Marco Antonio Vieira

Southern Africa’s Responses to International HIV/AIDS Norms (1990-2005)

The Politics of Assimilation

Brasília – 2013

Ministry of External Relations

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Secretary-General - Ambassador Eduardo dos Santos

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Editorial Staff:

Eliane Miranda Paiva

Fernanda Antunes Siqueira

Guilherme Lucas Rodrigues Monteiro

Jessé Nóbrega Cardoso

Vanusa dos Santos Silva

Graphic Design:

Daniela Barbosa

E-book:

Gráfica e Editora Ideal

Jefferson Mota

V665

VIEIRA, Marco Antonio

Southern Africa’s responses to international HIV/AIDS norms (1990-2005): the politics of assimilation / Marco Antonio Muxagata de Carvalho Vieira. – Brasília : FUNAG, 2013.

ISBN 978-85-7631-486-8

1. HIV/AIDS. 2. Combate. 3. Prevenção. 4. África do Sul. I. Fundação Alexandre de Gusmão.

CDU: 578.828(680/687)

Ficha catalográfica elaborada pela bibliotecária Talita Daemon James – CRB-7/6078

Depósito Legal na Fundação Biblioteca Nacional conforme Lei n° 10.994, de 14/12/2004.

Editorial Board of the Alexandre de Gusmão Foundation

President:

Ambassador José Vicente de Sá Pimentel

President of Alexandre de Gusmão Foundation

Members:

Ambassador Ronaldo Mota Sardenberg

Ambassador Jorio Dauster Magalhães

Ambassador José Humberto de Brito Cruz

Minister Luís Felipe Silvério Fortuna

Professor Clodoaldo Bueno

Professor Francisco Fernando Monteoliva Doratioto

Professor José Flávio Sombra Saraiva

Contents

List of Abbreviations

Preface

Acknowledgements

Chapter 1

The Incorporation of International HIV/AIDS Norms into Domestic Practices: An Introduction

1. Defining the Puzzle

2. Theoretical Framework: Preliminary Comments

3. Some Methodological Considerations

4. Organisation of the Thesis

Chapter 2

“The HIV/AIDS Securitisation Norm (HASN)” – An Analytical Framework for Understanding the Global Securitisation of the Epidemic

1. Introduction

2. The Conceptualisation of the Securitisation of HIV/AIDS as a Norm

3. Theoretical Perspectives on Norm Formation and the Securitisation Debate

4. Organisation of the Thesis

4.1. HIV/AIDS and Security: Setting the Debate

4.2. Translating Theory into Practice: from a Biomedical Approach to the Institutionalisation of HIV AIDS as a Security Issue

4.3. The Tri-Dimensional Character of HASN

5. Conclusions

Chapter 3

The “Norm Leaders”: Cognitive frames, Institutional apparatus and Norm Diffusion

1. Introduction

2. UNAIDS

3. The US Government

4. Transnational Networks of NGOs

5. Conclusions

Chapter 4

The Domestic Incorporation of HASN in Botswana: “The Model of Active Engagement”

1. Introduction

2. Setting the Stage: Botswana’s Post-Colonial Political Culture, HIV/AIDS and the Constitution of a “Norm Friendly” State

3. Institutional Strategies and HIV/AIDS Policies in Botswana

4. Leadership Perceptions and the Domestic Recognition of HASN

5. Norm leaders in Action: The Role of Multilateral Institutions, the US and Transnational Non-State Actors

5.1. The Multilateral Approach

5.2. Bilateral Approach: The United States Involvement in Botswana

5.3. The Transnational Community of HASN Seeking Domestic Legitimacy: The Role of Civil Society HIV/AIDS Organisations

6. Conclusions

Chapter 5

The Domestic Incorporation of HASN in Mozambique: “The Model of Instrumental Adherence”

1. Introduction

2. Setting the Stage: (In)dependence, Civil War, International Reconstruction and HIV/AIDS

3. Institutional Strategies and HIV/AIDS Policies in Mozambique

4. Leadership perceptions and the domestic recognition of HASN

5. Norm Entrepreneurs in Action: The Role of Multilateral Institutions, the US and Transnational Non-State Actors

5.1. The Multilateral Approach

5.2. The Bilateral Approach: The United States Involvement in Mozambique

5.3. The Transnational Community of HASN Seeking Domestic Legitimacy: The Role of Civil Society HIV/AIDS Organisations

6. Conclusions

Chapter 6

The Domestic Incorporation of HASN in South Africa: “The Model of Ideological Resistance”

1. Introduction

2. Setting the Stage: The Ideological Construction of Apartheid, the New South Africa and HIV/AIDS

3. Institutional Strategies and HIV/AIDS Policies in South Africa

4. Leadership perceptions and the domestic recognition of HASN

5. Norm Entrepreneurs in Action: The Role of Multilateral Institutions, the US and Transnational Non-State Actors

5.1. The Multilateral Approach

5.2. The Bilateral Approach: The United States Involvement in South Africa

5.3. The Transnational Community of HASN Seeking Domestic Legitimacy: The Role of Civil Society HIV/AIDS Organisations

6. Conclusions

Chapter 7

The Impact of HASN in Botswana, Mozambique and South Africa: Conclusions

1. Introduction

2. Summarising the Evidence Regarding the Three Case Studies

3. Assessing Results and the Implications of Case Findings to Theory

4. Conclusive Thoughts: The Way Forward

Bibliography

Appendix: List of Interviews in Alphabetical Order

List of Abbreviations

ABC

Abstinence, Be faithful and Condoms

AIDS

Acquired Immune Deficiency Syndrome

ANC

African National Congress

ACHAP

African Comprehensive HIV/AIDS Partnerships

ARV

Antiretroviral

ATICC

AIDS Training, Information and Counselling Center

AZT

Azido-Thymidine

BBCA

Botswana Business Coalition on AIDS

BOCAIP

Botswana Christian AIDS Intervention Programme

BOCCIM

Botswana Confederation on Commerce, Industry and Manpower

BDP

Bechuanaland (Botswana) Democratic Party

BONASO

Botswana Network of AIDS Service Organisations

BONELA

Botswana Network on Ethics, Law and HIV/AIDS

BONEPWA

Botswana Network of People Living With HIV/AIDS

BOTUSA

Botswana and US’ CDC Project

CADRE

Centre for AIDS Development, Research and Evaluation

CARE

Christian Action Research and Education

CBO

Community-Based Organisation

CCM

Country Coordinating Mechanism

CDC

Centers for Disease Control and Prevention

CNCS

Conselho Nacional de Combate ao Sida (National Council for the Fight against AIDS)

COCEPWA

Coping Centre for People Living With HIV/AIDS

COSATU

Congress of South African Trade Unions

CSIS

Centre for Strategic and International Studies

DCF

Donor Communication Forum

DFID

British Department for International Development

DMASC

District Multi-Sectoral AIDS Committees

DoH

Department of Health

DREAM

Drug Resource Enhancement Against AIDS and Malnutrition

ECOSOC

United Nations’ Economic and Social Council

ECSA

European Commission in South Africa

EU

European Union

FDA

Food and Drug Administration

FRELIMO

Frente de Libertação de Moçambique (Mozambican Liberation Front)

GAP

Global AIDS Programme

GDP

Gross Domestic Product

GP

Grupo de Parceiros (Partners Group)

GTZ

Deutsche Gesellschaft fur Technische Zusammenarbeit (German Society for Technical Cooperation)

HASN

HIV/AIDS Securitisation Norm

HGAP

Health Global Access Project

HIV

Human Immunodeficiency Virus

HSRC

Human Sciences Research Council

IASC

Inter-agency Standing Committee

ICASA

International Conference on HIV/AIDS and Sexually Transmitted Infections in Africa

ICASO

International Council of AIDS Services Organizations

IDASA

Institute for Democracy in South Africa

IHAA

International HIV/AIDS Alliance

ILO

International Labour Organization

IMF

International Monetary Fund

INE

Instituto Nacional de Estatística (National Institute of Statistics)

IISS

International Institute for Strategic Studies

ISS

Institute for Security Studies

IMC

Inter-Ministerial Committee

IO

International Organisation

MAC

Ministry AIDS Coordinators

MAP

Multi-Country AIDS Programme

MCC

Medicines Control Council

MISAU

Ministério da Saúde (Ministry of Health)

MONASO

Mozambican Network of Organizations Against AIDS

MRC

Medical Research Council

MSF

Médecins Sans Frontières (Doctors Without Borders)

MTP

Medium Term Plan

MTCT

Mother-to-Child Transmission

NAC

National AIDS Council

NACA

National AIDS Coordinating Agency

NACOSA

National AIDS Convention of South Africa

NACP

National AIDS Control Programme

NAP

Presidential Directive of a National AIDS Policy

NAP

National AIDS Plan

NAPWA

National Association of People Living With AID

NATO

North Atlantic Treaty Organisation

NGO

Non-Governmental Organisation

NIC

National Intelligence Council

NP

National Party

NPPHCN

National Progressive Primary Health Care Network

OAU

Organisation of African Unity

OECD

Organisation for Economic Co-operation and Development

ONUMOZ

United Nations Operation in Mozambique

PACHA

Presidential Advisory Council on HIV/AIDS

PAIGC

Partido Africano da Independência da Guiné e Cabo Verde (African Party for the Independence of Guinea-Bissau and Cape Verde)

PEPFAR

US President’s Emergency Plan for HIV/AIDS Relief

PIDE

Polícia Internacional de Defesa do Estado (International State Defence Police)

PLWHA

People Living With HIV/AIDS

PMA

Pharmaceutical Manufacturer’s Association

PMTCT

Prevent Mother to Child Transmission

PSI

Population Services International

RENAMO

Resistência Nacional Moçambicana (Mozambican National Resistance)

RSC

Regional Security Complex

SADC

Sothern African Development Community

SADF

South African Defence Force

SAFAIDS

Southern Africa HIV/AIDS Action

SANAC

South African National AIDS Council

SANNC

South African Native National Congress

SARPN

Southern African Regional Poverty Network

SARS

Severe Acute Respiratory Syndrome

SOC

Sectorial Organisation Committee

STP

Short Term Plan

SWAP

Health Sector Wide Approach

TAC

Treatment Action Campaign

TRIPS

Trade-Related Aspects of Intellectual Property Rights

UDF

United Democratic Front

UN

United Nations

UNAIDS

Joint United Nations Programme on HIV/AIDS

UNDP

United Nations Development Programme

UNECA

United Nations Economic Commission for Africa

UNESCO

United Nations Educational Scientific and Cultural Organization

UNFPA

United Nations Population Fund

UNGASS

UN General Assembly Special Session on HIV/AIDS

UNICEF

United Nations Children’s Fund

UNODC

United Nations Office on Drugs and Crime

UNSC

United Nations Security Council

US

United States

USAID

United States Agency for International Development

VCT

Voluntary HIV/AIDS Counselling and Testing

WHO

World Health Organisation

WTO

World Trade Organisation

WUSC

World University Service of Canada

YOHO

Youth Health Organisation

ZANU-PF

Zimbabwe African National Union – Patriotic Front

Preface

On the basis of various global mortality and morbidity indicators, HIV/AIDS can be considered the most devastating epidemic in the history of humankind. Yet, its epidemiological impact is of and in itself insufficient to explain the role HIV/AIDS has played in national and international political agendas. Historically, the issue-area of health has seldom dominated negotiations on bilateral, regional and multilateral forums. Moreover, the lack of political salience of infections that present similar (or even superior) lethality and/or incidence to HIV/AIDS, such as hepatitis C, malaria and tuberculosis, let alone the so-called “neglected diseases” Chagas and sleeping sickness, suggests that epidemiological gravity alone does not necessarily lead to urgent institutional and policy responses by states and the international community. Nor is it self-evident that the objective measures of the effect of pandemics is what turns them into emergencies or security threats in the eyes of policymakers. Additionally, the policies that should be adopted in response to these pandemics are oftentimes themselves the subject of intense political contestation, and are therefore also not objectively given.

It is precisely for these reasons that it is possible to speak of a global politics of HIV/AIDS. Accordingly, Marco Antonio Muxagata de Carvalho Vieira addresses in this book the topic of HIV/AIDS, itself inherently important, through a political perspective. In particular, the author explores the international emergence and differing national assimilations of the epidemic’s securitization norm, which posits its treatment as a long-term emergency, an exceptional security crisis which requires immediate action.

In treating securitization as an international norm, Vieira links two major strands of International Relations theorizing, namely, the constructivist scholarship and the securitization model of the so-called Copenhagen School. As he makes clear, HIV/AIDS was not always seen as a security threat; its securitization was a social and normative construction. Moreover, such construction was not the result of an unintentional and apolitical process of diffusion as portrayed in much of the literature on norms; rather, it was carried out by particular and self-conscious actors, especially the UNAIDS, the US government and transnational NGOs.

However, Vieira is not solely interested in the global emergence of what he calls the HIV/AIDS securitization norm (HASN), but also on its domestic influences. Hence, he also investigates how and to what extent this norm was internalized and translated into practice in three sub-Saharan African countries: Botswana, Mozambique and South Africa. For this purpose, the author carries out comparative case studies which largely follow the logic of Alexander George’s “Method of Structured, Focused Comparison”, in that he asks general questions in each country case to guide and standardize data collection, in so doing allowing for systematic comparison, but deals only with the HASN related aspects of these cases. The country cases have all been highly impacted by HIV/AIDS and have been subjected to international securitization pressures. Moreover, because they all belong to the same region, sharing relevant historical, colonial, cultural and developmental legacies, they allow for the control of related intervening variables.

The findings of the book are both theoretically and empirically interesting. Theoretically, Vieira shows how the same HASN has been internalized in different ways and degrees in the three countries, shedding light on the domestic factors which filter the assimilation of global norms. Empirically, his three country cases cover the full spectrum of norm adoption and consolidation: while Botswana changed both its mind and its practices in compliance with HASN, Mozambique changed only some of its practices opportunistically, but did not change its mind, and South Africa in general changed neither its mind nor its practices. The author argues convincingly that these discrepancies observed between the country cases can be explained in terms of different state-society relations, decision-making processes, matches between HASN and pre-existing political cultures, and political leaderships. In a world characterized by globalization and Robert Keohane’s “complex interdependence”, this argument constitutes a timely contribution which helps to bridge the traditional international/domestic divide.

The evidence offered by the book is also policy relevant. Though Vieira did not intend to critically evaluate the outcomes of HASN dissemination and consolidation, his empirical analysis does provide the basis for any such evaluation. It also illuminates the issues that should be taken into account in decisions on whether and how to securitize other epidemics in other countries. Interestingly, the case studies show that HASN also allows for a wide range of conflicting policy prescriptions and the political disputes that these prescriptions embody.

Finally, the book also raises thought-provoking questions regarding future developments. If and when HIV/AIDS is controlled – either through the development of a vaccine or the universalization of antiretroviral treatment and effective prevention measures – will the securitization of the epidemic be reversed, thereby leading to further politicization and contestation? Or will it lose its political significance altogether? How will the securitizing actors react in such a scenario? And could HIV/AIDS paradoxically cease to be seen as security threat precisely as a result of its successful securitization?

Whatever the case may be, this book constitutes the product of a very well carried out research project, which combines methodological and conceptual rigor with a masterful integration of theoretical approaches and rich primary empirical evidence. It is logically organized, clearly presented and cogently develops its main argument. It will undoubtedly become a most valuable source for any reader interested in the global politics and policy of HIV/AIDS and how it plays out in sub-Saharan Africa, as well as in contemporary International Relations theory.

André de Mello e Souza

Coordinator of Studies in International Governance and Institutions

Institute for Applied Economic Research, Brazil

Acknowledgements

I would like to acknowledge a number of individuals and institutions for their valuable assistance over the four years in which this thesis has been written. There are many others from whose help I have benefited during the longer period in which my interest for international relations has been consolidated.

I am most grateful to the Ministry of Education of Brazil through its Fundação Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for making financially possible the development of this research project. I also owe a special thanks to my supervisor, Dr. Chris Alden, for his guidance and friendly support. Dr. Alden generously shared with me his deeply established knowledge of Southern Africa and fully engaged in long discussions about my arguments and hypotheses. Without his sharp comments and criticisms, it would not have been possible to successfully finalise an academic work of this kind.

I have also benefited greatly from the support and intellectual stimulus from my gifted PhD colleagues and Professors in the Department of International Relations at the London School of Economics and Political Science (LSE). The LSE and the IR Department have also provided me with all the necessary facilities and additional funds to conduct the relevant research both in the UK and abroad. The Department’s North-South Seminar (IR509) was particularly important, while testing my ideas in a tremendously rich and constructively critical environment. In this regard, the invaluable expertise and intellectually-sharp advice of Dr. Dominique Jacquin-Berdal, who led the IR509 seminar until her premature death in January 2006, served as an inspiration and source of motivation over the years. The Institute of International Relations at the Catholic University of Rio de Janeiro provided the early foundation on which my academic career has been built. I wish to thank the entire departmental staff, especially Dr. Letícia Pinheiro, Dr. Monica Herz and Dr. Maria Regina Soares de Lima, for having introduced me to this fascinating area.

During my time conducting field research in Southern Africa, I made lifetime friends and benefited from the generosity of academics and institutions. I gratefully acknowledge the support given by the Department of Political Science at the University of Pretoria. Despite being pressed by time, the Head of the Department, Prof. Maxi Schoeman, and all members of staff were always willing to contribute to my research with specialised information and academic materials on a wide range of relevant subjects. I very much appreciate the comprehensive support of the University of Pretoria’s Centre for the Study of AIDS and its entire staff. I have also spent long research hours at the beautiful University of Witwatersrand and I am very grateful to the helpful assistance of academics, librarians and administrative personnel. I would also like to thank everyone in Botswana, Mozambique and South Africa, in the various academic institutions, public and private sectors, multilateral organisations, NGOs and think-tanks that directly or indirectly contributed to this work. A special mention in this regard is made to all my interviewees for their precious time and patience. It is also a pleasure to acknowledge the help of generous friends who have kindly provided me with shelter, essential contacts and, most importantly, camaraderie during my time in the region.

I am fortunate to have a loving and supportive family. Despite all the setbacks and stressful moments, they unconditionally stayed by my side throughout the process of writing this thesis. Finally, I wish to thank my wife, Simona, who made everything worthwhile. Your sensibility, generosity, friendship and encouragement gave me so much strength in periods of uncertainty. I am deeply grateful to you.

Chapter 1

The Incorporation of International HIV/AIDS Norms into Domestic Practices: An Introduction

1. Defining the Puzzle

Nothing we have seen is a greater challenge to the peace and stability of African societies than the epidemic of AIDS […] We face a major development crisis, and more than that, a security crisis.

James Wolfensohn

On 10 January 2000, the then US Vice-President Al Gore chaired a landmark Security Council Meeting devoted to the security impact of HIV/AIDS in Africa. It was the first time in the history of the UN that an issue related to health rather than the military had been considered a potential threat to international security. Four years earlier, the Joint United Nations Programme on HIV/AIDS (UNAIDS) had been created to deal with the expanding global epidemic; this was also an unprecedented event. Never before had the international community of states put in place a global structure of governance such as the UNAIDS to deal with an epidemic of a single disease. Following the January 2000 meeting, national governments adopted a number of high-profile declarations of commitment and multilateral agreements. These documents articulated ideas, policy principles and norms, aiming to tackle the emerging threat of HIV/AIDS. By this time, HIV/AIDS had placed itself firmly on the international security agenda.

The present study is focused on the impact of this singular international phenomenon, namely the global securitisation of HIV/AIDS, on the domestic structure of three African states: Botswana, Mozambique and South Africa. These countries are geographically located in the epicentre of the global HIV/AIDS epidemic, Southern Africa. However, notwithstanding their common HIV/AIDS burden, Botswana, Mozambique and South Africa present fairly different political cultures/identities and social institutions which reflected upon the distinctive way they responded to the influence of international HIV/AIDS actors and norms. So, by investigating the latter’s impact in these rather diverse settings, this thesis aims to empirically evaluate variations in the effects of norm adaptation across states. It addresses three interrelated questions:

1. What explains the similarities and differences in the effects of international HIV/AIDS norms on the conduct of these Southern African states?

2. What are the policy outcomes resulting from the interaction between the international proponents of the securitising of HIV/AIDS and their domestic audiences in Botswana, Mozambique and South Africa?

3. To what extent have HIV/AIDS securitisation attempts been more successful in one domestic setting than in another?

In response to these questions, I present three models of state reaction to the securitisation of HIV/AIDS found in the three empirical cases: 1) the model of active engagement exemplified by Botswana; 2) the model of instrumental acceptance pursued by Mozambique and, finally; 3) the model of ideological resistance illustrated by the South African case. These archetypes are analytical simplifications of the socialisation outcomes identified in each of the above case studies. Through their examination, this thesis hopes to demonstrate that the widely used notion of “Sub-Saharan Africa” (or more specifically “Southern Africa”) poorly reflects the diversity of policy responses and local interpretations of HIV/AIDS. In this regard, I argue that, despite a certain level of pre-colonial/colonial homogeneity and a densely intertwined post-independence regional history, Southern African states have developed very distinct national characters. This is more evident in the case of Mozambique, due to the distinctive influence of Portuguese colonialism, Marxism-Leninism, civil war and (internationally-driven) post-conflict reconstruction in the formation of its national ethos. However, it is also true in the cases of Botswana and South Africa, in spite of their similar colonial backgrounds and shared regional past. As shown in more detail later, the approach of the British colonial power to the ethnically homogeneous and politically stable protectorate of Bechuanaland (currently Botswana) differed significantly to that which was applied to the racially divided and fiercely disputed region which is now South Africa. Contrasting with Botswana’s case, racial strife between the Boer white supremacists and the indigenous black population played a fundamental role in understanding South Africa’s history and politics. These historical differences had an enormous impact on the formation of these states’ particular political cultures and social configurations.

The study also provides a theoretical framework for understanding the securitisation of HIV/AIDS as an international norm defined and promoted mainly by multilateral bodies, powerful states in the north, and transnational HIV/AIDS advocacy networks (including here NGOs, CBOs, and epistemic communities). The HIV/AIDS securitisation norm (HASN) is an intellectual attempt by the present analysis to synthesise in a single analytical concept the myriad of ideas and international prescriptions about HIV/AIDS interventions. The application of this analytical tool aims to facilitate the management of empirical data as well as to provide a coherent conceptual basis for this thesis.

2. Theoretical Framework: Preliminary Comments

This research project aims to make a contribution to a growing literature looking at the transnational emergence and domestic impact of norms in international relations. In this respect, it proposes a theoretical innovation which consists of a synthesis between the securitisation framework (Buzan et al., 1998) and the constructivist scholarship on international norms (e.g., Finnemore, 1993; Risse, 1994; Risse, Ropp and Sikkink, 1999; Barnett and Finnemore, 1999; Finnemore and Sikkink, 1998). This latter perspective challenges traditional neorealist/neoliberal theories that stress material factors (economic, military, etc.) as determining the impact of ideas and norms. Rather, for these social constructivists, “material factors and conditions matter through cognitive and communicative processes, the “battle ground of ideas”, by which actors try to determine their identities and interests” (Risse and Sikkink, 1999:7).

Despite this constructivist emphasis on the role of social interactions in constituting international norms, this approach has systematically failed to understand and empirically identify the processes of communicative behaviour by which actors/states internalise those norms. Whereas the specialised literature in the domestic structural constraints (political culture, state-society configurations, regime type, etc.) to an international norm’s penetration is well established (e.g., Risse, 1994, 1995; Klotz, 1995; Legro, 1997; Checkel, 1999), the same cannot be attested for constructivist studies looking at the actual dynamic interaction between international and local normative orders. This scholarship has also neglected the special character and importance of the social construction of international security norms. It tends to focus exclusively on “good” international norms and on the domestic “violators” of those norms and their “bad” local practices (Acharya, 2004:239).

Conversely, Ole Waever, the inventor of the concept of securitisation in international relations, claims that “security should be seen as a negative, as a failure to deal with issues of normal politics” (Buzan et al., 1998:29). The advocates of the securitisation model (as articulated in the works of the so-called Copenhagen School) built on the speech-act theory (Austin, 1962; Searle, 1969) to understand how (securitising) actors engage in argumentative practices to convince (socialise) audiences about the threatening character of a particular issue. In this regard, securitisation, as an analytical concept, is a very helpful tool in unfolding processes whereby issues are moved from the realm of normal politics (politicisation) to that of emergency (securitisation). The securitisation framework is used here as a theoretical device with which the author traces incidences of securitisation towards the HIV/AIDS epidemic at the system level and in the domestic structure of the three case studies.

According to this particular understanding of security relations, the use of instruments of securitisation by political leaders is aimed at avoiding catastrophe and massive death in moments of allegedly exceptional (security) crises (Buzan et al., 1998). In this sense, it represents the contrary of the abovementioned “good” models of international governance, since the latter deals with situations of normality in international relations. Drawing upon these insights, it is shown later that, at the global level, HIV/AIDS was successfully securitised by powerful actors, namely UNAIDS, the US government and transnational HIV/AIDS NGOs. In this regard, this thesis claims that the global securitisation of the epidemic became an international norm embedded in diverse international declarations and agreements that urged states to create long-term policies and permanent bureaucracies. Similarly, the creation of an international body to deal with HIV/AIDS, namely UNAIDS, has crystallised the epidemic as an enduring security threat. The insidious and gradual impact of the HIV/AIDS epidemic transformed this particular security crisis into a long-term emergency. This important particularity of the HIV/AIDS case poses some theoretical challenges to the normality/exceptionality division in the securitisation framework.

At the domestic level, the discursive interactions between these global speakers of securitisation and their state audiences were also fundamental elements in understanding the processes by which international HIV/AIDS norms were socialised domestically. In this instance, the case studies revealed different internal dynamics of securitisation. However, the actual application of the securitisation framework to the case studies demonstrated that it is not sufficiently equipped to empirically reveal the limits between processes of politicisation and securitisation towards HIV/AIDS policies.

States are complex audiences of securitisation. They are not black boxes as the (neo) realists say. Rather, states represent collective entities composed of different institutions, cultures and individuals. This means that, even when a national government endorses, at the global level, the international norm claiming for the securitisation of HIV/AIDS, it is still important to understand the influence of this norm in the social and power-laden contexts within which domestic securitisation practices take place. It is only then that the analyst can decisively determine whether or not a securitisation move is successful. Thus, it is argued here that the securitisation framework should be complemented with other analytical tools that would allow for a more comprehensive understanding of the inter-relation between securitising actors, their audiences and the social and political contexts where these actors are situated. In this respect, the thesis explores the domestic determinants that either constrained or facilitated HIV/AIDS securitisation processes within the three case studies. It focuses on their particular political cultures, state-society relations and types of political leadership.

This analysis is inspired by (yet not firmly grounded in) the insights of a number of constructivist authors who looked at national-level factors in attempting to understand the impact of international norms (e.g., Risse, 1994; Klotz, 1995; Cortell and Davis Jr, 1996, 2000; Legro, 1997; Checkel, 1999). Risse, for example, argued that the capacity of external actors to successfully promote norms is dependent upon the particular configuration of state-society relations as well as the nature of political institutions, and “the values and norms embedded in the political culture” (1994:187). Similarly, Checkel asserts that the domestic influence of international norms is a function of the congruence between the norm and the pre-existing political culture of the target state (1999:86). Cortell and Davis Jr. claimed, in turn, that the measurement of the domestic salience of an international norm demands the investigation of “changes in the national discourse, the state’s institutions and state policies” (2000:70). I believe that this type of disaggregation exercise is essential to achieve a better understanding of the (rather striking) variation in HIV/AIDS securitisation outcomes across Southern African states.

So, what the above suggests is that the social constructivist branch of international norms’ authors and the securitisation literature are, in many aspects, complementary. With regards to this thesis’ problematic, the securitisation theory provides analytical instruments to elucidate how transnational securitising actors persuade domestic audiences that HIV/AIDS should be dealt with in terms of security. Conversely, the constructivist perspective on norms allows the analyst to identify the broader social and political structures in which these discursive interactions actually happen. The theoretical make-up as well as the advantages and implications of this combination are further exposed in the upcoming chapter.

3. Some Methodological Considerations

There is no such a thing as a logical method of having new ideas […] discovery contains an “irrational element” or a “creative intuition”

Karl Popper

The initial design of this research project sought to explore the regional assimilation of international HIV/AIDS norms through the examination of the Southern African Development Community (SADC). Given that HIV/AIDS is aggressively spreading throughout southern Africa, it is reasonable to assume that states in the region would look for co-coordinated action in tackling the epidemic. Accordingly, the regional institution, the SADC, would be the appropriate forum to promote deeper cooperation towards HIV/AIDS policies, since it can provide the institutional resources for harmonising national policies and for defining regional strategies to face the epidemic.

However, these initial assumptions about the role of this particular institution as a recipient of international norms were not confirmed. Two research visits to the SADC’s headquarters in Gaborone, Botswana, and a number of interviews with officials involved with HIV/AIDS regional activities revealed an institution struggling to coordinate the HIV/AIDS policies of its member states and at the margins of national decision-making. Evidence collected during field research in Botswana, Mozambique and South Africa has also exposed these countries’ common disregard for regional HIV/AIDS initiatives led by SADC and an inward-oriented tendency while defining common strategies to combat the epidemic. The explanations for this lack of regional commitment towards HIV/AIDS policies are complex and it is not the aim of this particular research to explore them. It is suffice to say that HIV/AIDS is not an exceptional case in Southern Africa regarding lack of effective regional cooperation. It is, in fact, part of a general trend that has inspired a number of academic works, particularly in the area of regional security studies (e.g., Evans, 1991; Albright, 1991; Vale, 1991, 1994; Khadiagala, 1994; Booth and Vale, 1995, 1997; Malan, 1998; Tsie, 1998; Tapfumaneyi, 1999; Thompson, 1999; Alden and Le Pere, 2000; Baregu, 2003; Nathan, 2004).

Nathan, for example, argued that the inefficiency of collective security arrangements within the SADC is due to the combination of three main factors, which have hampered the “development of trust, institutional cohesion, common policies, and a unified response to crises” (2004:1). Firstly, he points to the absence of common values among SADC member states as the most important problem in understanding poor security coordination in the region; a second related problem has to do with their reluctance to give away a measure of their sovereignty rights to a regional security regime; finally, this unwillingness to partially surrender sovereignty stems from the political weakness of many member states, which undermines the implementation of regional strategic plans (Nathan, 2004:3). He asserted that SADC member states are essentially incompatible in terms of their domestic and foreign policies, which would impair the establishment of a successful regional organisation. In his words,

A viable regional organisation might be able to develop common policies and perform a range of security and cross-border functions but its members must have sufficient commonality in values if the body is to be at all viable. Frequent interaction between member states will not in itself overcome divisions and mistrust that derive from incompatible national policies. Common values are the foundation rather than the outcome of close political and security co-operation (2004:14).

The important point to bear in mind here is that, notwithstanding the creation of regional structures and policy guidelines, the SADC has not been able to put in place an effective institutional mechanism for inter-state policy harmonisation along the lines of the international securitisation of HIV/AIDS. In spite of the coordinating efforts of the SADC’s Secretariat, little progress was made in implementing regional HIV/AIDS interventions. As a result, the domestic structures of states have prevailed in terms of being the central and autonomous settings in which processes of norm incorporation have been more strongly manifested. In this respect, Acharya notes that variations in the regional acceptance of international norms depend upon the “differential ability of local agents to reconstruct transnational norms to ensure a better fit with prior local norms” (2004:239). In the Southern African context, this processes of norm localisation had a significant impact only at state level, since the SADC has not developed a strong normative structure that could accommodate new transnational understandings on security issues.

Given the above, the sources of explanation of this study cut across two inter-related levels: It is argued here that,

1. At the system level, the international establishment of HASN represented a structural constraint (yet also an opportunity) in terms of the capacity of Botswana, Mozambique and South Africa to make autonomous decisions about HIV/AIDS policies.

2. At the domestic level, the understanding of the process by which HASN is incorporated in their domestic structures is dependent upon the analytical unpacking of the dynamic relationship between political, ideological and societal processes within states.

The rationale behind the selection of the case studies is as follows:

• Firstly, they all present extremely high HIV prevalence rates. At the end of 2005, South Africa alone had an estimated 5 million people living with HIV, which represents roughly 20% of its adult population. The situation in Botswana is even worse, with around 24% of its adult citizens carrying the virus. In Mozambique, 16% of the adult population, which corresponds to 1.6 million people, are similarly infected (UNAIDS, 2006a).

• Secondly, given their equally dramatic HIV/AIDS situation, these countries have all been subjected to substantial pressure from the international community to securitise their HIV/AIDS epidemics. Moreover, they are all major recipients of bilateral and multilateral aid to combat the epidemic, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank’s Global HIV/AIDS Program of Action, and the US President’s Emergency Plan for HIV/AIDS Relief (PEPFAR).

• Lastly, despite this common international pressure, they present quite distinct colonial experiences, political cultures, and levels of economic development, which allows the author to engage with a wide variety of domestic configurations.

It is important to clarify that this thesis is an exploratory investigation of three case studies. As such, it provides evidences that sustain the hypothesis that the externally induced securitisation of HIV/AIDS (here called HASN) resulted in three models (or outcomes) of state reaction. This methodological approach neither involves a strong causal inference nor the attempt to systematically apply a supposedly universal theoretical model to a particular “objective reality”. Rather, the theoretical conceptualisation of HASN is solely intended to organise and limit the analytical scope of this thesis and, as a corollary, to contribute to a particular debate in the international relations literature. Thus, the methodological position taken here is more closely linked with a humanistic and interpretative approach (along the lines of Max Weber’s Verstehen and hermeneutics) as opposed to an objectivist/positivist view about the production of knowledge in social sciences.

Although the present study follows a historically coherent line of events, it is not attached to a very strict time-framing. Rather, the investigation concentrates strongly on identifying a particular universe, which characterises one important phenomenon: the global securitisation of HIV/AIDS. The case studies were examined within the class of events that defined this particular phenomenon. In this sense, I refer to historical developments that occurred mostly from the early 90s to the present day. Most of the primary data was collected in the year 2004 and, for that reason, the principal time-cut of the present examination is on that year. This does not however mean that subsequent events were not taken into consideration. Their relevance was assessed for consistency with the research proposal and then included in the analysis accordingly.

Given the scarcity of secondary materials tackling key issues, such as the role of external actors in HIV/AIDS policy decision-making, a great deal of research was conducted directly in Botswana, Mozambique and South Africa. During two research visits, in July/September 2004 and February 2006, the author consulted numerous primary sources (Government’s publications, donors’ policy statements, meetings’ proceedings, etc.) and conducted interviews with a wide range of actors in both the private and public sectors. Additionally, a number of local newspapers, academic articles and specialised books were examined. The internet provided access to many key policy documents, reports and a wide array of official documentation from the UNAIDS, the US and transnational NGOs. Some representatives of those actors were also interviewed on the ground in Gaborone, Maputo and Johannesburg/Pretoria.

The most challenging methodological aspects of this research were related to the reconstruction of events and processes which were neither documented nor accessible to the larger public. On many occasions, the author relied on the memory of the interviewees to retrace policy decision-making procedures, to understand the functioning of state institutions and to assess the role of international partners in influencing domestic HIV/AIDS policies. Moreover, some of the most important actors were either not available or were unwilling to provide the relevant information. It is important to bear in mind, in this respect, that HIV/AIDS is still a very sensitive and politicised issue in some national contexts. These gaps in data were filled by other documental sources and interviews with lower-ranked individuals, who nonetheless were in possession of reliable knowledge about (or were directly involved with) the issues under examination here.

I would like to offer a final note on definitions and terminology. All the central concepts used in this thesis are first explained, and then applied in a coherent manner. The particular usage of “international norm”, “securitising actor”, “audiences of securitisation” and “referent objects of security” is further clarified in the next chapter. Given the symbiotic application of two sets of theories with their own particular terminologies, certain concepts may at times be intertwined. It is worth noting, in this respect, that the terms “securitising actors”, “norm leaders” and “norm entrepreneurs” are used interchangeably due to their similar meaning, as representing the actors who embrace and promote a particular interpretation of a social event. Similarly, the concepts of “norm takers” and “audiences” are both used to describe the actors who receive, react and reconstruct the HIV/AIDS securitisation norm.

4. Organisation of the Thesis

This thesis is divided into seven chapters, including the present introduction and the conclusions. The five core chapters are organised as follows: Chapter 2 provides an analytical framework for guiding the subsequent empirical analysis. It further develops on the theoretical underpinnings and implications of HASN as well as explaining the historical process of the emergence and consolidation of this norm in the international system. It also looks at the origins and evolution of the academic and policy debates linking HIV/AIDS and security and how they were translated in terms of principles and norms for state action.

Chapter 3 looks at three major global securitising actors (or norm leaders/entrepreneurs) concerning the securitisation of HIV/AIDS. These are the UNAIDS, the US Government and a number of transnational HIV/AIDS non-governmental and faith-based organisations. It is claimed that by using different persuasion strategies and operational resources, such as UNAIDS’ knowledge-based authority about the epidemic, the US’ disproportional material capabilities and the transnational NGOs’ ability to spread information, these actors became powerful sources of the diffusion of HASN. This chapter explores their different (and many times conflictive) rationales, sources of legitimacy and worldviews about HIV/AIDS and how they promote those particular understandings worldwide.

The three subsequent chapters examine the process by which HASN was absorbed in the domestic structures of this thesis’ audiences (or norm takers), namely Botswana, Mozambique and South Africa. These chapters focus on these countries’ political cultures and colonial legacies, the particular characteristics of state-society relations and the sources of political leadership. Chapter 4 explores the case of Botswana and shows that a significant degree of conformity between international and national normative systems shaped the HIV/AIDS policy process in this Southern African state. It argues that post-colonial Botswana developed a political culture friendly to Western values and this was reflected in its policy response to HIV/AIDS. Moreover, the government’s commitment to the social and economic uplifting of Botswana’s people coupled with a stable political system and strong public institutions have also contributed to a national response to HIV/AIDS in line with the international agenda of the securitising actors.

The Mozambican case is analysed in chapter 5. It reveals a domestic context rooted in a political culture that has experienced very high levels of dependency on international actors. Given the virtual destruction of the state as the result of a prolonged civil war, Western powers, international institutions and NGOs have been active in the country’s political process from very early on. Furthermore, the social and economic decline of the country due to war has contributed to the emergence of a culture of survival among its political leadership. In this respect, Mozambique’s elites have instrumentally used the country’s many crises to influence the international community of donors. This kind of management of dependency (Bayart, 2000) is aimed at gaining external support, therefore perpetuating deep-rooted patterns of domestic control. The incorporation of HASN in Mozambique should be interpreted against this background.

Chapter 6 examines the South African case. It shows that South Africa’s assimilation of HASN took place in a domestic context profoundly marked by the legacies of the Apartheid regime. It is argued that the South African government (largely under Thabo Mbeki’s rule) has placed HIV/AIDS within a broader political agenda of opposing Western white domination in Africa. In this respect, the government’s rationale is primarily ideological and clashes with the established authority of HASN norm leaders. Mbeki has systematically challenged the Western scientific community, pharmaceutical corporations and Western policies on tackling the global epidemic. This active dissidence of the South African government towards HASN should be situated in a political culture strongly permeated by ideological and racial divisions. However, contrasting with the cases of Botswana and Mozambique, in South Africa a vibrant and proactive civil society sector has confronted the government’s views and policies on HIV/AIDS. In addition to their domestic activism, these civic organisations link up with transnational networks of NGOs, who then convince international organisations (IOs) and major donor states to exert pressure on the government to change its HIV/AIDS policies. As a result, Mbeki and his Minister of Health have softened up their antagonistic rhetoric and, in 2003, the South African government finally agreed to provide universal access to AIDS drugs in the public health system.

The conclusive chapter sums up the most important theoretical and empirical findings of the thesis. It also points to possible avenues for further research, mostly concerning processes of international (security) norm incorporation at the regional level and the conceptual expansion of HASN to incorporate the securitisation of other critical epidemic diseases. Regarding the former, the analytical concept of regional security complexes (Buzan, 1983; Buzan and Waever, 2003) could be applied in a subsequent study of Southern Africa to structure a more detailed examination of whether national concerns about HIV/AIDS could (or could not) be tied together into a single regional formation (or audience of securitisation).

Chapter 2

“The HIV/AIDS Securitisation Norm (HASN)” – An Analytical Framework for Understanding the Global Securitisation of the Epidemic

1. Introduction

This chapter discusses the emergence and diffusion in the late 90s of an innovative conceptualisation of security that proclaims the global HIV/AIDS epidemic an emergencial threat to international peace and stability. The study provides a framework for understanding the securitisation of the HIV/AIDS epidemic as an international norm defined and promoted mainly by epistemic communities of academics and international organisations, powerful states in the north, and transnational HIV/AIDS advocacy networks. The HIV/AIDS securitisation norm is an intellectual attempt by the present chapter to synthesise under a single analytical concept the myriad of ideas and international prescriptions about HIV/AIDS interventions.

The following discussion explores the theoretical and empirical foundations of HASN. Specifically, it first explains what is meant by considering the securitisation of HIV/AIDS as an international norm. The chapter then investigates some analytical advantages for the present study in linking the constructivist literature on the emergence and diffusion of international norms with the securitisation perspective. It points to some important shortcomings in both scholarships and elaborates on how they could work more efficiently as a combined analytical tool. It also assesses the empirical contributions of HASN to the theoretical debate on how pre-existing normative orders, political structures and agents condition the domestic reception of international norms. Finally, the work explores the conceptual and empirical origins of HASN. It focuses on the social construction of HIV/AIDS as a security threat and how these ideas became crystallised into international norms.

2. The Conceptualisation of the Securitisation of HIV/AIDS as a Norm

Before the actual exploration of the advantages in linking the securitisation framework and the constructivist debate about norms, some conceptual issues should be briefly clarified. The HASN is analytically divided here in two integrated parts: 1) one that defines the idea of HIV/AIDS as a security issue, which presupposes rights and obligations (norm); and 2) one which prescribes the right policies to be implemented at the international, regional and national levels to combat the threat posed by the epidemic (rule). In this respect, one can say that the (international) norm is deterministic in terms of defining a unique and uncontested understanding of what the HIV/AIDS epidemic is and also normative in the sense of knowing what are the supposedly best policies to be put in place by states.

At first glance, the concept of regime sounds analytically more comprehensive than the concept of norm. For example, Stephen Krasner provides a definition of international regime which encompasses a “set of implicit or explicit principles, norms, rules, and decision-making procedures around which actors’ expectations converge in a given-area of international relations” (1982:186). However, in Krasner’s formulation regime is not a single concept but a set of blurry terms that are really hard to cope with when applied to specific empirical cases. Hence, to avoid intangible definitional complexities, the present analysis has opted for a minimalist conceptualisation of HASN in terms of an internationally agreed prescriptive framework promoted with the help of states, IOs and transnational advocacy networks. It accepts Krasner’s definition of norm as “standards of behaviour defined in terms of rights and obligations” (1982:186). This is different from rules that comprise the application of norms to particular situations. As Kratochwil points out, “the regime literature emphasises this important difference in arguing that rules deal with specific problems while norms are more general prescriptions” (1984:687). Since HASN presents characteristics of both, the subsequent discussion conveys in a single definition the above understandings of norms and rules.

The main interest of this study is not on the actual interpretation of HIV/AIDS as a security issue. To put it in other words, the present analysis is not mainly concerned with the question of why HIV/AIDS has been securitised. Rather, it aims to show what explains the securitisation of HIV/AIDS and how this norm has been diffused worldwide. In doing so, it looks at the origins of this particular normative understanding and the social mechanisms by which this so-called norm exercises influence in the behaviour of states. It is important to make clear, therefore, that the present analysis does not engage with the ongoing debate about the (real/imagined) links between HIV/AIDS and security. Nor is it the purpose of this chapter to judge either the reasonableness or the ethical implications of the securitisation of HIV/AIDS. In this sense, the normative aspects of HASN should not be confounded with questions about whether the securitisation of HIV/AIDS moves the response from the domain of universal humanitarianism to that of self-referential national interest. As highlighted later, most of the writers and practitioners looking at HIV/AIDS and security operate within this basic dichotomy. For some of these actors, it has become necessary to securitise HIV/AIDS precisely because the human security/developmental approach to the epidemic produced only an insufficient response in the international system. For others, the framing of HIV/AIDS in the language of national security can push the response in the wrong policy direction. Elbe, for example, asserts that this is due to susceptibility for undemocratic decision-making in situations of national security crisis, with power concentrated in just a few state institutions, such as the military and intelligence services, and away from civil society groups (Elbe, 2006:121).

