggested that the massive investment in Botswana was not translating into significant progress.
Botswana is one of a group of countries in southern and southeast Africa, from Namibia in the southwest to Mozambique in the east, with very high rates of HIV/AIDS infection. In each of these countries, the prevalence of HIV/AIDS in the fifteen to forty-nine age group is above 15 per cent, making this the hardest-hit region in the world. Botswana once had the highest recorded rate of all – 38 per cent – but last year UNAIDS used new data to revise that figure down to a quarter of the population.
The figures need to be treated with caution. Although prevalence data is used in all the standard international comparisons, it is not the ideal measure of the success of HIV/AIDS programs. The prevalence of the disease can grow even if the rate of new infections is falling, especially when treatment programs are prolonging lives. Meanwhile, data on the incidence of HIV infections is often patchy or not collected at all. These deficiencies in the data have made the job of assessing progress doubly difficult.
The task of preventing HIV/AIDS, rather than simply treating the disease, is also being undermined by social and cultural practices – some of which are longstanding and others a result of an accelerated process of modernisation in recent decades. As Karen Leiter, the co-author of a new report on Botswana and nearby Swaziland, Epidemic of Inequality (Physicians for Human Rights, 2007), writes: "If we are to reduce the continuing, extraordinary HIV prevalence in Botswana and Swaziland, particularly among women, the countries' leaders need to enforce women's legal rights, and offer them sufficient food and economic opportunities to gain agency in their own lives."
ADDRESSING THE UN GENERAL ASSEMBLY IN 2001, Botswana's president, Festus Mogae, described the AIDS epidemic as "a crisis of the first magnitude". Unlike neighbouring South Africa, where Thabo Mbeki's government has been agonisingly slow to recognise the need for action, or other neighbouring countries where corruption and poor government undermine all public health programs, the Botswanan government had both the means and the will to act. For Alex de Waal, the government's reaction to the epidemic echoes the way the governing Botswana Democratic Party has handled earlier crises. In his influential book, Famine Crimes (Indiana University Press) published a decade ago, de Waal described the unusually effective anti-famine policies adopted by the government in the early 1980s. He concluded: "Botswana is an anomaly in Sub-Saharan Africa ... a chronically food-deficit drought-stricken country that has consistently averted famine ... Botswana's enduring multi-party electoral system, the high levels of professionalism and accountability in its public service have been intimately linked ... It is made possible by wealth: Botswana is by far the richest of the countries considered in this book."
From the early 1960s to the late 1990s, annual economic growth in Botswana averaged 7.5 per cent – a rate unmatched in Africa and almost unique worldwide. The discovery of diamonds soon after independence certainly played an important role, but in other African countries a single, lucrative commodity – generally oil or diamonds – has had a devastating impact on democracy and the quality of government. As William Easterly shows in his recent book, The White Man's Burden (Penguin, 2006), the sudden increase in wealth raises the stakes in the struggle between the elites and the rest of the population, producing repression and corruption. Botswana largely avoided both, giving it the highest rating among African countries on Transparency International's corruption perceptions index. Botswana also has a lively, independent media, unafraid of challenging the government – especially, this year, over its controversial Intelligence and Security Services Bill. This is significant for the HIV/AIDS effort: research commissioned by de Waal found that "a free press is positively associated with energetic governmental AIDS policies" more than any other factor the study considered.
Botswana's first president, Seretse Khama, is usually credited with laying the foundations for Botswana's economic record and its political stability. Susan Williams' recent book Colour Bar: The Triumph of Seretse Khama and His Nation, (Penguin, 2006) depicts Khama as a calm, rational leader with a self-deprecating sense of humour. The fact that he had a legitimate claim to leadership of the largest ethnic group in Botswana before independence and was the democratically elected president for the first fifteen years afterwards gave his government two different sources of legitimacy. It also meant a greater degree of continuity between the pre– and post-independence periods than existed in many other African nations. The result was stability and a political style that could adapt to the institutions of representative democracy. Features of Botswana's traditional political culture – especially the fact that power was centralised in the chiefs – also helped to create favourable conditions for Botswana's positive economic development.
But, despite its remarkable record, the Botswana Democratic Party, which has been in office for over forty years, has been shedding electoral support. Although the opposition is fragmented, its share of the vote at the last national election – 48.3 per cent – was the highest since independence. The views of the government's critics seem to be gaining wider support.
Before I left Melbourne for Gaborone, I talked to Kenneth Good, an Australian academic who was deported from Botswana in 2005 after lecturing in politics for fifteen years. Good – a combative seventy-three-year-old who has repeatedly criticised the government's political and economic record and its treatment of minorities – would certainly be a nuisance to a government that seems acutely sensitive to bad publicity, but deportation was a massive overreaction. In Gaborone, Elmon Tafa from the radical wing of the main opposition party, the Botswana National Front, said that international agencies rate Botswana highly only because "they're comparing us with outright dictatorships". Closer to the middle of the political spectrum, many people expressed concern that some senior government figures – especially the vice-president, Ian Khama – are moving towards a more authoritarian style of administration. (Khama, a former army general, will become president next year when Festus Mogae's current term ends.) This shift, they say, is typified by the security legislation and the decision to require seventeen journalists and academics, previously free to visit Botswana at will, to apply for permission to enter the country.
Among the seventeen were David White and John Reed, journalists with the London-based Financial Times, who wrote a detailed survey of Botswana for the paper in June 2006. What probably got White and Reed into trouble was their frank account of the government's dispute with the San people, who have been vigorously encouraged, and sometimes forced, to leave their homes in the Central Kalahari Game Reserve. In a case that attracted international attention, the San took their fight to the High Court of Botswana in 2002. Survival International, the London-based organisation that campaigns for tribal groups, argued that the government's decision to remove the San from the reserve was destroying their culture; the government responded by accusing the organisation of treating the San as "anthropological relics". Three judges heard the case and two, including Justice Unity Dow, accepted the San's argument. In a remarkably blunt judgment, Dow criticised both parties to the action but concluded that the government's removal of the San from the reserve was "unlawful and unconstitutional".
Log Raditlhokwa, a lecturer in social work at the University of Botswana, believes that the most worrying development in Botswana is what he calls "the decline of democratic ideals". We met at his office in the middle of the university's attractive, low-rise campus and walked across to the staff cafe. "The government used to consult on many issues," Raditlhokwa told me. "It didn't embark on major changes without giving people the opportunity for discussion."
This approach accorded with the long-standing practice in Botswana of holding large meetings, or kgotlas, of senior men to advise the chief. Trusting leaders to make the final decision rested on a belief that they would do the right thing – and Raditlhokwa argues that this trust has been undermined by falling confidence in the government and its leadership. But the government uses Botswana's excellent reputation among credit agencies and international institutions as ammunition against its critics. According to Raditlhokwa, "They say, ‘The opposition is always complaining', but look at what Standard and Poor's says, look at what the World Bank says."
Contributing to the problem is the fact that civil society in Botswana is relatively under-developed, partly because the country's economic success meant that Western aid was withdrawn before non-government organisations had a chance to become financially stable. Young professionals were attracted to better-paid positions in government and the bureaucracy – although these, and the opportunities to teach at the university, are limited. As Jeff Ramsey, an adviser in the president's office, told me later in the week, one of Botswana's problems is that it can't make full use of a growing number of young graduates.
Despite his concerns about the direction of the governing party, Raditlhokwa obviously didn't want to leave me with the impression that Botswana's problems are insurmountable. As we walked back towards his office, he stopped to say: "Botswana is doing fine. But I'm worried that it doesn't have the institutional structure to sustain that."