The focus of the present analysis is rather different. It aims to set up an analytical framework to understand the formation of a powerful global claim for the securitisation of HIV/AIDS. Building on social constructivist insights of other authors (e.g. Finnemore, 1993; Finnemore and Sikkink, 1998; Ruggie, 1998), this chapter argues that international HIV/AIDS norms – or “standards of appropriateness” (March and Olsen, 1998) - have changed considerably since the early 80s. It shows how these cognitive maps evolved from an early biomedical, and then developmental approach, to one based on the securitisation of the epidemic. This framework also works as a useful investigative tool in this thesis’ later assessment of the impact of the global securitisation of HIV/AIDS on the domestic structure of three states in Southern Africa, namely Botswana, Mozambique and South Africa.

Therefore, the use of norm here is broadly analytical. It refers to this study’s appreciation of the (almost) consensual agreement by governments, IOs and NGOs that HIV/AIDS indeed represents a special type of emergency and that governments should implement the internationally devised best practices to fight the epidemic. As shown later, the explicit and tacit rules/norms/principles governing HASN were consolidated in successive conferences where states’ representatives met and reached agreements intended to foster a particular understanding of the global epidemic. In these conferences, the signatories of joint declarations agreed upon general principles, identified specific recommendations for state behaviour and established decision-making procedures at the multilateral and state levels.

3. Theoretical Perspectives on Norm Formation and the Securitisation Debate

This section aims to combine in a single analytical framework some of the theoretical contributions given by the securitisation framework and the constructivist scholarship on norm formation and diffusion. It explores the analytical advantages that such a merge could offer to the understanding of HASN.

Fundamentally, the constructivist scholarship on international norms focuses on the mechanisms by which ideas emerge and spread. This school is divided into two inter-related perspectives. The first research agenda looks primarily at the system level (Finnemore, 1993; Barnett and Finnemore, 1999; Finnemore and Sikkink, 1998). It focuses on how international norms emerge and the means of their propagation in the international system. This perspective is also interested in the actors who embrace and promote these norms. They focus on the role of transnational social movements, multilateral institutions and states as teachers of norms.

The second group stresses the process by which international norms penetrate the domestic structure of states (Cortell and Davis Jr., 1996; Risse, 1994; Klotz, 1995; Gurowitz, 1999; Legro, 1997). This perspective confines the analysis to how the particular political, societal and cultural characteristics of states produce distinct outcomes in terms of the domestic absorption of international norms. They describe the levels of convergence between international and domestic understandings of a given issue and how bureaucracies, legal systems, and shared principled beliefs serve as filters for international norms.

In general, these perspectives are exclusively concerned with universal norms of good international citizenship (protection of wildlife, promotion of human rights, protection of women and minority rights, anti-slavery campaigns, transnational movements against land mines, etc.) and with how they promote normative change (Acharya, 2004; Carpenter, 2005). However, norm formation and diffusion in international politics also involves other types of norms. These authors usually ignore the essential quality and special appeal of some of these international norms that are identified as responding to existential threats to peace and security.

The present argument claims that, by way of drawing the line between processes of politicisation and securitisation, Buzan et al. (1998) framework provides an important contribution to the constructivist scholarship on international norms in terms of pinning down the constitutive dynamics of international security norms. Concerning this chapter’s discussion, the securitisation framework offers, with some degree of precision, the analytical parameters to understand the historical process that led to the current global securitisation of HIV/AIDS. Through the application of the four constitutive elements of the securitisation speech-act (as presented below), it is argued later that HIV/AIDS has been successfully constructed as a security threat by a number of very powerful securitising actors. In fact, by the examination of the emergence, dissemination, and final institutionalisation of HASN, this chapter aims to go beyond these authors’ typology, arguing that, at its final stage, the securitisation process becomes an international norm. It does not mean, however, that after being widely accepted at the global level, HASN has become automatically embedded in the domestic structures of the states most affected by the epidemic. As demonstrated later, despite their joint declarations and formal commitments in multilateral gatherings, the actual response of governments to the global securitisation of HIV/AIDS is dependent on their pre-existing political attitudes towards the epidemic. In what follows, this section briefly examines some relevant assumptions underlying the securitisation framework.

Drawing upon early postulations of the speech-act philosophy (Austin, 1962; Searle, 1969), the so-called Copenhagen School (e.g. Wæver, Jahn, and Lemaitre, 1987; Wæver, Lemaitre and Tromer, 1989; Buzan, Kelstrup, Lemaitre, Tromer and Wæver, 1990; Wæver, Buzan, Kelstrup, and Lemaitre, 1993) posit that security is not a static concept, as understood by traditional security studies, but an intersubjective rhetorical practice. Through his speech-act theory, Austin (1962) recognises the transformative importance of language in social relations. For him, speech is a form of social action which has a significant political impact. Rather than only describing events or encoding information, he demonstrates that, through the use of speech-act, social/political actors define standards for social activity. Consistent with Austin’s early formulations, Wæver (1989) and his Copenhagen colleagues pioneered the definition of security as a form of speech-act. For him, the utterance of security entails the claim that some issue represents an existential threat to a valued referent object and that the exceptionality of the threat would justify extreme measures to deal with it. In this sense, to label something in security terms is nothing more than a discursive articulation in which social/political actors try to inculcate a particular quality (threat, emergency, etc.) into an issue.

Based on this premise, Buzan, Wæver and Wilde (1998:36/37) broke down the security speech-act into 4 constitutive parts. They say that, in framing something in terms of security, a (i) securitising actor(s) should present a (ii) specific issue as an (iii) existential threat to the survival of a (iv) referent object. For them, securitisation is only successful when a securitising actor is able to convince a significant audience that something constitutes a threat. In that sense, the measurement of (in) security is not given only by an objective assessment of the actual nature of the threat but mainly by the analysis of the conditions by which a securitisation claim becomes widely accepted and eventually institutionalised. After an issue is successfully securitised, the next step is the institutionalisation of the security rhetoric. At this stage, there is no further need to persuade others through the use of discourse. The security argument and the sense of urgency are implicit in the standards of behaviour, principles, policies, and bureaucratic procedures that were created to deal with the problem. The securitisation is institutionalised only if the threat (either perceived or real) is resilient enough to demand the build-up of standing bureaucracies and procedures.

Those attempting to institutionalise the securitisation of new threats, as in the case of transnational advocacy networks (Greenpeace is a good example, concerning environmental issues), have in general to face the resistance from a international political context still dominated by traditional security institutions. The degree of either confrontation or adequacy towards these securitisation moves can vary greatly, depending on the characteristics of the political setting (either multilateral, regional, or national) in which securitisation is attempted (Buzan et al., 1998: 29).

International norms can assume various forms and most of them fall in the realm of politicisation. This means that they are in general part of normal public debate and policy decision-making and do not represent an urgent matter requiring actions outside the usual political procedures. However, depending upon circumstantial changes, issues can be moved further up in the list of policy priorities, requiring a special type of politics and increased allocation of human and material resources. As shown later, the HIV/AIDS epidemic is an interesting example, whereby an issue has been gradually moved from the politicised to the securitised category. In this sense, one can say that the process of constituting international security norms is analogous to the image of a pendulum that swings from politicisation to securitisation and vice-versa in terms of the perceived levels of urgency and threat that are allocated to a specific issue. In the case of HIV/AIDS, the pendulum has already swung from politicisation to securitisation and, as long as the disease is eventually controlled, it can move back to the sphere of politicisation.

Given the above considerations, this chapter proposes that the explanation of the cognitive process by which issues in the transnational system are moved from the category of normality to emergency and back, is the most compelling contribution of the securitisation framework to the study of how international security norms emerge and spread. In this respect, the securitisation theory fills an important gap in the literature on international norms; that is their lack of interest on the strategic social construction of threats to international security. Consistent with the view put forward by the Copenhagen group, in general, and Buzan et al., in particular, this study argues that, through the use of rhetoric practices (speech-act) as well as other forms of persuasion, HASN entrepreneurs promoted change in pre-existing interpretations of the HIV/AIDS global epidemic. As further elaborated in the following section, these actors successfully reframed the disease from an early biomedical issue to the current immediate threat to global security.

However, despite its relevance to the present discussion, the securitisation scholarship has, at least, two very important shortcomings. Firstly, the aforementioned pendulum analogy illuminates a fundamental problem common to most of the proponents of the securitisation approach, including Buzan et al. (1998). This is the empirical identification of the tipping point in which an issue is moved from an area of normality to one of exceptionality. In other words, the question is “how, in practice, can the analyst draw the line between processes of politicization and processes of securitization?”(Buzan et al., 1998:21). In the military sector, emergency measures are very clearly defined (i.e. declaration of war), but in the case of health (incidentally, the securitisation framework does not contain a health sector), is the international community really responding to the epidemic in emergency mode? Indeed, the creation of special HIV/AIDS bureaucracies and policies at system, regional and state levels indicates that the aforementioned pendulum has moved towards the institutionalisation of the security threat.

Nevertheless, this does not mean that a significant world audience was convinced about the emergencial threat posed by the epidemic. Contrasting with the more present danger of international terrorism, for example, the insidious character of HIV/AIDS has disguised the actual magnitude and emergency of the security threat. This particular feature of the securitisation of the HIV/AIDS epidemic challenges previous understandings about the determinants of successful securitisation claims. It is suggested here that the successful securitisation of HIV/AIDS can only be measured by looking at the internalisation of its constitutive principles in the domestic structure of states.

According to Buzan et al. (1998:41), the defining characteristic of a successful securitisation is the acceptance by an audience that something is threatening and demands exceptional action. Therefore, the actual understanding of the limits between politicisation and securitisation is dependent on a strong analytical focus on the acquiescence of the audience. At a global level, this chapter argues that the securitising of HIV/AIDS can be empirically demonstrated by the widespread acceptance of the securitisation claim in multilateral organisations, namely the UN. In this respect, it is shown that states’ adherence to prominent international declarations of commitment indicates that the large audience of UN member-states was convinced about the specific security nature of HIV/AIDS. However, the national governments’ acquiescence at the international level did not translate into the immediate internalisation of the securitisation norm at the domestic level. This means that in the domestic structure of states, the securitisation of HIV/AIDS presented different outcomes in terms of its assimilation. This point relates to the second problem of the securitisation framework.

While digging deep into the theoretical puzzle, Buzan and his followers neglect the empirical verification of actual processes whereby issues, after being successfully securitised in the realm of discursive practices (speech-act), become widely embedded in transnational institutions and states’ bureaucracies. These authors also lack conceptual tools to understand the impact of externally induced securitisation processes in pre-existing regional and domestic systems. A similar criticism was first raised by authors (Balzacq, 2005; Stritzel, 2005) who pointed to the need of proper social contextualisation in the analysis of processes of securitisation. Notwithstanding their emphasis on the role of social power and facilitating conditions (1998: 31-33), Buzan et al. do not satisfactorily elaborate on the interplay between the autonomous linguistic practices of securitisation and the structured social and power contexts in which those practices take place. Instead, they centre the analysis almost exclusively on the subjective practices of discourse, omitting, therefore, the strategic environmental factors that deeply influence them.

This chapter claims that these conceptual tools are better provided by the abovementioned “second wave” constructivist scholarship on international norms.

This literature maintains that states and regional institutions do not react in the same manner to externally induced/imposed normative frameworks. Rather, their particular domestic and regional contexts conditioned the reception of international norms by governments and regional institutions alike. Within this research agenda, a number of important factors have been shown to condition the domestic incorporation of international norms. They have argued that variations in the domestic adaptation of international norms can be explained by the distinctive features of local actors’ principled beliefs and cognitive identities as well as by the (mis)match between international norms’ prescriptions and states’ political structures.

Peter Gourevitch (1978), for example, has usefully demonstrated, in his influential analysis of the role played by domestic structures in mediating the effects of systemic pressures, that some actors have more access than others to policy discussions due to the particular institutional configurations of the decision-making process. Other authors explored a number of similar issues. These are the causal link between the ability of international norms to influence state behaviour and the different configurations of state-society relations (Risse, 1994), the congruence between international norms and pre-existing political cultures (Checkel, 1999), the processes wherein domestic groups appeal instrumentally to international norms to further their own local interests (Cortell, and Davis Jr., 1996), and the processes by which international norms reconstitute national interests (Klotz, 1995).

While attempting to demonstrate causality relations between international norms and domestic policy structures, these scholars have shown that states are not only passive recipients of international norms but also respond to them in distinctive ways. In other words, in understanding norm diffusion in the inter-state system, they have demonstrated that the agency role of norm takers does matter a great deal. International actors and norms meet at the state-level particular cultural, social and political contexts that do not necessarily go hand in hand with their prescribed guiding principles. As illustrated later, South Africa is an interesting case in this regard. Despite the objective threat posed by HIV/AIDS (the virus is spreading faster in South Africa than anywhere else in the world), the South African President, Thabo Mbeki, and his close advisers, including the Minister of Health, have constantly defied the mainstream international approaches to the epidemic. Mbeki links the epidemic’s spread to poverty and the deep-rooted legacies of the Apartheid regime. Until recently, he also claimed that HIV and AIDS are not related and that pharmaceutical companies, backed by powerful states, are exploiting (one could also say securitising) the epidemic exclusively to achieve financial gains.

The South African government’s ideological resistance to HASN entrepreneurship in the country clearly illustrates how a cultural mismatch (Checkel, 1999) between external and internal understandings of the epidemic’s impact can hamper the process of successfully transmitting the HIV/AIDS securitisation norm from the international to the domestic. In South Africa, this conflictive encounter between international normative understandings (securitisation) and local belief systems and practices (de-securitisation) resulted in sustained domestic resistance to the internationally prescribed securitisation of the HIV/AIDS epidemic. The remainder of this chapter seeks to find empirical support for the theoretical assumptions put forward here.

4. The Origins and Substance of the HIV/AIDS Securitisation Norm (HASN)

4.1. HIV/AIDS and Security: Setting the Debate

The following analysis focuses on the concept of security and the current understandings of its relationship with the HIV/AIDS epidemic. It describes the ideational changes in the definitions and referent objects of security since the early 80s and how HIV/AIDS became part of this academic and policy debate.

The notion of security in international relations is a contentious one. It is muddled by a plethora of unresolved debates about its actual meaning. These debates can be divided into two main groups. The first is made of scholars who interpret security mostly as national or state security, which basically means fear from military threats from states against other states. This school in security studies is deeply rooted in the realist tradition of international relations (e.g., Carr, 1939; Morgenthau, 1948). The realist understanding of the national security problem is well exemplified by the widely acknowledged idea of the security dilemma (Herz, 1950). This is the notion that the security needs of one state will necessarily lead to the insecurity of other states as each interprets the behaviour of others as potentially dangerous (Buzan, 1991:14). For realists, the international system is anarchic, signifying the lack of a central authority restraining state behaviour. In this rather unstable external environment, states will inevitably develop military capabilities to protect themselves.

This largely pessimistic view of security is shared by contemporary neo-realist authors such as Kenneth Waltz (1979) and John Mearsheimer (1990), who envisage the balance of power politics as the permanent structural feature of the international system (Baylis, 2005:302). Kenneth Waltz, in particular, had a profound impact in the area of security studies. His neorealist theory argues that the structural characteristics of the international state system moulds state behaviour. According to Waltz, states are the most important analytical units in international relations. For him, the utmost goal of states is self-preservation, “since no one can be relied on to do it for them” (Waltz, 1979:109). In this sense, he argues that “the units of an anarchic system are functionally undifferentiated. The units of such an order are then distinguished primarily by their greater or lesser capabilities for performing similar tasks” (Waltz, 1979:97). This means that the structure of a particular system is defined by the distribution of capabilities among like units rather than through differences in their character and functions (Waltz, 1979:98). In Waltz’s formulation, therefore, security can be only achieved through balancing the power capabilities of the most important units in the system.

Since the early 80s, however, the neorealist conceptualisation of inter-state security relations has been challenged by a growing number of writers who argued for an alternative understanding of security (Buzan, 1983/1991; Ullman, 1983; Jahn, Lemaitre, and Wæver , 1987; Tickner, 1992; Buzan et al., 1998). This new research agenda included in the security analysis non-military threats as well as non-state actors. Richard Ullman (1983), for example, argued that national security can be undermined by events other than military conflict. He articulated an unconventional definition of national security threat in terms of an action or series of events (such as internal rebellions, blockades and boycotts, decimating epidemics, catastrophic floods, etc.) that threatens drastically the quality life of the inhabitants of a state and/or narrows the policy options available to the government of a state or a nongovernmental entity (Ullman, 1983:133). Following the same trend, Barry Buzan (1983/1991) made analytically clear the distinction between economic, political, environmental, social and military security threats that could affect states and non-state actors alike. He also delineated the security dynamics at three inter-related levels, the individual, the state and the system.

The introduction of this new security agenda in academic works was accompanied by a strong tendency in the wake of the Cold War’s collapse to shift the referent object of security from states to individuals. The United Nations was at the forefront of these developments. In 1992, following the request of the Security Council, the UN Secretary General, Boutros Boutros-Ghali produced the first of a series of influential documents aiming to address the changing international security order. Boutros-Ghali’s An Agenda for Peace outlined the rationale and methods for moving away from the Cold War’s conceptualisation of state security towards a closer focus on the security of individuals. The subsequent emergence of the human security perspective is intrinsically linked with the principles and themes initially developed in An Agenda for Peace. It focuses on a broad understanding of security that encompasses not only the security of states against external or internal armed threats, but also the security of people living within states against non-military threats, such as disease, environmental degradation, economic and social instability, etc. While breaking down state security into many subcategories, this perspective shifted the levels of analysis from states and the inter-state system to societies and individuals within and across states.

The United Nations Development Program (UNDP) was the first organisation to officially champion the human security perspective. The UNDP launched the concept of human security in 1994 through its Human Development Report. It lists several categories in which human security can be at risk, such as food security, economic security, personal security, community security and political security. Subsequently, UNDP proposed a series of measures to institutionalise the concept, as, for example, the formulation of a world social charter, the creation of a global human security fund and the recommendation of global taxes for resource mobilisation and the establishment of an Economic Security Council (UNDP, 1994:24-25). Following the lead of UNDP, other international bodies such as the International Monetary Fund (IMF) and the World Bank have adopted the concept of human security in their policy frameworks. In addition, a number of governments have also embraced the concept when defining their national security policies - Canada and Norway being pioneers in this regard.

HIV/AIDS clearly falls into this latter categorisation of security, which led to the adoption of this broad perspective by a wide range of governments, multilateral agencies and academics. This group has raised questions concerning the economic impact of the disease at the community and family levels, how the epidemic is engendering millions of orphans, whether it can become a threat to food security, how it contributes to crime and the implications of the epidemic to governance and economic development (Kristofferson, 2000; Elbe, 2001; Piot, 2001; Fourie and Schonteich, 2001; Chen, 2003; Leen, 2004). There have also been a number of academic studies and policy reports addressing the epidemic within the more traditional framework of security. Generally, this literature explores the indirect impact that HIV/AIDS could have on the territorial security and integrity of (mostly Western) states. The issues examined in this regard include, for example, whether high prevalence rates can constitute a threat to the national security of regimes friendly to the West, therefore requiring external intervention. They also assess whether economic and social burdens associated with HIV/AIDS could cause further domestic and regional instability in areas already characterised by entrenched conflict, and whether new strands of the HIV virus could penetrate Western societies (Heinecken, 2000, 2001a, 2001b; National Intelligence Council (NIC), 2000; Price-Smith, 2001, 2002; Singer, 2002; Elbe, 2003; Fidler, 2003a, 2003b; De Waal 2003, 2004; Prins, 2004; Garrett, 2005a, 2005b, Ostergard, 2002, 2005). Some of these scholarly studies and policy reports explore the implications of HIV/AIDS on the readiness of national armed forces with high HIV prevalence rates (Mills, 2000; Heinecken, 2001b; Elbe, 2002), and how international peacekeeping operations can serve as an important vector for further spreading HIV in the emergency areas where these forces are deployed (Tripodi and Patel, 2002; Bratt, 2002; Elbe, 2003, IASC, 2003).

What this amounts to is a two-tier perception of the security implications of the epidemic. At one level the referent objects are individuals and societies, whereas in the other states and the international system are seen as the main analytical focus. The human security approach in general accuses the traditional perspective of focusing exclusively on a narrow state-centric understanding of the security implications of HIV/AIDS that frequently ignores the well-being of people both affected and infected by the epidemic. In turn, traditionalist security theorists charge the human security approach of losing focus and expanding the concept too widely, thus neglecting very important questions about the impact of the epidemic on state institutions and governance (Ostergard, 2002; Elbe, 2001).

This chapter claims that these two tiers are not divorced from each other. It argues that the variations in meaning between human and national security approaches to HIV/AIDS indicate the presence of different mental models or road maps (Goldstein and Keohane, 1993:13) within a common worldview about the existential threat posed by the epidemic. This shared broad notion about the security threat posed by HIV/AIDS is what defines this group as a particular epistemic community (Haas, 1992). According to Haas, epistemic communities provide crucial information to policy makers by interpreting problems and offering solutions to those problems (Haas, 1992:4). They are not however a monolithic bloc in which all members agree with one another. Participants of an epistemic community do squabble over issues. What is important for an epistemic community is that members share a general worldview of a problem. With regard to this thesis’ case, their shared belief that HIV/AIDS is an emergencial threat does not necessarily translate into identical interpretations about how to deal with it and who the targets of the threat are (either states or human beings).

Moreover, this broader worldview is often based on feeble empirical evidence. Barnett and Prins (2006), for example, have raised interesting questions about the reliability of the evidence presented in some of the studies about HIV/AIDS and security. They point to serious problems in terms of poor data collection and the pervasiveness in some analysis of “factoids”, meaning “soft opinions that have hardened into fact” (Barnett and Prins, 2006:18). These authors’ analysis shed some light on the social construction of reality concerning the links between HIV/AIDS and security. This means that in the case of HIV/AIDS, the interaction between the various discursive articulations (or speech-acts) about the security impact of the epidemic is what really makes HIV/AIDS a security issue rather than any identifiable objective fact.

In light of the above, it is argued here that the human and national security perspectives on HIV/AIDS represent two general tendencies that the present study attempts to convey in a single analytical concept, HASN. As shown later, this is done by way of examining how these intellectual developments around the ideas of national and human security are translated in terms of international norms and practices through the work of states, transnational networks, and IOs, notably the US and UNAIDS. The epistemic community of scholars with an interest in the security aspects of HIV/AIDS is just one of the many providers and carriers of knowledge about the epidemic’s security impact. In this respect, the creation of a strong discourse claiming for the global securitisation of HIV/AIDS is the result of the interaction among powerful players involved in the epidemic’s policy arena. The question of who they are and how they are connected to each other as well as with their respective audiences plays a fundamental role in understanding the securitisation of the epidemic. It is important therefore to understand the ideational and political process by which those actors have successfully reconceptualised HIV/AIDS to signify security.

The following chapter demonstrates how those securitising actors/norm leaders used both national and human security arguments to spread the idea that, because HIV/AIDS threatens the security/survival of a referent object (either states or human beings), the epidemic should be treated as a special kind of emergency. As shown next, the new theorising about the security impact of the global HIV/AIDS epidemic coupled with the growing acknowledgment of its multidimensional and destructive impact promoted a turn in the way the epidemic would be responded to. At this stage, the aforementioned pendulum started to swing steadily towards the securitisation pole.

4.2. Translating Theory into Practice: from a Biomedical Approach to the Institutionalisation of HIV AIDS as a Security Issue

This section discerns how the above conceptualisation of the links between HIV/AIDS and security translated into actual political moves to securitise the epidemic. It unfolds the historical process whereby HASN emerged and, after reaching a “tipping point” (Finnemore and Sikkink, 1998), cascaded throughout the international system. The (un)successful internalisation of this international norm by states critically affected by the epidemic is assessed later through the analysis of its incorporation in the domestic structures of Botswana, Mozambique and South Africa.

The first notified cases of AIDS in the world occurred in 1981 among young gay men in New York (Hymes, Greene, and Marcus, 1981). In the early 80s in the US, the HIV virus became primarily associated with homosexuals. The early association of the virus with this politically unpopular group caused indifference towards social movements demanding a more assertive policy action from the US government. This lack of urgency in dealing with the problem was reproduced internationally.

During the 80s and early 90s, the responses from multilateral agencies were directed exclusively to the biomedical aspects of the epidemic. These early efforts were fragmented and under-resourced. Nobody identified the new disease as a mounting global threat. The World Health Organization (WHO) was very slow in responding to HIV/AIDS. This was mostly due to the perception among WHO’s officials that AIDS was a disease of well-off minorities in the richest states in the world. By contrast, WHO had been created to concentrate its resources on the provision of healthcare to poor populations in Third World countries (Iliffe, 2006:68). In 1986, however, following the publication of alarming reports about growing HIV prevalence in several parts of Africa, WHO began to address HIV/AIDS as a serious public health problem on a global scale. By this time, WHO had established its Global Programme on AIDS (GAP) and advised governments to create surveillance systems and HIV/AIDS committees within their Ministries of Health. It also set up a department of HIV/AIDS whose primary goal was to assist health ministries and governments to put in place national plans, through the provision of technical expertise, financial support and the centralisation of all the information about HIV/AIDS.

WHO’s Global Programme on HIV/AIDS was the first multilateral initiative that was aimed at raising the profile of the epidemic as a public health issue of global importance. It promoted a worldwide mobilisation of institutional and financial resources to deal with the epidemic. In its initial stages, GAP’s policy initiatives concentrated mainly on the promotion of public awareness, blood screening, condom distribution and prevention efforts. From 1986 to 1990, under the active leadership of the first head of GAP, Jonathan Mann, WHO helped to devise short and medium term plans for more than 150 countries (Iliffe, 2006:70). However, despite the rising global mobilisation against HIV/AIDS led by WHO/GPA, the rapid growth of the global epidemic was not yet seen as an emerging security threat. By then, Mann, the most important figure in the WHO’s Global Programme, propounded a human rights approach to the epidemic based on the American gay activism of the early 80s. His strategy of preventing discrimination against people infected by HIV served the interests of gay minorities in Western states well and somehow reduced the stigma surrounding them. Nevertheless, it was not clear whether Mann’s logic would be applicable to a mass heterosexual epidemic such as that in Africa (Iliffe, 2006:69).

In the early 90s, the proportion of people affected by HIV/AIDS in Western Europe and the US was still relatively low. In Africa, on the other hand, the prevalence rates were notably higher and growing rapidly. In spite of the already alarming HIV/AIDS situation on the African continent during this period, the US administration of George Bush Senior seemed unaware of the looming crisis. The shift in the US foreign policy as a result of the collapse of the Cold War system was not helpful to the cause of HIV/AIDS in Africa (Ostergard, 2002:339). With the end of the bipolar conflict and the disappearance of the Communist threat, the US began to reduce their diplomatic presence in Africa. Social programmes were discontinued or significantly reduced and diplomatic representations closed (The New York Times 07.05.2000).

The epidemic’s initial securitising move came in the mid 90s. As the virus spread at an accelerated pace in Africa, showing the ineffectiveness of the global response, WHO/GPA’s leadership began to fade. By this time, the international community had begun to realise that HIV/AIDS was not only a medical condition and that all branches of government and more international actors should mobilise against the impact of the epidemic. During this stage of the global epidemic, it became clear that no single United Nations organisation or state could provide the coordinated level of assistance needed to address the many factors driving the spread of HIV/AIDS, or help countries deal with its impact. A growing sense of urgency prompted the creation of special multilateral and national bureaucracies and more comprehensive policies to deal with the impact of the epidemic. Moreover, as a consequence of the end of the Cold War, the very meaning of security had been transformed. As already noted, normative reformulations of the concept of security prompted policy-makers and academics to rethink what the HIV/AIDS epidemic really meant in terms of a reformed security framework. According to the human security approach of the UNDP, for example, the protection of people against a wide range of new threats, including epidemic diseases, should be a primary concern of national governments and multilateral organisations (Axworthy, 2001:19).

As a result of these normative and policy changes, in 1996 the United Nations took an innovative approach by drawing six organisations together in a joint and cosponsored programme, the Joint United Nations Program on HIV/AIDS (UNAIDS). The creation of a separate multilateral HIV/AIDS agency was an unusual development in the history of the UN. In fact, it was the first time that the world organisation had taken this kind of approach to deal with a single disease. The UNAIDS is in charge of promoting a particular understanding of what HIV/AIDS is and how it should be dealt with by states and non-state actors alike. The UNAIDS embodies a variety of actors and has the institutional capacity to build up wide consensus towards HIV/AIDS policies and practices. The goal of UNAIDS is to catalyse, strengthen and orchestrate the unique expertise, resources, and networks of influence that each of these organisations offers. Working together through UNAIDS, the so-called cosponsors expand their outreach through strategic alliances with other United Nations agencies, national governments, corporations, media, religious organisations, community-based groups, regional and country networks of people living with HIV/AIDS, and other nongovernmental organisations (UNAIDS, 2001). The creation of an organisation such as this was a visible change of direction concerning the multilateral response to the epidemic.

It should be stressed nonetheless that the knowledge about the full-scope impact of HIV/AIDS, together with its necessary corollaries, policy and strategy, evolved gradually over time. In the beginning, the UNAIDS did not articulate a unified message concerning the security threat posed by the global epidemic. At this early stage, both researchers and high political authorities had not yet fully recognised, either through systematic scientific work or international policy debate, the potential impact that the epidemic could have on global security. As noted before, the UN system at the beginning of the 90s was going through a process of normative adaptation to the new post-Cold War international order. The transformation in the meaning of security was an integrative part of these changes. The UNDP, not accidentally one of the UNAIDS cosponsors, took the lead in 1994 by formulating and adopting the idea of human security as a core principle in promoting peace and development after the end of bipolarity. The expanding international acceptance of the concept of human security as a viable alternative to the national security logic of the Cold War resonated with pre-existing interpretations of HIV/AIDS. The human security perspective attracts attention to issues directly related to the impact of the epidemic, such as poverty, famine, social instability, etc. The renaming (or reframing) of HIV/AIDS in terms of human security can be partially seen as the result of these broader normative changes in the understandings about security.

The definitive turn in the language used to name, interpret and dramatise HIV/AIDS took place only in the late 90s. During this period, a growing circle of high profile politicians, transnational activists, and academics began consistently to make it clear that, indeed, the global HIV/AIDS epidemic was a serious threat to security (Prins, 2004). From that point onwards, the UNAIDS embedded this view and started to take the securitisation of HIV/AIDS as a teaching mission, whereby this organisation would work to supply states and other HIV/AIDS actors with information about the best HIV/AIDS policies and organisational practices at the state level (Finnemore, 1993).

Another important step towards the securitisation of HIV/AIDS came in 1999, when the Bill Clinton administration designated the global HIV/AIDS epidemic a threat to the security of the United States. It was the first time that a US President had provided such a designation to a disease. Clinton’s decision followed the release of an influential report produced by the US government’s National Intelligence Council (NIC) on “The Global Infectious Disease Threat and Its Implications for the United States”. This document described in detail the direct and indirect impact that the HIV/AIDS epidemic could have in the US and global security in the next 20 years. Moving in the same direction, on 10 January 2000, this unconventional thinking on security issues was captured at the UN Security Council (UNSC) when the US Vice-President Al Gore presided a historical meeting devoted to the impact of HIV/AIDS on peace and security in Africa (UNSC, 2000a). On that occasion, for the first time in the history of this institution, an issue, other than military, was granted the relevance of an international security threat. The UNSC resolution 1308 that followed fully recognised the potential threat posed by HIV/AIDS to stability and security and represented an important step towards achieving broad international conformance with HASN (UNSC, 2000b).

In April 2001, African states met in Nigeria to discuss the special challenges posed by HIV/AIDS. The resulting Abuja Declaration of 27 April 2001 was endorsed by all fifty three members of the Organisation of African Unity (OAU). They jointly declared that HIV/AIDS “[…] is not only a major health crisis but an exceptional threat to Africa’s development, social cohesion, […] as well as the greatest global threat to the survival and life expectancy of African peoples […] [my emphasis]” (OAU, 2001). Two months later, in 27 June 2001, the Heads of State and representatives of government adopted, at the 26th Special Session of the UN General Assembly (UNGASS) dedicated to HIV/AIDS, the Declaration of Commitment on HIV/AIDS. This document was a landmark in the history of the epidemic. It represented an official recognition by all the UN member states that the epidemic was a “global emergency” and “one of the most formidable challenges to human life and dignity”, therefore demanding global action and unrestricted commitment by member states. It also recommended that the multilateral response should be coordinated under the leadership of the UNAIDS, “[…] which could assist, as appropriate, member states and relevant civil society actors in the development of HIV/AIDS strategies […]” (UNGASS, 2001).

Also part of the agreements set up at the UNGASS, the establishment of the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria, represented a substantial step towards the actual implementation of HASN. The fund was formally established in 2001 by the UN and the G8 group of industrialised nations as the global war cashbox against the three most serious epidemic diseases in the world, namely tuberculosis, malaria and HIV/AIDS. Most developed and some middle-income states have established bilateral assistance mechanisms for assisting national HIV/AIDS plans in poor countries. Initially, these initiatives were located in classic foreign aid agencies, such as Britain’s Department for International Development (DFID) and the United States Agency for International Development (USAID). With the introduction of the Global Fund, some of these states have now shifted a large share of (in some cases most of) their financial assistance to the Fund (Garrett, 2005:12). The Global Fund is an unprecedented case of comprehensive multilateral action to finance the global fight against the three main global killers, namely malaria, tuberculosis and HIV/AIDS.

The Fund is an innovative wide-reaching mechanism of health financing. It is formed by a board of international partners (donor and recipient states, multilateral agencies, as the UNAIDS and the World Bank, NGOs and representatives from the private sector). The Fund’s secretariat is based in Geneva and deals with the routine activities of the organisation. It links the disbursement of HIV/AIDS grants to the creation of country coordinating mechanisms (CCMs). These country-based committees include not only members of the recipient government but also representatives of NGOs and the international community of multilateral and bilateral donors (Global Fund, 2005a). Under the “technical assistance” of the international partners, the CCM is responsible for preparing the proposals for the Global Fund. In fact, to be approved, the proposals should embody the principles and guidelines taught to states by the international actors involved with the promotion of HASN. After grant approval, the CCM is also in charge of overseeing the implementation of the projects. In recipient states, pre-existing institutional structures have to adjust to manage the Global Fund’s money. In general, the CCM nominates a few public or private agencies (in general either the National AIDS Council or the Ministry of Health) that will control the management of the funds (Global Fund, 2005a).

From 2001 onwards, the securitisation of HIV/AIDS became permanently infused into the international normative understandings of the epidemic. With the signature of the UNGASS Declaration of Commitment “a critical mass of states” (Finnemore and Sikkink, 1998:895) embraced the new norm proclaiming the securitisation of HIV/AIDS. In May/June 2006, Heads of State and Government gathered in New York to renew the strong commitments they made back in 2001 and to review progress in implementing the UNGASS Declaration. Despite the political manoeuvring of a few dissident states, this high level UN meeting was concluded with the adoption of a comprehensive political declaration that reaffirmed the national government’s engagement in the implementation of the policies and principles stated in the first UNGASS (UN General Assembly, 2006).

Yet, in several important respects, the understanding of HASN as a single and coherent normative framework should be contextualised within broader North-South ideological and political cleavages. The case of the political disputes over treatment with generic antiretroviral drugs (ARVs) is significant in this regard. The hope that ARVs brought to millions of people suffering from AIDS in poor countries encouraged some states in the South such as Brazil and India to produce and deliver generic ARVs to their populations. The quarrel that followed with pharmaceutical companies over the issue of patent rights was eventually decided in favour of those developing countries’ claims. In November 2001, in the Doha round of trade talks, the World Trade Organisation (WTO) agreed that TRIPS should not prevent states from taking measures to protect their societies against epidemic diseases such as HIV/AIDS.

This meant that, in a situation of threat to public health, governments could manufacture, buy and import generic copies of patented medicines. The Doha agreement of 2001 was an unprecedented move towards the securitisation of severe epidemic diseases. It was also perceived as a significant victory of (relatively) small states against the powerful economic interests of the North. For the first time in the history of trade negotiations, states were legally entitled to issue compulsory licences to copy patented drugs in case of health emergencies. These developments had a kind of emulative or cascading impact in the rest of the developing world (Finnemore and Sikkink, 1998). Transnational advocacy networks began pressuring donor governments and multilateral agencies to give a renewed relevance to the provision of generic HIV/AIDS drugs as a core priority in the domestic national plans to combat the epidemic.

The introduction of generic versions of branded AIDS drugs promoted a radical change in the manner global HASN leaders would relate to each other and with their securitising audiences. While the US government strongly backed the patent protection claims of pharmaceutical corporations, the UNAIDS/WHO launched in 2003 an ambitious global initiative for treating 3 million people by 2005, using both generic and branded AIDS medicines. It was only in 2005 that Bush’s Global Initiative on HIV/AIDS included a few generic medicines as part of its financial aid for treatment in developing countries. Those global divisions among HASN leaders reflected upon treatment policies at the national level of decision-making. As further shown later, South Africa and Mozambique adopted treatment plans based completely on generic drugs. The South African government took a more radical stance, while openly accusing the US-backed pharmaceutical companies of exploiting the suffering of impoverished Africans. Conversely, the Botswana government broke a deal with the US pharmaceutical giant Merck and the Bill and Melinda Gates Foundation by which they would provide branded AIDS drugs in the public health system. This is an issue to be further explored later on in this thesis.

4.3. The Tri-Dimensional Character of HASN

In order to enhance clarity, it is worthwhile at this point to be more specific about the content of the so-called HIV/AIDS securitisation norm. Basically, it has three interconnected dimensions. The first dimension is more subtle than the others and therefore empirical detection is more difficult. It concerns a broad subjective tendency in the international community to gradually move HIV/AIDS away from the area of “business as usual” while dealing with public health issues. This is part of a progressive historical transition that started years before the first actual utterance of HIV/AIDS to mean security in the mid 90s. This historical move towards the securitisation of HIV/AIDS can be generally identified by some watershed events in the history of the global response. These were, for example, the creation of the WHO’s Global Programme on HIV/AIDS in the mid 80s, when HIV/AIDS began to be seen as a very serious issue in some African countries. It was followed by the establishment of the UNAIDS ten years later, given the partial failure of WHO’s biomedical approach to the epidemic, and finally by the formalisation of the links between HIV/AIDS and security with the Security Council meeting of 2000 and the UNGASS Declaration of Commitment one year later.

It is beyond the scope of this thesis to engage in a comprehensive historical sociology of HASN. However, the argument here is that the social construction of the HIV/AIDS Securitisation Norm would not be comprehensible without the previous acknowledgment of the historical (social, material and interest-based) conditions that led to its creation. At the ontological level, this means that the HIV/AIDS actors constituted their social world in the same way that the social world they created defined the possibilities of their future interaction (Wendt, 1987). This dimension also corresponds to an externalist (Stritzel, 2005) understanding of securitisation that is generally neglected by the Copenhagen School. Contrary to its view of the securitisation process, the argument put forward here claims that the semantic articulation of security should be analytically integrated with the larger process of securitisation that involves social/political phenomena other than solely the speech-act. Stephan Elbe’s (2005) exploration of the biopolitical dimension of the securitisation of HIV/AIDS sheds some light on the contextuality problem in the majority of the securitisation literature. Foucault designates biopower as the power that “brought life and its mechanism into the realm of explicit calculations and made knowledge-power an agent for the transformation of human life” (Foucault quoted in Elbe, 2005:405). In demonstrating the biopolitical dimension of HIV/AIDS, Elbe uses the example of UNAIDS, “as an institutional apparatus for the detailed statistical, monitoring and surveillance of world population in relation to HIV/AIDS” (Elbe, 2005:405). Borrowing from Foucault’s reflections on the concept, he further argues that,

The unfolding of the securitization of AIDS follows a net-like deployment of biopower, as it is being simultaneously driven by a plethora of actors […] The net of the securitization of AIDS has been widely cast, corroborating Foucault’s view that biopower is never solely the property of one agent; it is always plural, decentralized and capillary in nature. “Power”, he reminded his readers, “is everywhere; not because it embraces everything, but because it comes from everywhere” (Elbe, 2005:407/408).

What is interesting in Elbe’s transposition of biopower to illuminate the securitisation of HIV/AIDS is that it allows for a holistic understanding of the securitisation process. Rather than being solely the activity of isolated securitising actors performing speech-acts, the securitisation process is seen through these lenses in the form of a chain of events and actors, or something that historically mutates and evolves into something else. In line with Elbe’s biopolitical stance on the securitisation of HIV/AIDS, I argue that the historical and social construction of the disease eventually led to the creation of a hegemonic grammar that portrays the epidemic in terms of a special type of problem, which demands special institutions and policies.

In this sense, the securitisation of HIV/AIDS can be understood as a constitutive element of a larger hegemonic world order that encompasses long-term political, ethical, economic and ideological spheres of activity on a global scale. This is what Gramsci called a historic bloc (Gramsci, 1971). According to Robert W. Cox, in the historic bloc “there is an informal structure of influence reflecting the different levels of real political and economic power which underlies the formal procedures for decisions” (Cox, 1993:63). For him, “international institutions perform an ideological role. They help define policy guidelines for states and to legitimate certain institutions and practices at the national level. They reflect orientations favourable to the dominant social and economic forces” (Cox, 1993:63). I do not use here the concept of historic bloc in precisely the same sense Gramsci (and also Cox, concerning international relations) gave to it. International relations are more diffused and complicated than the big power-centred concept of world order those authors conceived. However, Gramsci’s interpretation of history as a successive movement of powerful hegemonic forms of collective subjectivity is fully applicable to what was called here the first dimension of HASN. This means that the proposed securitisation of the epidemic is the result of social and political processes that are organically integrated into the current dominant historic bloc.

After the successful institutionalisation of the hegemonic grammar of HIV/AIDS, as seen, for example, by the creation of UNAIDS and later by the adoption of the UNGASS Declaration, the utterance of security becomes less important, or simply epiphenomenal. The next step is the actual application of the securitisation principles and policies. This relates to the second and third dimensions of HASN. The second dimension is narrower than the first in the sense that it provides the actual conceptual framework which defines/frames HIV/AIDS as a special kind of global emergency. It may also be defined in terms of principled beliefs “that mediate between world views and particular policy conclusions” (Goldstein and Keohane, 1993:9). This was demonstrated earlier in this chapter through the shift of arguments about the ways in which the epidemic threatens security. The formalisation of these principled beliefs about the securitisation of HIV/AIDS appears, for example, in the Security Council Resolution 1308/2000. As already noted, this document recognised HIV/AIDS as a threat to all levels of security (human, national and international).

The third and final dimension is more prescriptive/practical than the others and draws from the abovementioned principled beliefs. It sets up the policies, best practices and bureaucratic mechanisms that state and non-state actors should put in place to fight the HIV/AIDS threat. The list of recommendations is extensive, so the following concentrates on two key frameworks elaborated by UNAIDS and the US respectively in collaboration with other HIV/AIDS actors. These are UNAIDS’ “The Three Ones Framework” and the principles underlying President Bush’s Emergency Plan for AIDS Relief (PEPFAR). The UNGASS Declaration of commitment also appears in this dimension since it provides a very clear policy base for HIV/AIDS action.

In April 2004, the UNAIDS sponsored discussions in Washington among governments of affected countries, key donor states and multilateral organisations, aiming to achieve further international harmonisation on the HIV/AIDS global response. As a result of those talks, the participants agreed upon a set of guiding principles that became known as “The Three Ones”. Basically, “The Three Ones” is a blueprint of general policies to be implemented by all governments affected by the HIV/AIDS epidemic. Its strategic message is for donor states, multilateral agencies and governments affected by HIV/AIDS to coordinate their response to the epidemic within a single normative and institutional framework. The policies are:

1. One agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners;

2. One national AIDS coordinating authority with a broad based multi-sectoral mandate;

3. One agreed country-level monitoring and evaluation system (UNAIDS, 2004b).

Each of the three basic pillars of the “The Three Ones” is constituted by other principles for national authorities and their partners to follow. These principles are offered to states as a basis for optimising their national responses and improving coordination among all the actors involved (UNAIDS, 2004c). Shortly after the 2004 meeting, UNAIDS started to engage with other leading states in building commitment towards the fulfilment and wide adherence to these improved standards for state behaviour. Within the agreement that led to the adoption of “The Three Ones”, UNAIDS was recognised as the main facilitator between stakeholders as well as the institution with the responsibility of monitoring its implementation by national governments.

The UNGASS Declaration of Commitment of June 2001 is also an important guideline for action for both state and non-state actors. It describes the extent of the epidemic, the effects it has had, and the ways to combat it (UNGASS, 2001). It may also be considered part of the second dimension of HASN since it establishes what the main normative ideas that justify state action are. Although the UNGASS Declaration is not a legally binding document, it is a clear statement by governments about what HIV/AIDS represents and what they should do to reverse its impact. The Declaration provides the policy priorities agreed among states. These policies are a basic element for improving coordination across partners and funding mechanisms at the state level. The main tenants of the response, as established in the UNGASS Declaration are:

• Leadership: “strong leadership at all levels of society is essential for an effective response to the epidemic”.

• Prevention: “Prevention must be the mainstay of our response”.

• Care, support and treatment: “Care, support and treatment are fundamental elements of an effective response”.

• HIV/AIDS and human rights: “Realization of human rights and fundamental freedoms for all is essential to reduce vulnerability to HIV/AIDS”.

• Reducing vulnerability: “the vulnerable must be given priority in the response”.

• Children orphaned and made vulnerable by HIV/AIDS: “children orphaned and affected by HIV/AIDS need special assistance”.

• Alleviating social and economic impact: “to address HIV/AIDS is to invest in sustainable development”.

• Research and development: “with no cure for HIV/AIDS yet found, further research and development is crucial”.

• HIV/AIDS in conflict and disaster-affected regions: “conflicts and disasters contribute to the spread of HIV/AIDS”.

• Resources: “The HIV/AIDS challenge cannot be met without new, additional and sustained resources”.

The President’s Emergency Plan for AIDS Relief (PEPFAR) was launched in January 2003 by the US President, George W. Bush. It is a unilateral initiative of the US government which had a great impact in the global response to HIV/AIDS. The Plan is the largest global intervention of a single state to fight HIV/AIDS. Its contours were established by the United States Leadership against AIDS, Tuberculosis and Malaria Act of 2003. Among other things, the Plan involves large-scale HIV preventive efforts based on behaviour change that follows the “ABC” model (Abstinence, Be faithful and Condoms, in that order of priority). Although it was not the main focus of the plan, treatment with ARVs was also included as a complementary way to enhance prevention efforts by motivating patients to be tested (US Department of State, 2003). In fact, abstinence-until-marriage programmes are the cornerstone of the Plan, receiving a substantial share (33%) of the HIV prevention funds. Despite the US active investment in the formulation and adoption of multilateral arrangements, such as “The Three Ones”, the UNGASS, and the Global Fund, PEPFAR works mainly through bilateral aid programmes with target states.

It is important to note that the above recommendations and coordinating structures do not form a harmonious and coherent set of policies. As elaborated later, these policies are on many occasions competing, contradictory or overlapping. PEPFAR’s moral logic and the parallel (normative and bureaucratic) structure it put in place is the main source of conflict. The myriad of transnational HIV/AIDS actors with their sometimes chameleonic identities and alliances also add complexity to the understanding of HASN. At the domestic level, these transnational grievances unfold in distinct manners while interacting with local actors and their pre-existing belief systems and political cultures. The remainder of this thesis aims to dissect and analyse some of these complex processes.

5. Conclusions

This chapter has proposed a new conceptual framework to help in the understanding of the international responses to the HIV/AIDS global epidemic. By combining insights from the scholarship on international norms and the securitisation debate, this framework defined a single concept, namely the HIV/AIDS Securitisation Norm (HASN). It is aimed to analytically embrace the myriad of implicit and explicit principles, rules, and ideas underlying international action towards HIV/AIDS.

Regarding the historical constitution of HASN, the analysis has claimed that the securitisation of the HIV/AIDS global epidemic in the late 90s followed the steps described before from politicisation, in the early stages of the epidemic, to a securitising move through the emergence of a security discourse, in the early 90s, and finally to the institutionalisation of the securitisation process towards the end of the decade. This later period was marked by the creation of a specialised multilateral bureaucracy, namely the Joint United Nations Program on HIV/AIDS (UNAIDS), designed to respond to the global threat posed by the epidemic. Subsequently, as a result of the United Nations General Assembly Special Meeting on HIV/AIDS (UNGASS), the UN member states adopted unanimously the Declaration of Commitment on HIV/AIDS. By this time, the securitisation of the epidemic became a recognised international norm. This norm held a series of understandings, policy prescriptions and recommendations about the epidemic, which were internationally promoted as the panacea for efficient HIV/AIDS interventions.

The next chapter explores the role played by the UNAIDS, the US and the HIV/AIDS transnational NGOs as norm leaders. The UNAIDS upholds a global bureaucracy and is widely supported by the international community due to its knowledge claims about HIV/AIDS. The US is a superpower, controlling massive material and political resources, which allows it to promote globally their particular views on the epidemic. As intermediate institutions, the transnational non-governmental actors transit in between the two, bridging gaps and building winning coalitions at system, regional and local levels.

Chapter 3

The “Norm Leaders”: Cognitive frames, Institutional apparatus and Norm Diffusion

1. Introduction

This chapter is devoted to the actors who developed the main strategic prescriptions of HASN and the transnational mechanisms that promoted the diffusion of its concepts throughout the state system. It focuses on the three main securitising actors (or norm leaders) involved in the promotion of HASN, namely the Joint United Nations Programme on HIV/AIDS (UNAIDS), the US Government (notably under George W. Bush’s administration) and transnational networks of NGOs working with HIV/AIDS. These agents have strong and quite frequently contested views on appropriate behaviour in responding to the epidemic. As shown next, these normative contestations are very important elements in understanding the social and political makeup of the HIV/AIDS Securitisation Norm.

The following three sections provide an analysis of these three actors’ strategies and motivations in promoting HASN. They explore the different manners in which UNAIDS, the US, and transnational NGOs influence other states and non-state actors to comply with the norm. The study also unveils the particular social mechanisms by which they build their cognitive frames concerning the epidemic, the sources of their symbolic/actual power and how they affect the securitisation/diffusion of HASN. The conclusive section briefly introduces the upcoming analysis of the incorporation of HASN in Botswana, Mozambique and South Africa.

2. UNAIDS

In the foreword of UNAIDS’ 2004 Report on the Global AIDS Epidemic, Peter Piot assertively affirmed that “as our report indicates, we know what works”. Piot’s confidence on the guiding role played by UNAIDS is based on this organisation’s unmatched capacity to globally acquire comprehensive information and technical expertise on the evolution of the HIV/AIDS epidemic. This factor alone becomes an important institutional asset in terms of building its legitimacy as a global norm leader or, employing Foucault’s terminology, as an institution of truth.

In very sensitive and complex issue-areas, in which international policy coordination is needed, policymakers must rely on the advice given by recognised epistemic communities, including here authoritative multilateral institutions, capable of providing and disseminating information globally. This dependency upon international sources of expertise is even greater in states lacking the capacity to produce local knowledge about issues, as in the case of many developing states. This type of technical/bureaucratic authority on HIV/AIDS confers to the UNAIDS a great deal of symbolic power (Bourdieu, 1994) to influence states’ national policies as well as allowing it to spread that power on a global scale.

Bourdieu, for example, uses the term habitus to explain how human beings are socialised into “a system of durable, transposable dispositions which functions as the generative basis of structured objectively unified practices” (Bourdieu quoted in Dreyfuss and Rabinow, 1999:86). If one transposes his concept to the level of states and other transnational actors, UNAIDS can be seen as a source of habitus in the sense of determining the meaning of organised practices concerning HIV/AIDS. In this respect, Finnemore and Barnett (1999:700) observed that “even when they lack material resources, IOs exercise power as they constitute and construct the social world”. The authors resorted to Weberian assumptions about how bureaucracies produce and use knowledge to develop a constructivist approach to think of the role of IOs as autonomous and powerful non-state actors in world politics. Their claim about the important agency role of IOs offers an alternative approach to traditional perspectives. These conventional views see them exclusively as static structures, which are either an institutionalised representation of the balance of power logic between states (neo-realists) or used by them to maximise the benefits of collective action (neo-liberals). According to Mearsheimer, for example, “what is most impressive about international institutions is how little independent effect they seem to have had on state behaviour” (Mearsheimer, 1993:47).

The present study argues that IOs, in general, and UNAIDS, in particular, embody elements of agency and structure pointed out by both schools. It agrees with the constructivist assumption that the power of IOs derives from their capacity to produce autonomous knowledge and promote normative change. Since its creation, UNAIDS has led the global response to HIV/AIDS, defining new concepts and policy priorities that are adopted widely by states and non-state actors alike. In this sense, unlike what the (neo) realists hold, UNAIDS’ behaviour cannot be seen simply as the result of a compromise between its powerful member states. Rather, it produces a kind of autonomous social/scientific interpretation that has been proved strong enough to suppress other competing views concerning the epidemic.

The previous chapter discussed how international attitudes and interpretations regarding HIV/AIDS have changed since the inception of the epidemic in the early 80s. The creation of UNAIDS in 1996 was the result of the international community’s admission that HIV/AIDS would not be defeated by conventional public health institutions and policies. As mentioned elsewhere, there is simply no precedent in the history of the UN for the establishment of an autonomous bureaucracy to deal with a single disease. Thus, the very existence of this highly authoritative organisation could be interpreted as a sign that the epidemic has been gradually moved away from the dimension of politicisation. As has already been shown, since the late 90s there have been several academic studies and policy/intelligence reports assessing the implications of HIV/AIDS for security. UNAIDS fully embraced this new conceptualisation of the epidemic’s impact. Since then, it has become a strong securitising actor, promoting and further elaborating the current predominant view that links HIV/AIDS and security.

In a lecture given at the United Nations University in Tokyo, on 2 October 2001, Dr. Peter Piot, executive director of UNAIDS since its creation, exposed the links between HIV/AIDS and human security. He affirmed that,

We must pay attention to AIDS as a threat to human security, and redouble our efforts against the epidemic and its impact. Since the creation of UNAIDS six years ago, we have been positioning AIDS not only as a global epidemic of an infectious disease, but as a development issue, as well as an issue of human security (Piot, 2001: internet source).

At the London School of Economics, on 8 February 2005, he acknowledged the epidemic as “unique in human history” and as “an extraordinary kind of crisis”. Demonstrating the shift in the UNAIDS’ institutional rationale from an early politicisation of the epidemic to its current securitisation, Piot asserted on this occasion that,

I once thought that the answer [to HIV/AIDS] was that we all had to do much more and to do it much better. I was wrong. Routine development or humanitarian approaches and financing are not sufficient as a response to the pandemic. AIDS is exceptional in so many ways that only an exceptional response will succeed ... it needs to move to that level of exceptional action [my emphasis] (Piot, 2005a: internet source).

In July of the same year, while addressing the 3rd IAS Conference on HIV Pathogenesis and Treatment, in Rio de Janeiro, Brazil, Piot once again emphasised the special character of the epidemic and the need for an exceptional and comprehensive response. In his words:

I believe we need to move the response to AIDS into another league, on a par with other critical global issues such as climate change and extreme poverty, and not stay in our AIDS ghetto. Debating AIDS belongs as much in the UN Security Council as it belongs in scientific conferences (Piot, 2005b: internet source).

In spite of UNAIDS’ unmatchable capacity to shape understandings about HIV/AIDS, the strong influence of the US at both the Global Fund and UNAIDS confirms the (neo-realist) presumption that the autonomy of IOs is constantly checked by narrow national interests. Since the election of George W. Bush, in 2000, the US government has pursued its own foreign policy agenda to deal with the global epidemic. As demonstrated later, the main source of contention between the global HIV/AIDS polity and the US government is George Bush’s President’s Emergency Plan for AIDS Relief (PEPFAR) and the disruptions it has caused to the unified international front led by UNAIDS. This draws attention to the power-laden context in which securitisation dynamics occur. The differential power positions and political agendas of UNAIDS and the US demonstrates that the successful securitisation of HIV/AIDS is more than only a function of their linguistic competence, as generally asserted by members of the Copenhagen School (Balzacq, 2005).

The problem here is that, in general, social constructivist analyses (and I dare to include the Copenhagen School in this category) display an “oversocialised view of actors” (Barnett, 1999:7). Focusing attention solely on speech-acts diverts attention from both the strategic behaviour of actors and the political and social structures in which they are embedded. As noted in the following section, the rationale and strategic interest of the US in securitising HIV/AIDS differs from UNAIDS’ in a number of ways. Their organisational and political structures, policy orientations, and the strategies they implement to persuade their audiences are also markedly distinct.

Moreover, the normative power of the rational-legal authority that UNAIDS embodies has implications for the ways this agency produces, controls and disseminates social knowledge about HIV/AIDS (Barnnett and Finnemore, 1999:700). UNAIDS, as a semi-autonomous goal-oriented actor in international relations, has a clear (rational) interest in galvanising attention to the issue that legitimises its existence in the international system, namely HIV/AIDS. The successful securitisation of the epidemic put UNAIDS at the forefront of the global response, raising its institutional profile and importance as an indispensable institution in the fight against the epidemic. Conversely, without the epidemic or with its effects significantly reduced worldwide, the raison d’être of this organisation would be seriously compromised. For example, the eventual de-securitisation of HIV/AIDS would probably lead to the phasing out of UNAIDS or its incorporation into the wider bureaucratic structure of WHO. The maintenance of HIV/AIDS at the top of the global agenda is therefore a matter of survival to UNAIDS.

Barnett argues that “actors can engage in practices that attempt to rewrite the cultural landscape, and their motivations for doing so might stem from principled beliefs and/or instrumental gain” (Barnett, 1999:7). The controversy involving the overestimation of the HIV/AIDS epidemic in Africa by UNAIDS is an interesting illustration of Barnett’s point. Since 1998, the year of its first annual report, UNAIDS has presented increasingly dire figures about the global epidemic. In 2000, it estimated that 36 million people around the world were carrying the virus. In the latest update, in 2005, the number jumped to 40.3 million, with 25.8 million in Sub-Saharan Africa (UNAIDS, 2005c). However, a study commissioned by the US International Development Agency (USAID) and a number of national governments and private donors has shown that the number of HIV infections in East, West and Central Africa may be much lower than UNAIDS studies have initially indicated. On 6 April 2006, the Washington Post published an article by Craig Timberg, suggesting that UNAIDS officials could have intentionally “inflated” their reports due to “political calculations, with the emphasis on raising awareness and money” (The Washington Post 06.04.2006).

The allegedly over-catastrophic HIV/AIDS figures given by UNAIDS could be understood as an attempt to reinforce the emergencial (and security) character of the problem and, as a consequence, reaffirm this institution’s centrality in the global response. Despite the anecdotal character of this case, it shows that actors may derive their motivations to initiate a securitising move from an intricate combination of structural and individual factors. In one dimension, one could say that UNAIDS is embedded in a broad normative structure that portrays the epidemic as an existential threat to security. In another, this institution rationally manipulates these structural discourses in order to advance particular interests (survival in the case presented above). The study turns now to UNAIDS’ institutional mechanisms of HASN transmission.

UNAIDS works mainly as a coordinating body as opposed to a direct implementing and funding agency. Its bureaucratic structure is made up of a permanent Secretariat, based in Geneva, Switzerland. It is guided by a Programme Coordinating Board (PCB) which comprises 22 delegates of governments, representing all regions of the world, representatives of the 8 UNAIDS Cosponsors (UNICEF, UNDP, UNFPA, UNESCO, WHO, World Bank, UNDOC, ILO) and 5 representatives of NGOs, including associations of people living with HIV/AIDS. The PCB serves as the UNAIDS’ governing body and holds at least one annual working session at its headquarters in Geneva. Only the governments’ representatives have voting power at the PCB. The UN Cosponsors and Secretariat meet several times a year as the Committee of Cosponsoring Organizations (CCO) (UNAIDS, 2004a:4).

The largest donor to UNAIDS is the US Government, followed by the Governments of the Netherlands, the United Kingdom, Sweden, Norway, and Denmark. Other UNAIDS sponsors, such as the UN agencies and the World Bank, also provide direct financial support for country-based HIV/AIDS plans. Concerning the allocation of money, the Secretariat assesses projects and makes funds available for selected HIV/AIDS initiatives. All UNAIDS’ activities are discussed and further coordinated every two years through the Unified Budget and Work Plan. This is a very important institutional instrument for controlling overall accountability and structuring the organisation’s fundraising initiatives (UNAIDS, 2004a:4-5).

At the state level, UNAIDS operates mainly through the UN Theme Group. It is comprised of the country-based staff of the UNAIDS’ seven Cosponsors. In the Theme Group, representatives of the cosponsoring organisations share information, plan and monitor coordinated action between themselves and with other partners, and decide on joint financing of major AIDS activities in support of the country’s government and other national partners. The principal objective of the Theme Group is to support the host country’s efforts to organise an effective and comprehensive response to HIV/AIDS. In most cases, the host government is invited to be part of the Theme Group. Increasingly, other partners such as bilateral development agencies and NGOs have also been included.

To date, the UNAIDS has established more than 130 UN Theme Groups, covering all regions of the globe. For their day-to-day operations, most Theme Groups have set up special working groups that involve donors, NGOs and groups of people living with HIV/AIDS. In countries with high rates of HIV/AIDS infection, the Theme Group has the support of a UNAIDS staff member, called a Country Program Adviser (CPA). Elsewhere, a staff member of one of the seven Cosponsors serves as the UNAIDS focal point for the country. In addition to supporting the UN system, this staff member is in charge of reinforcing national commitment to HIV/AIDS action and providing information and guidance to a range of host country partners, including government departments and groups and organisations from civil society.

In 2000, the Security Council resolution 1308/2000 led to the creation of the UNAIDS Office on AIDS, Security and Humanitarian Response (SHR). Its main task is to devise strategies to assist states in meeting their multilateral commitments (UNAIDS, 2005a). Since the establishment of this new bureaucracy, UNAIDS has developed a number of specific “security” policies, such as the programmes it is adopting in the armed forces, peacekeepers and in complex emergencies. These programmes have been driven by the UNAIDS/SHR’s Global Initiative on HIV/AIDS and Security. This initiative focuses on reducing the vulnerability of populations and building the capacity of military and peacekeeping forces in three levels of security: 1) International security: with the focus on supporting HIV/AIDS interventions within UN peacekeeping operations; 2) national security: targeting uniformed services with a particular emphasis on young recruits, future peacekeepers and demobilising personnel; 3) humanitarian response/human security: which focuses on vulnerable populations in crisis settings and humanitarian workers (UNAIDS, 2005b:1).

Barnett and Finnemore (1999:713) observed that “having established rules and norms, IOs are eager to spread the benefits of their expertise and often act as conveyor belts of norms and models of good political behavior”. It is interesting to note that the UNAIDS case is consistent with this assumption. Considering the diffusion of HASN as an example, these conveyor belts correspond to the institutional mechanisms described above by which the UNAIDS Secretariat inculcates and globally enforces its norms. By December 2002, around 100 states had already set up National HIV/AIDS plans following the UNAIDS recommendations. Additionally, UNAIDS has helped 85 countries to establish National HIV/AIDS Councils. It has also supported these governments in the actual implementation of their national plans by assisting in many technical areas, such as the drafting of donor proposals, the process of integrating HIV/AIDS into broader development strategies, and the undertaking of reviews that assess the progress of the national responses (UNAIDS, 2004a). More importantly, UNAIDS/SHR, through its Global Initiative on HIV/AIDS and Security, has systematically instilled governments with the message that HIV/AIDS should be integrated into their national and regional security strategies. As with the mechanism of norm transmission described above, the UNAIDS/SHR office (which is located in Copenhagen) works as a conveyor belt by linking up with the UN Theme Groups based within states to introduce its principles and guidelines for action. By 2005, UNAIDS estimated that approximately 100 states worldwide were supported by the Global Initiative on HIV/AIDS and Security (UNAIDS, 2005b).

What the above suggests is that UNAIDS is a primary source of norm creation and diffusion by virtue of its widely recognised authority to orient and coordinate state and non-state actors towards the best policies to face the HIV/AIDS threat. Nonetheless, the constitution of what is referred to here as HASN is not only the work of an autonomous bureaucracy with knowledge claims about the epidemic. It is also the result of the interaction between powerful Western governments, namely the US government, and transnational networks of HIV/AIDS activists who operate strategically both inside and outside the institutional structure provided by UNAIDS. Their political agendas can contain shared as well as contested understandings about HIV/AIDS. This chapter will now explore the role played by some of these actors in the process of HASN formation as well as the political contexts within which they operate.

3. The US Government

As demonstrated in the previous section, UNAIDS is a powerful actor in creating and promoting social knowledge about HIV/AIDS. It is not alone though. The US government and its associate agencies also play a fundamental role in the process of creating international understandings about the epidemic. In shedding light on the US government’s contribution to the formation of HASN, one should first set the epidemic within the wider political context of US foreign policy at the beginning of the century. At the heart of the foreign policy of the Bill Clinton administration was the problem (later resolved by the terrorist attacks of 9/11) of how to use the disproportional power of the United States in the post-Cold War world. The answer back then was to join the EU and the UN in the construction of a kind of cosmopolitan new world order in which the notion of national sovereignty/security would be downplayed to a holistic conceptualisation of humanity. Bill Clinton’s approach to the global HIV/AIDS epidemic should be set against this same background of multilateral engagement. It is reflected by the Clinton administration’s successful attempt to include the epidemic in the agenda of the Security Council (Prins, 2004:941). In the historic January 2000 meeting, Vice-President Al Gore stressed the common security challenges posed by HIV/AIDS. He mentioned the “real and present danger to world security posed by the AIDS pandemic” and called upon other UN members to “see security through a new and wider prism and, forever after, think about it according to a new, more expansive definition” (UNSC, 2000a:2).

This important initiative at the global level was preceded by a significant normative turn in the way the US government portrayed and acted upon HIV/AIDS. In 1999, Clinton officially identified HIV/AIDS as a national and global security threat. During this period, the National Security Council became involved in the US policy to fight the global epidemic. It was the first time that this agency took onboard an infectious disease as a potential threat to the US (Johnson, 2002). Clinton doubled the budget for international HIV/AIDS relief to US$ 254 million and introduced a new interagency located in the White House, named the Office of National AIDS Policy. He also established a Presidential Advisory Council on HIV/AIDS (PACHA) to provide expert knowledge that would inform how the federal government should respond to the epidemic (Johnson, 2002). Notwithstanding the Clinton administration’s open securitising move towards HIV/AIDS, which was reinforced by the creation of new institutions devoted to this end, it is with George W. Bush that the US policies towards HIV/AIDS were significantly reframed and further implemented.

The George W. Bush administration’s response to the global epidemic reflected the logic of its own worldview. In this respect, any assessment of Bush’s foreign policy towards the HIV/AIDS has necessarily to deal with the subjective issue of how decision-makers see the role of the United States in the world and how the epidemic fits into this. Since the very beginning, the inner circle of Bush’s foreign policy establishment was infused by the realist ideas of an elite of neo-conservative ideologues, on the one hand, and the President’s own moral instincts, on the other. This merge between realism and morality turned into the ideological justification for a wide range of divisive policies (Wallis, 2005). The 9/11 incident gave the Bush administration the opportunity to fully develop this new foreign policy thinking and to act upon it. The pursuit of national security abroad was framed by the symbolic image of a battle between good and evil. The terrorist attacks reignited among foreign policy pundits the longstanding (yet prior to 9/11 dormant) foreign policy principle of an alleged “American exceptionalism” - the idea that, given the United States’ moral uniqueness and disproportional power, God has delegated to its leaders the divine duty to protect and lead the world. This means in the words of Michael Cox that,

[…] Most members of the Washington foreign policy elite do tend to see themselves as masters of a larger universe in which America has a very special part to play by virtue of its unique history, its huge capabilities and accumulated experience of organizing the world for the last 50 years. (Cox, 2003:21)

The rise of the United Sates as a “crusader state” (McDougall, 1997) is not a totally new development. It is rooted in a long history of idealism in the North American foreign policy that goes back to the Founding Fathers (Cox, 2003:8). However, since Ronald Reagan’s use of American ideology as a powerful foreign policy instrument against the Soviet Union, the world has not seen anything like the present strong idealist imprint of George Bush’s War on Terror. This time nonetheless, the perceived security threat does not come from a communist totalitarian regime but from a rather disperse global network of Islamic extremists backed by a handful of “rogue” states with weapons of mass destruction.

Goldstein and Keohane asserted that ideas, “and the principled or causal beliefs they embody”, provide “road maps” for political action. According to them, “these conceptions of possibility or worldviews are embedded in the symbolism of a culture and deeply affect modes of thought and discourse” (1993:8). Similarly, the present argument claims that the Bush government’s approach to the global HIV/AIDS crisis is deeply embedded in this worldview that understands the US as a special nation with global responsibilities.

You know, the world looks at us and says, they’re strong. And we are; we’re strong militarily. But we’ve got a greater strength than that. We’ve got a strength in the universality of human rights and the human condition. It’s in our country’s history. It’s ingrained in our soul. And today we’re going to describe how we’re going to act – not just talk, but act, on the basis of our firm beliefs (US Department of State, 2003b).

The idea of a practically innate burden to lead the world against HIV/AIDS becomes manifest in this fragment of a speech about the epidemic given by Bush, in 31 January 2003, two days after the announcement of his global HIV/AIDS plan. More than two years after the September 2001 events, the Bush administration publicly acknowledged the devastating impact of the global HIV/AIDS epidemic as a global emergency and seemed to be moving towards its securitisation. The Secretary of State, Colin Powell, stated that “bureaucracy as usual was unacceptable in dealing with this emergency, and we have moved forward urgently” (US Department of State, 2004a). He was talking about the launching of PEPFAR. Through this initiative, the President committed US$ 15 billion over 5 years. It is by far the largest pledge to HIV/AIDS international assistance by a single government to date. The funds will be spent largely on ongoing and new bilateral projects with recipient states.

Since the launch of the plan, the Bush administration has redefined its HIV/AIDS global strategy in terms of three main axes. The first axis keeps the traditional foreign aid approach through the activities developed by USAID. Here, the links between the US government and domestic NGOs with a transnational impact, which specialised in global HIV/AIDS relief and advocacy (mostly faith-based organisations), are more clearly perceived. Faith-based organisations have been implementing HIV/AIDS policies and programmes for USAID for decades. As noted in upcoming chapters, their strategic partnership has been constituted as a fundamental mechanism for the US government’s penetration in the domestic structure of the states afflicted by the epidemic. In a kind of linkage politics (Rosenau, 1969), government officials articulated common foreign policy strategies with those domestic religious groups in a deliberate attempt to influence the HIV/AIDS policies of other states and multilateral organisations.

The second axis explores the multilateral track. It operates mainly through the participation of US officials in key decision-making structures of international bodies, such as UNAIDS, the World Bank and the Global Fund. Financially, these multilateral bodies rely heavily on the support of the US. For example, from 1995 to 2005, the US government contributed US$ 182,390,000 to support UNAIDS’ policies and programmes. This amounts to more than 20% of the total contributions during this period, making the US the principal sponsor of this organisation (UNAIDS, 2005d). The Global Fund is also very dependent on US funding. The US government committed US$ 2.5 billion to the Fund for the period 2001-2008 which represents 30% of all the money pledged by states to the Fund (Global Fund, 2005c). These numbers are far from impressive nonetheless if compared with the US expenditure on bilateral programmes run by USAID. In fact, the ten years (1995-2005) of US contributions to UNAIDS corresponds to just a small fraction (less than 10%) of what the Bush administration spent on HIV/AIDS bilateral programmes for the year 2004 alone.

Finally, the third axis, and the largest, is PEPFAR. The Plan is run from the State Department by a Global Coordinator, Randall Tobias, also dubbed the AIDS Czar. Tobias’ Office is hierarchically on top of all the other HIV/AIDS structures in the US government. He reports directly to the Secretary of State, now Condoleezza Rice, who oversees the Plan’s progress. Its management is part of the overall national security apparatus of the US government. As Garret notes, “[PEPFAR] is located inside the State Department, where its mission is defined in both foreign aid and national security terms” (Garret, 2005:12). The plan targets five key areas, prevention by sexual abstinence being the number one priority.

USAID, the US diplomatic representations and the US Center for Disease Control and Prevention (CDC) are the key actors in charge of managing PEPFAR in target states. Institutionally, USAID has several advantage points given its geographical reach, well-developed infrastructure, and extensive experience in providing HIV/AIDS assistance to developing states in Africa and elsewhere. USAID’s international HIV/AIDS programme was established in 1986 and is currently undergoing projects in more than 100 countries all over the world. It funds a number of initiatives and develops partnerships with local groups, government’s agencies and other organisations as a key strategy for accessing and influencing HIV/AIDS activities in host states. The US Embassies are, in general, the headquarters of PEPFAR within states and the US Ambassador the frontline commander in the war against the epidemic. The CDC is an important actor in terms of its international recognition as an alternative source of policy guidance to national governments fighting HIV/AIDS. It is the most important agency in the US government for providing health information and improving public health through scientific research. It works in cooperation with governments throughout the world, advocating particular HIV/AIDS policies and strategies. As shown later, the introduction of a new (and more controversial) HIV testing policy in Botswana was, to a large extent, the result of CDC’s influential role vis-à-vis the Botswana’s government.

The establishment of PEPFAR suggests that the epidemic has been securitised within the US. According to the securitisation theory, for an issue to be successfully securitised, a significant audience should be persuaded by a securitising actor that something is threatening and that exceptional measures should be taken to deal with it. In the US’ political system, the convincement of Congress (which is formed by the elected representatives of the wider audience of the American people) could be seen as sufficient evidence of securitisation. The substantive engagement of the Bush administration with the global epidemic has been endorsed and mandated by the US Congress. In January 2003, for example, Congress authorised the first funds to put PEPFAR into motion and in May it approved the Executive Act (H.R.1298) which established the Plan. Therefore, given the Congress’ formal approval of the Executive’s securitising move, it can be strongly argued that the Bush administration spoke security successfully while describing the epidemic to its domestic constituencies.

The motivations behind the President’s HIV/AIDS Plan are mixed, nonetheless. The securitisation of HIV/AIDS as promoted by the US is the result of a complex compromise between domestic and international actors. Within the North American establishment, rhetorical security articulations concerning HIV/AIDS are continually interacting with other ideational and material foreign policy interests. Depending on the political circumstances of their interaction, they can either reinforce or contradict each other. For example, as part of PEPFAR, USAID is working on a complex system to purchase AIDS drugs and distribute them to 2 million people by 2008. It will be the biggest international aid scheme in USAID’s history, with the release of US$ 7 billion from PEPFAR to be used on AIDS drugs and related services (Graham-Silverman, 2005).

However, expensive patented drugs mostly from North American pharmaceutical companies are to be used in this program. Referring to concerns with drug safety, the US government has been putting up extra barriers to buying cheap generic drugs from developing countries, namely India and Brazil. The alleged links between the US Executive and pharmaceutical corporations has raised suspicion among governments, transnational AIDS activists and multilateral institutions around the real agenda of PEPFAR. Moreover, in the 15 countries included in Bush’s global HIV/AIDS programme, development agencies and NGOs fear that the huge parallel structure put in place by USAID will duplicate pre-existing systems for the management of HIV/AIDS funds and projects, such as the abovementioned “Three Ones”. The problem is that PEPFAR’s management strategies have been neglecting these multilateral mechanisms, bypassing National HIV/AIDS Councils and other established country coordinating structures.

The influence of evangelical Christians in the President’s decision to set up a HIV/AIDS global plan should also be added to the equation. Influential evangelical lobbying groups are behind the selective way the money is allocated to HIV/AIDS programmes in target states. Religious conservatives, including not only Protestants but also traditionalist Catholics and Jews, are the most loyal supporting base of President Bush’s Republican Party. The powerful influence of religious right wingers goes deep into the US Congress as well as into the Judiciary and the Executive. As a result of their strong lobby, at least one third of PEPFAR’s US$ 15 billion is earmarked to projects that stress abstinence until marriage as the primary preventive measure against the epidemic. In states financially supported by the US, assistance to HIV/AIDS programmes is attached to these moral strings.

In 2005, for example, Brazil took a strong position against the US administration’s attempt to link US$ 40 million in HIV/AIDS grants to an anti-prostitution pledge by the Brazilian government (The Wall Street Journal 02.05.2005). Brazilian authorities rejected the grants and reaffirmed their commitment to the country’s widely praised approach to the epidemic. Brazil has been seen by a wide community of HIV/AIDS specialists as a model in terms of best practices to fight HIV/AIDS. This success is in part due to the inclusive way they deal with high-risk groups as well as to the premise that prevention actions should be guided by epidemiological assumptions rather than moralistic ones. It is reflected in the strong investment by the Brazilian government in nationwide educational campaigns to stimulate the use of condoms by the public at large (Brazilian Ministry of Health, 2000).

This particular case sheds some light on a wider philosophical division among the HASN norm leaders/securitising actors. Brazil clearly follows the line of UNAIDS and other epistemic communities of public health specialists and HIV/AIDS activists. The US administration, on the other hand, has its own (mis) perceptions about the best policies to fight the global spread of the epidemic. During the 15th World AIDS Conference in Bangkok in 2004, the contrast between these two worldviews came to light in the fears demonstrated by HIV/AIDS activists that the widespread use of condoms had been played down by religious dogmas behind the PEPFAR plan (The Economist 15.07.2004). Similarly, the poor coordination between PEPFAR and the Global Fund/UNAIDS, concerning the funding of AIDS treatment, has led to a competitive political climate and the creation of duplicated (and more often than not redundant) systems for delivering ARVs (Interview Baggio 11.08.2004).

Building on the above analysis, one could understandably argue that these conflicting worldviews between secular pragmatism and religious morality undermine the understanding of HASN as a single and bounded community of knowledge. However, this chapter suggests that, rather than falsifying the conceptual relevance of HASN, this sort of dialectic engagement between its moral and pragmatic understandings reveals interesting empirical dynamics of norm formation and socialisation at the level of the international system. In the same manner, the dynamic interaction between ethical, technical and economic arguments with regard to the worldwide provision of AIDS treatment is also part of the wider intersubjective social processes that originated what is referred to here as HASN. As the next section shows, transnational civil society groups are important channels for the communication of international HIV/AIDS norms from the system to the state level and vice-versa.

4. Transnational Networks of NGOs

The widening of the international security agenda in the mid-90s to include non-military issues gave extra leverage to the international affairs of many non-state actors. A global public space emerged with transnational networks of activists pressuring governments and IOs to fulfil their human security commitments. Some of them framed their traditional causes, around areas such as human rights, development, and environmental issues, with the language of security to raise the salience of their claims. The constant flow of information, further facilitated by such technological tools as fax machines and the internet, brought the language of security to a wide range of non-governmental groups. Through world conferences, web-debates and the circulation of individuals, transnational networks have become acquainted with each other’s activities and developed similar world views on the security dimension of their distinct issue areas.

Transnational networks involved with HIV/AIDS issues grew against this backdrop of increasingly global interactions between non-state actors. During the early 90s, their actions were discursively framed by symbolic categories (such as development, humanitarianism, human rights, and, after 1994, human security) that appealed to a moral language familiar to the international community of donors (Carpenter, 2005:297). Since the late 90s, nevertheless, in the context of the growing international securitisation of the epidemic, these transnational actors have been increasingly unifying their discursive practises around the concept of security.

The global HIV/AIDS epidemic is a transnational issue par excellence. Its indiscriminate global impact blurs the traditional division between the domestic and the international. Accordingly, the proposed securitisation of HIV/AIDS also transcends the conventional practice of state sovereignty. It prescribes normative constraints to the way states behave towards their own citizens. As the international condemnation of the South African government’s alternative approach to HIV/AIDS has shown, go-alone national policies to tackle the epidemic are not an option. In highly affected regions, the global mechanisms for promoting and monitoring the implementation of internationally agreed HIV/AIDS national plans and bureaucracies are transforming the relations between states, its citizens and the international community.

In this respect, transnational HIV/AIDS activists are very important instruments of norm diffusion. Although often lacking material and economic power to make a difference, networks of activists promote norm change and adaptation by globally disseminating ideas, information and strategies (Florini, 1999). Since the early 90s, transnational NGOs with an interest in HIV/AIDS have increased in number and in the scope of their activities. In addition to their traditional ways of exerting influence, more recently they have been directly involved in the decision-making structures of important multilateral bodies, namely UNAIDS and the Global Fund. They are also important actors in promoting norm implementation at the state level (Keck and Sikkink, 1998). By their participation in National HIV/AIDS Councils, by lobbying governments of Western states as well as by linking up with civil society groups at the grass-roots level, transnational advocacy networks engage in discursive practices with domestic actors. In participating in these social and political interactions, they aim to ultimately transform behaviour and policies to match international prescriptions.

However, despite their important contribution in opening up an alternative political space for the inclusion and dissemination of HASN, the role of transnational HIV/AIDS actors in global governance should be better contextualised. These networks are immersed in (and are constituted by) the larger power relations which underlie the normative makeup of HASN. This means that those groups have to operate in (and adapt to) an environment which is dominated by a complex grid of ideational and material forces. The engagement of transnational NGOs in HIV/AIDS activities is determined not only by their own self-defined missions but also by the terms lain down by international organisations and states, in particular UNAIDS, the US and other donor states. The rhetorical strategies available to these advocates are therefore characterised by various political constraints. Yet, these limitations provide them with opportunities to mobilise resources and allies. As in a strategic process of framing (Snow et al., 1986), they use the hegemonic grammar of the epidemic (security) to galvanise support and to talk the language that their transnational constituencies and patrons certainly understand.

As noted before, the normative framework of HASN has been fractured by conflicting worldviews about HIV/AIDS. These views have ideologically divided the international community of HIV/AIDS activists into two main sets of organisations. The first and wider group supports a pragmatic and secular approach to HIV/AIDS and is aligned closer to UNAIDS and to most of the UN member states. The distinctive feature of these HIV/AIDS networks is that they seek to be widely recognised as an autonomous and legitimate political space for civil action regardless of either creed or ideological stance. They also stand for the scientific guidelines proposed by UNAIDS and WHO, regarding, e.g., the promotion of condoms as the best prophylactic available to anyone to counter the spreading of the epidemic. Contrary to the US government’s stance, they are also supportive of a treatment strategy focused on generic AIDS drugs instead of branded ones.

The International Council of Aids Services Organizations (ICASO) is one such organisation. Since 1991, ICASO has connected and represented HIV/AIDS NGOS networks from all five continents. Through its five regional secretariats spread throughout the globe, coordinated by a central bureau in Canada, ICASO brings the voices of community-based organisations from all over the world to the higher levels of decision-making at the state and multilateral levels. Their main arena of negotiation is under the institutional umbrella of UNAIDS’ Programme Coordinating Board, in which it is one of the NGO sector’s representatives, and the United Nations’ Economic and Social Council (ECOSOC). They discuss internationally and try to apply nationally the outcomes of those debates by lobbying governments at the domestic level and by disseminating information to other networks of NGOs. ICASO is an interesting example of a transnational channel for the transmission of HASN that works in both directions, bringing ideas and experiences from the grassroots levels to the international system and also promoting policy outcomes emanating from the HASN decision-making centres back to the recipient states.

Through widely exposing the actual or potential violations of HASN, ICASO also operates as a sort of watchdog of donor states’ commitments towards the fight against HIV/AIDS. In July 2005, for example, ICASO and Aidspan, another influential global HIV/AIDS network, launched in association with other NGOs from Europe, the US and Japan a worldwide advocacy campaign, called GF+. It sought to persuade governments of donor countries to increase their financial commitments to the Global Fund. The advocacy groups forming the GF+ claimed that with the pledges already made by donors, the Global Fund would not be able to launch new grants for the financial year 2006/7. This means that insufficient funds from developed states will probably hamper the G8’s promise to get close to the goal of universal access to AIDS drugs by 2010 (ICASOa, 2005). In the months preceding a donor conference to discuss the replenishment of the Global Fund, held in London, in September 2005, ICASO and its allies disseminated this politically important information (largely through the internet) in order to persuade a worldwide audience to sign a petition urging developed states to fulfil their HIV/AIDS commitments to the Fund (ICASOb, 2005). Despite their coordinating efforts, on 6 September 2005, soon after the end of the conference, the GF+ released a communiqué stating that the final pledges of money (US$ 3.7 billion) by donor states fell short of what the Global Fund needs to sustain and scale up the global fight against HIV/AIDS, tuberculosis and malaria (GF+, 2005).

Additionally, ICASO, in conjunction with the International HIV/AIDS Alliance (IHAA), another influential HIV/AIDS advocacy network, has overseen the implementation of the UNGASS’ Declaration of Commitment. These organisations have also used the Declaration as a political instrument for pressuring national governments to comply with the promises they have made to halt and reverse the impact of HIV/AIDS in their respective societies. In doing so, they disseminate the Declaration to local organisations and elaborate “advocacy guides” in which they enlist a number of strategies NGOs should pursue to encourage their countries to become more involved in the response to the epidemic. For example, ICASO recommended the organisation of meetings by domestic NGOs to “develop a common approach for your lobby and advocacy effort” (ICASO, 2001:6). It also advised local groups to work closely with UNAIDS representations and to encourage UN agencies and other multilateral actors “to modify their own workplans to ensure consistency with the Declaration of Commitment” (ICASO, 2001:6). In addition, ICASO suggested that NGOs should obtain copies of statements made by governments’ representatives in international gatherings and use them as advocacy tools at the national and regional levels (ICASO, 2001:6). Those are interesting illustrations of the means deployed by transnational HIV/AIDS advocacy groups to influence policy-making at the domestic level.

Another very proactive HIV/AIDS global network is the US-based Health Global Access Project (GAP). GAP’s stated mission is to “campaign for drug access and the resources necessary to sustain access for people with HIV/AIDS across the globe” (GAP, 2005). The organisation’s structure is made up of a core “national steering committee” of 20-25 people drawn from human rights, people living with HIV/AIDS, fair trade activists, and public health. It has three national programme coordinators leading national activities in the areas of advocacy, mobilisation and campaigns. Internationally, it is also represented at UNAIDS’ PCB and has staff members actively participating in international meetings at multilateral organisations and in target countries. GAP also pressures governments, IOs and multinational corporations by globally disseminating information with the potential for political impact upon public opinion. GAP exposed, e.g., the profits of pharmaceutical companies in rich states and how they sabotage developing countries’ efforts to produce cheaper generic drugs. They also use symbolic politics by framing situations with sensitive symbols that will make sense to a wider audience (GAP, 2005).

The second group is formed by HIV/AIDS activists pursuing a different normative agenda. Either for instrumental or ideational reasons, these networks of NGOs associated themselves with the US government’s global HIV/AIDS policies. Although holding the status of “non-governmental”, most of these organisations get money from the Bush administration’s PEPFAR plan and either directly or indirectly they work to achieve its goals. In most of these cases, instead of using its own embassies and international assistance agencies, the US government takes on these networks to actually implement its HIV/AIDS policies abroad. The funds are allocated to them either directly by US government’s agencies, such as USAID, or indirectly by multilateral agencies and other international partners.

Transnational networks linked to evangelical and right-wing religious sects are the most active advocacy groups promoting compliance with the HIV/AIDS principles of the US government. World Relief, World View, HOPE, CARE, Samaritan’s Purse, Catholic Relief Services and Opportunity International are some of the North American based international Christian organisations that are very active in HIV/AIDS related projects. Each of them will receive around US$ 100 million from PEPFAR to develop HIV/AIDS projects in target countries. World Relief, for example, is subordinate to the US National Association of Evangelicals, which is formed by around 50 member denominations and hundreds of evangelical churches all over the US. World Relief’s stated mission is “to work with, for and from the Church to relieve human suffering, poverty and hunger worldwide in the name of Jesus Christ” (World Relief, 2005). The organisation’s Mobilizing for Life project supports a moral/religious approach to HIV prevention (abstinence until marriage and fidelity within marriage) in Haiti, Kenya, Mozambique and Rwanda. Although they are not systematically promoted, pastors sometimes supply condoms to people who request them (Avert, 2005).

Additionally, there is a wide range of smaller international NGOs moving between the two groups. As the securitisation of HIV/AIDS got underway, they were attracted by the new funding mechanisms being put in place by the Global Fund and the US’ PEPFAR. These organisations saw in the massive influx of cash to HIV/AIDS programmes an opportunity to “stay in business” and expand their activities. Whatever humanitarian motives may have caused their creation, these NGOs have to generate surplus to stay active. This means that their financial needs sometimes precede any prior commitments with certain policy principles, as in the case of NGOs that are reducing their condom distribution programs to qualify for PEPFAR money (The Economist 28.07.2005).

Going beyond the idea that “transnational civil society actors matter” in international politics, what the particular phenomenon of HIV/AIDS transnational activism shows is that these actors are not always autonomous sources of normative change in international relations. They can also be instrumentally co-opted by powerful states interested in using them to advance their foreign policy objectives. Therefore, the puzzle here has been to empirically differentiate between the political agendas and policy processes of HIV/AIDS transnational NGOs from those of states and multilateral institutions. The above evidence suggests nonetheless that these boundaries are far from being unambiguous.

5. Conclusions

This chapter analysed the securitising actors or norm leaders that promoted the worldwide diffusion of HASN. It described the fundamental role of the UNAIDS as a recognised global authority on HIV/AIDS. It was demonstrated that, by constituting understandings and giving normative value to the epidemic, this organisation deeply influences the behaviour of state and non-state actors alike. In this sense, I argued that, despite the all-encompassing influence of the US, UNAIDS can be considered an autonomous actor in the international politics of HIV/AIDS. It produces and controls social knowledge about the epidemic and this is what constitutes its normative power. Then, the study examined the bureaucratic structures and social mechanisms by which this organisation creates and spreads HIV/AIDS norms from the system to the domestic levels.

The study has also focused on the role of the United States as a powerful actor in undergoing international normative change. It was shown that material and ideational motivations, derived from deep-rooted worldviews and interests, shaped the particular way the US government interpreted and reacted to the global epidemic. In this regard, the chapter has demonstrated that the US administration’s particular conceptualisation of HASN was the result of complex social interactions that included pharmaceutical companies, and their preference for costly brand-name AIDS drugs, conservative Christians, who are behind PEPFAR’s heavy promotion of abstinence and faithfulness practices, and, the Bush administration’s own political ideology.

Finally, this chapter has explored the important role played by transnational networks of NGOs as instruments of HASN diffusion. Like a conveyor belt, they promote normative change by transmitting norms from the international system to states and vice-versa. The chapter looked at the main strategies these social groups use to inculcate HIV/AIDS policy ideas and principles into the domestic structure of states. It has also exposed some central ambiguities in the institutional mission of those organisations. Reflecting broader structural contradictions in the global securitisation of HIV/AIDS, transnational NGOs of HIV/AIDS activists and service providers have been divided by their distinct moralistic, pragmatic and sometimes opportunistic motivations. In effect, one could say that those HIV/AIDS groups skilfully navigate in the turbulent waters that defined the normative contours of HASN, bringing relevant information to state and non-state actors and promoting HIV/AIDS principles according to the interests/ideas of their particular constituencies and patrons.

While more systematic research is needed to unveil the evolution and effects of the transnational phenomena underlying the emergence and global propagation of HASN, the argument presented in the previous and present chapters aimed to devise the theoretical and empirical basis for this further endeavour. The next three chapters will elaborate on how norm leaders link up with their domestic audiences through the setting up of offices and diplomatic representations. These bureaucracies interact with local NGOs, state agencies, politicians and key civil servants in the governments. As noted before, this process works as a sort of transnational transmission belt for the diffusion of HASN.

Yet, without denying the active role of international HIV/AIDS norm entrepreneurs in South Africa, Botswana and Mozambique, they impacted in very different degrees on the domestic structures of those states. As the following empirical chapters will demonstrate, the distinctive socio-political and cultural circumstances of those Southern African countries triggered different domestic dynamics of norm adaptation. This encounter between international normative understandings and local belief systems and practices resulted in dissimilar outcomes with regards to the national responses to the HIV/AIDS epidemic in each one of them.

Chapter 4

The Domestic Incorporation of HASN in Botswana: “The Model of Active Engagement”

1. Introduction

The unprecedented devastating impact of the HIV/AIDS epidemic in Botswana placed this small state in Southern Africa right at the centre of the worldwide fight against the disease. In the late 90s, Botswana became a fundamental test case for the effectiveness of the HIV/AIDS global response. The government’s efforts to overcome the epidemic were seen very favourably by the international community of donors, multilateral agencies and NGOs. Botswana’s stable political institutions, responsible government and well-run economy built a strong sense of trust among international partners. The generous international offers of human, technical, financial and material resources to fight HIV/AIDS are clear evidence of that fact. Notwithstanding their conflicting policy priorities, state donors, mostly the US, and multilateral and bilateral agencies found in Botswana a fertile ground for working with local HIV/AIDS actors and for fully developing their policy strategies to combat the epidemic.

The following analysis shows that Botswana’s actions on HIV/AIDS largely reflected the agenda of the transnational sources of HASN diffusion. In most African states, external interference in HIV/AIDS domestic policies is, to a large extent, a function of their high level of economic dependence on international funding (Baylies, 1999). In Botswana, on the other hand, financial resources have never been the most critical constraint on the formulation and implementation of HIV/AIDS national plans. Although the government still relies significantly on multilateral and bilateral donors to fund HIV/AIDS activities, Botswana is much less in need of foreign aid than most Southern African states (apart from South Africa).

This chapter claims, therefore, that a more fundamental normative accordance between international and national principled beliefs and norms underlies the high salience of HASN in Botswana. It is argued that the characteristics of Botswana’s political and social structures facilitated external access to its domestic system with the consequent building up of a robust domestic/international coalition supporting HASN. This means that 1) a relatively democratic but centralised state with a single party controlling the government since independence; 2) an assertive and committed political leadership 2) an efficient state bureaucracy; 3) a weak civil society in terms of home-grown political activism, as well as 4) the absence of an anti-colonial political culture, created the proper internal conditions for the acceptability of the international thinking on HIV/AIDS.

As a result, after a period of norm adaptation, Botswana’s government put in place an impressive process of securitisation praised by the international community as a positive example in Southern Africa. It is also shown here that the cascading of HASN was triggered by the skilful articulation of a security speech-act by President Festus Mogae and other influential securitising actors towards the end of the decade. In this respect, this chapter claims that, despite the actual context of high HIV prevalence rates in Botswana, the argumentative (and other) interactions between international securitising actors and domestic audiences were what really determined the successful securitisation of HIV/AIDS in the country.

2. Setting the Stage: Botswana’s Post-Colonial Political Culture, HIV/AIDS and the Constitution of a “Norm Friendly” State

The following explores some features of Botswana’s political system and culture. The study concentrates on the historical process whereby Botswana gradually moved from a pre-colonial political structure, based on traditional forms of authority, to a post-colonial modern state. In this regard, it demonstrates that the successful political and economic modernisation of Botswana allowed for the constitution of a “norm friendly” nation-state in Southern Africa. Ultimately, it means that the recognition of HASN in Botswana resonated with the previous acceptance of Western conceptions of modernity by the country’s political elites.

As shown next, Botswana is a case of state-centred domestic structure with great executive autonomy in decision-making. Its political culture values a top-down type of state-society relations which leaves less room for civil society participation in policy making. In this kind of political system, policy innovation is unlikely, unless promoted by the top leadership (Risse-Kappen, 1994:209). Indeed, it is demonstrated later that, prior to the election of the securitisation-oriented Festus Mogae, transnational exchanges between HASN leaders and Botswana’s HIV/AIDS domestic actors had less (even though a still significant) impact on HIV/AIDS policy making. In this sense, the Botswana case allows for the analytical isolation of the Presidency, in particular the president himself, as a key source of policy guidance and domestic norm diffusion.

The colonisation of Botswana was unique in Southern Africa. The colonial process was markedly less violent than, for example, in South Africa and Mozambique. According to Holm, the colonial rule in Botswana was “so mild that even the term “indirect rule” would be an exaggeration” (1988:183). In 1884, the chiefs of the indigenous Botswana people (Tswana) invited the British to take administrative control of their territory. They feared that without British protection the hostile Afrikaners would conquer their lands (Keulder, 1998). In 1885, the Tswana territory became the British Protectorate of Bechuanaland. The British ruled in Bechuanaland until independence in 1966. The colonial power did not oppose the traditional socio-economic system of chiefdoms. In fact, co-operation developed between the Tswana chiefly elite and the colonial administration (Good, 1992:72). The British were very supportive of the system of “rural capitalism” established by the Tswana chiefs (Bauer and Taylor, 2005:86). This allowed them far more freedom to engage in profitable economic activities as well as to perform functions for the benefit of the populace. Given the fact the fewer Europeans settled in the Protectorate, less pressure was placed in Britain to protect their interests at the expense of indigenous ones. This meant that racism was not so prevalent and power configurations less distorted than in other Southern African colonies (Keulder, 1998:99).

Another factor that distinguishes Botswana from the rest of Southern Africa is its ethnic homogeneity. The Tswana is by far the largest ethnic group in the country, amounting to 85% of the population (Bauer and Taylor, 2005:84). They are divided into 8 main chiefdoms: Bamangwato, Bakwena, Bangwaketese, Batawana, Bakgatla, Bamalete, Barolong and Batlokwa (Wiseman, 1977:73). Although the powers of traditional leaders were substantially reduced, they remained very prominent during the colonial period. In the 19th century, the leaders (or chiefs) of those tribes had exclusive control over economic resources, such as cattle, land and labour. With the support of the colonial power, they became very powerful individuals, controlling territory, population and resources (Good, 1992:69). The Bamangwato was the largest and the most important of those groups. During the 1880s, Khama III (the king of the Bamangwato people and grandfather of the later President Seretse Khama) was one of the wealthiest individuals among the Tswana people and the largest cattle-owner (Good, 1992:70).

An indigenous form of elite nationalism grew considerably during the 1950s and 60s. In the mid 50s, Seretse Khama, heir of King Khama III, and a barrister trained in London, began to organise political activities aiming at independence from Britain. In 1961, the British provided some degree of political and administrative autonomy to the protectorate. A legislative council was set up after limited national elections. In 1962, Khama formed the Bechuanaland Democratic Party (BDP). BDP was founded as the party of bourgeois nationalists, who had previously joined the colonial power to promote a particular kind of socio-economic system. An extremely popular figure among an electorate eager for independence, Khama easily won the 1965 elections. Acting now as the Prime Minister of BDP, Khama maintained the push for the complete independence of Botswana, which was achieved on 30 September 1966.

Since independence, BDP has been the hegemonic political force in Botswana. It has elected all three presidents to date, Seretse Khama, Quett Masire and Festus Mogae. Its dominance derives from it being the party that peacefully led Botswana to independence and economic growth (Wiseman, 1998). The charismatic appeal of Khama is also an important factor in understanding the consolidation of BDP’s political power. Bauer and Taylor, for example, argue that “once Khama was elected president, his personal prestige virtually guaranteed the BDP’s repeated election victories until up to his premature death in office in 1980” (2005:97). After independence, Khama’s government managed to reconcile internal tribal divisions under a liberal and non-racial regime. His job was facilitated by the aforementioned homogeneous ethnic composition of Botswana’s indigenous people (Wiseman, 1977:73).

The political organisation of the Botswana state was inspired by the British parliamentary system. The legislature at the national level is formed by the National Assembly which consists of 57 members elected by popular vote. It also has four special non-elected members appointed by the president. The constitution provides for a strong executive whereby the president is both head of state and head of government. The president is not elected directly by the Botswana people. He/She is instead chosen by the National Assembly’s members to serve a five year mandate. The executive cabinet is made up of members of the ruling party in the National Assembly. It is appointed by the president usually without previous consultations with the Parliament. As elsewhere in Southern Africa, in Botswana the influence of the president over the parliament is significant. In this respect, Bauer and Taylor assert that “the small size of the national legislature ensures that more than a majority of MPs from the ruling party are either ministers or deputy ministers”. The cabinet members are therefore “easily able through sheer numbers to determine the BDP parliamentary delegation’s position in any vote” (2005:95).

Botswana’s post-independence constitution established a formal role at the national level for traditional Tswana leaders in the form of the House of Chiefs (Bauer and Taylor, 2005:95) – an advisory body which has no legislative capacity. Keulder argues that Botswana’s National Assembly often ignored the advice of the House of Chiefs and that “only five were literate enough to read and comment on the bills that were forwarded to them” (1998:109). Despite its clear limitations in terms of political participation, the establishment of the House of Chiefs helped the government to engage those leaders in the political modernisation of rural areas. Their formal participation in the government’s structure has also created an important institutional mechanism to address potential clashes between the traditional and modern forms of political authority (Keulder, 1998:109).

In the period following independence, BDP engaged in the implementation of laws and policies regarding the creation of a “developmental state” in Botswana (Taylor, 2002). In this regard, the government rapidly expanded the central government’s institutional apparatus leading to a significant increase in the delivery of public services (Du Toit, 1995:33). According to Du Toit, BDP has succeeded in establishing a technocratic state with an autonomous bureaucracy that “contributed as a vital ingredient to the quality of statehood that evolved in post-independence Botswana” (1995:47). BDP’s post-independence nationalism was underpinned by the fundamental task of economic growth and social development (Taylor, 2002:5). This national project was accepted and advanced by the political and bureaucratic elites and, concomitantly, it gained widespread acceptance amongst both the rural and urban populations (Taylor, 2002:5).

During the heyday of socialism in post-colonial Africa, all the significant political factions in Botswana were supportive of a strategy of development based on a system of welfare capitalism. At independence, Botswana was in the group of the 25 least developed countries in the world. Its physical and social infrastructures were highly underdeveloped, which was reflected in its extremely high levels of poverty and adult illiteracy. However, over the past four decades the country’s situation has changed dramatically. In contrast with most of its regional neighbours, the Botswanan government has traditionally committed a large share of its public budget to spending in fundamental social areas. During the 70s and 80s, for example, the government significantly reduced the rates of child mortality (children who die before the age of 5) and malnutrition and steadily improved levels of literacy in the adult population. In the public health sector, the country had in 2003 a per capita expenditure of US$ 358, the highest in Southern Africa (UNDP, 2003). The GDP per capita of Botswana jumped from US$ 300, in 1966, to US$ 3066, in 2001. Currently, Botswana is classified by the World Bank as a middle-income country as compared to its status of least-developed in the late 60s. With diamonds as its main source of revenue, Botswana is today a wealthy and politically stable state in Southern Africa.

Botswana faces many challenges nonetheless. Chief among them is the dire magnitude of the HIV/AIDS epidemic. The first case of AIDS in the country was officially reported in 1985. From the time of the first notification onwards the number of HIV infections soared rapidly, cutting across all social groups and economic classes. In 1995, ten years after the first notified case, Botswana’s Ministry of Health estimated that 13% of the population was infected by HIV (Ministry of Health, 1997). In 2004, Botswana had an estimated number of 400,000 people living with HIV in a country with a relatively small population of approximately 1.8 million. This amounts to 37.3% of Botswana’s adult population (UNAIDS, 2004d).

Due to the impact of HIV/AIDS, life expectancy in Botswana is only 39 years, while it is estimated that it would have been 72 without the disease (UNDP, 2000). In the last 20 years, the plague of HIV/AIDS and its destructive impact has put at risk Botswana’s hard-won social and economic achievements. In Botswana, the HIV/AIDS epidemic is destroying years of impressive realisations in human development. It has caused extreme human suffering, deepening poverty, social dislocation and economic destitution. If the progression of HIV/AIDS is not halted, it is estimated that by 2021, Botswana’s GDP will be something in the order of 24-38% less than what it would have been without the epidemic (UNDP, 2000:2).

In the politics of AIDS, the case of Botswana is puzzling. It challenges the common belief that economic underdevelopment and HIV spreading are directly related. With nearly 40% of its population carrying the HIV virus, Botswana’s health system remains one of the best on the African continent (UNDP, 2004). As will be demonstrated in more detail, since the first cases appeared in Botswana, the government has closely followed international medical guidelines for action. Since 1998, President Mogae has pushed the HIV/AIDS problem to the level of a national catastrophe. Special state agencies, policies and high-profile partnerships were established with a wide range of well-resourced actors to contain the epidemic.

The abovementioned characteristics of Botswana’s domestic structure influenced the trajectory of the national response to HIV/AIDS. The peaceful and negotiated transition to independence with the continuation of friendly relations with the previous colonial power facilitated Botswana’s subsequent penetration by Western ideas, such as in the case of transnational norms concerning HIV/AIDS. Conversely, as shown later in the examples of Mozambique and South Africa, the colonial heritages of most African states resulted in quite negative perceptions of Western influence. Additionally, the ethnic homogeneity of Botswana’s society, coupled with its early inclusion in the BDP’s project of nation-building, facilitated the Tswana elites’ task of unifying the nation in situations of perceived crisis. Finally, Botswana’s centralised and top-down political system provided transnational HASN leaders with just a few entry points into the domestic structure of decision-making. Rather than building coalitions at the civil society level, they reached the top skeleton of decision-making. After 1998, the openness of Mogae to the ideas of those (securitising) actors reflected upon the (rather successful) securitisation of the epidemic in the country.

3. Institutional Strategies and HIV/AIDS Policies in Botswana

This section outlines how HASN penetration in Botswana underwent a long process of adaptation (or reconstruction), which was reflected in the progression of the policy responses put in place by the government over the years. In this regard, the latest National Strategic Framework (2003-2009) and the launching, in 2002, of the large-scale provision of antiretroviral drugs in the public health system represented the ultimate policy outcomes in terms of the institutionalisation of HASN in Botswana’s political structure of decision-making. These outcomes saw the creation of new tasks and procedures and the displacement or considerable adaptation of previous methods. During the process, the target issue (HIV/AIDS) was institutionally rearranged to become central in the existing hierarchy of policy priorities.

Due to its stable political situation and an efficient health system, Botswana responded to the problem of HIV/AIDS earlier than its Southern African neighbours, including South Africa and Mozambique. During the first ten years of the epidemic, however, the response was confined to a number of policy interventions at the level of the Ministry of Health without the political engagement of higher authorities in the government (Interview Tselayakgosi 16.02.2006). The first phase of the national response (1987-1993) coincided with the beginning of the worldwide expansion of the epidemic. In 1988, the government of Botswana set up the National Aids Control Programme (NACP) and developed a Short Term Plan (STP). It was followed by a more comprehensive five year plan (1989-1993), named the First Medium Term Plan I (MTP I). These two plans were based on the action framework provided by the WHO’s Global Programme on AIDS.

By this time, WHO had changed its initial view of HIV/AIDS as primarily a public health problem of rich countries in the West. As already noted, around the mid-80s, an expanding international epistemic community of doctors, NGOs, and other HIV/AIDS actors had given global publicity to the heterosexual epidemic and its particular impact in Africa (Iliffe, 2006:69). During this initial stage, WHO collaborated closely with Botswana’s Ministry of Health in implementing policies focusing mainly on HIV/AIDS surveillance and control. The number one priority set by WHO was to screen blood supplies in health facilities in poor countries so the medical system would no longer create new infections. Following WHO’s advice and with its technical assistance, the Epidemiology Unit of Botswana’s Ministry of Health set up a blood screening programme and stepped up its controls of the use and provision of disposable needles in the National Health System (Ministry of Health, 1997).

Another key objective of WHO was to invest in mass public education, which in the absence of a vaccine or cure, was the only means available to check the epidemic. In Botswana, during the late 80s, radio and press were widely used to spread information about HIV/AIDS. Posters, t-shirts and car bumpers were also produced and extensively distributed. The catchphrases used in the government’s campaigns followed the standards set up by WHO. Posters with slogans such as “AIDS Kills” and “Use Condoms” were put up in health facilities and other public places (Ingstad, 1990:29). In 1988, the Ministry of Health launched an educational campaign, having the promotion of condom as the central message. As Heald notes, “[HIV/AIDS campaigns] were all phrased in terms of the accepted formulations of the international organizations. Reading the plans one can not but be impressed.” (2005:5).

These campaigns had a very limited impact nonetheless. In the early 90s, because of the high publicity given to an elusive illness that most people had not experienced in their real lives, HIV/AIDS became ironically known amongst Botswanans as the “radio disease” (Ingstad, 1990:29). In 1992, the HIV prevalence rate in antenatal clinics was already exceeding 15%, the same as in Mozambique in 2000. It was clear at this point that WHO’s initial strategy was having little effect. As with most states in Africa, in Botswana the Western (technical) message of prevention through condoms and mass education did not make a significant impact in controlling the fast-growing epidemic. The scientific/rational approach of WHO was proved insensitive to the pre-existing cultural and social complexities of their target states.

As already seen, given the widespread frustration with WHO’s narrow (medical) approach to HIV/AIDS in the early to mid 90s, international discourses concerning HIV/AIDS started to shift again. Now, the epidemic was not seen any longer as solely a medical problem that could be addressed through preventive measures such as public education and mass distribution of condoms. The African epidemic had shown that risky sexual behaviour is also about gender vulnerability, deep-rooted cultural traditions and extreme poverty. In this sense, chapter 2 demonstrated that the first half of the 90s was a period of redefinitions in the global HIV/AIDS response. An inter-paradigmatic conflict took place between WHO and other multilateral actors and state donors over the definition of HIV/AIDS policies and principles.

This stalemate in the HIV/AIDS global response was reflected in Botswana’s domestic initiatives. From 1993 to 1997, the period between the first and second medium-term plans, the Botswanan government lost most of the energy displayed in the late 80s. Throughout the 90s, and following the initial line of WHO, HIV/AIDS was still seen by most officials in the government as solely a medical condition which should be dealt with by the Ministry of Health. In this respect, a high-ranked official at the National AIDS Coordinating Agency (NACA) asserts that,

Until the early 90s we were still in the stage of denial. People in the government thought that it was not a real problem that the Ministry of Health was just trying to make us cautious about HIV/AIDS. But then came the time, around the mid 90s, when we realised how big the problem was and if we did not aggressively react it could be it; we would have a whole generation wiped out […] It only really cascaded though from 1999 when Mogae took office. His leadership was fundamental in this respect (Interview Tselayakgosi 16.02.2006).

An interesting thing about the Botswana case is that at the time when the epidemic was spreading most quickly in the country (in the early 90s), the government slowed down the response. Despite the alarming progression of HIV/AIDS, state officials seemed unconvinced about the seriousness of the problem. According to the Ministry of Health’s review of the MTP I, one major constraint to its implementation was the “minimal involvement of Ministries and senior management as well as inadequate involvement of local government structures” (Ministry of Health, 1997:31). In this respect, the above remark from the NACA’s official suggests that the definitional moment or the tipping point in which a securitisation move became widely accepted by a target audience came only with the assertive leadership of Festus Mogae, after 1998.

By this time, the authoritative presence in Botswana of the newly formed UNAIDS also gave a new impulse in the securitisation attempts of international norm leaders. As already noted, the creation of this multilateral agency was the result of a revamped global initiative for tackling HIV/AIDS. Thus, the emergence of a revitalised and more unified (security) discourse among global HIV/AIDS actors coupled with the election of a new (open-minded) president in Botswana, brought crucial momentum to Botswana’s HIV/AIDS response. As demonstrated next, Mogae’s discursive interactions with (reformed) sources of HASN diffusion transformed him into a key norm leader who aggressively pushed for the securitisation of the epidemic.

From the mid-90s, the Botswanan government slowly began to realise that the Ministry of Health alone would not be able to face the challenges posed by the fast expanding epidemic. It was by then that the identification of HIV/AIDS as an emergency and an exceptional kind of problem began to become more salient in the discourses of local and international stakeholders. Under the presidency of Ketumile Masire, the government formulated the Presidential Directive of a National AIDS Policy (NAP). This policy document articulated for the first time the government’s concerns about the impact of the epidemic on the country’s development. It acknowledged the multi-dimensional impact of HIV/AIDS and mobilised a variety of sectors to collaborate on the national response. NAP represented a significant change in the policy debates on HIV/AIDS in Botswana. Its portrayal of HIV/AIDS as a development issue had a significant impact on how the epidemic would be presented in public debates in the subsequent years. NAP defined new policy standards that were further consolidated with the adoption of the second Medium Term Plan for the period 1997-2002 (MTP II). This revised strategic plan substantially changed the focus of HIV/AIDS interventions from a health-based approach to a comprehensive multisectoral response.

The adoption of the MTP II was illustrative of the evolving nature of normative understandings of the HIV/AIDS epidemic at the global level. The preparation of the MTP II coincided with the emergence of policy studies and academic reports addressing the epidemic in non-conventional terms. In 1996, the launching of the MTP II also corresponded at the multilateral level with the creation of UNAIDS. As shown in chapter 2, during this period, a growing number of analysts, think-tanks, international organisations and state agencies began to explore the links between human/national security and HIV/AIDS.

The transfer of power from Ketumile Masire to Festus Mogae in April 1999 represented a watershed event in Botswana’s HIV/AIDS national response. Mogae’s proactive role at the National Aids Council (NAC) gave new impetus to Botswana’s HIV/AIDS response. In the first year of the new administration, the government of Botswana, under the directive of the President’s office, put in place the National AIDS Coordinating Agency (NACA). This new organ replaced the outdated National Aids Control Programme (NACP) of the Ministry of Health. In terms of the political management of HIV/AIDS, the most important institutional change brought by NACA was the shift in the locus of leadership from the Ministry of Health to the Presidency. Chaired by Mogae, NACA became responsible for mobilising material and human resources and coordinating the national response in all levels of decision-making. In collaboration with many national and international partners, NACA set up a national committee to revise the MTP II and formulate a new strategic framework to facilitate its further implementation. This new framework aimed to provide clear guidance for ministries, NGOs and the private sector as well as to enable them to work in a collaborative manner under the centralised authority of NACA (NACA, 2002a).

Additionally, in 2001, during the preparation of the national strategic framework, and following the advice of UNAIDS, the Botswanan government incorporated the idea of mainstreaming HIV/AIDS into all its ministries’ bureaucracies and levels of decision-making. It was done through the establishment of Ministry AIDS Coordinators (MACs), which were focal point units within the Ministries. They act as infiltrated agents of sorts, spreading the securitisation message of the HIV/AIDS national response. MACs target both the internal and external domains. Internally, in the workplace, they address the needs and vulnerabilities of the staff and formulate internal policies and guidelines. Those guidelines were taught to civil servants in seminars and workshops organised by MACs. Externally, they assess the comparative advantages of the specific bureaucracy in contributing to the coordinated national response to the epidemic. Simply put, MACs are responsible for adapting the Ministries normal functions and businesses to the needs of the national multisectoral response to HIV/AIDS (NACA, 2003a:57).

In September 2002, Mogae launched the Strategic Framework for HIV/AIDS (2003-2009). It represented the most inclusive and comprehensive HIV/AIDS action guide elaborated in Botswana to date. This revised strategy incorporated the new international developments concerning the conceptualisation of the HIV/AIDS epidemic as an emergencial threat. The language used by Mogae in the framework’s foreword is indicative of the more aggressive approach taken by the Botswanan government. He says,

Having declared HIV/AIDS a national emergency, this National Strategic Framework is my Government’s pronouncement on how we will continue to address this emergency […] outlining an aggressive and determined response, this framework brings all the stakeholders together into the fight” (NACA, 2003a:1).

A new feature of the strategic framework was its stronger emphasis on policies directed towards the provision of anti-retroviral drugs (ARVs). This renewed importance given to treatment was in conformity with the discovery of a more efficient and less harmful combination of HIV/AIDS drugs. As part of the domestic incorporation of these new global developments, in 2001, the Botswanan government, under the leadership of Mogae, put in place a bold plan to roll out ARV drugs nationwide. Botswana was the first state on the African continent to put in place a plan aiming to provide antiretroviral drugs to all its AIDS patients. The possibility of delivering ARVs on a mass scale helped to reactivate policy-makers, health workers and NGOs of people living with HIV/AIDS.

In January 2002, the national ARVs programme, named Masa (‘new dawn’ in Tswana), was launched. The objective of Masa is to provide treatment to everyone in need of it. By 2005, with financial and technical assistance from a public/private experiment, the African Comprehensive HIV/AIDS Partnerships (ACHAP), the government had set up 20 operational ARV sites all over the country, covering something like 40,000 patients through the public health system (Ministry of Health, 2005a). The Infectious Diseases Care Clinic, at the Princess Marina Hospital, in Gaborone, is currently the largest ARV treatment site in Africa. In April 2004, it had 9,000 patients enrolled for AIDS treatment (Interview Tselayakgosi 16.02.2006). As further explored later, the Masa programme was a unique initiative in Southern Africa. While most countries in the region invested in the provision of generic AIDS drugs, the Botswanan government chose to ally with the US pharmaceutical Merck to provide branded drugs in the public health system. The introduction of treatment in 2002 gave renewed urgency to other areas of the HIV/AIDS national plan. As shown later, the launching of several Voluntary HIV/AIDS Counselling and Testing (VCT) centres and the introduction of routine testing in public health clinics were corollaries of the Masa programme (Ministry of Health, 2005a).

Likewise, the re-engagement of the government in prevention campaigns was due to the realisation that “giving antiretroviral drugs without stopping new infections would be akin to trying to mop up a floor without first switching off the tap responsible for the flood” (Interview Tselayakgosi 16.02.2006). Yet, concerning the prevention of HIV infection, Mogae’s administration invested strongly in the (alternative) securitisation ideas promoted by the US government. From 2003/2004, Bush’s PEPFAR initiative sponsored prevention campaigns with a new strategic focus on abstinence and faithfulness instead of the previous emphasis on the use of condoms. As seen later, because of PEPFAR, large amounts of money became available in Botswana to implement these kinds of prevention strategies.

At this later stage of Botswana’s HIV/AIDS response, Mogae was leading a massive national effort to slow down the epidemic with most Ministries, international partners and other HIV/AIDS actors engaged in the fight. The following section elucidates how his strong personal leadership gave a unified direction to the national HIV/AIDS response amidst conflicting normative precepts and practices of securitising actors. Similar to the cases of Mozambique and South Africa, in Botswana the particular perceptions and beliefs of key decision-makers were decisive elements in understanding the domestic assimilation of HASN.

4. Leadership Perceptions and the Domestic Recognition of HASN

This section argues that Mogae’s security language with regard to HIV/AIDS was influenced by the appearance of a more extreme international view of the threat the global epidemic represented. It suggests that he was successfully persuaded by international and national advisers (securitising actors/norm leaders) that HIV/AIDS should be securitised. Then, Mogae himself became a key securitising actor in Botswana. In fact, he was a crucial actor in promoting the cascading of HASN domestically.

Mogae’s strong securitisation language after 1999 had a significant impact on the national response to HIV/AIDS. He seized on the epidemic as the most urgent challenge facing Botswana, even going so far as saying that the epidemic was a threat to the very survival of Botswana as a viable nation. At this point, Mogae officially declared HIV/AIDS a national emergency, giving high priority and strong political support to the fight against it. The vocabulary of securitisation became recurrent in the language Mogae used to describe the threat posed by the epidemic. The use of discursive metaphors that translated the epidemic in terms of an enemy to be defeated became commonplace in his speeches. The president set himself as the commander-in-chief of the nation in the war against the spread of the virus and its impact. His aggressive pronouncements marked a change in the manner the Botswanan government would rhetorically frame HIV/AIDS.

As Risse-Kappen notes, “ideas do not flow freely” (1994:185). This means that ideas are attached to particular carriers (or norm leaders) who try to spread them widely. Indeed, the idea of securitising HIV/AIDS was embraced by Mogae in a time when powerful epistemic communities and donor states were also framing the epidemic on those terms. If one compares the extract below of Mogae’s speech in 2000 with UNAIDS assertion about the impact of the epidemic in Botswana, released in the same year, one will clearly identify the similarity in the use of a specific terminology to assess the threat the epidemic symbolises and therefore how it should be dealt with.

[...] Let us as Africa take responsibility for ourselves and be true leaders in fighting the greatest threat to our development and security. Let us deal with the HIV/AIDS epidemic as an emergency and respond with measures that a crisis deserves. Let us divert resources from military expenditure to fighting the HIV epidemic [my emphasis] (UNECA, 2000: internet source).

[...] The HIV/AIDS epidemic in Botswana is the deadliest emergency and the biggest social and economic crisis facing the country today. After three decades of sustained economic growth, HIV is threatening to wipe out hard-won gains in social development [my emphasis] (UNAIDS, 2000:8).

Similarly, Mogae’s emphasis on words such as “threat”, “emergency”, “war” came about just at the same time as the Clinton administration formally declared HIV/AIDS a “threat” to US National Security. In this respect, it is interesting to note the very influential role played by the US government’s agencies and the private sector in assisting Botswana’s response to the HIV/AIDS epidemic. As shown later, the US is the most important donor state in the country, sponsoring various HIV/AIDS projects through the PEPFAR programme and the private sector. These institutional and financial bounds facilitated the harmonisation of national discourses on the epidemic and its consequent impact on the definition of policy directions.

The domestic salience of HASN in Botswana was to a large extent due to Mogae’s openness to these transnational ideas. In this respect, his sympathetic stance towards Western-based knowledge of the epidemic, coupled with the need for coherent policy prescriptions in a perceived situation of emergencial crisis, are crucial elements in explaining the successful securitisation of HIV/AIDS in Botswana. Mogae’s particular beliefs and perceptions of externally defined HIV/AIDS principles deeply influenced his policy choices. As seen in the forthcoming case studies of South Africa and Mozambique, when presented with similar external pressures to securitise HIV/AIDS, decision-makers can display quite distinct reactions. Acharya notes, for example, that “localization does not extinguish the cognitive prior of the norm-takers but leads to its mutual inflection with external norms” (2004:251). In the case of Botswana, key elements of Mogae’s belief system and decision-making style shaped his sensitivity to the securitisation demands of international actors.

Contrasting to the Marxist-Leninist and strong anti-colonial background of Thabo Mbeki, in South Africa, and Joaquim Chissano, in Mozambique, Mogae’s worldview was informed by knowledge, values and concepts originated in the Western liberal community as well as in the lessons learnt from his country’s smooth transition to independence. During his period abroad, Mogae was trained within the Western European tradition of political liberalism and welfare capitalism. He graduated in economics at Oxford University then served as governor for Botswana at the International Monetary Fund (IMF), African Development Bank and World Bank. From 1976 to 1980, he worked for the IMF in Washington DC. Mogae’s professional socialisation within those multilateral bodies helped to shape his political identity, which would influence his future behaviour as Botswana’s leader. His close links with these dominant Western institutions, which are often perceived as political instruments to legitimise and further perpetuate a type of global apartheid against disempowered African societies (Bond, 2002), set him aside from other southern African leaders, namely Thabo Mbeki, in South Africa, and Robert Mugabe, in Zimbabwe. Unlike Mogae, these former liberation fighters frequently defy Western hegemonic orthodoxies, which they identify as forms of neo-colonial interference in Africa. As seen later, Mbeki’s combative stance towards the mainstream knowledge about HIV/AIDS is an example of this.

Building on the legacy and personal prestige of Seretse Khama, Mogae also shaped his political outlook in terms of continuity with his country’s past. A clear sign of Mogae’s commitment to the tradition of Botswana’s first leader, he chose Ian Khama, the son of Seretse Khama, as his vice president. As already seen, Khama was a pragmatic leader who challenged traditionalism and racism and unified the country under the banner of economic and social development (Holm, 1988). The importance given by Khama to the development of Botswana, during and after the colonial years, provided everlasting political capital to his successors. This is clearly demonstrated by the uninterrupted election victories of Khama’s BDP since independence (Wiseman, 1998).

In terms of leadership style, Mogae can be described as a kind of “task-oriented leader” (Keller, 2005:210). According to Keller, “task-oriented leaders exhibit a more directive management style, viewing others as tools to be used to accomplish the all-important mission rather than as actors with legitimate views that must be respected and accommodated [my emphasis]” (2005:210). Despite Keller’s interesting definition of “task-oriented leaders”, he does not discuss the crucial issue of how an “all-important mission” is defined. It has been shown here that the process of securitising an issue (in other words, turning it into an “all-important mission”) depends on intersubjective linguistic processes which involve consultation and engagement with others. Mogae’s identification of HIV/AIDS as an “all-important mission” was the result of his interaction with various actors upholding a number of different views. In this respect, Mogae’s direct involvement with HIV/AIDS state bureaucracies, such as NACA, as well as his links with HIV/AIDS epistemic communities based in Botswana exposed him to a marketplace of ideas (Kaufmann, 2004) concerning the epidemic. In this sense, the features of a “task-oriented leader” only surfaced in Mogae’s leadership style after he was successfully persuaded of the emergency of the HIV/AIDS threat.

As shown later, Mogae’s decision to establish routine HIV testing in Botswana, at a time when it was not common practice among African states, was due to a long consultative process in which the US representation in the country played a key role (Interview Roels 13.02.2006). However, after the decision was made, Mogae simply ignored opposing views which defended the confidentiality of tests. To boost enrolment in HIV testing, he went further, trying to push forward a very controversial measure which would establish compulsory HIV testing for students applying for government’s scholarships. In this respect, he allegedly said that “I know it won’t be popular. But I think we are going to do it anyway” (The Washington Times 10.04.2004).

But how did Mogae’s rhetoric impact on the domestic political and social structure of Botswana? Chris Hill affirms that the leader’s political appeal depends upon “qualities of brilliance, strength and emotional insight, and then circumstances in which there is some kind of political or emotional vacuum to be filled [...]” (2004:110). Concerning Botswana, this meant that in a circumstance of (perceived) national emergency and uncertainty about the future, Mogae successfully conveyed his charismatic appeal with a security rhetoric that emphasised the perception of threat on the collective national imagination. The use of fear as a political tool to unite society under a set of principles and policy goals is not a novelty in politics (Mueller, 2005). In the case of Botswana, this task was further facilitated by a political culture of strong popular reliance on the personal guidance of the top leadership. As already noted, Mogae has constantly recited in speeches that, if nothing is done, the people of Botswana are risking extinction from AIDS. For example, in a State of the Nation address, in Botswana’s parliament, he categorically asserted that,

The nation has been informed, and the message must be repeated from this rostrum that HIV/AIDS is the most serious challenge facing our nation, and a threat to our continued existence as a people. But we shall never surrender, we are fighting back and together we shall win (Ministry of State President, 2001:2).

This kind of sentiment coming from the nation’s leader have an important socialising effect on both the country’s political institutions and on people’s understandings about the security impact of the epidemic. The appeal of the leader is even stronger in domestic contexts which lack a vibrant civil society providing alternative views about issues. As analysed later, HIV/AIDS civil society groups in Botswana were successfully co-opted by the government and international partners to work within a common policy paradigm.

Therefore, in personalist political systems such as in Botswana (as well as Mozambique and South Africa), individual (charismatic) leaders are fundamental target audiences of international securitising actors. The way they respond to (accept, adapt or reject) the securitisation claim will fundamentally determine the depth and form of securitisation. In the case of Botswana, Mogae’s leadership characteristics combined with Botswana’s enabling political culture have facilitated the persuasion work of the HASN leaders. In this sense, Mogae has successfully prioritised HIV/AIDS as an immediate threat and mobilised institutions, resources and citizens to deal with it. In what follows, the study turns to the analysis of the role of external actors in shaping Botswana’s HIV/AIDS structures and policies.

5. Norm leaders in Action: The Role of Multilateral Institutions, the US and Transnational Non-State Actors

5.1. The Multilateral Approach

This section argues that, since the onset of the global securitisation of HIV/AIDS, around the mid 90s, policy structures in Botswana have been very receptive to the influence of international organisations. In this regard, the so-called “UN family”, especially UNDP and UNAIDS, have played a key role in helping ministries and other state agencies to develop policies and programmes and in assisting the government in their implementation.

As already shown, the setting up of the Second Medium Term Plan (MTP II) represented a transitional stage in the process of internalising a new (and more aggressive) transnational conceptualisation of the HIV/AIDS epidemic. The Plan, for the first time, recognised the multidimensional impact of the epidemic and the need for a comprehensive response that included a coalition of sectors working under a single authority. These changes commenced in 1994, in the same year UNDP released its report on human security, and came into force in 1997, one year after the UN had promoted a similar institutional shift with the creation of its own multisectoral co-coordinating agency, the Joint United Nations Programme on HIV/AIDS (UNAIDS). These new areas of international concern, particularly with regard to a more concerted response to the epidemic, guided the development of MTP II’s strategies.

During the preparation of the Plan, from 1994 to 1996, these transnational ideas were introduced in Botswana through an extensive consultative process involving a series of “programming workshops” (Ministry of Health, 1997). The activities were developed by the Botswanan government in concert with multilateral agencies. UNDP, for example, played a key role during the elaboration of MTP II. In several of those workshops, UNDP brought together high ranked officials from several Ministries, the private sector, NGOs and international partners. In these meetings, UNDP and other UN agencies taught those actors how to fulfil their roles in the new HIV/AIDS policy machinery established by MTP II. The knowledge-based authority of multilateral agencies has given them substantial leverage in persuading the government about the existential threat posed by HIV/AIDS and the urgent need for its securitisation. These organisations constantly examined the HIV/AIDS policy establishments of Botswana and provided ideas and models to improve them. For example, WHO (and then UNAIDS) has been in favour of greater bureaucratic centralisation in coordinating an expanded HIV/AIDS response which would include all international and domestic HIV/AIDS actors. During the formulation of MTP II, a WHO/UNDP-led team reviewed Botswana’s HIV/AIDS structures and policies and recommended the establishment of a supra-ministerial agency to coordinate the overall national response. NACA was set up in 1999 as a follow-up of this recommendation (Interview Tselayakgosi 16.02.2006).

From 2003, the Strategic Framework for HIV/AIDS (2003-2009) further formalised the channels of communication between domestic and external HIV/AIDS actors. Currently, the institutional space in which the persuasion practices (or speech articulations) of these organisations take place are constituted by two main forums. These are the Botswana HIV/AIDS Partnership Forum, which is coordinated by NACA, and the Expanded Development Partner Forum, a group made up by the UNAIDS Theme Group and other bilateral and multilateral partners. The Botswana Partnership Forum is the main channel for international organisations and bilateral donors to interact with high-ranked government officials. The outcomes of their meetings are brought up at the National Aids Council and, thus, to its chairperson, the president himself. The Expanded Partner Forum is the common space whereby bilateral and multilateral actors coordinate their activities and harmonise policy positions. Since the emergence of PEPFAR, the collective work of this forum has been undermined by the “go-alone” approach of the US as well as by the aforementioned incompatibilities over HIV/AIDS policies between the US and multilateral partners (Interview UNAIDS Programme Officer 15.02.2006).

The UNAIDS and its co-sponsors produced a number of comprehensive studies on the dire implications of HIV/AIDS in Botswana which have had a significant impact on policy decision-making. One such an example is the Botswana Country Report on Women, Girls and HIV/AIDS. The study highlighted the specific challenges faced by young women in Botswana and their centrality in any effective intervention to halt the spread of HIV/AIDS (UNAIDS, 2004e). In 2004, the UNAIDS Theme Group played a major role in producing this report. Based on its findings and policy recommendations, a committee, chaired by the Minister of Health, developed a special national plan of action for women, girls and HIV/AIDS (Interview UNAIDS Programme Officer 15.02.2006). Usually, the release of these studies is followed by meetings with government officials, who would eventually propose the translation of the studies’ recommendations into policy (Interview UNAIDS Programme Officer 15.02.2006). As acknowledged by UNDP, “in going upstream on HIV and AIDS policy advocacy, UNDP relied on aggressive marketing of research output to sensitive policy makers as well as the general public” (UNDP, 2001:4). For example, in 2000, UNDP developed a Botswana Human Development Report dedicated to the impact of HIV/AIDS on Botswana’s human development achievements since independence. This latter document showed a disquieting decline in Botswana’s human development index and a deteriorating performance in relation to other countries at the same level of economic development (UNDP, 2000:2). The report had the intended effect of prompting the Botswanan government to further intensify the response to the epidemic.

The launch of the Botswana Human Development Report 2000 was in many respects the crowning moment of UNDP Botswana’s upstream policy impact, for it allowed UNDP to seal government policy and commitment in responding to the HIV and AIDS epidemic. (UNDP, 2001:4)

Since 2002, the UNAIDS has been a very strong advocate of “The Three Ones” framework in Botswana. Despite ongoing inter-bureaucratic feuds between NACA and the Ministry of Health, a consultative process led by the UNAIDS’ Theme Group has gradually established the primacy of NACA in Botswana’s HIV/AIDS institutional architecture – as recommended in the second key principle of the “Three Ones”. Botswana is also moving towards the achievement of the first and third principles. In this respect, a new comprehensive action framework for 2003-2009 was created and it has been implemented and Botswana’s HIV/AIDS monitoring and evaluation systems are among the best in the whole African continent (Interview Tselayakgosi 16.02.2006).

These were outcomes of a robust securitisation move promoted by UNAIDS and its associated agencies, which aimed to persuade the Botswanan government to scale-up the epidemic’s response. Following the poor implementation of the first Medium Plan (1989-1997) and the very slow implementation of the second (1997-2002), those agencies decided to systematically engage in a more aggressive advocacy strategy. They focused on key social actors such as the president, leading politicians, the private sector and traditional leaders, “with a view of turning them into informed campaigners and decision-makers” (UNDP, 2001:2). Thus, from the outset of this revamped strategy the challenge was, to “[establish] through research and advocacy, a common consensus on the magnitude of the HIV and AIDS problem and the threat it posed to governance, the economy and the character and stability of society [my emphasis]” (UNDP, 2001:2).

An important caveat at this point: Although the establishment of special bureaucracies and policies, which are in line with the HASN’s prescriptions, is strong evidence of norm penetration in Botswana, it is not a definitive confirmation of the actual cascading of HASN domestically. As noted later in the cases of Mozambique and South Africa, even when national governments formally agree in setting up those agencies and in adopting the recommended policies, they can find manners to perpetuate pre-existing understandings and forms of political action. Therefore, the actual empirical measurement of the extent of HASN penetration into the domestic structure of a particular state is given by the assessment of the political leaders’ engagement in the implementation of national plans to fight the epidemic. In this sense, the acceptance by key leaders in the government of the necessity to securitise the epidemic will be conducive to a friendly environment for the activities of HASN leaders, leading to the cascading of the norm, as indeed is the case in Botswana.

In Botswana, the securitisation efforts of UNAIDS and UNDP have clearly paid off. In 2000, Mogae declared the HIV/AIDS epidemic a national emergency and the foremost threat to human security in Botswana. As already shown, Mogae now personally leads Botswana’s HIV/AIDS efforts as the chairman of NACA. Also a dividend of this more forcible approach, the implementation of MTP II was accelerated and currently a new strategic framework is under implementation. In addition to this, since the late 90s, the government has dramatically increased funding for health and gone further to de-link the HIV/AIDS budget from the exclusive control of the Ministry of Health so that funding can be made available more efficiently for other sectors also involved in the multi-sectoral national response (Interview Tselayakgosi 16.02.2006).

In July 2004, Botswana has also started to receive financial support from the Global Fund. The Ministries of Finance and Development Planning were the recipients of the first grant of US$ 18 million to be invested in scaling-up Botswana’s response to HIV/AIDS (Global Fund, 2004: internet source). NACA is the Global Fund’s Country Coordinating Mechanism in the country. It is responsible for managing the funds according to the requirements established in the grant agreement. The Botswana Network of AIDS Services Organisations (BONASO) was the main beneficiary of the Global Fund resources in the civil society sector (DailyNews 16.05.2006). As further demonstrated later, local NGOs are very strictly constrained in their capacity to manage funds and to develop programmes independently. NACA have complete control over the disbursement of the Global Fund’s money to local NGOs which are subjected to periodic assessments by the government on the development of their activities (Interview Tselayakgosi 16.02.2006).

The close involvement between multilateral bodies, notably UNAIDS, and the Botswanan government was rebalanced in 2003 with the introduction of the US government’s PEPFAR in the country. The different securitising views of the US and UNAIDS provoked a certain degree of polarisation over policy priorities, concerning prevention, treatment, and HIV testing. The chapter turns now to the examination of the involvement of the US in promoting its own securitisation of HIV/AIDS in Botswana.

5.2. Bilateral Approach: The United States Involvement in Botswana

The US participation in Botswana’s HIV/AIDS response began later than that of the abovementioned international organisations. Contrary to the multilateral approach of these agencies, the US has invested in the bilateral route. In some cases, it develops its own policies without strong involvement in states’ institutions and coordination forums. In accessing Botswana’s domestic structure, the US government has also built winning coalitions with faith-based organisations at the civil society level. As noted in the upcoming section, these networks of religious groups are useful transmission belts, spreading the US securitisation message throughout the country.

The most important collaboration between the US and Botswanan governments in the area of HIV/AIDS has been the partnership between the Ministry of Health and the US’ CDC, named the BOTUSA project. At its beginning, the focus of this project was on programmes exclusively directed at medical research on tuberculosis. Since the late 90s, however, when the HIV/AIDS epidemic became a very serious problem in Botswana, BOTUSA has expanded its mandate to also develop HIV/AIDS programmes (Interview Roels 13.02.2006). In 2000, BOTUSA began a period of rapid growth with the advent of the CDC’s Global AIDS Programme to support prevention, treatment, care, and surveillance of HIV/AIDS. The securitisation move made by the Clinton administration by this time had a significant impact on BOTUSA’s mission as well as on its relationship with the Botswanan government. Clinton’s global HIV/AIDS initiative substantially increased funding to BOTUSA. It also became more involved with the formulation and implementation of plans rather than only with HIV/AIDS research and financial support. By this time, BOTUSA had initiated a bold project called Tebelopele to develop Voluntary Counselling and Testing Centres (VCTs). Since 1999, BOTUSA has built and staffed 16 Tebelopele centres throughout Botswana. One interesting characteristic of the Tebelopeles is that they are not integrated into the normal public health facilities of the Ministry of Health. Until 2004, the network of Tebelopeles was completely run and funded by BOTUSA.

In 2004, the US government stepped up its involvement in Botswana’s national response. The US Embassy took a strategic role after Botswana was chosen as one of the 15 countries to benefit from Bush’s PEPFAR initiative. It formed an interagency team comprising BOTUSA, the US Embassy’s Emergency Plan Team and the USAID’s Regional Center for Southern Africa (RCSA). They are jointly in charge of the strategic planning and implementation of PEPFAR in the country. With the introduction of PEPFAR, much more funding became available to the HIV/AIDS activities run by those agencies (IRIN News 09.03.2005). These funds are allocated to new or underway HIV/AIDS projects that maximise the domestic implementation of PEPFAR’s principles.

In Botswana, most of the money from PEPFAR is directed at HIV prevention efforts with a focus on abstinence and faithfulness projects (the “AB” side of the “ABC” paradigm). It supports Botswana’s Ministry of Education in developing abstinence curricula in schools as well as other similar programmes targeting vulnerable young people. The US government is funding, for example, the radio soap opera known as Makgabaneng. The logic behind the radio programme is that listeners will identify with characters in the drama and emulate their behaviour. Prior to the arrival of PEPFAR in 2003, it had a strong message for young people to condomise. However, given the new approach of Bush’s administration, the show’s producers adapted dialogues and scenes to emphasise more “AB” and less “C” (Interview Letshwiti 14.02.2006).

Another strategy of the US mission is to support the activities developed by local faith-based organisations. As will be shown in more detail, the US government through BOTUSA has strengthened the capacity of those groups to deliver the “AB” message across Botswana. Additionally, at the district level, the US Embassy coordinates the work of American Peace Corps trainees who help to build capacity and evaluate the response within DMACs. The US Peace Corps were reintroduced in Botswana in 2003 after their withdrawal six years previously on the grounds that Botswana was no longer in the group of least developed countries. The reactivation of the Peace Corps programme in Botswana was part of the expansion of the US global response to HIV/AIDS. They are very important norm leaders at the grass-roots level since, as part of their work, they interact with local authorities, school teachers and other members of the community to educate them about HIV/AIDS prevention as well as to encourage them to be tested at the local Tebelopele center (Interview Roels 13.02.2006). The securitising work of the US Peace Corps in Botswana can also be understood as a functioning mechanism of the wider process of controlling and modifying human life on a global scale. This corresponds to Foucault’s concept of biopolitics, or what I referred to in chapter 2 as the first (structural) dimension of HASN.

The US government has also been, with the Ministry of Health, developing treatment activities which include training medical staff in the public health system on ARV management and treatment quality assurance. It also provides technical and financial support to laboratorial facilities and to the Ministry of Health’s monitoring and evaluation systems. The US government also collaborates with the African Comprehensive HIV/AIDS Partnership (ACHAP). ACHAP is a partnership of the US pharmaceutical, Merck, the Bill and Melinda Gates Foundation and the Botswanan government. It was established in 2000 to help the government to achieve the goals set up in the National Plan. ACHAP develops several programmes with a large number of partners in both the public and civil society sectors. The partnership played a major role in devising and implementing the abovementioned Masa Programme. The Bill and Melinda Gates and Merck Foundations have each allocated US$ 50 million to the initiative for the period of 5 years (2000-2005). In 2004, they agreed to extend their involvement in Botswana until at least 2008 (Interview Rajamaran 28.01.2006).

The Merck Foundation is a very active participant in the formulation and implementation of the projects it supports in Botswana. The first chairman of ACHAP was Dr. Donald de Korte, a physician and former director of Merck’s subsidiary in South Africa. In this respect, the ACHAP-Masa framework provides strong empirical evidence of the successful process of amalgamation between Botswana’s domestic HIV/AIDS structures and international sources of norm diffusion. ACHAP has shown the possibility of successfully harmonising national and international interests and ideas through the creation of a shared public-private institutional structure with a single raison d’être, and guided under the framework given by HASN. In effect, it was the first time that a pharmaceutical company had involved itself directly in ARV distribution in a developing state (Interview Rajamaran 28.01.2006).

The fact that Merck chose Botswana as the beneficiary of this programme was not accidental. Botswana is a country in dire need of HIV/AIDS treatment and possesses a stable government, which is friendly to Western institutions. While donating its branded AIDS drugs, the Merck’s initiative avoided the problem of local manufacture or importation of generics. This is a key issue in other developing countries which have vigorously campaigned for increased access to generic drugs. As further analysed in the upcoming chapters, Mozambique and South Africa have refused the US approach to HIV/AIDS treatment based on expansive patented drugs. Conversely, the Botswanan government accepted the terms and conditions imposed by the US pharmaceutical giant. Merck’s and Gates’ US$ 100 million donation is attached to very strict limitations on the Botswanan government’s autonomy to pursue its own policies on AIDS treatment.

As noted later, the Mozambican and South African governments, albeit for different reasons, have been more suspicious of the “generosity” of pharmaceutical companies backed by the US government. Currently, Botswana uses mostly branded AIDS drugs for its ARV programme. The two ARVs donated by Merck, Stocrin and Crixivan, are still under patent rights in their main markets in Europe and the US. Unlike Mozambique and South Africa where patents for many ARVs have been issued, by 2005 the Botswanan government has not registered the generic substitutes of Nevirapine neither the fixed dose combination of Zidovudine and Lamiduvine that are currently manufactured by pharmaceutical companies based in India (Druce, Kgatlwane, Mosime and Ramiah, 2004:17).

Notwithstanding the close involvement of the US government in the Masa programme, there have been constant frictions between PEPFAR and the Ministry of Health/ACHAP concerning the ownership of the national ARV treatment programme. The former claims that because they are actively involved in the national government’s ARV therapy programme, in terms of financing, training and capacity-building activities, they could claim that the growing number of patients under treatment in Botswana is also an accomplishment of PEPFAR. The Botswanan government and its partners at ACHAP have a different opinion. They think Masa is their exclusive initiative since ACHAP is planning, managing and financing the entire process on the ground in terms of building clinics, paying physicians and nurses and providing the actual medicines to patients as well as monitoring their adherence to them (Interview Roels 13.02.2006).

Despite these differences of opinion between PEPFAR and the Ministry of Health/ACHAP, the US government has been quite effective in pushing through its agenda into Botswana’s HIV/AIDS policies. The abovementioned US Center for Disease Control has used the BOTUSA partnership as an entry point into the decision-making structure of the Botswanan government. The US staff based in Gaborone works very close to the Ministry of Health’s officials as well as other HIV/AIDS specialists at NACA. Although the US government has not been very keen on large cooperative groupings, it also participates in the coordination structures that NACA has created to harmonise the activities of international partners (Interview Rajamaran 28.01.2006). BOTUSA/CDC was an influential actor behind Mogae’s 2003 decision to implement routine testing in all Botswana’s VCT clinics.

Botswana was the first country that introduced this policy in Africa at a time when it was not recommended by UNAIDS. Before 2003, the government had favoured the “opt-in” approach. This is basically the idea that the patient, after a pre-HIV test counselling, must specifically consent for an HIV test while visiting a health facility. This is in line with the human rights perspective of the WHO/GPA tradition that was preserved by UNAIDS. The US government’s CDC, on the other hand, pressured its Botswana counterpart to change its testing policy to the “opt-out” system. By this approach, the pre-test counselling is eliminated and the patient is notified that an HIV test will be conducted unless he/she openly refuses it. This serves to diminish the “agency role” of patients by introducing a semi-compulsory testing system in which patients are routinely tested if they do not say otherwise.

Since 2002, CDC has strongly pushed for the Botswanan government’s adoption of the “opt-out” approach. It brought to the country several foreign specialists to give talks about the system, produced and promoted a number of policy papers and hosted technical meetings on the subject (Interview Rajamaran 28.01.2006). CDC’s longstanding experience in dealing with HIV/AIDS in the US and its high institutional stature among officials within the Ministry of Health were also important factors in building domestic consensus (Interview Rajamaran 28.01.2006). The issue was also brought up at meetings between NACA, the Ministry of Health and international partners. In this regard, one of the associate-directors of BOTUSA/CDC in Gaborone attests that,

There were a number of forums and meetings where the issue [routine testing] was brought up […] I remember that in one particular meeting the whole issue of the different paradigms was brought to the table […] maybe these meetings have helped to win over the technical people of the Ministry of Health and they approached the people in the National Aids Council and then officers close to the president realised that it was time for us to radically shift this approach by introducing routine testing (Interview Roels 13.02.2006).

After a period of intense consultative processes, Mogae announced in October 2003 that he wanted routine testing fully operational in the public health system until January of the following year. ACHAP was very supportive of introducing routine testing in Botswana. According to an official in the Ministry of Health, the Masa programme would benefit significantly from a system that “encourages” patients to get tested. Since the beginning of Masa, a major issue has been to identify the people who are HIV-positive and need ARV treatment (Interview 14.02.2006). Mogae’s decision raised concerns among UNAIDS officials and human rights advocates who have been sensitive to the rights of people living with HIV/AIDS (PLWHA). Under the new programme, health workers can record the names of patients who have been tested positive. The new plan has been denounced by global HIV/AIDS activists as an infringement of the rights of patients to confidentiality and to refuse medical care (The Boston Globe 24.10.2003).

By the time of the writing of this thesis, neither Mozambique nor South Africa had adopted similar measures. It is neither the official policy of the SADC’s HIV/AIDS structures. They still work within the UNAIDS/WHO voluntary testing paradigm, as designed by Jonathan Mann’s WHO/GPA in the mid 80s for preventing discrimination against people infected by HIV. In spite of the strong presence of US agencies in those countries, their governments resisted the pressure to adopt routine testing. In this sense, the Botswana case shows the more pervasive (as wells as persuasive) character of US securitising actors within Botswana’s domestic structure. The next section explores how those actors link up with civil society groups and transnational networks of NGOs to further inculcate the idea that the epidemic should be securitised.

5.3. The Transnational Community of HASN Seeking Domestic legitimacy: The Role of Civil Society HIV/AIDS Organisations

Botswana has not had a long history of strong civil society movement. It dates back to after its independence, in 1966, but since then civil society has grown very timidly in the country (Good, 1996; Tsie, 1996, Holm and Darnolf, 2000; Stegling and Mosima, 2002). Bauer and Taylor, for example, assert that “the general consensus around civil society in Botswana seems to be that it has been “historically absent” in the country, only showing some signs of life from the early 90s onwards” (2005:99). Botswana’s model of democracy, based on a strong state bureaucracy driven by a well-established political elite, has undermined the thriving of an autonomous and vibrant civil society sector. Since independence, the government has controlled the growth of civil society organisations through incorporating them into the state’s bureaucratic structures. According to Holm and Darnolf, “civil society exists as an extension of the bureaucracy rather than as a set of independent actors confronting politicians and civil servants” (2000:99). In this respect, the relationship between state and civil society actors in Botswana can be characterised as a top-down process in which the latter has become highly reliant on the paternalistic approach of the former.

This also applies to the HIVAIDS civil society sector. In Botswana, the challenges posed by the HIV/AIDS epidemic were conducive to the development and rapid growth of several local NGOs. However, due to Botswana’s characteristic of state-dominated domestic structure, they have had a limited impact in policy-making. These organisations face challenges similar to those of other countries in Southern Africa. These include lack of resources, high staff mobility and shortage of technical and management professionals. Given these shortcomings, local HIV/AIDS NGOs have been either co-opted by the state agencies they seek to influence or absorbed by transnational norm leaders with an interest in shaping HIV/AIDS policies. In both cases, local NGOs find themselves deeply constrained in their ability to independently affect the process and outcomes of decision-making.

These groups co-ordinate their activities at several interdependent levels: Firstly, HIV/AIDS NGOs organise themselves through four umbrella organisations which assist the varied individual groups. The Botswana Network of People Living with HIV/AIDS (BONEPWA) supports organisations of people living with HIV/AIDS (PLWHA). It runs 17 support groups and also works as the representative and spokesperson for PLWHA at NACA. BONASO is the umbrella organisation for most NGOs working with HIV/AIDS activities. Its main objective is to support HIV/AIDS NGOs in terms of capacity building, information sharing, advocacy, lobbying with the government and promoting a united approach among them (BONASO, 2004). There is also the Botswana Network on Ethics, Law and HIV/AIDS (BONELA), which addresses issues related to human rights of PLWHA and their protection against discrimination. Finally, there is the most developed and organised of them, the Botswana Christian AIDS Intervention Programme (BOCAIP). This network of faith-based organisations was created in 1997 to coordinate the work of the religious sector in the government’s multi-sectoral response.

At the state level, these umbrella organisations co-ordinate actions with the government’s national HIV/AIDS response. Unlike the highly politicised stance taken by their counterparts in South Africa, the relationship between these organisations and the Botswanan government is fairly collaborative. The projects and sources of funding of local HIV/AIDS NGOs are strictly regulated by the Botswanan government. Contrasting with the ill-resourced Mozambique, for example, the government of Botswana has its own bilateral channels for financing the activities of local NGOs working with HIV/AIDS, which has tightened state control over the policy agenda of those groups (Interview Tselayakgosi 16.02.2006). As already seen, NACA also mediates the allocation of funds from the Global Fund to local NGOs. In this regard, BONASO’s Executive Secretary, Daniel Motsatsing, has complained that NACA does not fully involves NGOs in the management of the Global Fund’s money. Usually, BONASO plays a larger role at the level of implementation, at the receiving end of policy-making, without further engagement in the elaboration and management of programmes.

The NGO sector formally participates in the NACA framework through a discussion forum. These meetings provide them with the opportunity to regularly assess their collective capacities and discuss their progresses and constraints in specific areas (Interview Tselayakgosi 16.02.2006). Simply put, this forum is a semi-institutionalised space within NACA in which civil society groups synchronise and direct their agendas and projects towards the principles and objectives set up by the generally agreed National Strategy to HIV/AIDS. There is also civil society representation at the National AIDS Council. At the local level, HIVAIDS civil society groups harmonise their activities with the local DMSACs. They provide quarterly reports of the development of their projects that will afterwards be submitted to NACA and other stakeholders in the central government and international partners (Interview Tselayakgosi 16.02.2006).

Notwithstanding their formal participation in these HIV/AIDS structures, NGOs work more as facilitators among international partners and the government than as actual agenda setters. As already said, their influence in decision-making is very limited. They react to the decisions of their sponsors rather than influence the actual process of decision-making. Even at the level of policy implementation, these groups lack capacity. Due to their irregular funding, NGOs dealing with HIV/AIDS have to dedicate most of their time to resource mobilisation. As a result, they have to adapt their activities to the policy priorities of their changing donors. This creates confusion and impairs the constitution’s continuing commitment with any set of principles (Interview Letshwiti 14.02.2006). For example, the Youth Health Organization (YOHO), a local HIV/AIDS NGO, uses money from PEPFAR to develop a number of HIV/AIDS projects, including educational campaigns promoting abstinence and fidelity among the youth. Before the advent of PEPFAR, YOHO had been funded by a US based NGO, called Advocates for Youth, which promoted HIV prevention policies more in line with the secular view of UNAIDS. In 2006, YOHO’s contract with Advocates for Youth ended and it was not renewed. In this respect, an officer from YOHO suggested that Advocates for Youth “did not get enough money in the US to continue our partnership because they are an anti-abstinence organization […] so we now have to adhere to “ABC” to stay in business” (Interview Letshwiti 14.02.2006).

In contrast with its secular counterparts, BOCAIP (the umbrella framework for faith-based organisations) has a more established role in Botswana. It is the key partner of ACHAP and BOTUSA in the civil society sector. In line with the PEPFAR guidelines, BOCAIP offers a morally-centred approach to HIV/AIDS based on abstinence and faithfulness. BOTUSA has assisted the efforts of BOCAIP to establish various counselling centres for PLWHA throughout Botswana. It has a network of 125 churches which provides volunteers to work as HIV/AIDS counsellors and educators. It runs eleven fully-operational centres which have trained up to 450 counsellors. Their counselling and prevention programme claims to have reached 500 million people since it started in 1997 (Interview Letshwiti 14.02.2006).

With the support of the US, faith-based organisations became the main HIV/AIDS NGOs in Botswana. Christian HIV/AIDS Groups have a two-tiered strategy to reach out to people and spread their particular securitisation message. Firstly, those faith-based groups participate in the coordination mechanisms as described above. This ensures that their voice is heard at the highest levels of decision-making, therefore allowing them to exert significant influence over the government and other international and national partners. Secondly, these organisations explore the bilateral route. They undertake intensive campaigns on absenteeism and faithfulness at the community level and develop their own counselling services that are not always integrated in the broader national plan. Those are autonomous initiatives, which are closely linked with the strategies of transnational Christian associations for combating the global epidemic. Despite the government’s efforts to maintain a tight grip on the activities of HIV/AIDS NGOs, it has been incapable to effectively monitor the massive flux of resources and the connections established between local and international faith-based organisations, which often bypass the government’s structures (Interview Tselayakgosi 16.02.2006).

There are also a large group of transnational NGOs and HIV/AIDS foundations operating in Botswana which align more closely with the secular principles of the UNAIDS and its partners. These are, for instance, the Bill Clinton Foundation, the International Council of Aids Services Organizations (ICASO), and the International HIV/AIDS Alliance (IHAA), among others. For example, in December 2004, ICASO and IHAA elaborated a discussion paper about the role of civil society groups in the development of the “Three Ones” (ICASO and IHAA, 2005c). While promoting this paper worldwide, they sought to improve awareness and increase the involvement of local NGOs in the promotion of the “Three Ones” principles at the national level. BONASO was the focal point in Botswana for involving local HIV/AIDS groups in this project. Unlike the US-backed religious groups, in general these secular INGOs exclusively operate within the parameters and goals established by the national plan. They also link up with local umbrella organisations such as BONASO to facilitate coordination and to share information between and among local and international NGOs as well as with the government. ICASO is a good example of a transnational HIV/AIDS network which built very complex mechanisms (or transmission belts of norms) linking global, regional and local HIV/AIDS groups based in the capital, Gaborone. At the regional level, BONEPWA and BONASO are affiliated to the Southern Africa Network of Aids Services Organizations (SANASO) which is, in turn, part of both the SADC institutional structure and the global advocacy network formed by ICASO. As already shown, ICASO is one of the five NGO’s representatives at the UNAIDS’ Programme Coordinating Board, in charge of guiding this organ’s response to the worldwide HIV/AIDS epidemic.

At their respective levels of political engagement, these advocacy bodies perform similar institutional missions and share the same (secular) values and policy concepts of the epidemic. This allows them to establish channels for the penetration of ideas on Botswana’s political structure. As already noted, ICASO has been working as an unofficial supervisory body of the national governments’ commitment to UNGASS. In Botswana, it receives periodic reports from BONASO on the progress and problems faced by the government in implementing the principles agreed during the UN special meeting of 2001 (Interview Letshwiti 14.02.2006). By deploying those tactics of norm advocacy, the abovementioned transnational networks helped to embed into the domestic structure of Botswana the principles that have been manifested and agreed upon at the UN’s global meetings on HIV/AIDS.

6. Conclusions

This chapter established that the particular features of Botswana’s domestic structure favoured the development of a strong political commitment to implement the transnational prescriptions of HASN. In this respect, the study focused on the domestic factors that explained the high domestic salience of this international norm in the country. Firstly, it focused on the distinctive features of Botswana’s political culture and system. It showed that the combination of a centralised and top-down system of decision making, a culturally and ethnically homogeneous society, and the strong political guidance of a Westernised political elite favoured the assimilation of HASN in the country.

Secondly, the study explored the intricate process of HASN adaptation in Botswana. It showed that the agenda of debates and the decision-making process in Botswana were, from the very beginning, set by the international evolution of HASN. In this regard, the establishment of national plans for action and the introduction of new policy concepts in the internal arena of deliberation were deeply influenced by developments outside Botswana. It was shown that the crisis in the global response to the epidemic, which eventually led to the creation of the UNAIDS in 1996, slowed down the pace of Botswana’s response and promoted a domestic reformulation on its HIV/AIDS policy priorities and goals.

Thirdly, at the level of individual leadership, the consolidation of HASN came during the presidency of President Mogae, from 1998. His contribution has been mostly in terms of giving a strong sense of authority and engaging both state bureaucracies and society through the use of a strong securitisation language. It was claimed, in this respect, that the successful convincement of the highest authority in the country that HIV/AIDS should be securitised represented the tipping point after which the cascading of HASN occurred in Botswana. As noted later, political leaders in Mozambique and South Africa were subjected to similar external pressures from HIV/AIDS securitising actors. Yet, in those domestic contexts the persuasion efforts of international actors were challenged/mitigated by individuals with very distinct worldviews and personal beliefs concerning the epidemic.

Fourthly, the chapter outlined the institutional mechanisms of norm incorporation, the policy principles, and the modes of operation of international HASN leaders in Botswana. Despite their shared securitisation cause, these actors displayed quite distinctive (and at times conflictive) views on the epidemic and how to react to it. The analysis concentrated on the role of multilateral organisations, namely UNAIDS and its associate agencies, and how these international bodies intervened in the formulation of national HIV/AIDS plans and in the constitution and outlook of HIV/AIDS bureaucracies. It also looked to the independent role played by the US government and how it pushed forward its own moral understandings about how to prevent the spread of HIV in Botswana. Moreover, and contrasting to the other case studies, it was demonstrated here that the issue of pharmaceutical patents was not a source of conflict between the governments of the US and Botswana. Unlike the generic-based ARV programmes of other states in Southern Africa, Botswana adopted a unique plan for the roll-out of (mostly branded) first-line AIDS drugs, which was highly supported by the US government, the US pharmaceutical giant, Merck, and the Bill and Melinda Gates Foundation.

Finally, the chapter explored the role of civil society organisations working with HIV/AIDS in Botswana. It examined how these organisations were moulded by and reacted to dynamics of norm diffusion in their relations with government structures and international partners. Given the corporatist model of state-society relations in Botswana, local HIV/AIDS groups were more like extensions of the government’s bureaucratic apparatus than independent actors in the civil society sector. Except from the more autonomous role played by faith-based organisations backed by powerful transnational partners, local HIV/AIDS NGOs worked mostly as implementing agencies, supporting the pre-determined priorities set up in the national HIV/AIDS plan. Transnational NGOs, on the other hand, such as ICASO, managed to penetrate Botswana’s domestic structure by linking up with their local counterparts, namely BONASO. As already seen, BONASO’s participation in formal structures of policy-making served as an entry point to the (secular) ideas of transnational advocacy networks.

As further elaborated later, Botswana can be seen as a success story of HIV/AIDS securitisation, if compared with South Africa’s ideological reservations towards international (norm) interference and the Mozambican political elites’ conditional delegation of power to the international actors promoting HASN. Unlike the cases of South Africa and Mozambique, where the domestic recognition of HASN was sometimes likened to their colonial and racial legacies, in Botswana those issues have not created domestic resistance or rejection to it. In this respect, Botswana’s early definition of a non-racial national identity, without experiencing a destructive civil war and lacking a strong anti-colonial feeling, contributed significantly to the definition of a domestic structure friendly to Western sources of HASN transmission. The thesis turns now to the analysis of these processes of norm incorporation in Mozambique.

Chapter 5

The Domestic Incorporation of HASN in Mozambique: “The Model of Instrumental Adherence”

1. Introduction

This chapter examines how the characteristics of Mozambique’s political culture and system conditioned the domestic adaptation of the policy prescriptions promoted by HASN transnational leaders. It shows that, contrasting with this thesis’ other case studies, in Mozambique the unparalleled level of international intervention since the mid-eighties, but particularly from the outset of the UN’s peacekeeping operation in 1992, coupled with its distinct colonial and postcolonial legacies, are fundamental factors in understanding processes of norm incorporation in the country. As demonstrated later in Mozambique, rather than an actual internalisation of the norm, conformity to HASN should be situated in the larger context of the country’s dependency on donors. It is claimed here that, notwithstanding their lack of effective sovereignty, Mozambique’s elites have instrumentally used the country’s HIV/AIDS crisis to skilfully influence people in the international community.

In this sense, the present chapter argues that the international proponents of HASN were not able to truly convince the Mozambican government that HIV/AIDS should be seen as an exceptional kind of problem. Rather, their securitisation claims were reframed domestically according to the Mozambican elites’ deep-rooted practices of dependency politics. Thus, a shallow and instrumental securitisation process was launched by Mozambique’s ruling elites as a means to please the international community of HIV/AIDS donors and international NGOs, therefore perpetuating and further improving traditional patterns of foreign assistance to the government’s agencies. The chapter also investigates the role of transnational and national civil society actors in the national response to HIV/AIDS. It shows that the HIV/AIDS civil society sector in Mozambique is almost completely formed by all types of transnational/international NGOs that are not actual manifestations of Mozambican society. The growing deterioration of the state’s public institutions during Mozambique’s prolonged civil war further increased the importance and influence of those organisations. Their allegiances with powerful Western states and multilateral institutions worked in favour of the penetration of HASN into Mozambique’s domestic system.

2. Setting the Stage: (In)dependence, Civil War, International Reconstruction and HIV/AIDS

This section illuminates the historical processes that led to the creation (and then re-creation) of the Mozambican state. As shown next, the failure of the post-colonial project destroyed an incipient sense of national unity/identity and led the political elites to engage in neo-patrimonial politics to survive and stay in power. Moreover, the ensuing dependency on the international community and the massive presence of foreign agencies and international NGOs, which literally replaced governmental institutions, further weakened the government’s authority. In this sense, the dynamics of HASN’s penetration into Mozambique’s domestic structure resembles more general understandings of African politics and society that regard the state as being deprived of effective sovereignty and functioning as a kind of “incubator” (Harsch, 1997) for developing the dominant social group. While arguing more generally about Africa, Bayart described this kind of strategic connection between internal and external political forces in terms of “politics of extraversion”.

The leading actors in Sub-Saharan societies have tended to compensate for their difficulties in the autonomization of their power and in intensifying the exploitation of their dependents by deliberate recourse to the strategies of extraversion, mobilizing resources derived from their (possibly unequal) relationship with the external environment (Bayart, 2000:218).

In Mozambique, the use of tactics of extraversion for private gains accelerated in the mid 90s with the increase in international aid for reconstruction. Given the strong international intervention in all aspects of Mozambican economic and political life, the government has not been able to exert its sovereignty rights and make independent decisions about the state’s future. In Mozambique, external dependence became a mode of political action. The institutional apparatus engineered (and for some time run) by the UN peacekeeping force was superposed to traditional notions of power relations and authority. To maintain its hold on power and maximise wealth, Mozambique’s weakened political elites had to manage their external dependency and adapt to Western views and values of democracy and liberalism. These dynamics of extraversion were also reflected in the relationship between transnational HASN leaders and the Mozambican government.

Mozambique is a particular case in Southern Africa. Its colonial and post-colonial experiences were quite distinct from those of its regional neighbours. While in Botswana, for example, the transition to independence was peaceful and marked by the formation of a stable and representative political system, in the Mozambican case the Portuguese left behind a country destroyed by war and with a burdensome colonial legacy. In the nineteenth century, the Portuguese colonial administration lacked both the inclination and the resources to firmly establish itself in the colony. It sought to fill its administrative deficiencies through issuing large concessionary grants to foreign companies (mostly British). In return for a small share of less than 10% of the profits, Portugal granted these companies administrative powers and near-complete control over the territories in which they operated. As a result, the colony was divided into three semi-autonomous regions: north, central and south. This early fragmentation of the country by the Portuguese contributed to the formation of different “nations” inside Mozambique, which impaired the constitution of a single Mozambican national identity after independence (Newitt, 2002).

Moreover, contrasting with British colonies in Southern Africa, in Mozambique the colonial power did not undertake any effort to educate an indigenous elite. The modern sector was supported by an embryonic educational and cultural structure only in the coastal cities of Lourenço Marques (Maputo) and Beira. In the early twentieth century, Portuguese liberal-minded governments made attempts to improve educational standards in the colonies. By this time, a class of mestizo intellectuals had managed to establish their own political and cultural associations and newspapers (Newitt, 2002:187). In 1933, this process was reverted with the instauration of a fascist regime in Portugal led by António Salazar, the Estado Novo. Under Salazar (1933-1974), political organisation and freedom of expression became virtually impossible in Mozambique. Dissident movements were either persecuted by Salazar’s secret police (the infamous Polícia Internacional de Defesa do Estado – PIDE) or forced into exile (Sousa, 1977).

Given Salazar’s stranglehold on Mozambique, there was never any attempt to set up a transitional political structure or to prepare an indigenous elite for the task of government (Chabal, 2002:43). The curtailment of the indigenous people from any kind of political representation or from the expression of native views had an important influence in the political evolution of Mozambique after independence. The authoritarian legacy of the Estado Novo contributed to the formation of an unrepresentative form of political leadership in the post-colonial state based on an imported ideology, Marxism-Leninism (Chabal, 2002:42). By the time of independence, the idea of a Mozambican nation was alien to the majority of Mozambique’s population (90% illiterate and 97% rural) who were integrated in ethnic clans as their universe of social and political allegiances (Abrahamsson and Nilsson, 1988:23).

During the period around 1964, the Frente de Libertação de Moçambique (Frelimo) launched its guerrilla warfare against the Portuguese. Frelimo was composed of different ethnic groups from both northern and southern provinces, the central area being more marginal to the movement. The insurgence was initially led by Eduardo Chivambo Mondlane, who was later killed in a bomb blast orchestrated by the Portuguese secret services. Following a long negotiation period, marked by infighting, intrigue and defection, Mondlane managed to unity a loose grouping of exiled nationalist organisations to fight together against the Portuguese colonialists (Hanlon, 1990:25). Armed by the Soviet Union, Frelimo inflicted heavy losses upon the Portuguese forces. The ten years from 1964 to 1974 witnesses a bloody war with enormous human and material costs for both sides that culminated in the Cravos Revolution in Portugal and the subsequent opening of independence negotiations with the African insurgents. In 25 June 1975, Frelimo became the country’s single party and its leader, Samora Machel, the first president of the new independent state of Mozambique.

From 1975 to 1984, Mozambique embarked on a radical socialist experiment. Following the soviet model, Machel introduced a rigid one-party system, the nationalisation of key sectors of the economy, state management of social services, the banning of religious activities as well as the curtailment of strikes and the collectivisation of the agricultural production (Alden, 2001:5). The Frelimo leadership believed that the newly independent state of Mozambique needed to break free from the socio-economic inheritance of colonialism and establish their regime under a revolutionary and emancipatory model.

Short of resources, the government set up inefficient state-run farms at the expense of the peasant farmers, who were traditionally the major producers in the country. It also engaged in a process of social engineering with resettlement projects intended to improve the management of resources and facilitate the socialist indoctrination of the rural populations. Those measures encountered resistance from the already economically strained peasant farmers who reacted by reducing production output and turning to the black markets (Alden, 2001:7). The hostility towards the radical changes promoted by Frelimo assumed a regional and ethnic character, something unusual up until this point in Mozambique. Populations in the central parts of Mozambique became very suspicious of Frelimo and its modernising policies.

Internationally, Frelimo launched a series of policies that would further aggravate its security and economic situation. In 1976, it introduced sanctions against Rhodesia by cutting its vital link to the port of Beira. Additionally, in the strategic province of Tete, Frelimo provided a safe haven for the Zanu guerrillas fighting the Rhodesian government. In response, Ian Smith’s regime authorised military incursions into Mozambican territory and sponsored the establishment of a guerrilla movement in central Mozambique, the Mozambican National Resistance (Renamo). Despite being largely an external creation of the Rhodesian government, Renamo built a strong support base among the growing numbers of unsatisfied groups in the central and northern provinces (Alden, 2001:7).

It was proved that Frelimo’s modernisation project was incapable of replacing traditional values and economic structures with a new system of social norms and economic relations. Renamo exploited the disillusionment of the local populations over the failure of the central government by offering new visions along ethnic lines. According to Abrahamsson and Nilsson, Renamo’s strategy of popular mobilisation took the form of a “politicisation of ethnicity” (1988:94). The traditionally marginalised Ndau people from central Mozambique formed the power base of Renamo whereas Frelimo was seen as representing the rival group of Shangaan (Tsonga) people, living in the Southern provinces of Gaza and Maputo (Vines, 1996:130).

By the early 80s, Renamo, with the logistic and financial backing of the South African government, unleashed a series of violent and orchestrated actions in the countryside, attacking the state’s infrastructure, intimidating entire populations, and further crippling the economy (Vines, 1991:57). At the same time, the South African Defence Force (SADF) launched several raids into Mozambique’s capital, Maputo, in retaliation for Frelimo’s sheltering of ANC members. The destabilisation strategy unleashed by Renamo and sponsored by the Apartheid regime was proved very effective.

In 1983, during its Fourth Party Congress, Frelimo reckoned that a radical turn on its domestic and foreign policies was fundamental in avoiding the full collapse of the post-colonial state (Ebata, 1999:142-145). However, Frelimo was unable to take decisions as a united front. The crisis provoked deep divisions within its political ranks. According to Hanlon, “this became particularly serious in the early 80s, when the Politburo seemed paralysed and unable to act on the war and the economy” (1991:26). It was also by this time that ideological shifts within the party had become more apparent. Instead of the grandiose post-colonial project of creating a socialist society in Mozambique, Frelimo engaged in a daily struggle to maintain control of the state as well as for its own survival as a coherent political unity. “Nine years of war and hardship have smashed not only the economy, but also the early enthusiasm, ideals and good political intentions” (Hanlon, 1990:263). Faced with this resource-sapping struggle, an impoverished Frelimo turned to the West for assistance. It joined the IMF and accepted the conditions of the Western powers, opening itself for drastic economic reforms.

In the late 80s, Joaquim Chissano, the successor of Samora Machel (who was killed in a plane crash in 1986) promoted a drastic move away from scientific socialism. Frelimo sought the technical and financial support of the IMF and the World Bank to put in place a bold strategy of economic liberalisation and structural reforms, aiming at the revitalisation of Mozambique’s economy. In 1989, Chissano formally renounced Frelimo’s loyalty to Marxism-Leninism, opening party membership and committing himself to democratic rule. On 30 November 1990, a new liberal constitution was promulgated, establishing direct presidential elections, separation of powers, limited presidential terms and free press (Newitt, 2002:201). Frelimo’s sudden move towards Western democracy and economic liberalism further complicated its internal coherence and domestic legitimacy. The failure of the socialist project undermined much of the Frelimo leaders’ moral authority and credibility, forcing them to reinvent themselves as committed neo-liberal capitalists. In this instance, the destruction of Frelimo’s early post-colonial project remoulded Mozambique in the image of many other (failed) states in Africa. A class of aspirant bourgeoisie grew strong within Frelimo. After 1990, party members were allowed to engage in private businesses while holding office, which set the stage for rampant corruption and the plunder of states’ assets (Alden, 2001:12).

In 1992, after the conclusion of peace talks between Frelimo and Renamo, the UN began to play a central role in Mozambique as the organisation in charge of facilitating the implementation of the General Peace Agreement and rebuilding the Mozambican state in the image of a Western liberal democracy. The signature of the peace agreement coincided with a unique period in international history. The end of the Cold War triggered a liberal euphoria among Western societies. A humanitarian normative project took hold with transnational activists, governments and multilateral institutions giving renewed priority to the provision of international norms based on human rights and democracy. The UN, which since its creation had been constantly overshadowed by the geo-strategic game played by the two super-powers, captured the opportunity to redefine its role in the international system. The UN Secretary-General, Boutros Boutros-Ghali’s landmark document, An Agenda for Peace, was one of those attempts to fully engage this organisation in its original mission as a promoter of enduring international peace.

This revised doctrine of military humanitarianism (Slim, 2002), no longer eclipsed by the need to respond to the threat posed by the two Cold War contenders, legitimised action against regimes in places as far apart as Somalia, Kosovo, Haiti and Afghanistan. Boutros-Ghali’s An Agenda for Peace set out the guiding principles for the UN’s peacekeeping operations in the post-Cold War international context. The document sketched the UN’s new instruments for peace and security, emphasising not only the traditional policing of cease-fires and the organisation of elections but also the whole process of nation-building, including powers to create interim governments and the setting up of reformed state institutions (Boutros-Ghali, 1992). As a result, the UN peacekeeping operations became more comprehensive, longer and greater in number than during the Cold War era.

Mozambique represents a particular case in which the application of this post-Cold War peacekeeping doctrine becomes a fundamental factor in understanding the reconstitution of the Mozambican state after the end of the civil war. After partial successes, as in the case of Cambodia, and total failures, as verified in Angola, the UN operation in Mozambique (ONUMOZ) emerged as the decisive case for testing and confirming the revised formulas of peacekeeping and state reconstruction in situations of complex emergencies. Frelimo was aware of the UN’s setback in Angola and its pressing need to succeed in Mozambique. Due to its particular ability to play by the international rules at the same time as envisaging clear economic and political advantages in the process of doing so, Frelimo accepted and fully collaborated with the peacekeeping mission. Although taking on a secondary role in the process of rebuilding the state, Frelimo’s leadership knew that they would almost certainly come out victorious from the 1994 presidential elections and inherit a fairly stable, institutionally reformed, and internationally legitimate sovereign state, ready for a fresh start after 25 years of failed socialism and civil war (Interview Negrão 09.08.2004).

Since the advent of democracy, Mozambique has experienced enduring political stability, impressive economic growth rates of around 9% a year, and a consistent influx of generous foreign assistance/investment. Over the five year period from 1997 to 2002, the former interventionist power, South Africa, became the largest foreign investor, accounting for an impressive 49% of Mozambique’s Foreign Direct Investment (FDI) (Grobelaar, 2004:83). However, Mozambique is still enormously dependent on foreign assistance. Nearly 50% of the country’s GDP is based on external aid (Castelo-Branco, 2002:5). International technical assistance (even ten years after the conclusion of the UN peacekeeping mission) is central to the functioning of most state institutions.

This reality also applies to HIV/AIDS policies. In Mozambique, the international commitment to helping the government face the epidemic is just one aspect of the extensive international involvement already in place in the country. Compared to this thesis’ other case studies, Mozambique felt later the impact of HIV/AIDS. Curiously, the civil war was an important factor in explaining the belated development of the epidemic in the country. During the 80s, most of the population was isolated and inaccessible, with many refugees in neighbouring countries. Moreover, Mozambican ports and railways had been substantially damaged by Renamo’s sabotage attacks, which further hindered the free movement of peoples and goods. As soon as this war-induced isolation ended in 1992 and the levels of population mobility increased, HIV spread rapidly all over the country (Interview Palha de Sousa 09.08.2004). UNAIDS estimates that in Mozambique, nearly 200,000 new HIV infections occur every year, of which 30,000 are among children. Mozambique’s National Institute of Statistics (INE) revised down its life expectancy projections for 2010 from 50.3 to 36.4 years, allowing for the impact of the epidemic (INE, 2002). Over 500 infections occur daily and an estimated 220 people die of AIDS each day (UNAIDS, 2004d).

The massive securitisation move of the late 90s presented Mozambique with an opportunity to benefit from the huge amounts of money being pledged by international donors and multilateral institutions to fight the global epidemic. The Mozambican government appeared to fully embrace the securitisation prescriptions of HASN and to move towards their institutionalisation. However, Frelimo’s adherence to international HIV/AIDS norms should be understood against the backdrop of its long-term dependency on international financing. The creation of a particular political culture in Mozambique, characterised by the use of the country’s many crises to influence the international community, has also framed the manner by which Frelimo absorbed the proposed securitisation of HIV/AIDS. As shown in more detail later, in the minds of the most experienced leaders, who in many ways personified the Mozambican state, the HIV/AIDS epidemic was just another chapter in Mozambique’s long history of disaster followed by international relief. The challenge for Frelimo would be to adapt to the securitisation language of the global response, therefore gaining the sympathy (and money) of HASN leaders.

3. Institutional Strategies and HIV/AIDS Policies in Mozambique

The incorporation of HASN in Mozambique, and its impact on the government’s response to HIV/AIDS should be situated within the context of a profoundly weakened state. In the aftermath of the civil war, Frelimo had to deal with the impact of the growing epidemic alongside the huge task of rebuilding the state. In the early 90s, while many countries in the region were experiencing strong development gains and economic growth, Mozambique’s population was on the brink of starvation, the economy in ruins and the government completely disrupted. The HIV/AIDS epidemic took hold in Mozambique against this backdrop of civil war, economic and political reconstruction, weak state institutions, erratic leadership and natural disasters.

From the mid 80s until the signing of the peace agreement with Renamo in 1992, Mozambique saw a slow expansion of the epidemic with no clear unified response from the government. In 1986, in the apices of the civil war, Frelimo first identified HIV/AIDS as a potentially serious health problem. Health officials observed the rapid expansion of HIV/AIDS in the neighbouring countries and realised that they had to start doing something because “it will come to us soon” (Interview Palha de Sousa 09.08.2004). However, by this time, the spreading of the disease had been eclipsed by the more prominent threat posed by Renamo (Interview Palha de Sousa 09.08.2004).

During this early period, the government’s response to HIV/AIDS was extremely limited. In 1988, it set up Mozambique’s first National HIV/AIDS Commission. Two years later, the Ministry of Health, under the technical assistance of WHO’s Global Programme, put in place an HIV/AIDS Epidemic Alert System (Centre for the Study of AIDS and the Centre for Human Rights, 2004b:19). These early initiatives, nevertheless, were hampered by the incapacity of the government to cope with a multitude of other problems that demanded more urgent action than the newly discovered disease. Renamo’s more brutal and destructive form of warfare after 1980 forced Frelimo to divert further resources to fund defence, at the expense of health, education and other social services (Andersson, 1992).

By this time, Renamo was engaged in a campaign to destroy Frelimo’s support base by targeting public infrastructures and by intimidating NGOs and international organisations working in the field. As a result of Renamo’s campaign, by the early 90s, “about half of the nation’s schools and a third of its health clinics had been damaged or destroyed” (World Bank, 1997:1). The activities of the Ministry of Health were circumscribed to the areas under Frelimo’s control. In the central provinces, where Renamo established its own provisional government, Frelimo’s state was completely absent. In those areas, basic social services were delivered by Catholic organisations and a few other religious NGOs, which were seen by Renamo as either neutral in the conflict or opposing Frelimo’s anti-religious bias (Newitt, 2002:217).

From 1993, the situation began to change due to a more stable environment after the General Peace Agreement. By then, international NGOs, donor states and multilateral organisations began to arrive in the country with HIV/AIDS projects and activities. Lacking central coordination and national guidelines from the Ministry of Health, many of these foreign actors acted unilaterally, bypassing the government. They were free to set up comfortable offices in Maputo and develop their own programmes with different priorities and principles. Their activities further weakened the government’s institutional capacity as many ill-paid health workers left for the much better-resourced private (non-profit) sector (Interview Palha de Sousa 09.08.2004).

Internationally, the leadership crisis experienced by WHO’s Global Programme also contributed to the organisational confusion that took place in Mozambique in the 90s. Mozambique’s increasing dependence on international actors undermined the government’s autonomy to define national HIV/AIDS policies as well as its ability to implement an effective national strategy. Foreign NGOs and donor states virtually took over the national response to the epidemic without any coherent centralised control from the government. In fact, during this period, the government’s institutional apparatus was still being restructured by ONUMOZ.

International NGOs’ preference for concentrating their health-related, and other, resources in specific provinces, for example, the Danish in Tete, the Dutch in Nampula, the European Union in Zambézia, the Italians in Sofala, helped undermine both national and local control and coherence of health programmes (Collins, 2006:17).

The actual “national” response to the epidemic began only in 1998 through the National Programme to Combat HIV/AIDS set up by the Ministry of Health in collaboration with UNAIDS. This was followed by the creation of an Inter-Ministerial AIDS Commission comprised of eight ministers. The government revised the early National Programme to Fight AIDS and agreed to implement a short-term plan and three medium-term plans in the following years (Centre for the Study of AIDS and the Centre for Human Rights, 2004b:19/20). This period corresponded at the international level to the advent of the global securitisation of HIV/AIDS. UNAIDS arrived in Mozambique in 1997 and immediately engaged with the Ministry of Health to devise and implement policies in line with a more aggressive response to the epidemic.

In March 2000, the Ministry of Health launched Mozambique’s first comprehensive and National Strategic Plan to Combat STDs/HIV/AIDS (PEN) for the period 2000-2002. As part of the Three Ones’ prescriptions, the plan adopted a multisectoral approach to the epidemic, attempting to involve a greater number of state and non-state actors at all levels. Also following the international formula, in May 2000, a new bureaucracy, chaired by the Prime Minister, was established to coordinate the multisectoral response, the Conselho Nacional de Combate ao Sida (CNCS). The CNCS had on its mandate the responsibility for the coordination of all governmental and non-governmental HIV/AIDS activities (Ministério da Saúde, 2000).

In 2001, a transnational NGO, the Médecins Sans Frontières (MSF), became the first organisation to introduce AIDS treatment sites in Mozambique. The MSF was followed by a Roman Catholic group, the Sant’Egidio Community, which in 2004 was providing treatment in the non-governmental sector to around 3,000 people (Interview Bortolot 05.08.2004). The Mozambican government launched its own ARV programme in 2002 under the control of the Ministry of Health. The Clinton Foundation helped the Ministry to develop a five-year operating plan for scaling-up HIV/AIDS care and treatment (Ministério da Saúde and Clinton Foundation, 2003a). The provision of free ARVs is a fairly recent development in Mozambique. It coincided, on a global level, with the UNGASS declaration of commitment on HIV/AIDS, in which state leaders agreed to fight the epidemic by investing in a dual strategy of prevention and treatment (UNGASS, 2001). Up to 2002, there was no mention given to ARVs in Mozambique’s national response. It has only been prioritised in the latest Strategic Plan (2004-2008) and the Global Fund is providing the first significant funding for ARV therapy in the country (Ministério da Saúde, 2003b). The government’s treatment plan has nonetheless progressed very slowly. By 2005, only 16,000 patients were on ARV treatment in the public health system out of the 210,000 in urgent need of it (Ministério da Saúde, 2005).

Additionally, in 2003 Mozambique became one of the fifteen countries to benefit from PEPFAR funds. The introduction of PEPFAR in Mozambique’s national response added complexity to the coordination initiatives of the government and its international partners. The US government pledged U$ 27 million to be applied in HIV/AIDS prevention and care projects for a period of 5 years (US Department of State, 2005:67). The first instalment of U$ 11 million only became available 18 months after the launch of the programme by George Bush. As shown in more detail later, the delay was caused by disputes concerning the procurement of AIDS drugs as well as by the US insistence in abstinence and faithfulness approaches to HIV prevention (Interview Saíde 11.08.2004).

As of 2004, Mozambique’s national response to HIV/AIDS had shown a certain amount of progress. Despite the slow implementation of the ARV treatment plan, an increasing number of people were accessing those AIDS drugs in the public health system. The financial assistance from the Global Fund and PEPFAR was finally having a positive impact at the grassroots levels with the setting up of treatment clinics and HIV testing and counselling centres. However, outside the capital city, Maputo, the reality was not so reassuring. Most of the multilateral agencies and NGOs were based in Maputo, resourced with new cars and well-paid employees. In the rural areas, just a few religious groups, local NGOs and a handful of government’s health workers struggled to maintain rural hospitals and health units, which were in general falling to pieces. In most of the cases, development agencies did not set up offices in the rural areas to monitor the application of their funds in HIV/AIDS projects. Moreover, as a result of Renamo’s political control of many parts of Mozambique’s central and northern provinces, which are currently badly affected by the epidemic, the Ministry of Health is scarcely present in those areas, the population being left unassisted by the government (Interview Johannsen 18.08.2004).

The problem in Mozambique is the lack of national ownership of HIV/AIDS initiatives. The role of the government is to (poorly) manage the projects devised and funded by international actors. In this respect, the government is just an intermediary between the (dominant) externally defined policies of international donors and the needs of the Mozambican population suffering from the epidemic. The actual denationalised character of the CNCS (which is the supposedly national structure created to strengthen the government’s response to the epidemic) is a clear illustration of this fact. Due to the shortage of skilled people in the country, many middle-level positions in the bureaucracy are filled by foreigners.

According to the Director of the AIDS programme in the Ministry of Health, Dr. Mouzinho Saíde, Mozambicans were marginalised by foreign partners when, in a prolonged initial stage, the CNCS meetings were conducted in English instead of Portuguese (Interview 11.08.2004). In one of those meetings, held in the CNCS headquarters in Maputo, in August 2004, the author witnessed the central role played by the so-called Group of Partners (GP) (see section 5.1) in setting the agenda for discussions. On this occasion, under the leadership of UNAIDS, the GP bypassed both the Ministry of Health and the CNCS’ executive board in leading the debates about the further implementation of the national ARVs programme and on the definition of priorities concerning the establishment of new VCT centres in rural areas.

However, the uneven and asymmetrical character of the relationship between the government of Mozambique on the one hand, and the international HASN leaders on the other, did not exclude the former from playing an active role in negotiating the domestic recognition of HASN. Rather, as the next section demonstrates, Mozambique’s political elites used their privileged position as the principal securitising audiences in the country to exert political agency. They talked the language of securitisation as “a make-believe” claim which was used to keep international donors (securitising actors) onboard. In this sense, political leaders in Mozambique perceived the domestic incorporation of HASN as an opportunity to enhance and consolidate traditional patterns of their relationship with international actors rather than a genuine convincement of the intrinsic validity of this norm.

4. Leadership perceptions and the domestic recognition of HASN

This section maintains that in Mozambique the vigorous securitisation move of HASN leaders towards the end of the 90s was translated in terms of strong political leadership by the government’s political elites only at the level of rhetoric. It appears that their actions were often intended to please an international audience of donors without an effective engagement in the actual implementation of plans. On the surface, the policy outcomes coming up from the dealings between the government and its international partners seemed very encouraging, with the elaboration of comprehensive national plans to tackle the epidemic and the financing of fully-staffed and well-equipped bureaucracies, such as the CNCS. However, underneath this apparent positive engagement of Frelimo’s policy-makers, the politics of HIV/AIDS revolved around state leaders’ other concerns with power and state control.

As demonstrated in more detail next, in Mozambique HIV/AIDS institutional structures run in parallel, and are sometimes superposed to (or even merged with), international bureaucracies of bilateral donors, international NGOs and multilateral agencies. Frelimo’s political stability depends largely on the maintenance of good relations with these international sources of financing which, in turn, sustain the government’s dominant position vis-à-vis domestic opposition groups (namely Renamo). In institutionally weak states such as this, political leaders’ perceptions about the nature of security threats differ greatly from the security concerns of well-established polities.

The traditional “security dilemma” logic assumes that security threats are external to states and that one state can counter the aggressive action of others by using military dissuasion. The realist conceptualisation of the “security dilemma” is rooted in the Cold War period, during which the continuous balance of power between the United States and the Soviet Union defined the general parameters for international security relations. However, the “(in)security dilemma” that affects weak states like Mozambique is of a different nature. In general, the prevailing security threats in states lacking institutional capacity and social cohesion are domestically oriented rather than internationally motivated. In the case of Mozambique, Frelimo defined “national security” in terms of how to acquire financial resources to perpetuate long-term patterns of state control given the constant threat posed by the growing power of Renamo.

This particular trend of the country’s political culture was reflected in Frelimo’s particular ideas and actions towards the HIV/AIDS epidemic. Rather than being seen as a security threat, the potential seriousness of the HIV/AIDS problem has been perceived by top leaders in the government as a comparative advantage, which is used by the government to benefit from the massive global mobilisation of resources to fight the epidemic. In this sense, the imported ideas about the security implications of HIV/AIDS were reconstructed by Frelimo’s elites to fit with pre-existing patterns of their relationship with external actors. In this way, it can be seen that the adoption of HASN’s prescriptions by Mozambique’s leaders was aimed at gaining outside support and relieving the state from both domestic and international pressure.

For example, the government has used the resources of powerful international partners to gain more leverage in relation to Renamo. This is clearly illustrated by the unbalanced regional allocation of money and development of HIV/AIDS activities in the country. Traditional Renamo strongholds in the central and northern parts of Mozambique are marginalised by the Frelimo state, whereas most of the HIV/AIDS action is concentrated in the Frelimo-dominated south, especially in the Maputo area. The central provinces of Sofala and Manica, which showed in 2002 the worst HIV prevalence rates in the country (21.1% and 19.8% respectively), are particularly neglected by the government. Not incidentally, these areas were also the sites of great activity by the Portuguese while fighting Frelimo as well as being the place where the Rhodesian government first established Renamo (De Brito, 1996:472). The fact that President Chissano, as well as his successor in the 2004 elections, Armando Guebuza, represent the “old guard” of Frelimo is also illustrative of the government’s regional bias against Renamo (Vines, 1996:130).

Despite Chissano’s background as a guerrilla fighter and as a radical socialist leader, he has shown over the years an impressive capacity to adapt to new political circumstances while simultaneously maintaining (or even improving) levels of international cooperation. A former devotee of Marxism-Leninism, Chissano has turned himself into a promoter of market liberalism in Southern Africa. This extreme ideological conversion is an interesting illustration of the pragmatism driving Frelimo’s leadership since the socialist dream collapsed in the mid 80s. Mozambique’s accession to the exclusive group of Commonwealth states is a clear example of Chissano’s political/ideological malleability. Despite Mozambique’s Portuguese colonial heritage, Chissano successfully claimed Mozambique’s membership in this Anglophone club of Commonwealth nations. It was mostly justified on the grounds that Mozambique had historically cooperated with the Commonwealth states against both the Rhodesian and Apartheid regimes and had paid a huge political cost as a result. In fact, Chissano believed that joining this prestigious organisation would bring economic benefits and significantly raise Mozambique’s international profile (Newitt, 2002:233). Similarly, while referring to Frelimo’s close cooperation with the international community in the aftermath of the dramatic floods that reached Mozambique in 2000, Newitt argued that,

Once again Frelimo had been caught unprepared by the magnitude of the challenge it faced, though with some skill the party leadership used the catastrophe to do what it had always done best, to win friends and influence people in the international community […] This was confirmed by Chissano himself who, in a television interview during the flood crisis, renewed his call for the cancellation of Mozambique’s foreign debt, so that Mozambique could raise fresh loans (Newitt, 2002:235).

The political astuteness of Chissano and his ability to fit into different ideological/normative frames was also reflected in his government’s commitment to international normative frameworks to combat HIV/AIDS. For example, during the UNGASS meeting in June 2001, the Mozambican Prime Minister, Pascoal Manuel Mocumbi, declared the government’s full adherence to the Declaration of Commitment and urged other states to engage in a coordinated global fight against the epidemic,

My Government believes that the Declaration we are about to adopt at this historic meeting should ensure a global commitment towards coordinating and strengthening of national, regional and international efforts to combat the epidemic in an integrated manner. We urge the international community to show the necessary political will to relieve the unprecedented sorrow and pain the pandemic is causing to humanity (UN General Assembly, 2001: internet source).

Accordingly, in April 2004, Mocumbi’s successor, Luisa Diogo, addressed the international community of donors at the Second African Partnership Forum of NEPAD in Maputo. Diogo mentioned the devastating impact of HIV/AIDS in Africa and the urgent need for vigorous measures to be taken by African leaders because,

Thousands upon thousands of teachers, health professionals, engineers, and agronomists, among other cadres, are losing their lives [...] They are leaving orphans behind and are wiping out the investment that was made in training them [...] It is thus urgent that Africa and its cooperation partners strengthen their strategic partnership in the struggle against this evil [...] So we don’t see HIV/AIDS just as a public health problem, but as a question of strategic and development security [my emphasis] (Panapress, 2004: internet source).

The Prime Minister’s public commitment to the securitisation of HIV/AIDS was aimed at a particular international audience of bilateral donors. By saying that African countries needed to “strengthen their strategic partnership with its cooperation partners”, Diogo meant that donors should increase the influx of foreign resources to face an alleged “question of strategic and development security”. Chissano himself has also used the multilateral stage to reinforce Mozambique’s acceptance of international understandings of the security impact of HIV/AIDS. In September 2003, during the UN General Assembly’s Informal Panel Discussion on HIV/AIDS, he affirmed that,

The HIV/AIDS pandemic is reversing the developmental gains made in the past decades and is posing the greatest threat to sustainable development of the region […] We are committed to fight HIV/AIDS and other diseases as contained in the United Nations Millennium Declaration and the United Nations General Assembly Special Session on HIV/AIDS […] Our commitment is also reflected in the Abuja Declaration on HIV/AIDS issued in 2001 (UN General Assembly, 2003:16).

At the level of the government’s interactions with its domestic audiences, however, the acknowledgement of HIV/AIDS as the greatest threat to development and security has not been as straightforward as it appears in the above quotations. In 2004, for example, the Minister of Health, Francisco Sogane, while addressing a domestic audience of public health workers, admitted the special magnitude and impact of HIV/AIDS, but mentioned that malaria (the number one cause of death in Mozambique) was the Ministry’s main public health target. Similarly, during the run-up to the 2004 elections, HIV/AIDS was an issue that did not strongly galvanise the electoral campaigns of either Renamo’s or Frelimo’s presidential candidates (Interview Negrão 09.08.2004). The new Mozambican President, Armando Guebuza, the winner in the 2004 election, maintained Frelimo’s traditional line of high-profile declarations of commitment to HASN followed by discrete leadership.

As noted above, the framing of HIV/AIDS as a security issue is alien to the traditional understandings of the Mozambican elite about what a security threat is (or should be). While the epidemic may impact political stability and economic development in the long-term, it poses little immediate threat to Frelimo’s hold on power. In fact, the viewpoint of key political leaders in the government is that the epidemic is an opportunity to create new (and to improve old) channels of international humanitarian assistance. In this sense, while depicting HIV/AIDS in terms of an emergencial security problem, the government is just speaking the language of the international community of donors and multilateral organisations. Behind the scenes, nonetheless, the epidemic is perceived by Mozambican policymakers as a serious public health concern along with a number of other diseases badly afflicting the country (Interview Saíde 11.08.2004). In Mozambique, the global securitisation of HIV/AIDS became an important source of international revenue in a country badly dependent on foreign aid. It is thus important to Frelimo’s leadership to play along with the securitisation game, therefore keeping wealthy international sponsors engaged in the national response to the epidemic.

5. Norm Entrepreneurs in Action: The Role of Multilateral Institutions, the US and Transnational Non-State Actors

5.1. The Multilateral Approach

This section examines the role of multilateral agencies in Mozambique’s national response to HIV/AIDS. It is argued that UNAIDS and its associate UN agencies maintained and further reinforced the patterns of institutional influence established during the period of the ONUMOZ mission. The particular interventionist character of the UN peacekeeping operation and its organisational format shaped the subsequent configuration of the relationship between international agencies and the Mozambican government. The UN’s entrenched presence in (and actual reconstruction of) Mozambique’s political system turned this multilateral body into a powerful transnational source of HASN transmission in the country.

The provisional institutional structures created by the General Peace Agreement gave the UN’s Special Representative in Mozambique, Aldo Ajello, extensive powers to lead Mozambique’s reconstruction process. Synge, in effect, quoted a Frelimo official referring to ONUMOZ as a “state within a state” (1997:36). Ajello established a Supervisory and Monitoring Commission (CSC) as the central authority in the country in charge of the implementation of the Peace Agreement’s provisions. The commission was chaired by Ajello and was composed of Frelimo’s and Renamo’s members along with the governments of Italy, France, the United Kingdom, Portugal and the United States. The relationship between the CSC and the international community of donors was further institutionalised through the creation of an alternative committee to discuss the development of the mission’s projects. In this regard, Chris Alden affirms that,

The Committee Structures created by the General Peace Agreement gave the international donor community an unprecedented and direct role in the conduct, management and policy-making of the country. Their voice increasingly influenced aspects of the peace process as they – the financiers of the various projects undertaken by ONUMOZ – scrutinized the budgetary implications of committee decisions (Alden, 2001:51).

Besides its direct participation in policymaking, the UN provided many foreign (mostly white) middle-level staff to fill essential gaps in the Mozambican state institutions. In most of these organs, English, instead of the locally spoken Portuguese, became the “working language” among high-ranked civil servants. The UN’s departure after the 1994 elections did not bring to an end the international interference in Mozambique’s political and economic spheres. During this early period, the consolidation of democratic and independent political institutions was still far from being concluded. In fact, Mozambique’s deep-rooted economic and administrative dependency on state donors, international NGOs and multilateral agencies was further deepened during the reconstruction period, hampering any prospect of effective sovereignty.

Likewise, under the leadership of UNAIDS, the UN agencies have profoundly influenced the process of decision-making towards HIV/AIDS policies from the very beginning of the government’s response in the late 90s. It was done through their intensive participation in the formulation, funding and implementation of National Plans and HIV/AIDS activities. Contrary to other states in Southern Africa, which responded earlier to the epidemic, Mozambique had not developed institutional mechanisms to monitor the penetration of global securitising actors that occurred in the late 90s. During this period, the high number of international partners involved with all kinds of activities and sources of financing made it almost impossible for the government to assess the progress of the national response in the country (Interview Saíde 11.08.2004). It was by this time that UNAIDS took responsibility for coordinating national action against the epidemic. In this respect, UNAIDS first important intervention was towards devising a coordination structure for channelling funds through the Ministry of Health. As already noted, in 1998, it also helped the government to set up its first unified national programme to fight HIV/AIDS.

In 2000, UNAIDS and fifteen donor states commenced a joint articulation of their efforts through a Group of Partners (Grupo de Parceiros – GP). The GP was an attempt to harmonise the efforts of the international community of donors within a single action framework. It works as an advocacy group that links what are considered the best international practices with regard to the management of the epidemic with national partners in the government and civil society (Interview Uane 17.08.2004). It also facilitates the exchange of HIV/AIDS information and builds consensus among all bilateral and multilateral partners (Ministério da Saúde, 2004). While acting as a single actor, the GP is neither directly involved in the implementation of the National Plan nor in monitoring the application of HIV/AIDS funds. UNAIDS, on the other hand, plays a more direct role in the process of decision-making. It channels funds to the Ministry of Health and CNCS and participates very actively in the process of implementing and managing the National Plan (Interview Chambule 13.08.2004). UNAIDS is one of the GP leading interlocutors at the CNCS’ meetings. In fact, it closely assisted the government in the setting up of the CNCS’ bureaucratic structure as well as in the definition of its working relationship with other state institutions and international partners (Interview Baggio 11.08.2004).

One of the statutory aims of the GP is to improve the CNCS’ institutional capacity and management capacity as well as to collaborate on the definition of its mandate and policy priorities (Interview Uane 17.08.2004). Especially important is its role as a bilateral transmission belt between the HASN global community and the Mozambican government. The GP, with the Ministry of Health and the CNCS, established mechanisms of consultation to discuss the prioritisation and allocation of resources to particular projects. In this respect, the main coordination framework between donors and the government is the Health Sector Wide Approach (SWAP). SWAP was created in 1997 to coordinate the external financing of the National Health System as a whole. Backed by major multilateral actors, such as the World Bank, SWAP has also been used as the formal mechanism to coordinate HIV/AIDS external assistance in Mozambique (Ministério da Saúde, 2004). Although funds are also provided bilaterally by donors for the implementation of the national HIV/AIDS plan, the logic behind using SWAP is to include the HIV/AIDS response in the context of the overall needs of the public health system (Ministério da Saúde, 2004). The creation of a parallel health structure to deal exclusively with HIV/AIDS at the expense of the wider health system has been a recurrent concern of the Mozambican government (Interview Saíde 11.08.2004). Despite the government’s concerns with its ownership of HIV/AIDS programmes, the inclusion of HIV/AIDS in the SWAP system further increased foreign participation in policy decision-making (Interview Saíde 11.08.2004).

On its current shape, SWAP has two operational mechanisms to manage the funding of the National HIV/AIDS Plan: 1) the Sectorial Organisation Committee (SOC) is formed by the GP, Ministry of Health, and international NGOs. It hosts high profile bi-annual meetings, chaired by the Minister of Health, to assess the development of programmes and to decide on financial allocations and the feasibility of projects; 2) the SWAP’s Technical Group (SWAP-TG) is made up of middle-ranked bureaucrats in the government and technical professionals working for bilateral and multilateral partners. They meet on a bi-weekly basis under the leadership of the CNCS’ executive to discuss technical details concerning the implementation of projects.

The money allocated to HIV/AIDS programmes takes a fundamental share of SWAP’s overall budget for the national health system. In the context of the global securitisation of HIV/AIDS, three large funds (the Global Fund, the World Bank’s Multi-Country AIDS Programme (MAP) and the Bill Clinton Foundation) have committed more than US$ 300 million for the period 2004-2008 (Ministério da Saúde, 2004). The Global Fund, for example, is a major financier of HIV/AIDS activities in Mozambique. The total five year value of the grants awarded to Mozambique is US$ 153 million (Global Fund, 2006). It has its own operative liaison with health authorities in the government, a Global Fund Portfolio manager, who keeps the Global Fund staff in Geneva up to date on key policy developments in the country (Interview Saíde 11.08.2004).

The CNCS is the official recipient of the Global Fund’s money through SWAP. However, it is the Ministry of Health that actually manages the funds. UNAIDS works very closely with the Ministry, which gives special leverage to this agency in influencing the government’s positions. This lack of centralised control created intense inter-bureaucratic politics and poor coordination of the activities of international partners. After 1998, institutional conflicts intensified over HIV/AIDS policy control, particularly between the Ministry of Health and the CNCS. These were power struggles over the management of the resources coming from abroad (Interview Milagres 18.08.2004). The CNCS leadership is severely disadvantaged in this respect. The highest ranked civil servants within the CNCS’s organisational hierarchy have virtually no executive power, being subordinated to the decisions made by the Minister of Health. According to its mandate, the CNCS is in charge of coordinating the work of all state bureaucracies, being, therefore, hierarchically above them. However, inside the political structure of the CNCS, the Ministry of Health absorbs almost all activities. The actual institutional format of decision-making sets the Ministry of Health at the top of the CNCS Council, whereas other Ministries and Agencies are allocated to secondary positions (Interview Saíde 11.08.2004). Although statutorily the Prime Minister is the chair of the CNCS, he does not participate directly in the decision-making process. The Minister of Health is the agenda-setter and the main source of leadership.

The international partners have access to the process of decision-making through the formal mechanisms described above and also by their direct participation in the institutional structure of the Ministry of Health. With the weakening of the state’s structures in the context of the civil war, international NGOs and the UN’s agencies working on the ground filled the gap left by the Ministry, virtually becoming the only organisations able to deliver health services in the many areas inaccessible to the government. This created a kind of permanent synergetic relationship in which the Ministry, even though it is the only recognised institution to lead the process of responding to HIV/AIDS, lacks autonomous capacity to effectively do so, and therefore must rely on the international organisations established in the country. Moreover, coordination problems within the CNCS structure and between this organisation and other state agencies left plenty of manoeuvring space to the far better prepared international partners to take the position of agenda-setters at the CNCS. In theory, the CNCS’ role would be one of elaborating, approving and implementing the strategies established by the National Strategic Plan. However, in practice all these steps are indirectly controlled by both the GP and by the direct intervention of UNAIDS and other UN agencies. The former has the budgetary power to influence decision-making options whereas the latter relies on its knowledge claims about the epidemic to influence the government’s decisions. Similarly to the international interference during the ONUMOZ period, Frelimo’s leadership delegated extensive powers to the multilateral components of the GP within the CNCS, frequently staying on the backbench in the course of the decision-making process.

The CNCS’s institutional fragility was also manifested in the Ministry of Health, which allowed international agencies, such as the UNAIDS, for example, to fill the gaps in the bureaucratic structure of the Ministry. The Ministry of Health’s self-governing mandate is heavily constrained by the GP. In the view of top officials within its structure, the Ministry has become more like an agency that manages a wide array of independent projects led by international NGOs and multilateral institutions than the repository of leadership and centralised planning (Interview Saíde 11.08.2004). The interference of these external actors divides the bureaucratic structure of the Ministry since donors often invest in separate programmes, capturing important segments of the Ministry’s qualified staff. These civil servants become loyal to donors, receiving differential incentives and resources. This is an issue of symbolic importance since the authority of the government is clearly undermined and the sense of nationhood weakened.

This should not be understood nonetheless as an actual transfer of political power from the government to a foreign authority, but rather as the indirect impact of a group of powerful international actors with disproportional material resources and strong knowledge/scientific claims about how to best organise an efficient national response to the epidemic. In this respect it is interesting to note that, contrasting with the cases of South Africa and Botswana, where the boundaries separating the state institutions from the international bureaucracies are clear, in Mozambique there is a sort of blending between the two. This kind of decision-making structure, highly infused by international actors, served the interests of Mozambique’s political elite well. The collaboration between the government, on the one hand, and international HASN leaders, on the other, helped to perpetuate long-term patterns of internal control by Frelimo’s leading actors. As already noted, the external environment has traditionally been a major source of political legitimacy and economic power to Frelimo. In this sense, the government’s engagement in skilful argumentative practices (or speech-acts) with donors and multilateral agencies compensated for the disproportional international interference on domestic HIV/AIDS policies and structures.

5.2. The Bilateral Approach: The United States Involvement in Mozambique

The participation of the US government in Mozambique’s response to HIV/AIDS began in 2000 with Bill Clinton’s global HIV/AIDS initiative. The programme was run by USAID and focused on prevention and care projects along the Maputo Corridor and the Beira region, two areas with high levels of HIV/AIDS prevalence. By this time, the US government’s perception of HIV/AIDS as a health problem had already been replaced by a more holistic view based on the security and developmental implications of the epidemic. In Mozambique, this was manifested by the USAID’s substantial expansion of its HIV/AIDS programmes and areas of interventions. It invested heavily in projects with an emphasis on the multidimensional impact of the epidemic. For example, the US government under Clinton significantly contributed with technical and financial resources to the setting up of CNCS in ensuring the fulfilment of its role of coordinating the various aspects of a comprehensive national response (USAID, 2003).

In 2004, the US involvement in Mozambique dramatically increased with the launching of Bush’s HIV/AIDS initiative. The sudden arrival of PEPFAR’s securitisation machinery raised the profile of the US Embassy in the national fight against the epidemic. Following the launching of Bush’s Plan, the epidemic was immediately fast-tracked to the top of the policy priorities of the US representation in Maputo. The US Ambassador, Helen La Lime, became the “commander-in-chief” of all PEPFAR efforts in the country. Under La Lime’s leadership, the US Embassy hosted a team of senior officials from USAID, US Human Services Center for Disease Control and Prevention (CDC), Department of Defense and the Peace Corps. This sort of “war operation” against HIV/AIDS triggered by PEPFAR was not harmonised with previous securitising strategies and coordination structures that were put in place by other international actors. (Interview Baggio 11.08.2004)

The US does not participate in any of the multilateral mechanisms described above. They negotiate the allocation of funds either through the intermediation of the USAID and some US based NGOs or by bilateral talks between Ministry of Health and the US Embassy. PEPFAR was neither integrated in the SWAP nor in the Group of Partners, USAID and the US Embassy being the main policy and finance managers in the country. In this respect, the UNAIDS-led GP feared that the PEPFAR approach could further dilute the government’s leadership role in the national response by creating an alternative policy arena outside the official mechanisms of collective decision-making (Interview Baggio 11.08.2004). PEPFAR arrived in Mozambique at a time when institutional mechanisms had already been created by UNAIDS and its co-sponsors to articulate the work of international partners. Moreover, the securitisation attempts of UNAIDS and its co-associates had also been absorbed and HIV/AIDS policies and practices defined. In this respect, the coordination of the activities of international HIV/AIDS actors was made more difficult by the parallel system created by the US. As a high-ranking official at CNCS noted - “PEPFAR was parachuted inside Mozambique in an advanced stage of our partnership with other multilateral and bilateral donors. It was definitely a source of disruption in the overall national response” (Interview Milagres 18.08.2004).

Like in Botswana, PEPFAR exclusively sponsors government initiatives, as well as NGOs based in Mozambique, which closely follow the principles and policies supported by the Bush administration. However, in Mozambique the securitisation message of the US was not as compelling as it was in its diamond-rich neighbour. For example, the US pressure for the adoption by the Botswana government of a more aggressive policy towards HIV testing has not had the same impact in Mozambique. Whereas Botswana’s policy makers have firmly embraced the advice of US pundits concerning the implementation of a semi-compulsory HIV testing system, their counterparts in Mozambique have aligned closer with the voluntary testing model of UNAIDS/WHO (Interview Baggio 11.08.2004).

As a general case, the strong influence of the UN in Mozambique has considerably constrained the autonomous role of US agencies (Interview Baggio 11.08.2004). As already seen, the UN played a fundamental role in the rebuilding of Mozambique’s bureaucracies. For many years, Mozambique was virtually a protectorate of the UN peacekeeping mission. Its influence and legitimacy in the country are reflected in the special position of UNAIDS inside the government’s decision-making structures. On the other hand, the US has only firmly arrived in Mozambique at an advanced stage of the national response. The different policy orientations of the US government and UNAIDS were transposed to the Mozambican context which led to a certain degree of conflict over the definition of their respective roles in the broader national response to the epidemic. The Mozambican government, in turn, was not a passive observer between the UN and the US. It played a mediating role while trying to accommodate the policy agendas/interests of both sides within the national strategic framework.

The triangular relationship between the government of Mozambique, the UNAIDS-led GP and the US government has been particularly difficult in two policy-areas: HIV prevention and the procurement of ARV drugs. Concerning the latter, the controversy is related to the US Government’s resistance to support the use of a generic fixed-dose combination of Nevirapine and two other anti-retroviral drugs (Lamivudine and Stavudine), which is widely used in Africa to prevent mother-to-child transmission (MTCT) of HIV. As already shown, PEPFAR does not allow the purchase of drugs that were not approved by the US Food and Drug Administration (FDA), even if they were approved by WHO’s qualification system, as in the case of the “3 in 1” generic combination.

During a visit to Mozambique, in April 2004, Randall Tobias, the man in charge of leading PEPFAR globally, reaffirmed that because of quality concerns it was not US policy to use this generic AIDS drug (Kaiser Daily 29.04.2004). Despite PEPFAR’s unwillingness to accept the fixed-dose combination, funding systems were available for such treatment from the Global Fund, World Bank and Clinton Foundation, among others. With the financial support of those agencies, the generic combination has been widely adopted by treatment clinics in Mozambique. Aside from the much cheaper cost of the generic drug, it consists of a single pill and single dose medication, which facilitates adherence to treatment. Mozambican health officials claimed that a multiplicity of drug regimes would further burden a rundown public health system (Interview Saíde 11.08.2004). Furthermore, the duplication of efforts in drug procurement is seen by both the government and UNAIDS as overwhelmingly complicated in a poor country like Mozambique (Interview Milagres 18.08.2004). In fact, Mozambique was at an advanced stage of establishing mechanisms to fund and implement AIDS treatment based on WHO’s 3 by 5 model, which has endorsed the use of low-cost and high-quality generics to achieve the goal of 3 million patients under treatment by 2005.

Therefore, the difficult task of the Mozambican government was to find a way to include the massive financial support of PEPFAR without disrupting the existing system for scaling-up access to treatment. During 2004, the Ministry of Health conducted skilful negotiations with PEPFAR representatives in which the position of the government eventually prevailed (Interview Milagres 18.08.2004). Currently, PEPFAR funds projects in Mozambique involving the use of generic drugs. However, until 2005 it only supported initiatives related to the non-pharmaceutical part of ARV treatment, such as the expansion of treatment sites, the improvement of laboratories and the training of health personnel (Interview Saíde 11.08.2004). The government was backed by UNAIDS, which by this time was engaged in the promotion of “The Three Ones” in Mozambique. The avoidance of overlapping activities of donors was precisely what motivated the creation of this action framework. Besides, WHO and UNAIDS were also involved in the global promotion of the “3 by 5” program (WHO and UNAIDS, 2006). The US government was also under intense pressure from transnational HIV/AIDS activists and NGOs of doctors (namely the MSF) who advocated for a single system of drug evaluation based on WHO’s widely regarded qualification process.

In May 2004, the US Government announced that it would revise procedures to fast-track the assessment of the fixed-dose combination for use in programmes financed by PEPFAR. However, it reaffirmed the centrality of FDA as the only recognised agency responsible for evaluating and approving the use of drugs in the US government’s HIV/AIDS assistance programmes. One year later, FDA issued the first tentative approval for the generic combination of three AIDS drugs manufactured by an Indian firm and soon after, the US administration allowed its purchase and distribution in the 15 target countries under PEPFAR (FDA, 2004). Although those negotiations were conducted at an international level, the Mozambican government played an important role while convincing the US representation in the country of the damaging impact of its approach towards AIDS treatment. Even before the US government’s decision of 2005, the CNCS and the Ministry of Health managed to persuade PEPFAR to accept the terms of the agreement by which AIDS treatment in Mozambique would be centred on generic drugs (Interview Saíde 11.08.2004).

With regard to HIV prevention, the Strategic Plan (2000-2002) established that the principal prevention strategy of the national response should be the promotion and massive distribution of condoms (CNCS, 2000:4). The revised Strategic Plan for 2004-2009 conceded that abstinence and faithfulness should be included but the key message was still that “the use of condoms must be promoted when abstinence and fidelity are not practiced” (CNCS, 2005:12). This slight change in the Mozambican government’s approach to HIV prevention can be attributed to its (economic) interest in firmly establishing the US in the wider group of international donors. Mozambique received US$ 25 million of PEPFAR funds in 2004, and US$ 48 million in 2005 (US Department of State, 2005:21). This is significantly more money than any other donor state and multilateral organisation has given in the same period of time. Despite the Mozambican government compromising with the demands of PEPFAR, in practice, however, it maintained its traditional approach of massive condom distribution and education as the most effective form of HIV prevention.

Given the lack of engagement with the “AB” strategy by the Mozambican government, the US sought to bypass the CNCS and the Ministry of Health by linking up directly with transnational and religious groups based in Mozambique. In 2004, the US government granted US$ 100 million in PEPFAR funds to eleven organisations to conduct HIV/AIDS prevention through abstinence and faithfulness in all the fifteen PEPFAR focus countries, including Mozambique. Although the individual grant amount to each organisation in each country is mostly unknown, the CNCS estimates that the US government has given at least US$ 100,000 to small local based NGOs that followed PEPFAR’s predicaments (Interview Milagres 18.08.2004).

These two particular cases are interesting illustrations of the actual role of the government of Mozambique in the national response to HIV/AIDS. Rather than being an agenda setter and policy implementer, it functions as a manager between the international/transnational sources of funding and their particular policy priorities. The above also suggests that, despite its lack of central control and domestic ownership, the government has played the securitisation game with sufficient ability to maintain and further increase bilateral and multilateral sources of revenue for HIV/AIDS related programmes. Notwithstanding the huge economic gains offered by the US, Mozambican decision-makers managed to accommodate opposing international views without jeopardising Mozambique’s relationship with any of its international partners.

5.3. The Transnational Community of HASN Seeking Domestic Legitimacy: The Role of Civil Society HIV/AIDS Organisations

In Mozambique, the period after 1984 saw a substantial increase in development assistance from international NGOs backed by the Western powers, such as Britain and the US. With the end of the civil war, this process was enormously accentuated by the establishment of a wide range of international NGOs in the country. This unprecedented period of NGO growth promoted a revolutionary change in Mozambique’s civil society sector. The constitution of a post-conflict civil society sector in Mozambique is, to a large extent, the result of this foreign invasion.

In Mozambique, the model of state corporatism inherited from Portugal and preserved by Frelimo hampered the establishment of strong local civil society groups in urban areas with autonomous political agendas. In rural areas, informal social networks based on kinship and traditional authorities have usually served as either intermediate institutions between state and society or as the sole form of socio-political organisation in the absence of the central government. After 1980, by the time the war had begun to spread throughout the country, an incipient informal civil society sector filled the public spaces left by the government. The virtual collapse of the state, particularly in rural areas, accentuated the role played by traditional community networks as alternative providers of public services and as the guarantors of social rules and political organisation (Negrão, 2003:4).

The previous traditional social networks, which informally organised themselves to cope with their community needs in the absence of the state, were profoundly transformed by the imported organisational model and political agendas introduced by Western NGOs financed by donor states and multilateral institutions. A number of foreign voices that were motivated by interests ranging from ideology/religion to technical support shaped a new social environment in Mozambique. These organisations had in general strong constituencies on their support basis in donor states and multilateral institutions and sought to build local linkages with groups having similar concerns at the national level (Alden, 2001).

This reality of benign international interventions after the end of the Cold War was well-known by Mozambique’s political elite and civil society alike. As analysed before, the ONUMOZ operation was one remarkable attempt to rebuild an African state following the political and economic assumptions supported by the Western liberal democracies. A fundamental part of Mozambique’s process of nation-building, NGOs have exercised considerable influence over the government’s definition of policies and programmes. In fact, the NGOs’ and multilateral agencies’ effective monopoly of professional skills as well as material, logistic and technical resources has prevented the government’s institutions and local civil society groups from pursuing any alternative to their imported programmatic agendas (Santos, 2003).

The role of NGOs as HASN entrepreneurs is not easy to empirically assess. The multitude of organisations with different ideological motivations and areas of interest added further complexity to the Mozambican case. In 1993, the Mozambican Network of Organisations Against AIDS (MONASO) was created to improve coordination among HIV/AIDS NGOs. Currently, it has 360 members working with a wide range of different HIV/AIDS activities. MONASO is also the official representative of the civil society sector at the CNCS. However, notwithstanding its attempts to create an environment more conducive to coordination, MONASO operates in a domestic system dominated by powerful international NGOs with competing policy priorities (Interview Magaia 16.08.2004).

Local HIV/AIDS NGOs have had a very modest impact in comparison with their international counterparts. In fact, the type of Western Non-Governmental Organisation that arrived in great numbers in the country after 1992 was completely alien to the Mozambican society. Even today local people refer to these NGOs as a foreign thing (Interview Negrão 09.08.2004). Local NGOs working with HIV/AIDS were usually either formed or co-opted by international NGOs to direct the implementation of projects as if they were their “local partners” (Interview Magaia 16.08.2004). They were merely local reproductions of the institutional formats, methodologies, and mandates of their international counterparts, which were totally unknown to the traditional forms of civil society organisation in Mozambique. According to Negrão, for example, “the language used in meetings is English, the funds come from abroad, and the recruitment of staff was detrimental to the local productive and administrative fabric” (2003:3). The corrosion of state institutions during the civil war and the weak development of a native and independent civil society favoured the growth of countless similar organisations. Given the almost total destruction of the social infrastructure of the state, international aid NGOs, alongside the UN, have been the only working institutions in the country for a long time (Interview Negrão 09.08.2004).

In Mozambique, many international HIV/AIDS NGOs are simply business organisations which turned to HIV/AIDS projects precisely because of the securitisation of the epidemic and the resulting substantial increase of funds coming from multilateral organisations and donor states. Some organisations even included HIV/AIDS activities on their institutional missions just to gain access to this money (Interview Baggio 11.08.2004). Many of these NGOs have no ideology of their own. Their financial dependency on key donor states and multilateral agencies conditioned their conceptions about HIV/AIDS interventions. Given this reliance on international sources of funding, these groups find themselves serving as intermediary institutions that facilitate the entry of HASN’s prescriptions in Mozambique according to the preferences of their powerful sponsors. Due to the financial impact of securitising actors and the lack of effective state control, NGOs that were (or became) involved with HIV/AIDS found a fertile environment in Mozambique to expand their activities and funding sources.

The INGOs operating in Mozambique are not nonetheless homogenous. They differ in many important aspects, such as their distinct sources of financing (particularly important in this respect are their different levels of autonomy from donor states and multilateral organisations), whether they are exclusively working with HIV/AIDS or if they have the epidemic as one of many other areas of intervention, the short or long-term scope of their programmes, and how they link up with other domestic HIV/AIDS actors in the government and civil society.

There is a large group of very active organisations that work either autonomously as health service providers in emergency situations or link up directly with government agencies through joint initiatives. They are faith-based groups, transnational networks of HIV/AIDS activists, and development assistance organisations, which are financially backed by their own fundraising campaigns (sometimes on the streets of European cities), by religious institutions, such as the Roman Catholic church, as well as by Western governments and their development agencies, such as USAID. They are well-established transnational groups with a clear institutional mission and significant funds at their disposal. In this respect, it is worth mentioning OXFAM, MSF, CARE, GOAL, Handicap International, Health Alliance International, among others. There are also international foundations that lobby foreign governments and pharmaceutical companies, direct funds to specific HIV/AIDS projects and also establish partnerships between national and international agencies. The Bill Clinton Foundation is an important example in this regard.

As is the case with Botswana, faith-based organisations are the most organised and well-established HIV/AIDS NGOs in Mozambique. The Roman Catholic Church and Christian transnational NGOs, largely backed by the US government, are very important in this respect. Catholicism is well rooted within Mozambican society. In the late 80s, after many years of government-led persecution of religious activities, the Catholic Church regained its influential status in Mozambique. An interesting measure of its reasserted position in Mozambique was the prominent mediating role the Roman Catholic’s Sant’Egidio Community played during the peace talks in Rome and subsequently during the electoral process. Similarly, the Comunidade de Sant’Egidio is very active in HIV/AIDS related activities. They promote key aspects of the proposed securitisation of HIV/AIDS as, for example, with regards to their strong support to the UNAIDS’ “The Three Ones” framework (Interview Bortolot 05.08.2004).

Additionally, since February 2002, around 1,000 people in Maputo, and another 1,400 distributed between 6 regions, began to benefit from the Drug Resource Enhancement Against AIDS and Malnutrition (DREAM) (Interview Bortolot 05.08.2004). The project works in synchronisation with the Ministry of Health through the Sistema Nacional de Saúde (National Health System). The HIV/AIDS patients are directed to the DREAM centres, after been tested and counselled in the Gabinetes de Atendimento e Testagem Voluntária (Voluntary Testing and Assistance Cabinets), based on public hospitals (Interview Bortolot 05.08.2004). Although it has proved efficient in providing complementary treatment and care without overstretching public resources, the DREAM Project has focused largely on communities in the province of Maputo (Notícias 09.08.2004). The lack of laboratories outside the capital city to check CD4 levels, an essential procedure for the accurate prescription of drugs, and the irregular presence of counselling and testing units in the countryside, has held back the nationwide expansion of DREAM (Interview Bortolot 05.08.2004).

Despite the important role played by religious-based organisations within the Global HIV/AIDS Polity, these groups are not seen as belonging to the same identity group as other secular international partners. As already shown, this is because their religious dogmas are often at odds with the pragmatic prescriptions of HASN entrepreneurs, such as on its support of government policies which promote sexual education and mass condom distribution. Moral reformists, such as protestant and catholic groups, emphasise de-securitising initiatives, such as long-term changes in sexual behaviour and the reinforcement of family and community values. Evangelical groups based in Mozambique, such as the very influential Igreja Universal do Reino de Deus (Universal Church of the Kingdom of God), follow a similar line, providing essential health and counselling assistance, but also stimulating stigmatisation while linking the disease with God’s punishment against sexually depraved sinners. On the other hand, multilateral institutions such as UNAIDS, and INGOs such as the MSF, which in the main part work in unison with faith-based groups, stress the short-term emergencial situation that demands effective and immediate measures against the security threat posed by the epidemic.

The Washington D.C. based NGO, Population Services International (PSI), is also very active in Mozambique. PSI was founded in 1970 and since then has expanded its social marketing projects to over 70 low-income countries. PSI’s first HIV/AIDS prevention project in Mozambique, focusing on the promotion of abstinence, fidelity and condoms, began in 1994. Their major sponsor in the country is the US government through USAID. Its stated institutional mission is to set out commercial strategies to promote health products and services that make it easier for low-income and other vulnerable people to engage in healthier behaviour (PSI, 2004). PSI is currently involved in many HIV/AIDS programs in the country. It assists the Ministry of Health in the implementation of counselling and testing at 16 sites, all of which are located within or nearby the existing health clinics and hospitals. PSI is also behind Mozambique’s very popular JeitO brand condoms, which were introduced in 1995 and sell an average of 10 million units a year. The condom project is implemented by PSI as a component of the National Strategic Plan to Combat STDs/HIV/AIDS, with funding from USAID and the Dutch Embassy (PSI, 2004). Their campaigns are based on the abovementioned “ABC” principles; abstinence and delay of sexual relations to young people not yet sexually active, mutual fidelity and condom use to high-risk groups and members of the general population exhibiting high risk behaviour (Interview Milagres 18.08.2004).

PSI’s long-term project to combat the epidemic in Mozambique is rooted in a strong moral foundation which is supported by powerful evangelical Christian lobbies in the US. Contrary to the Sant’Egidio Community, however, PSI is formally a secular organisation which also promotes the use of condoms as a mean to curb the spread of HIV among high-risk groups, such as commercial sex workers and their clients, migrant workers, truckers and intravenous drug users. In this respect, PSI displays an interesting combination of short-term pragmatic action, while promoting the use of condoms, and moral principled-beliefs linked with abstinence and faithfulness. This double strategy combining the different approaches to HIV prevention of UNAIDS and the US would not be achievable in a purely faith-based organisation such as, for example, the Sant’Egidio Community.

Given the characteristics of the HIV/AIDS NGO sector in Mozambique, it is fair to say that the idea of a boomerang effect (Keck and Sikkink, 1998; Risse and Sikkink, 1999), whereby local groups would link up with transnational partners to pressure national governments from above, does not apply to the Mozambican case. In the Mozambican political context, the distinctive transnational and national identities of civil society actors are not clearly defined. The civil society sector in Mozambique is mostly dominated by foreign actors who act transnationally and have their headquarters abroad, usually in the US and Europe. The government is highly dependent on the services they provide and on the capacity they have to attract funds and qualified personnel to the country. Domestic normative change, therefore, is negotiated between those actors and the government without the actual mediation of indigenous domestic groups. In this respect, INGOs play simultaneously the combined roles of international development partners and domestic pressure groups, lobbying the government to adopt their preferred HIV/AIDS policies and principles.

6. Conclusions

This chapter sought to understand the HIV/AIDS political process emanating from the dynamics of HASN incorporation in Mozambique. In doing so, it assessed the particular features of Mozambique’s political culture and how they greatly influenced the manner by which international HIV/AIDS actors and norms were received by state and civil society actors alike.

Firstly, the chapter highlighted the characteristics of Mozambique’s political system in a historical perspective. It was established that, due to its singular colonial legacy and post-colonial experience, the Mozambican political elites turned into intermediary agents (or managers) between international donors and the domestic interests of the dominant class. This was mainly the result of the failed socialist experience and the following dependency on donors to maintain (and sometimes run) the country’s public institutions. It was also shown that, given the collapse of the Marxist-Leninist national project, Frelimo lost its original raison d’être and then became solely concerned with how to keep its hold on power. Thus, the HIV/AIDS epidemic and the massive flux of resources available at the global level were perceived by political leaders in Maputo as an opportunity to boost their dominant position rather than an actual threat to national/human security. In this regard, the chapter explored the political rhetoric of leaders and to what extent this reinforced the domestic validity/salience of the HASN’s prescriptions.

It was demonstrated that the securitisation claims of HASN leaders were adapted to traditional forms of dependency politics carried out by skilful leaders within Frelimo. Hence, Chissano’s administration (and later Guebuza’s) spoke the securitisation language, aiming to convince his international interlocutors (and sponsors) of Mozambique’s alleged engagement in the war against HIV/AIDS. However, it did not reflect upon the actual cascading of HASN into Mozambique’s structure. As already seen, even by 2005, the CNCS and the Ministry of Health were still struggling to lead Mozambique’s response to HIV/AIDS given the lack of clear and centralised leadership from top leaders in the government.

Secondly, the chapter assessed the increasing impact of the epidemic in the country from the late 80s and the resulting policies that were put in place by the government to face it. The aim here was twofold: to describe the special dynamics of the epidemic’s impact in Mozambique; and to explain the historical progression of the government’s response from the early politicisation of the epidemic to its current securitisation under the auspices of the international community. Then, the analysis turned to the role played by the international partners as HASN leaders and how they interacted with the government of Mozambique. This section described the institutional mechanisms put in place to facilitate political coordination between donor states, multilateral agencies and the government of Mozambique and how they functioned as transmission channels of norms from the international community to the Ministry of Health and the CNCS. The main point here was the actual analysis of the decision-making structure and the policy debates between the UNAIDS-led GP, the Mozambican government and the US representation in the country.

Finally, the argument focused on the mechanisms whereby INGOs participated in the overall national response to HIV/AIDS. It was claimed that, rather than building internal coalitions with local NGOs to advance their agendas, INGOs occupied the social vacuum left by an almost non-existent civil society sector in Mozambique. The destruction of the country’s social fabric due to war and the weight of its oppressive colonial and post-colonial history are behind Mozambique’s lack of truly indigenous social movements that would work as a counterweight to the state. Given that fact, INGOs involved with HIV/AIDS projects established themselves as the only recognised non-state actors representing the interests of (and providing services to) people infected and affected by HIV/AIDS in Mozambique. In this sense, transnational groups, such as CARE International, PSI, MSF, the Sant’Egidio Community, among others, were the actual constituents of the HIV/AIDS NGO sector in the country. The agenda and ideologies of those transnational actors were conceived and developed outside Mozambique and were in the majority of cases influenced by the ideas and preferences of their Western sponsors.

One interesting thing about the Mozambican case is that, even surrounded and permeated by powerful foreign HIV/AIDS actors on all sides, the government was able to exert agency and negotiate the terms of HASN incorporation in the country. As already demonstrated, the Mozambican government was very assertive in the discussions with PEPFAR concerning the implementation of a plan for ARV treatment based on generic AIDS drugs. Similarly, the US government’s “AB” strategy was also challenged by Mozambican decision-makers who instead adopted UNAIDS’ approach to HIV prevention, with a much stronger emphasis on the use of condoms. Those examples are indicative of the far more influential role of UNAIDS in Mozambique when compared with the US’ PEPFAR. It also reveals the argumentative capacity of Mozambican policy makers (audiences of securitisation) to receive, process and assertively respond to the demands of HIV/AIDS securitising actors. As such, local audiences in Mozambique did not remain passive targets of their much more powerful transnational interlocutors.

Chapter 6

The Domestic Incorporation of HASN in South Africa: “The Model of Ideological Resistance”

1. Introduction

This chapter explores the dynamics of HASN incorporation in South Africa. It claims that the South African government (largely under Thabo Mbeki’s rule) has situated HIV/AIDS within its broader political agenda of opposing Western white domination in Africa. Although in 1994 South Africa achieved a peaceful transition to a democratically elected black majority government, the unhealed wounds left by Apartheid are still influencing discourses and defining political action in the country. As noted later, this is also manifested in the South African government’s reaction to Western understandings of the HIV/AIDS epidemic. In this regard, the government’s rationale is primarily ideological and clashes with the established authority of international HASN leaders.

One of the key issues examined here is the politicised, divisive and racialised environment inherited from the Apartheid era and how it influenced the reception of international HIV/AIDS norms and actors in the country. The work also focuses on the role of political leadership in the fight against the epidemic and how individuals holding powerful positions within the South African government were deeply influenced in their decisions by their social and cultural contexts. It is argued that those in the higher echelons of the government have used HIV/AIDS as a political springboard to voice an alternative African view and develop their own understandings of the epidemic. This explains the government’s continuous adherence to a cautious (and sometimes combative) approach to HIV/AIDS prevention and treatment policies as devised by Western HIV/AIDS actors.

However, decision-maker’s orientations do not directly translate into policy outcomes. Individual preferences are tempered by many external and domestic constraints such as the institutional format of decision-making (more or less open to the participation of domestic and international political forces, for example), and the historical circumstances in which decision-makers find themselves. To analytically organise these trends, the present chapter focuses on three inter-related factors. These are 3) the institutional format of the decision-making process; 2) the international and domestic sources of HASN entrepreneurship in South Africa, mainly multilateral organisations, the US, and HIV/AIDS NGOs; and 3) the behavioural choices and deep-rooted values and ideologies embedded in South Africa’s political culture which have informed the decisions of key policymakers in the government.

2. Setting the Stage: The Ideological Construction of Apartheid, the New South Africa and HIV/AIDS

This section describes some historical processes that led to the formation of a particular political culture in South Africa. It explains the origins of white racism and how it created a country politically divided along racial lines. As shown next, despite South Africa’s widely praised peaceful transition to democratic rule in 1994 and the subsequent achievement of lasting political stability and sound economic growth, black economic alienation and resentment against the white population is still present and strong in South African society. In this respect, the leader of the government of national unity, and the principal liberation movement during Apartheid, the ANC, failed to live up to many expectations and promises. Given the huge social demands on the state and its budget and institutional constraints, poverty, crime and unemployment remain entrenched and have in fact worsened in many areas since 1994.

Therefore, South Africa’s controversial post-1994 HIV/AIDS policies should be situated against this broader backdrop of a profoundly divided society and a government searching for directions in the face of a growing domestic and international disenchantment with the post-Apartheid ideology of “African Renaissance”. Accordingly, the clashes between the government of President Thabo Mbeki and the international community of HASN leaders are indicative of a post-Apartheid political culture that rejects Western injunctions and hails uniquely African solutions to African problems, such as HIV/AIDS.

The present territorial contour of the South African state, as well as the collective perceptions of its national identity, is rooted in a long and conflictive history that goes back to the 17th century with the establishment of the first European colonial settlement in the Cape region. In 1652, the Dutch East India Company set up a commercial station on this strategic trade route. Initially, the company intended to use the station to restock its ships, so reducing the costs of its trade with the East Indies. Also part of their policy of cost reduction, the Dutch officials sought to produce supplies locally by stimulating the permanent settlement of white farmers on the land seized from the indigenous inhabitants (Davies, O’Meara and Dlamini, 1988:4). Over the following 150 years of Dutch colonialism, these white farmers (vryboers – ‘free farmers’) developed an autonomous identity and culture, including the gradual development of a new Dutch-derived language, later called Afrikaans (the Dutch word for ‘African’). The Boer (farmer) settlers (predominantly Dutch but also French and German) brought to the Southern tip of Africa a distinct set of principles and values based predominantly on the Calvinist faith. They developed a singular racist interpretation of religion, which justified the subjugation of the black population in biblical terms. These processes of identity formation were the basis for the later development of a strong Boer/Afrikaner nationalism and its corollary, the Apartheid system.

After expropriating their land, the white settlers subjugated the Khoi and San inhabitants of the Cape and other outlying areas. They grew into a large number of landowners producing wine, wheat and other crops. Conflict soon emerged between them and the Dutch colonial power. The settlers resented the corrupt and inefficient colonial administration. They were subjected to very strict controls, being obliged to sell what they produced to the Dutch East India Company at very low fixed prices (Davies, O’Meara and Dlamini, 1988:4). Around the mid 18th century, in an attempt to escape the economic restrictions imposed by the Company, a large number of Boers moved deep into the unknown areas beyond the company’s jurisdiction. During these incursions, the settlers had to challenge the powerful Xhosa people (Thabo Mbeki, South Africa’s current president, is originally from a Xhosa tribe in Transkei (now Eastern Cape) which became later a “Bantustan” under the Apartheid regime). For approximately 50 years, they fought each other for the control of grazing lands in the region of the Fish River without any clear conclusive outcome (Omer-Cooper, 1994:22).

The colonial conquest of what is now South Africa encountered fierce resistance from the culturally and ethnically diverse indigenous population. As late as the mid 19th century, the central and eastern areas of present-day South Africa were still occupied by five powerful African kingdoms (the Zulu, Ndebele, Swazi, Basotho, and Bapedi). After 1830, the expansion of the British and Boer colonialists to the hinterland of South Africa brought them into armed conflict with these various groups. Notwithstanding the much superior military power of both colonial powers, the majority of these native societies managed to remain economically and politically independent throughout the century (Davies, O’Meara and Dlamini, 1988:6).

During the 19th century, the Afrikaner identity was further strengthened as a result of British colonialism in South Africa. In 1806, the British crown seized the Cape from the Dutch. The British rulers initiated significant social and political changes in the region through introducing free trade policies and gradually abolishing slavery in the Cape colony. This policy of relaxing labour and market controls led to increasing antagonism with the Boer settlers. As a response, in the mid/late 1830s, they once again migrated in large numbers to the interior.

In the 1860s, with the discovery of the world’s largest deposits of diamonds and then gold in Kimberley and Johannesburg, the British interest in South Africa grew substantially. In a matter of years, the previous expensive, unproductive and burdensome colony turned into the “golden pot” of the British Empire. In the following decades, the British sought to reverse the independence of the Boer republics of Transvaal and the Orange Free State. It was only possible through the use of British military power against the Boers. Following the British victory in the Anglo-Boer War (1899-1902), the two republics were finally incorporated as part of the British colonies in South Africa.

In South Africa, the discovery of valuable minerals completely transformed the previous social systems and forged new forms of social relations, culture and modes of living. As a matter of fact, the final colonial conquest of the African societies was only completed in the late 19th century with the establishment of the mining industry. It drew a very large number of black workers from all over Southern Africa to the goldfields of Witwatersrand (Patan, 1965). African peasants left their land and families to join the hordes of people heading to the mines. Given the rapid industrialisation of South Africa, from 1910 to 1940 this system of migrant labour was adapted and further expanded to other economic sectors, such as agriculture and industry. Some authors (Benatar, 2001; Walker, Reid, and Cornell, 2004) believe that the introduction of diamond and gold mining in South Africa, in the late 19th century, helped to create the right social and economic conditions for the subsequent spread of epidemic diseases, including HIV/AIDS.

South Africa has traditionally had a strong dependency on migrant labour from rural areas and from other countries in Southern Africa. It has been the principal source of labour to the mines, factories, offices and domestic services. Initially labour mobility was the result of economic opportunities in the diamond and gold fields which prompted entire populations to areas in which they could make a living. This later became the official policy of the Apartheid regime. It was in the mining industry that many institutions and forms of exploitation were first developed and later converted into their modern form with the institutionalisation of the Apartheid system. With the advent of Apartheid, this system was reinforced and formalised by the National Party government. South Africa’s black population was pushed into crowded and unsanitary homelands which led to the breakdown of traditional social structures. Apartheid’s system of social engineering, with large-scale forced removals and relocations, further deteriorated the social conditions and economic viability of these black communities. Due to long hours working and periods away from home, many children were looked after by neighbours and adults other than their parents. This situation led to child abuse and prostitution. Health treatment was very scarce and diseases, including those of a sexually transmitted nature, went untreated.

Politically, notwithstanding the Boer’s crushing defeat in the war, the actual losers were black Africans whose interests were sacrificed in the pursuit of reconciliation between the British and the Afrikaners (Dubow, 2000:1-2). In 1907, Transvaal and the Orange Free State regained self-determination and in 1910 they formed, with the provinces of Natal and Cape, the Union of South Africa. In the first decade of South Africa’s existence, the white rulers fully consolidated their power and gradually increased their regulatory control over the black populations. The new state, under the leadership of Louis Botha, sustained and reinforced laws of racial segregation that had already been in place in several provinces. For example, under Botha’s new draconian laws, African landownership rights were strictly controlled, turning self-sufficient peasants into wage workers for white farmers, mining companies and factory owners.

In January 1912, a number of prominent men and women founded the South African Native National Congress (SANNC). This new organisation (which became the ANC ten years later) aimed to support and advance African civil and political rights at a time when a unitary white supremacist state appeared to crystallise in South Africa. Although elite Africans had engaged in political activism since at least the late 19th century, SANNC represented something new in the South African context. It was the first genuinely national organisation and was dedicated to overcoming racial divisions and extending citizenship rights in South Africa (Dubow, 2000:1-3). By this time, the constitutive ethos of the South African nation was beginning to be more clearly defined through the formal establishment of the political struggle between, on the one hand, the Afrikaner ideology of white supremacy, and, on the other, the SANNC/ANC’s African nationalism.

The four-decade history of Apartheid and the black resistance to it has been extraordinarily well-documented and analysed (e.g. Carter, 1980; ANC, 1988; Mandela, 1995; Dubow, 1995; O’Meara, 1996; de Klerk, 1999). In short, the resistance to Apartheid became more aggressive during the 60s when the ANC adopted a policy of armed struggle. During the 70s, the Apartheid state faced the black resistance with a more lethal and violent strategy. Mass protests against Apartheid policies were met with extreme brutality by the government’s security apparatus. This backfired against the regime with an increase in mass mobilisation over the years. With many of the ANC’s leaders either in prison or exiled and all African nationalist movements banned, trade unions became more involved in the anti-Apartheid struggle. In the late 80s, the Congress of South African Trade Unions (COSATU) joined the United Democratic Front (UDF), an alliance of hundreds of civil society organisations, in a campaign of civil disobedience intended to weaken Pretoria’s regime (Du Toit, 1995).

In the early 90s, given the human and economic cost of state repression, the regional and international political isolation, the economic crisis triggered by international sanctions, and the almost unanimous condemnation of the international community, the government of Frederik de Klerk finally agreed to negotiate the end of Apartheid. The settlement culminated in the historic election of ANC’s leader Nelson Mandela in 1994 to the presidency of South Africa.

The constitutive features of South Africa’s society (burdened with social and political struggles, population mobility, racial exclusion, and characterised by drastic political transformation since the early 1990s) has significantly contributed to the explosive expansion of HIV/AIDS in the country. During the early and mid 80s, at the time HIV started to appear in South Africa, state-sponsored violence against anti-Apartheid movements triggered political instability and social turmoil in overcrowded townships. In the final years of the Apartheid regime, the almost total disruption of civil society had resulted as a consequence of the cycles of oppression and resistance in the townships. This volatile environment has masked the progress of HIV/AIDS and created the right conditions for its spread (Whiteside and Sunter, 2000:62). It has also helped the development of a system of values and social practices that was reflected in the manner in which both political leaders and the South African society at large responded to the impact of the epidemic (Benatar, 2001).

South Africa has one of the fastest-growing HIV/AIDS epidemics in the world. From 1982 to 2003, the number of HIV infections in the country escalated from only 2 cases to around 5 million. The World Health Organization (WHO) estimates that, currently, South Africa has more people living with HIV than any other country in the world. AIDS is the major cause of death in South Africa. In 2002 alone, it accounted for 40% of all deaths in the country, and over half of the deaths in the provinces of KwaZulu-Natal (52%) and Mpumalanga (51%) (Rensburg and Friedman, 2002:21-22). Average life expectancy is expected to fall from approximately 60 years to 40 years between 1998 and 2008. According to recent statistics by UNAIDS, around 1,000 people die from AIDS in the country every day. Initially, the disease primarily targeted white male homosexuals. However, as the virus spread throughout the 80s, so the disease began to reach other groups. Currently in South Africa, the HIV/AIDS epidemic is having a severe impact on the young, heterosexual, black, and economically poor populations. Young women aged 20-30 have the highest prevalence rates. As some studies demonstrate, since a great percentage of South Africa’s population falls into this age group, HIV/AIDS can potentially have a very serious impact on socio-economic development (Whiteside and Sunter, 2000:58).

With the election of Nelson Mandela in 1994, Apartheid’s draconian controls on black South Africans were relaxed. However, more than ten years after the end of Apartheid, the lessening of structural inequalities in South African society is still far from being concluded. At the outset of the new government, everything had to be done from the scratch. As a consequence of decades of racism, President Mandela inherited an unbalanced public health system. The healthcare facilities designated for whites in urban areas were fully equipped and very sophisticated, whereas health structures for black people, mostly in rural areas, were extremely poor. The challenge facing the ANC government was to move towards making healthcare accessible to all South Africans, irrespective of their colour or geographic location. This was not an easy task nonetheless. Decades of unjust allocation of resources would not be reverted overnight. Another result of the impact of the political transition was that the state bureaucracies had to go through a process of procedural and staff rearrangement. The ensuing disputes between the new occupiers and the remaining representatives of the old regime as well as the redefinition of goals and organisational routines led to an extended period of bureaucratic semi-paralysis, which impacted the efficiency and availability of services in all public sectors (Strode and Grant, 2004).

The HIV/AIDS epidemic did not appear in South Africa in a vacuum. It became part of the ideological dynamics of change in South African society that helped to shape the understanding of what this virus and the resulting illness represented. In the early 90s, the South African government had to cope with a significant rise in the levels of HIV prevalence in the context of a historic process of political change. Out of the challenges facing political leaders during the transition process, HIV/AIDS was perceived as the least problematic in a series of threats that seemed to hinder the success of the political transition. Impeding risks of violence and uprising in KwaZulu-Natal and Witwatersrand, including even the potential occurrence of a civil war, concentrated the energies of the government’s decision-makers and ANC members alike (Marais, 2000:6). Thus, in terms of South Africa’s security environment, clearly HIV/AIDS was not an issue during this period. However, HIV silently took hold in South Africa’s society and rapidly proliferated.

The subjective influence of Apartheid on social interpretations of the HIV/AIDS epidemic is also important. The racial stereotypes created in the context of the Apartheid regime are still present in the way South African people see and react to the epidemic. Issues taken for granted in the West, as matters of individual choice – such as the use of condoms, for example – are in South Africa part of complex social interpretations. In South Africa, the link between the promotion of the use of condoms and an allegedly Western (white) plot to control the growth of black populations is widespread. The urban legend that HIV was introduced by whites in the final years of Apartheid to exterminate blacks is not unusual among well-informed South Africans.

In South Africa, the racial discourse, placing of blame on a kind of neo-colonialism, and the socio-political environment inherited from the white regime were internalised in the way people define causal relationships, and how they think they should respond to HIV/AIDS. In this respect, the stigma associated with HIV/AIDS is a result of, and at the same time reinforces, the social structure of South African society, characterised by deep-seated social divisions, exclusion, and racial prejudices. Therefore, a crucial difference between South Africa and this thesis’ other case studies is the legacy of the Apartheid regime and how social/racial fragmentation helped the spread of the virus as well as creating huge ideological barriers to its combat (Interview Ala 23.07.2004). As demonstrated later, the defining impact of Apartheid in shaping the political culture of South African society is a key factor in understanding why some decision-makers, such as the President himself and the Minister of Health, have taken a rather deviating stance towards the HIV/AIDS epidemic. Those actors are embedded in social structures and norms that have a profound influence on their behavioural choices. In that sense, the examination of how the behaviour of individuals is influenced by their social milieu is fundamental in understanding the broader determinants of the responses to the epidemic in the country.

3. Institutional Strategies and HIV/AIDS Policies in South Africa

This section argues that in South Africa, state responses to HIV/AIDS were characterised by the government’s politicisation/racialisation of the epidemic. Both the Apartheid regime and the post-1994 ANC governments framed HIV/AIDS in terms of the mindsets of their longstanding racial divisions. The former defined HIV/AIDS as an epidemic of the black people, whereas the latter perceived the disease as a legacy of the draconian white minority’s policies against the black population. The influence of international HASN leaders in South Africa was markedly distinctive in this respect. Despite the end of the international isolation of South Africa in the early 90s, and some notable changes in policy direction since 1994, the engagement of the global community of HASN in South Africa’s response to HIV/AIDS has been complicated by fiery domestic infighting and the personal sensitivities of high-ranking politicians in the government.

Since the late 80s, South African health professionals and many civil servants working in public health related areas seemed aware of the threat posed by HIV/AIDS. In 1985, the Department of Health (DoH) released its first report acknowledging the presence of HIV/AIDS in South Africa. By this time, the government’s reaction was notoriously modest (Furlong and Ball, 2005). Botha’s regime, and its conservative white electorate, saw AIDS as an illness limited to the black population, drug users, and/or homosexual men (Fourie, 2005). Moreover, at the top levels of decision-making, the nascent epidemic was overshadowed by more urgent threats, such as the economic sanctions against the regime, the political isolation imposed by the international community, the ever-present threat of hostile states in Southern Africa, the widespread social unrest in black urban areas and the guerrilla campaign promoted by ANC (Furlong and Ball, 2005:131).

In 1987, disquieting reports from South Africa’s Medical Research Council (MRC) revealed a significant increase in heterosexual transmission among African miners and other black communities. By then, HIV/AIDS had begun to be more widely recognised as a real public health threat to the general black population. This increased the government’s discriminatory association of HIV/AIDS with black people. As Fourie puts it, “the “gay plague” had become the “black death” – an untimely addition to the greater National Party pathology of a “swart gevaar” [black danger]” (2005:96). Within the ANC cadres, on the other hand, some influential voices blamed the white minority government as well as Western governments for artificially producing the HIV virus to decimate blacks (Fourie, 2005:96). During this early period, Botha’s administration was so concerned with the preservation of the Apartheid regime that few governmental efforts were directed at a disease that seemed to strike mostly the black population.

In the year 1989, the elaboration of a comprehensive policy response to HIV/AIDS was facilitated by the changing political landscape at the outset of de Klerk’s administration. During this time, a more participative environment was established due to the legalisation of the liberation movements and their subsequent inclusion in public policy debates. In March 1990, the government met ANC leaders for the first time to debate the impact of HIV/AIDS in South Africa. They presented a joint request for funds and technical assistance from WHO’s HIV/AIDS Global Programme (Furlong and Ball, 2005:132). Additionally, by this period, the DoH was assisted by WHO in setting up eleven HIV/AIDS training, information, and counselling centres, known in South Africa by the acronym ATICCs.

It was only in October 1992, however, that the first clear attempt to devise a coherent national HIV/AIDS plan was developed through a consultative effort put in place by the ANC, the DoH, and a variety of representatives from Civil Society, such as labour, business, religious and other civic structures. The result was the establishment of a national body for HIV/AIDS activities, named the National AIDS Co-coordinating Committee of South Africa (NACOSA) (Schneider, 1998:7). For the first time since the onset of the epidemic in South Africa, the government allowed a truly inclusive body to discuss the national public response to HIV/AIDS. Despite these positive developments, by this point the government was still primarily concerned with fundamental political negotiations with the ANC and other liberation movements that five years later led to the conclusion of the political transition to democratic rule. This meant that the government perceived HIV/AIDS as a less important issue compared with the major political challenges the National Party had to face in terms of preserving its political weight (even its survival as a force of significance) during and after the transitional period. Moreover, the racial bias of the National Party was strongly manifested in the way HIV/AIDS policies were implemented. Furlong and Ball, for example, noted that the ATICCs were strategically located “where they served almost exclusively whites; only in mid-1993 was one for Soweto approved” (2005:133).

With the inauguration of democracy, and still at manageable levels, the new Mandela government seemed willing to engage in a broad effort to face the looming prospects posed by the epidemic. It was clear that the new government had a comprehensive knowledge of both the medical and socioeconomic effects that HIV/AIDS could cause the South African people (Schneider, 1998:6). In 1994, ANC had robust and detailed projections showing that HIV/AIDS was emerging as a major public health issue in the country (Butler, 2005:593). Those predictions indicated, for example, that by 2005 something like 24% of South Africa’s adult population would be infected with HIV if effective prevention campaigns were not implemented (ANC, 1994).

The NACOSA plan was approved by the whole range of social actors: religious groups, trade unions, as well as locally-based organisations and the private sector, which helped in its elaboration (Scheneider, 1998:7). In June 1994, it became the first official South African National AIDS Plan (NAP). The Minister of Health, Dr. Nkosazana Zuma, fully endorsed NAP and committed the DoH to its implementation through the establishment of a Directorate of HIV/AIDS and Sexually Transmitted Diseases. The Plan recognised the multidimensional impact of the epidemic and the necessity of an intersectoral partnership to respond to it. Important factors compounding to the virus spreading, such as, for example, unemployment, migration, civil and military mobility, gender, et cetera, were constitutive parts of South Africa’s national strategy to face the HIV/AIDS epidemic. The conditions were in place therefore for an effective response to the epidemic. However, this has still not happened. In the years following the setting up of NACOSA, the HIV/AIDS epidemic spiralled out of control with an exponential increase in the number of people infected.

UNAIDS arrived in South Africa in November 1996 to assist the government in the national response. It established a working group on HIV/AIDS surveillance that compiled and organised data on the epidemic in the country (UNAIDS, 2002:2). Since then, UNAIDS has produced a number of epidemiological and policy reports that were subjected to close scrutiny by the top-leadership in the country. By the end of the 90s, divisions between two competing paradigms were already visible in the public policy debates on HIV/AIDS. The non-governmental sector and parts of the health bureaucracy aligned more closely with the views and prescriptions of the epistemic community of HASN leaders, such as UNAIDS. Conversely, the ANC leadership began to forge its own (African-Renaissance inspired) interpretations and policy recommendations on the epidemic. The divergences between these two broad worldviews would be further accentuated over the years.

In 1997, three years after the setting up of the National Plan, not much had been accomplished to contain the spread of the epidemic. After a hopeful start, the institutional mechanisms put in place to harness political commitment proved to be ineffective and undermined by controversy and fragmentation. In the same year, a comprehensive National Review of South Africa’s response to the HIV/AIDS epidemic suggested reforms, regarding the institutional arrangements established during the outset of Mandela’s administration. The review pointed to the problem of interdepartmental conflict and the narrow focus on the health sector and recommended the moving of responsibility to the Deputy President as an attempt to guarantee political leadership to a higher level of political authority. Based on the review’s recommendations, the government decided to set up an Inter-Ministerial Committee (IMC) on HIV/AIDS. Formed by Cabinet Ministers and their deputies, the IMC’s task was to facilitate co-ordination between departments and improve their political commitment to addressing the epidemic. Ironically, the IMC was first headed by the then Deputy President, Thabo Mbeki, who later embraced rather unconventional ideas on HIV/AIDS. The committee was disbanded in 1999 and replaced by the South African National Aids Council (SANAC).

In 2000, already under the presidency of Mbeki, the health minister Manto Tshabalala-Msimang (who, like her predecessor Dlamini-Zuma is a medical doctor) launched a new plan named the HIV/AIDS/STD Strategic Plan for South Africa, 2000-2005. The contents of the plan were based upon the template given by UNAIDS as well as in the previous NAP of 1994 (DoH, 2000). Despite its widely praised holistic approach, the new plan lacked from the beginning clear political commitment and created divergences with civil society groups by excluding the ARV option for AIDS treatment (Butler, 2005:595). It followed UNAIDS advice to create a single HIV/AIDS coordinating agency headed by the top political leadership in the country. SANAC became South Africa’s national HIV/AIDS coordinating body. The Deputy President Jacob Zuma was appointed the first chair of the National HIV/AIDS Council (DoH, 2000). In 2006, during a rape trial, Zuma admitted to have engaged in unprotected sex with his alleged victim, who he knew was HIV positive (Mail & Guardian 31.05.2006). This extreme case of reckless behaviour crudely reveals the immense gap separating the international norms guiding HIV prevention and the social and cultural contexts in which political leaders operate in South Africa.

Despite its far-reaching agenda, SANAC has not fulfilled the expectations of becoming the leading HIV/AIDS institutional body in South Africa (Schneider, 1998b). SANAC is considered one of the most unproductive bodies of this kind in Southern Africa (Interview Caesar 08.07.2004 and Interview Ralph 25.08.2004). This is due mostly to domestic divergences surrounding HIV/AIDS policies. A common criticism towards SANAC is that its current structure is controlled by the DoH, which is the sole agenda-setter for all meetings. This prevents other SANAC members from including issues in the discussions (Strode and Grant, 2004:23). Moreover, as a sign of the government’s scepticism towards the mainstreaming of knowledge about HIV/AIDS, SANAC excluded leading HIV/AIDS researchers and NGOs, the Medical Research Council, and the Medicines’ Control Council (Butler, 2005:594). Not incidentally, International partners were also not represented at SANAC.

In March 2000, Mbeki and Msimang surprised domestic and international audiences when announcing the formation of a Presidential Advisory Panel (DoH, 2001). Formed largely by non-South Africans, its tasks included the assessment of some established scientific principles concerning the HIV virus and its links with the immune deficiency that leads to AIDS, as well as to review evidence that AZT and Nevirapine, two essential drugs in the treatment of AIDS, were ineffective and toxic (DoH, 2001). Apparently, Mbeki was seduced by the view of a few dissenting scientists, called ‘denialists’, the most notorious of whom was the US-based doctor Peter Duesberg, who scientifically questioned the link between HIV and AIDS and the efficacy of anti-retroviral drugs.

Mbeki’s personal beliefs deeply influenced the way his government would address the epidemic. Government officials began to advocate that rather than the HIV virus, deep-rooted social problems, such as poverty and exclusion, were behind the immunodeficiency experienced by many black South Africans. The government’s questioning of the efficiency of AIDS drugs has also fundamentally impacted the collective imagery of South Africans. In a society in which figures of leadership are very important, Mbeki’s and his Minister of Health’s ideas about ARVs greatly influenced people’s reasoning about whether they should take them or not. According to a health worker interviewed in 2004, in Pretoria, the irregular provision of drugs is not the only problem they face; there is also the issue of convincing patients of the reliability and safety of these medicines.

In November 2003, amid great controversy between civil society groups and the government’s top-level decision-makers, namely President Mbeki himself and the Minister of Health, the Cabinet finally approved an ambitious plan to roll-out anti-retroviral treatment to an estimated 53,000 people by the end of March 2005. The government’s decision was the result of a lawsuit filed by an important South African HIV/AIDS NGO, the Treatment Action Campaign (TAC), against the Minister of Health and nine of the provincial health ministers. It was basically comprised of two claims: the first one compelling the government to make the drug Nevirapine available in the national public health system and the second ordering it to produce a clear national policy to prevent mother-to-child infection. At the end of 2001, the Constitutional Court of South Africa ruled in favour of TAC and ordered the government to initiate the immediate provision of Nevirapine nationwide. After a series of court appeals, in which the government insisted that Nevirapine was toxic and that further research on its effects were needed, in May 2002, the Constitutional Court upheld the High Court’s decision.

Even after the release of South Africa’s care and treatment plan, the government continued to challenge the efficiency and reliability of ARVs. Following the launch of the government’s plan to provide access to ARVs therapy, the Health Minister engaged in a campaign to promote alternative methods for preventing and treating HIV/AIDS such as garlic, lemon and beetroot. Moreover, during the 15th International Aids Conference, in Bangkok, in July 2004, Msimang created widespread bewilderment among participants, when she publicly questioned the validity of Nevirapine, an essential drug in preventing the transmission of HIV from mother to child (This Day 12.07.2004; The Star 15.07.1004). She claimed, referring to research undertaken by South Africa’s Medicines Control Council (MCC), that mothers who used this drug could develop resistance to ARVs in the future. Four years before Bangkok, at the international AIDS conference in Durban, South Africa openly cast doubts on the link between HIV and AIDS and questioned the reliability of ARVs. Mbeki stated on that occasion that he did not believe that a single virus could be responsible for all of Africa’s public health problems (Mbeki, 2000a: internet source).

Although the defensiveness of Mbeki’s administration has slightly eased after 2005, South Africa is still reluctant to follow the international guidelines agreed by national governments in multilateral forums of negotiation. During the 2006 UN High Level Meeting on HIV/AIDS, the South African diplomacy worked hard to reverse the UNGASS Declaration of 2001 with regard to the goal of universal access to treatment (Aidsmap 01.06.2006). It also lobbied against the proposal of setting clear targets for national governments in the areas of prevention, care and treatment (Aidsmap 01.06.2006). These actions of the South African delegation suggest that confrontational mentalities guiding the policy preferences of decision-makers in Pretoria are still intact.

As noted later, the arrival of PEPFAR in South Africa, in 2003/4, was also a source of contention with the South African government, given the US insistence on purchasing only expensive name-brand AIDS drugs. The Cabinet approval of a general ARV program was predicated on using the cheaper generic drugs instead of the more costly brands. The US position was described by members of the ANC government as a capitalist plot against South Africa and its people. This illustrates the fact that the socialisation work of HASN leaders, such as the US government, has encountered in South Africa a strident resistance from Mbeki’s government and its suspicion of the Western powers’ (good) intentions in Africa.

4. Leadership perceptions and the domestic recognition of HASN

This section claims that deep-rooted principled beliefs and worldviews of top leaders in the South African government blocked (or at least deeply constrained) the cascading of HASN’s prescriptions in South Africa. It is shown that in the South African political context, external norms concerning HIV/AIDS were framed (adapted) by political elites to meet the existing normative order based on the contestation of white/western domination. In this sense, the characteristic of the South African decision-making system of power centralised in a few powerful individuals posed huge barriers to the securitising efforts of international HASN leaders. As analysed later, this led to tactical alliances with like-minded HIV/AIDS civil society groups within South Africa, aiming to bring pressure to achieve domestic policy change.

From the outset of democratic rule in South Africa, the ANC has demonstrated an increasing tendency for hierarchical and centralised leadership. When Mandela assumed power in 1994, after a period of revolutionary euphoria, the general tendency in the party’s leadership was to view mass mobilisation as a potential source of instability rather than a legitimate manifestation of democratic rule (Johnson, 2002). This inclination for centralised political control has been further intensified during Mbeki’s presidency. After his election, in 1999, and with the ANC power already entrenched in the government’s machinery, intolerance towards dissent became very salient. Public criticism towards ANC policies was often depicted as counter-revolutionary or even racist. Furthermore, the many decades of anti-Apartheid struggle gave a huge amount of symbolic power to the ANC government. This logic also applies to state policies towards the HIV/AIDS epidemic. Mbeki’s rejection of social mobilisation and protest politics for the definition of South Africa’s official position on HIV/AIDS had as a consequence a system of decision-making characterised by the personal rule of the President and the inner circle of his loyal supporters. Therefore, rather than unfolding complex systems of government and administration, the behaviour of a single individual, or a small group of decision-makers, can be considered a more central variable to the understanding of the South African government’s actions on HIV/AIDS.

Thabo Mvuyelwa Mbeki was born on 18 June 1942. The son of a former ANC president, he joined this organisation in 1956, initially in the ANC Youth League, advancing quickly through its ranks. During 1963 to 1967, he studied economics in Britain at the University of Sussex and subsequently worked in the ANC’s offices in London. He was also a member of the South African Communist Party and a sympathiser of the Soviet regime, where he received military training in the early 70s. Throughout his life, he passionately engaged in the cause of black liberation in Africa and the fight against Apartheid, establishing contacts with leading figures all over the world, becoming one of ANC’s most prominent figures since then. After the ANC assumed the government of South Africa, he was chosen for the pivotal function of Deputy President to Mandela, with the actual responsibility of running the daily activities of the government. Mbeki was then pinpointed as Mandela’s natural successor, taking over the presidency in 1999.

Mbeki’s background of fighting white oppression against the black population deeply influenced his political choices while in the South African presidency, including decisions made with regard to the area of HIV/AIDS. A recurrent feature of his speeches is the mentioning of deep-seated legacies from the Apartheid era as the source of the social and economic problems faced by South African society. He regularly uses the racial and colonial factors as underlying causes of the conflicts between political and social forces in the country and to explain the role played by Western governments in Africa.

Internationally, Mbeki is engaged in a political struggle against global injustice and underdevelopment. Moving beyond discursive practices, he proposed real programmes, such as NEPAD and the African Renaissance, aiming to raise Africa’s profile in global affairs. Regionally, Mbeki’s constant support and public defence of Mugabe’s tyrannical regime in Zimbabwe is another example of how ideological and racial factors play an important role in understanding his policy positions. Mbeki responded to domestic criticism of his approach to Zimbabwe lashing out against white sectors in the media and other opposition groups who, in his view, were linked with “white supremacists” (Schoeman and Alden, 2003:6). In fact, ANC’s historical ties with Mugabe’s ZANU-PF have troubled Mbeki in taking serious action against Harare. As Schoeman and Alden put it, “if there is one thing that South African politics and foreign policy have made clear since 1994, it is that once the issue of race becomes entangled in the situation, South Africa cannot exercise its commitment to demands of good governance and human rights abroad” (2003:6).

Similarly, Mbeki’s interpretations of the HIV/AIDS epidemic in South Africa cannot be disassociated from the broader political context of South Africa’s anti-Apartheid struggle and its (normative) legacies. For him, the epidemic exposes all the global disparities that threw the African continent into continued dependence. The South African president has been an outspoken critic of the unequal distribution of wealth generated by globalisation and the responsibility of developed states in perpetuating this situation (Eboko, 2005:42). For example, in October 1999, in an inspired speech at the launch of the African Renaissance Institute in Pretoria, Mbeki addressed these issues. He said:

The problem we are facing [...] is the reality that many among the developed countries of the North have lost all sense of the noble idea of human solidarity. What seems to predominate is the question, in its narrowest and most naked meaning - what is in it for me! What is in it for me! And all this with absolutely no apology and no sense of shame. (Quoted from Jacobs and Calland, 2002:14).

In this respect, Mbeki’s resistance to HASN entrepreneurship in South Africa can be understood in terms of a wider ideological contestation against the dictations of the mainstream scientific knowledge and the resultant dogmatism of Western paternalistic solutions to the African problems. His speeches clearly echo widely held perceptions about the relationship between Africans and their former white colonial rulers. Responding to this historical legacy, Mbeki redefines both the common Western knowledge about the HIV/AIDS epidemic and what would be the appropriate responses to it. The HIV/AIDS epidemic and Mugabe’s regime in Zimbabwe were interpreted by the South African leader through the same mindset, which was the result of long-term historical and sociological processes. These examples are interesting social constructions derived from intersubjective processes that are not grasped by rational accounts of human behaviour. In the words of Mbeki;

We have in practice made the statement that we are determined that the African masses should reclaim their right to determine their destiny. We have done what we should and must do to ensure that the people fully enjoy the fruits of their liberation from colonial and racial domination (Mbeki, 2004: internet source).

The above statement would fit well into the speech of any of the ANC’s influential leaders during the hot years of the Apartheid regime. It shows that, despite the obvious changes in South Africa’s political power configuration after 1994, the discursive tools used by political leaders are still quite the same. Basically, what Mbeki meant, while saying “to ensure fully the fruits of liberation from racial domination”, was resistance to any interference in how South Africa deals with its domestic and regional affairs. It also means fighting the residual colonial influence, reflected in a new kind of foreign domination in the era of globalisation. Concerning HIV/AIDS, this foreign domination is personalised by the economic interests of big pharmaceutical corporations, the US’ political agenda in Africa, and the control of scientific knowledge by Western epistemic communities and multilateral agencies.

The allegedly monopoly of truth concerning Western responses to HIV/AIDS, and the alternative perspective upheld by the South African government, were highlighted by Mbeki himself, amid great controversy, in his opening speech at the 13th International AIDS Conference, held in Durban, on 9th July 2000. On this occasion, he stated that,

Some in our common world consider the questions I and the rest of our government have raised around the HIV/AIDS issue as akin to grave criminal and genocidal misconduct. What I hear being said repeatedly is do not ask any questions! [...] As I listened and heard the whole history told about our own country, it seemed to me that we could not blame everything on a single virus (Mbeki, 2000a: internet source).

On 3 April 2000, a few months before the Durban Conference, Mbeki issued a controversial letter to world leaders vehemently asserting his views about the HIV/AIDS issue. He affirmed, for example, that

Not long ago, in our country, people were killed because the established authority believed that their views were dangerous and discredited. We are asked now to do precisely the same thing that the racist Apartheid tyranny we opposed did, because, it is said there exists a scientific view that is supported by the majority, against which dissent is prohibited (Mbeki, 2000b:19).

The open questioning of the established scientific knowledge about HIV/AIDS has reinforced the scepticism and denial that have prevented behavioural change in South Africa’s society. From the government’s point of view, AIDS was a side effect of decades of exploitation, underdevelopment, and racism. Thus, and contrasting with the securitisation emphasis given by the international community of HASN leaders, there would be very little that the government of South Africa could do in the short-term to fight it. The solution to the AIDS problem would rest in long-term policies to combat poverty, malnutrition, and poor socioeconomic conditions. Although undoubtedly misleading, the South African president’s approach to HIV/AIDS is not irrational as some of his critics claim (Cohen, 2000:590). Mbeki’s reasoning is logically consistent with the ideas that traditionally guided his political activities as an ANC member. Domestically, he is linking the seriousness of the epidemic with the dreadful legacy of Apartheid‘s social engineering and the consequent de-empowerment of black people. Internationally, he seeks to use the epidemic to address deep structural contradictions present in the neoliberal paradigm.

At the practical level nonetheless, his message led to confusion and a slow response from the government. By taking away the sense of urgency, strongly advised by domestic and international promoters of HASN, Mbeki decided to fight two powerful adversaries at the same time: the epidemic itself and the international and domestic actors promoting its securitisation. It is not clear-cut whether Mbeki is actually using the denialist position as a form to legitimise his stance and defy the international community or if he truly believes that HIV and AIDS are not related issues. What is important to bear in mind here is the impact of decision-makers’ ideas and deep-rooted values in shaping South Africa’s understandings and responses to HIV/AIDS. It is also important to understand the political and ideological environment in which the HIV/AIDS epidemic took hold in South Africa and how the interpretations and responses to the epidemic were influenced by this environment.

In what comes next, this chapter assesses the role of HASN entrepreneurs in the country and the way HIV/AIDS civil society groups mobilised domestically and linked with those external actors to influence policy decision-making at the governmental level.

5. Norm Entrepreneurs in Action: The Role of Multilateral Institutions, the US and Transnational Non-State Actors

5.1. The Multilateral Approach

In South Africa, the normative influence of multilateral HIV/AIDS actors began to have some impact in decision-making only after 1990. Before that, Botha’s discriminatory laws against HIV-positive individuals had been the antithesis of the human rights approach of WHO’s HIV/AIDS Global Programme. Excluded from WHO, the Apartheid regime did not take part in the intensive HIV/AIDS planning of the mid 80s (Iliffe, 2006:72). In 1990, however, the NP government, together with the ANC leadership, requested WHO’s assistance in the national fight against HIV/AIDS. This opened the door for the more proactive role of this organisation in the country. This move was also very representative of changes in South Africa’s domestic politics and international status. A few years earlier, the idea of initiating policy debates with the ANC would have been inconceivable to the NP’s leadership. In the same way, the international labelling of South Africa’s Apartheid as a “pariah state” would have precluded it from participation (and receipt of aid from) multilateral schemes such as the WHO’s Global Programme on HIV/AIDS.

After the democratic transition was concluded in 1994, multilateral contacts gradually began to be re-established. As already shown, by the time Mandela came to power, the WHO/GPA had already been sending technical personnel to help in the implementation of NAP. In the years following the installation of the newly-elected ANC government, a more consultative and participatory decision-making process led to the expectation that all national and international HIV/AIDS stakeholders would work together in responding to the impact of the epidemic. As in other states in Southern Africa, South Africa adopted the international guidelines for action, which prescribed a variety of HIV/AIDS policies, strategies and the development of specific institutions to deal with the epidemic (Johnson, 2004:108). This period coincided in the international sphere with the securitisation move that led to the creation of UNAIDS, in 1996. The more radical line of the international community urged states to adopt a multisectoral approach to the epidemic coordinated by a single agency placed at the top of the national policymaking structure. The South African government embraced these new policy ideas and seemed to be moving towards their implementation (Johnson, 2004:108). Additionally, in the first stage of NAP, the lack of locally trained personnel gave a special clout to foreign experts from WHO/UNAIDS and other epidemic communities of HIV/AIDS specialists. According to Crewe, it was a time when international HIV/AIDS actors became very influential in advising the government about how to respond to the epidemic (Interview 28.07.2004).

However, despite this more positive policy environment for the penetration of international HIV/AIDS norms and actors, UNAIDS and its affiliated organisations faced in South Africa a state bureaucracy still going through the process of deep restructuring. The animosity between old-era Apartheid civil servants and the new ANC bureaucrats as well as among the various levels of government added to the chaotic and confusing efforts to implement NAP (Interview Crewe 28.07.2004). Besides, UNAIDS’ strategy in the country was criticised for being too optimistic about the leadership role of the newly-established national and provincial governments in the overall HIV/AIDS response (Interview Crewe 28.07.2004). The ANC’s overburdening task of running a still politically troubled state, in search of a unifying national project and identity, downplayed the internationally-claimed security relevance of HIV/AIDS. In this respect, the global securitisation of the epidemic of the late 90s was an external phenomenon completely alien to the pre-existing cognitive frames of the domestic political audiences in charge of building the new South African state. Mandela himself later recognised that his government’s response to the epidemic was obfuscated by what were then perceived as potentially greater threats to the future of the South African state (Interview Crewe 28.07.2004).

Since 2000, the institutional format for coordinated action between international development agencies, multilateral bodies, donor states and the South African government has been that provided by “The Three Ones” framework. Formally, SANAC represents the coordinating authority in the country and is also South Africa’s Country Coordinating Mechanism (CCM) to the Global Fund. In April 2002, the Fund approved a grant of US$ 72 million to be used over two years in HIV/AIDS and tuberculosis programmes. The first beneficiary was KwaZulu-Natal, the South African province hardest hit by the epidemic. As shown in more detail in the next section, by this time political/ideological disputes between the national and some provincial governments were strongly shaping the HIV/AIDS policy environment in South Africa, therefore further complicating the work of multilateral agencies and donor states.

In June 2002, the South African government tried to block the Global Fund’s grant to KwaZulu-Natal, claiming that the application had bypassed the national government. The Minister of Health expressed that any proposal should have been discussed at SANAC before being submitted to the Fund. Government officials from KwaZulu-Natal affirmed that they applied directly to the Fund because South Africa had not yet established a Country Coordinating Mechanism at the time of the application. After more than a year of conflicting arguments and failed negotiations, a final agreement was reached between the South African government and the Global Fund in August 2003, now also including the province of Western Cape as well as the AIDS NGOs LoveLife and Soul City (Ndlovu, 2005:12/13). The imbroglio was only resolved after the Global Fund agreed that the National Treasury would act as the main recipient of the money and that SANAC would coordinate the implementation of the proposals. However, in May 2004, the money was still held up in Pretoria (Aegis News 03.05.2003). Of the total awarded by the Fund to KwaZulu-Natal, which amounted to US$ 26.741 million, 48% was disbursed as at the end of April 2005 (Ndlovu, 2004:12). According to the South African government, complex technicalities surrounding the grant agreement have caused the delays. However, in the view of some HIV/AIDS NGOs, it was evident that the delay was linked to political attitudes towards anti-retroviral treatment (Interview Nukeri 23.07.2004).

In the first ever Global AIDS Conference held in Africa, in Durban, from 9 to 14 July 2000, Mbeki raised questions about the harmful nature of ARVs and defended studies which supposedly demonstrated the inefficacy and toxicity of those medicines (Mbeki, 2000:20). Even with approved legislation allowing better access to generic AIDS drugs, the South African executive disallowed the use of single-dose Nevirapine, a drug which was approved by WHO and that is widely used to prevent mother-to-child transmission (PMTCT) (Epstein, 2001:190). As already shown, in 2002 the government’s decision was overruled by South Africa’s Constitutional Court, which obliged the government to provide the anti-retroviral drug in the public health system. WHO and UNAIDS have continuously supported the use of Nevirapine for PMTCT and a significant part of the Global Fund’s money is to purchase this particular drug. In this respect, the GP’s grant to KwaZulu-Natal, which had a strong PMTCT component, was seen by Pretoria as a foreign interference in the sovereign rights of the South African government to decide about the safety standards of HIV/AIDS drugs (Interview Nukeri 23.07.2004). Given the highly politicised HIV/AIDS policy environment in South Africa, the Nevirapine issue gained ideological contours with the government accusing the pharmaceutical industry and Western powers of putting profits before the life and health of Africans (Mail & Guardian 19.12.2004).

Despite those divergences, UNAIDS has been able to introduce some institutional innovations in the way the South African government manages its relationship with international partners. For example, in line with the “Three Ones” principles, in 2000 the DoH put in place a Donor Communication Forum (DCF). This body serves to coordinate activities and avoid duplication between donors, multilateral bodies and NGOs. In this way, the South African government can more easily facilitate communication between governmental and international partners as well as develop a more synchronised response to the epidemic. Additionally, the DoH, through funding from UNDP and the local UNAIDS Theme Group, has developed a database (Donor Matrix) aimed at monitoring donors’ financial commitments to HIV/AIDS in the country (Ndlovu, 2005:1).

There are two basic channels in which international money arrives in South Africa. It is either channelled through the National Treasury to specific governmental departments and private service organisations or bilaterally to NGOs, research institutions, and other non-governmental institutions (Interview Balfour 23.08.2004). Concerning the bilateral route, the South African government’s monitoring of resources coming from international aid agencies is patchy. Since donors channel their funds directly to service providers and research institutes, the government does not comprehensively collect information on the allocation of these resources (Ndlovu, 2005:4). In addition, the aforementioned “Donor Matrix” does not provide a reliable guide of donor spending in the country given that it is based on donor commitments over many years instead of the actual allocation and disbursement of money. This lack of control allows that international donors explore loopholes in the system to directly reach local governments and NGOs without any interference from the central government.

As a general case, it is fair to say that the relationship between the government and international agencies with regards to HIV/AIDS programmes is based on a kind of cautious co-operation. This means the existence of clear and well- established bilateral and multilateral channels of resource allocation and technical assistance from organisations such as the DIFD, UNICEF, Global Fund, UNAIDS, UNPD, USAID (PEPFAR), and others. Nevertheless, and contrary to this thesis’ other case studies, the high reliance upon public sector funds for South Africa’s HIV/AIDS response helped to enhance the government’s own domestic policies at the expense of the agenda of international donors.

Currently, although only 1% of South Africa’s overall GDP is based on international aid, the country is ranked among the top five for countries that received the largest shares of HIV/AIDS foreign financial commitments. During the period of 2000/2002, 99% of all health aid to South Africa was for the epidemic (UNAIDS and OECD, 2004). It is a clear indicator of the growing international concern over the impact of HIV/AIDS in the country. However, contrasting with Mozambique, for example, where more than 90% of all HIV/AIDS financing comes from international sources, in South Africa only 40% of HIV/AIDS funds are from donors. This allows the government to reduce the power of multilateral actors to influence the national response to the epidemic.

The institutional relationship between multilateral donors and the South African government is circumscribed to the lower ranks of political authority without any further engagement with the top levels of decision-making. While in Botswana and Mozambique there seems to exist a more direct engagement between HASN leaders and the government’s highest authorities, in South Africa this relationship is intermediated by intricate layers of state bureaucracy at provincial and central levels. For example, Ian Ralph, Health Advisor at the European Commission in South Africa (EC), indicates that, although the EC delegation has been working in close collaboration with the DoH for quite a long time, it has no contacts at the higher levels of decision-making. Ralph described the relationship between donors and the South African top decision-makers as “poor and occasional”. He mentioned that “we usually deal with middle-ranked bureaucrats in the DoH” (Interview 25.08.2004).

This lack of direct communication has undermined the speech-act practices of international HASN leaders in South Africa. Even when discursive interactions did take place, the clash between transnational and domestic understandings of HIV/AIDS appeared insurmountable. In 2002, in an attempt to persuade Mbeki that HIV was the cause of AIDS, Pieter Piot, the director of UNAIDS, was brought to Cape Town for a low-profile meeting with the South African president. After long hours of discussion, the outcome was thoroughly unsuccessful with Mbeki firmly defending his unorthodox views on the epidemic (The Economist 12.12.2002). Despite the anecdotal character of this particular event, it is an interesting empirical snapshot on the conflictive dynamics of discursive persuasion that characterise the South African process of HASN incorporation.

After 1999, the HIV/AIDS policy environment became so politicised in South Africa that relations with UNAIDS became permanently strained. Essentially, the divergence between the government and this multilateral body is a function of their different definitions of precisely the policy problem of HIV/AIDS. In contrast with the South African government’s developmental and long-term approach, this multilateral agency focuses on ameliorating the impact of HIV/AIDS in terms of an emergencial national crisis. These competing actions, interests and ideas can be translated in terms of, on one hand, international securitising actors attempting to respond with urgent measures to placate the emergencial threat posed by the epidemic, and, on the other, domestic politicising actors who stress the structural and long-term social-economic problems that fuelled the spreading of the virus.

Therefore, given the domestic resistance posed by the government of South Africa, the most effective mechanisms by which HASN norm leaders have managed to introduce its principles in the South African domestic structure has been by linking up with domestic (like-minded) actors, such as some provincial governments, opposition members and ANC discontents in the national parliament, and by using the judicial system via local NGOs, as in the case of TAC.

5.2. The Bilateral Approach: The United States Involvement in South Africa

The United States is an important development partner of the South African government. From the early years of democratic rule, the US government, mostly through the work of USAID and the US’ CDC, has helped the consecutive ANC administrations to develop primary health care structures in the poorest zones of the country. From 2000, at the outset of the global securitisation of HIV/AIDS, Clinton’s Global Initiative on AIDS injected considerable funds into South Africa’s fight against the epidemic. The US is currently the largest bilateral donor to South Africa’s health sector. In 2004 alone, already under Bush’s PEPFAR, it provided a total of US$ 100 million in financial support, the majority of this being for activities related to HIV/AIDS prevention, care and treatment (US Department of State, 2005:99).

However, notwithstanding the substantial involvement of the US in supporting South Africa’s national response to HIV/AIDS, the bilateral relations between the ANC and the US government in this particular area has been marked by growing dissent. One key area of dispute has been the pressure of pharmaceutical manufacturers, backed by the US government, to repeal a South African law enacted in 1997 that enables the government to import and produce generic substitutes of patented drugs (Bond, 1999). The two consecutive ANC governments have pursued a policy of slashing the costs of branded drugs by pushing for the local production of cheaper generics. This move boosted South Africa’s drug industry and it is currently the largest in Africa. It also led to clashes between national government priorities and the economic interests of foreign pharmaceutical companies.

In 1998, the Pharmaceutical Manufacturer’s Association (PMA) sued the South African government over the new legislation (Mail & Guardian 14.04.2004). The trial dragged on for three years when, finally, in 2001, after intense international and domestic lobbying, the PMA dropped the lawsuit. Meanwhile, acting on behalf of the pharmaceutical industry, the US government strongly resisted attempts by the South African diplomacy to defend the legality of South Africa’s position at the World Trade Organization (WTO) (Bond, 1999). Moreover, since the inception of PEPFAR in South Africa, USAID has insisted that the South African government should use the financial assistance of the US government to purchase branded ARVs from US-based pharmaceutical companies instead of using the money to buy cheaper generics elsewhere. This move was interpreted by individuals in both civil society and public sectors as skilful political (and financial) manoeuvring by which the US government would guarantee that aid money is eventually redirected into the American economy. At the same time, PEPFAR’s investment in AIDS treatment would also build a (rather opportune) positive international image of the US as a nation which cares and acts on the plight of HIV/AIDS in Africa (Interview Caesar 08.07.2004; Interview Magongo 20.07.2004; Interview Nukeri 23.07.2004).

In December 2004, the ANC’s online journal published a harsh attack on US government health officials, accusing them of “treating Africans like “guinea pigs” to promote AIDS drugs” (ANC, 2004). The controversy surrounded the drug Nevirapine. The article refers to violations of patient safeguards in a trial conducted in Uganda. The article claimed that Dr. Edmund Tramont, chief of the US National Institutes of Health (NIH), who was in charge of the project in Uganda, “[...] entered into a conspiracy with a pharmaceutical company to tell lies to promote the sales of Nevirapine in Africa, with absolutely no consideration of the health impact of those lies on the lives of millions of Africans” (ANC, 2004). It also affirmed that “upon learning of the potential lethal side effects of Nevirapine, President Bush and his administration did nothing to stop the shipment and usage of the drug in Africa. They must be held accountable for their inaction” (ANC, 2004).

The efforts of the US (and other European states) to protect the interests of the pharmaceutical industry have been perceived by some powerful individuals within the ANC leadership as an “imperialist plot” against millions of Africans in need of essential drugs (Interview Ralph 25.08.2004; Interview Magongo 20.07.2004). In the imaginary of key decision-makers in the government, the US political backing of profit-oriented pharmaceutical corporations resembles the colonial system of imperial Britain whereby state power cleared the way for (and benefited from) the exploitative activities of big private capital (Interview Ralph 25.08.2004). Furthermore, during Apartheid, some views within ANC political ranks implied a direct link between biological weapons research programmes in the United States and its NATO allies and the spread of HIV/AIDS (Mzala, 1988). This also helped to lay the foundation for ANC’s later suspicion about the real intentions of the US government with regards to its HIV/AIDS policies in Africa (Youde, 1995:8).

In this sense, the local production of generic versions of AIDS drugs symbolises a genuine African reaction to the hegemony of (white) Western capitalism and science by transferring essential medical technology to the hands of black people. An interesting point in this regard is that, whereas in Mozambique the government’s contestation of the US’ interference in the procurement of AIDS drugs was more strongly based on technical concerns about implementation costs and the overlapping of different drug regimens, in the case of South Africa, ANC’s administration framed its disapproval in terms of an upfront accusation of economic (neo-colonial) exploitation of the African people. This illustrates how similar external securitisation moves by HASN leaders, in this case concerning PEPFAR’s policies for AIDS treatment, are reconstructed domestically to fit with particular normative ideas, worldviews and practices.

In line with its broader HIV/AIDS securitisation strategy, as unleashed by Bush’s PEPFAR in 2003, the US government put in place in South Africa its own system of aid provision. All HIV/AIDS activities of the US have been integrated into PEPFAR under the exclusive management of USAID/CDC and the US Embassy in Pretoria. The approval of funds for the implementation of plans are subjected to the US Global Aids Coordinator at the State Department in Washington and PEPFAR’s projects are run by the US Ambassador in Pretoria (US Department of State, 2005). As in the cases of Botswana and Mozambique, the US representation in South Africa avoided firmly engaging with the pre-existing multilateral mechanisms that were put in place to coordinate the work of international partners. It deals bilaterally with more than 200 partners in the public, private and non-profit sectors (US Department of State, 2005).

However, contrasting with the other case studies, the US has very few entry points in the national structure of policy decision-making. Given South Africa’s quite explosive HIV/AIDS policy environment, the President and his Cabinet Members (namely the Minister of Health) have constantly tried to shield themselves from the interference of external and domestic actors perceived as hostile to the government’s views. Similarly to the aforementioned multilateral institutions, US representatives only meet with middle-ranked officials in individual Ministries and at SANAC to assess their particular needs concerning the overall national response (Interview Balfour 23.08.2004). This system actually favours PEPFAR’s broad strategy of bypassing national coordinating structures to more rapidly mobilise groups and address problems at the grassroots levels. The Minister of Health has insisted that PEPFAR should be more closely integrated into government systems for external funding. She claimed that South Africa “had not asked for PEPFAR’s assistance” and that the Ministry’s coordination efforts to strengthen the country’s response to HIV/AIDS should not be jeopardised by duplicated and sometimes unaccounted initiatives of the international partners (Aidsmap 23.06.2006).

Besides its participation at the national level, PEPFAR also negotiates directly with provincial executives the application of earmarked funds on local programmes (Interview Caesar 20.08.2004). The South African Constitution of 1996 adopted a federal system of government with great autonomy at the provincial level. According to the Constitution, provinces may have executive and legislative powers coexisting with the national sphere over a number of issues, including health policies (Dikeni, 2002). Crewe argued that, with regard to HIV/AIDS, this “jumble of authorities” led to the central government and nine provincial governments having ten different policies in crucial areas (Crewe, 2000:29). In her words, “what this has meant is that much energy has been spent in feuding and in arguments over ownership, policy, and programmes, rather than in looking for shared vision and policy and programme developments” (2000:29).

In this kind of decentralised political system, the extent of the (direct or indirect) international influence at the provincial level of decision-making is dependent on the political/ideological stance taken by the local administration vis-à-vis the central government’s policy positions. For example, the former Premier of Western Cape province, Peter Marais, was noted for his independent policies towards HIV/AIDS. In February 2002, he struck a deal with the producer of Nevirapine, Boehringer-Ingelheim, by which the pharmaceutical company accepted to provide the drug free of charge for a period of five years (Mail & Guardian 19.09.2002). Marais’ opposition party, the Democratic Alliance, has been a strident critic of the national government’s unconventional views on HIV/AIDS and of its delay in implementing a national plan to deliver ARVs. On the other hand, Mpumalanga province during the same period did not demonstrate any effective progress on the universal roll-out of Nevirapine. Not incidentally, the provincial ANC administration is a well-known supporter of the national government’s dissident position (Mail & Guardian 19.09.2002).

Since 2003, the US government – through its CDC represen-tation in South Africa – has advocated for the introduction of routine or “opt-out” HIV testing in the public health system. However, despite the growing support for the opt-out system among many HIV/AIDS stakeholders (including the HIV campaigner and South African Supreme Court of Appeals Judge, Edwin Cameron) voluntary counselling and testing (VCT) remains the standard procedure in the country (Aidsmap 24.05.2006). As already noted in a previous chapter, Botswana was the first country in Africa to introduce this new (and more aggressive) approach to HIV testing in 2004, after considerable domestic lobbying from the US/CDC. Contrary to Botswana, the domestic resistance to routine testing in South Africa was mostly due to the construction of a particular post-Apartheid political culture with a very strong emphasis on individual human rights. The elaboration of South Africa’s first National HIV/AIDS Plan, in the early 90s, took place at a time when the South African National Bill of Rights was also being drawn up and discussions on human rights issues were at their peak (Schneider, 1998a:5). Therefore, the protection of the human rights of people testing positive for HIV has been a key element of South Africa’s response to the epidemic.

With regard to HIV prevention policies, PEPFAR’s “ABC” approach has also faced important challenges in South Africa. In a country with one of the highest rates of rape in the world, sexual coercion is cited by local NGOs as creating huge barriers to abstinence for girls and women (Interview Nukeri 23.07.2004). In fact, except for a (significant) number of Christian groups financed by the US government, the majority of civil society groups and government agencies dealing with HIV/AIDS in South Africa accept the more pragmatic view of multilateral agencies. Despite the financial incentives offered by PEPFAR, most of those secular groups reject (or at least moderate) the US administration’s moralistic approach to HIV prevention, concentrating instead on awareness campaigns and on the distribution of condoms (Interview Nukeri 23.07.2004).

So, in spite of the aggressive securitisation move of the US government in South Africa, the ideological bias of Mbeki’s administration made changes of direction in the South African government’s HIV/AIDS policies very difficult. Rather, the general (mis) representation of the US government as a new form of colonial/imperial/interventionist power led to a certain degree of suspicion (even hostility) towards PEPFAR’s HIV/AIDS initiatives in the country. In other words, the road maps (Goldstein and Keohane, 1993), within which key South African leaders operate, served as very powerful filters (or stumbling blocks) to the policy ideas of the US securitisation front.

5.3. The Transnational Community of HASN Seeking Domestic Legitimacy: The Role of Civil Society HIV/AIDS Organisations

From the very beginning, and as the HIV/AIDS National Plan put clearly, any effective policy initiative to tackle HIV/AIDS would require a full and co-coordinated action between the state agencies and civil society organisations involved with the epidemic. The NACOSA plan, adopted by the South African government in 1994, was the first formal institutional arrangement put in place to include, in the state-led effort to combat the epidemic, society-based organisations working specifically with HIV/AIDS (Marais, 2000:31).

Prior to assuming the government of South Africa, the ANC worked closely with the first NGOs that appeared in South Africa to deal with the HIV/AIDS epidemic. The most influential of these were the AIDS Consortium, the AIDS Law Project, the National Progressive Primary Health Care Network (NPPHCN), and the National Association of People Living with AIDS (NAPWA). These organisations led the way during this first period of the epidemic’s response. In cooperation with the ANC, they launched many successful initiatives such as the Charter on HIV/AIDS and Human Rights (1992), later endorsed by the first ANC administration, and a Code of Good Conduct on HIV/AIDS in the Workplace. The latter was turned into government policy during Mandela’s presidency (Heywood, 2004:2).

Yet, by the end of the 90s, NGO involvement in HIV/AIDS policymaking had begun to decline significantly. The reasons for this deterioration in the exchanges between state and non-state actors were varied and complex and it is not the aim here to discuss them in detail. It is suffice to say that, after 1994, many former civil society activists either moved into government or forged formal alliances with it. More importantly, the growing authoritarian tendencies of the South African government, following the election of Mbeki, led to a very low tolerance to policy positions contrary to those of the government (Johnson, 2002:222). Even within the government, decisions on AIDS policy were made at the political level away from bureaucrats and top civil servants (Johnson, 2004:121).

The clash between civil society and the South African government came to the fore in 1996/1997 in two separate episodes. The first was Sarafina 2, a highly controversial musical intended to promote awareness among the youth. The merit of the musical’s content was questioned by newspapers and NGOs and some doubts were raised about the proper use of the national DoH’s budget in sponsoring the project. The second was the visibility given by the government to a group of researchers who claimed to have developed an AIDS vaccine, called Virodene. It was later found that the vaccine in case was in fact an industrial solvent. A number of NGOs as well as the MCC accused the government and the researches of serious misconduct (Marais, 2000).

In South Africa, there are around 650 NGOs focusing on HIV/AIDS related issues (I do not include here other civil society and economic groups either affected or with an interest in the epidemic, such as trade unions and private companies). Due to their proactive role as the government’s watchdogs as well as major securitising actors with regard to the politics of HIV/AIDS in South Africa, this thesis concentrates on the analysis of organisations concerned with lobbying and advocacy and with ensuring that people living with HIV/AIDS have their rights protected and that the government upholds its constitutional obligations in providing health care and social assistance to them. Three organisations were identified as notably influential in fighting for the rights of people living with HIV/AIDS and as an alternative voice outside the government’s spheres of decision-making, namely NAPWA, The AIDS Consortium, which is basically an “umbrella” agency with a membership of more than 100 smaller organisations, The AIDS Law Project, and its further corollary, TAC. Given its domestic leadership and international salience, the remainder of this section concentrates on the role played by TAC as a powerful source of HASN diffusion within South African society.

Officially created on 10 December 1998, TAC was the result of an increasingly domestic and international acknowledgement, in the late 90s, of the importance of ARVs treatment to scale down the impact of HIV/AIDS worldwide. It is a powerful lobbying organisation, pressuring the South African government, as well as pharmaceutical corporations, to provide free treatment (or at least drugs with a significantly reduced price) to all people in need of them. As declared on its web page: “Its main objective is to campaign for greater access to HIV treatment for all South Africans, by raising public awareness and understanding about issues surrounding the availability, affordability and use of HIV treatments”. Through its mobilisation campaigns and judicial actions, TAC has been able to instrumentally use the international normative framework of HASN to change the political landscape of HIV/AIDS interventions in South Africa. To do so, TAC has firmly embraced international discourses of human rights/security as the driving force to gather national and international support for its cause.

Domestically, TAC has built its legitimacy through the use of a discursive tool that combines the international representation of the epidemic, as a security and human rights issue, with domestic and deep-rooted images of the anti-Apartheid struggle. This is clear in the use of traditional anti-Apartheid human rights slogans on its national campaigns, such as, for example, the “Defiance Campaign” and the “Civil Disobedience Campaign”. So, while constructing the movement’s domestic legitimacy and support, TAC redefined some constitutive principles of HASN to fit into pre-existing domestic beliefs and practices. As Acharya puts it, “while the initiative to spread transnational norms can be undertaken either by local or foreign entrepreneurs, diffusion strategies that accommodate local sensitivity are more likely to succeed than those who seek to supplant the latter” (2004:249).

In this respect, it is interesting to note that TAC has confronted the government of South Africa, and its inaction towards the supposed security threat posed by the HIV/AIDS epidemic, using similar persuasion strategies of those deployed by the liberation movement during the Apartheid period. Back then, transnational actors worked in unison with opposition groups in South Africa as well as in exile to exert pressure on the Apartheid State (Black, 1999). Their language and proposed action was based on the international norm of racial equality, within a broadening human rights perspective, that was then applied to the particular context of South Africa’s Apartheid (Klotz, 1995:44). The outcome of these tactics was the construction of a complex multi-levelled capacity to enable action and promote domestic change.

Similarly, TAC has also built a multi-faceted capacity through linking up with state and non-state actors in different levels of political/social interactions. At the international level, TAC interacts, in global AIDS conferences and other high profile multilateral meetings, with international organisations and other transnational NGOs with similar interests and ideas. Then, at the domestic level, it shares information, mobilises its mass base and liaises with other activist organisations of PLWHA. In pressuring the government, it also uses the formal political and judicial channels available in South Africa. TAC’s campaigns have drawn strongly upon a human rights discourse with the international support of important HASN leaders, such as UNAIDS. The language used in those events differs slightly from the more straightforward state security approach of other securitising actors, namely the US. In this sense, TAC has strategically constructed a speech-act (or securitisation claim) that appeals to the long-term sensitivities of South Africa’s society.

In the late 90’s, TAC intensively participated in transnational advocacy networks, which succeeded in influencing domestic change in South Africa. It also influenced the pre-existing belief among donors, other governments and the UN system itself, that therapy with ARVs was too complex for health systems in the Third World and that prevention campaigns were more cost-effective than treatment (Heywood, 2004). These international actors, after being resocialised with new ideas about the proper responses to the epidemic, then began pressuring governments, including the government of South Africa, to apply national HIV/AIDS plans that emphasise the importance of the provision of treatment to people suffering with AIDS.

However, and in contrast with the cases of Mozambique and Botswana, in South Africa the government strongly resisted domestic and international pressure to change its HIV/AIDS policies. An illustrative example of this fact is that only after TAC took legal action against the government was a comprehensive plan for the roll-out of drugs put in place in the country. From 1999 onwards, the government of Mbeki began to use ideological discursive strategies to undermine TAC’s legitimacy. Concerning the provision of Nevirapine, for example, the government has accused TAC of representing the interests of the pharmaceutical corporations instead of the South African people.

Whether or not one introduces the ideological factor into the picture, Mbeki’s motivations become more evident. The denialist position taken by many ANC leaders, including President Mbeki himself, and its discursive linkages with post-colonial white domination in South Africa lie beneath most of his support to “African born” initiatives to combat the disease, as the Virodene fiasco has shown. Following this line of reasoning, TAC emphasis on the efficacy and urgent need of Western drugs and therapies would further aggravate the African dependency on powerful and inconsiderate capitalist interests, mainly with regard to the pharmaceutical industry. Along those lines Heywood asserts that,

Mbeki clothed the ‘scientific’ views of the denialists in a political analysis of neo-colonialism, disease, and economy [...] Pharmaceutical companies that manufacture antiretroviral drugs were deemed to be part of a capitalist conspiracy to undermine the ANC government [...] It was hinted that HIV might even be an imaginary epidemic invented by pharmaceutical companies and neo-colonialists to make profits and to continue to dent Africa’s view of itself [...] Based on these contentions, it did not require a great leap in logic to depict treatment activists and mainstream scientists as agents of an ‘omnipotent apparatus’ (imperialism or the pharmaceutical companies) (Heywood, 2004:9/10).

While analysing the above statement, it becomes evident that at the core of the confrontation between TAC and the South African government is the ideological and racial bias of the latter that masks the real policy problem, namely the high costs of branded AIDS drugs. However, there seems to exist a common ground between TAC and the government when it comes to the role played by big pharmaceutical companies in South Africa. For example, Zachie Achmed, TAC’s Chairperson, asserted that, “[...] we’ve challenged the giants Pfizer, Glaxo SmithKline, Bristol Meyer Squibb, Abbot, and Roche. We will never forget that millions of people have died and will continue to die because they profiteer from medicines. They have blood on their hands [...]” (Achmed, 2001:4). In effect, TAC eagerly supported Mbeki’s administration in the court case brought by the PMA against the government.

The difference, nonetheless, lies in their use of distinct understandings and discursive strategies. TAC identifies the pharmaceutical corporations with Western capitalist interests and pragmatically stresses the need for alternatives to the dependency on the drugs they produce, whereas the government uses the ideological language of white dominance and neo-colonialism to describe the role played by them. It shows how different interpretations/perceptions of the same problem can limit rationality and produce confusion and conflict, therefore undermining the common goal of combating the epidemic. Given this political (and interpretative) deadlock, TAC has challenged (the norm-violating) South Africa by participating in a transnational structure that simultaneously pressures the government from both inside and outside.

As already noted, Keck and Sikkink (1998) gave the name “the boomerang effect” to the process by which NGOs bypass intransigent national governments, directly approaching the international community. Risse and Sikkink (1999) built upon this concept to further develop a five-phased “spiral model” of domestic norm socialisation. According to them, successive boomerang throws by domestic opposition groups will lead to gradual domestic change, going through the stages of 1) repression, 2) denial, 3) tactical concessions, 4) prescriptive status and, finally, 5) rule-consistent behaviour.

Despite significant problems with this theoretical framework (which I briefly expose in this thesis’ conclusions), it helps in understanding the effects that TAC’s securitisation strategies had on the behaviour of the South African government. In this respect, one could say that Mbeki’s administration has already moved from the denial stage of the spiral model to that of tactical concessions to the demands of norm leaders. At this stage, “the norm-violating state seeks cosmetic changes to pacify international criticism” (Risse and Sikkink, 1999:25). Notwithstanding the South African government’s aggressive stance towards TAC, the transnational mobilisation led by the latter had a clear impact on the change of tone in the language of decision-makers in Pretoria. In 2003, for example, the supposed divorce between Mbeki and the denialist position led Bill Clinton to state that the South African president was “no longer in denial” (Aidsmap 12.04.2005).

However, the phase of tactical concessions is a very precarious one, “since it might move the process forward toward enduring change [...] but it can also result in a backlash” (Risse and Sikkink, 1999:25). In fact, the persistent acrimonious relationship between the government of South Africa and the international community of HASN leaders indicates that there is still a long way to go before Pretoria accepts the validity claims of the norm and engages more positively with the prescriptive/normative agenda of the domestic opposition led by TAC.

6. Conclusions

HIV/AIDS is an epidemic fuelled by many factors that are common to most African nations, such as poverty, social/racial exclusion, gender imbalances and underdevelopment. However, these are not the only causes behind the fast and unchecked pace by which the virus progressed in South Africa. Despite its persistent and long-term social problems, post-Apartheid South African governments have developed fairly efficient social infrastructures when compared with the majority of states on the continent. Moreover, South Africa is today an economic and political power in the region with a dynamic economy and stable democracy. Why is it then that states with much less socioeconomic development have had more success than South Africa in the fight against HIV/AIDS? In the words of Walker, Reid and Cornell, “the spread of the disease is also influenced by personal choices, political responses and cultural factors” (2004:19).

Regarding the dynamics of HIV/AIDS in South Africa, this chapter attempted to unveil those personal choices, political responses, and cultural factors surrounding the national response to the epidemic. It identified four main characteristics of South Africa’s domestic context that made a strong impact on the way HIV/AIDS initiatives were formulated and conducted by the government. These were: 1) a highly racialised and unequal socioeconomic environment, inherited from the white minority system of racial segregation, which paved the way for the rapid spread of the virus throughout the country; 2) the cultural/social legacies of the Apartheid regime that are still present in the way people interpret and react to the epidemic; 3) the influence of those legacies upon the mindsets of key decision-makers, such as the President himself, creating dubious directions, lack of coordination with civil society actors, inter-bureaucratic disputes about policy priorities and poor leadership from the South African government; 4) a vigorous sense of black nationalism and the identification of the international donors, pharmaceutical companies and Western governments with exploitative economic and political neo-colonial interests.

The chapter also illustrated how those particular features of South Africa’s domestic structure conditioned the entry of HASN into the country. It was shown that, in the South African case, the capacity of domestic and international securitising actors (or policy entrepreneurs) to influence the ideas and preferences of key decision-makers in the government proved to be limited. For example, it was demonstrated that it was only through the use of the national legal system that TAC managed to advance its demands for the countrywide provision of the HIV/AIDS drug Nevirapine to prevent mother-to-child transmission. Given the rather intractable HIV/AIDS policy environment in South Africa, TAC also explored the transnational arena to exert pressure on the South African government by directly communicating with the international community. This was exemplified by its fierce lobbying at Global AIDS Conferences and at the UN General Assembly’s Special Meetings on HIV/AIDS.

On the international side, UNAIDS’ framework of concerted action “The Three Ones” and the UN’s Declaration of Commitment on HIV/AIDS (UNGASS), even though agreed upon by the South African government, lacked personal engagement and concrete actions. Some of the activities of the US’ PEPFAR programme in South Africa were also hampered by the government’s suspicion of pharmaceutical corporations and their political and economic connections with the US government.

Yet, although the cascading of HASN has not yet occurred within South Africa, there are clear signs that the engagement of the international and domestic community of HASN leaders has triggered some normative change in the country. For example, on 18 February 2005, fifteen months after the official launching of the South African government’s ARVs programme, Tshabalala-Msimang finally announced that the Department of Health had finalised negotiations with drug companies to supply ARVs to public hospitals. This represented significant progress given the very slow pace of the drug procurement process. Only two days before the announcement, TAC had organised a march on Parliament to demand the wider availability of ARVs in the public health system (Aidsmap 22.02.2005).

The government’s adoption of the international norm recommending universal access to AIDS treatment points to an incipient depersonalisation of norm compliance in South Africa, resulting in the domestic institutionalisation of this particular norm independently from the individual beliefs or the moral consciousness of leaders in the government (Hall and Taylor, 1996). Whether this process will eventually lead to the further cascading of HASN in South Africa is however still uncertain. In fact, as shown by the Health Minister’s confrontational stance in international HIV/AIDS conferences and in her dealings with TAC, the South African government remains very active in its attempt to block the entry of HASN to the country.

Chapter 7

The Impact of HASN in Botswana, Mozambique and South Africa: Conclusions

1. Introduction

In June 2006, the delegates of the UN General Assembly gathered in New York to review the progress made by the UN member states in adopting the 2001 UNGASS Declaration of Commitment on HIV/AIDS as well as to renew their political commitments urged in the Declaration. As already shown, after the first UNGASS meeting of 2001, a significant mass of states (Finnemore and Sikkink, 1998) agreed upon a comprehensive set of principles, conventions and policies to deal with the security threat posed by the epidemic. Similarly, the global mobilisation against HIV/AIDS, that firmly started in the mid 90s, has led to the creation of a specific international HIV/AIDS organisation, namely UNAIDS, multilateral and bilateral sources of funding to HIV/AIDS initiatives (such as the Global Fund, the World Bank’s MAP, and the US’ PEPFAR), as well as an extensive network of transnational HIV/AIDS NGOs.

As a result of these transnational processes, this thesis has argued that the securitisation of HIV/AIDS has increasingly become part of the collective understandings informing a global community of HIV/AIDS actors. These collective understandings about the epidemic and their further translation into policy principles were cast here under a single analytical concept, the HIV/AIDS securitisation norm (HASN). However, the present work has shown that the definition of the normative and policy frameworks of HASN by key international norm leaders was markedly antagonistic. Despite sharing the same claim for the securitisation of the epidemic, internal divisions concerning the proper means to achieve it put global securitising actors in two separate (opposing) camps led by the US government and UNAIDS respectively. As noted in chapter 2, notwithstanding those disagreements, the normative robustness of HASN increased gradually over time.

Following an initial definition of HASN’s conceptual basis, the description of the historical (and rather divisive) process by which it became firmly embodied in the international security agenda and the examination of its main international/transnational proponents, the study then treated HASN as a constant, or a given element of the analysis rather than a variable. In this respect, the argument put forward here assumed that states highly affected by the HIV/AIDS epidemic were subjected to the same (or at least very similar) external pressures to securitise HIV/AIDS. However, the global HIV/AIDS polity and the securitisation norms they supported have had a variable impact on the domestic structure and in the daily practices of national governments. Given that, the study investigated the different processes and outcomes resulting from the penetration of transnational HIV/AIDS securitisation norms into the domestic political arena of three states in Southern Africa: Botswana, Mozambique and South Africa.

In this conclusive chapter, I evaluate the findings of the three empirical cases in light of the research questions and theoretical propositions presented in chapters 1 and 2. These questions refer to 1) the similarities and differences in the effects of international HIV/AIDS norms on the conduct of Botswana, Mozambique and South Africa; 2) the policy outcomes resulting from the interaction between international HASN leaders and their domestic audiences in those three Southern African States and; 3) the extent to which HIV/AIDS securitisation attempts have been more successful in one domestic setting than in another. The chapter begins by briefly summarising the evidence found in the three case studies. It then proceeds to show how this thesis’ findings could contribute to the proposed merge between the constructivist literature on international norms and the securitisation framework. Finally, the work concludes with some final observations mainly regarding potential avenues for future research.

2. Summarising the Evidence Regarding the Three Case Studies

Botswana: The case of Successful Securitisation

Botswana is the case of a well-established developmental state in Southern Africa. It presents a top-down corporatist system of state-society relations which have impaired the formation of an autonomous and outspoken civil society sector. Since independence from Britain, in 1966, the consecutive BDP governments have gradually built robust state institutions and an efficient system for the delivery of social services. Due to Botswana’s smooth transition from colonial rule, which helped to create a political culture friendly to Western ideas, HASN securitising actors encountered a receptive political environment for the promotion of new ideas. Similarly, the (unusual for Southern African standards) ethnic and linguistic homogeneity of Botswana’s society created the right conditions for the establishment of a strong national identity and the wide recognition of the BDP state as the legitimate representative of the interests of the Botswanan people.

Due to Botswana’s centralised system of decision-making and a highly state-dependent civil society sector, the national executive, in particular the president himself, was a key target of the international and domestic promoters of HASN. In fact, the tipping point after which the domestic cascading of the norm occurs was only reached in Botswana after Mogae became fully engaged in promoting the securitisation of the epidemic. Given his proximity to values and concepts which were originated in the Western liberal community as well as the lessons learnt from Botswana’s peaceful colonial past, Mogae’s pre-existing cognitive frames were easily adapted to the securitisation claims of international HASN leaders. In this sense, President Mogae’s early conversion into a strong securitising actor led to the domestic salience of HASN and its consequent cascading throughout Botswana’s domestic system.

As a result, Botswana can be seen as a success story concerning international attempts to securitise HIV/AIDS in states with extremely high HIV/AIDS prevalence rates. This means that within Botswana’s domestic system HASN has acquired “a taken-for-granted quality and are no longer a matter of broad public debate” (Finnemore and Sikkink, 1998:895). Currently, HIV/AIDS is widely recognised by both the government and civil society as a real threat to the survival of Botswana as a viable nation. A clear sign of Botswana’s full engagement with HASN prescriptions, the Botswanan government has declared HIV/AIDS a national emergency and, in 2002, it launched the first comprehensive plan on the African continent to roll-out AIDS drugs.

Transnational HIV/AIDS actors, such as ICASO, for example, have played a significant role in Botswana as conduits of HASN’s prescriptions from the international to the domestic levels. Through advocacy networking (Keck and Sikkink, 1998) and strategic coordination with local organisations, these groups helped to domestically embed the HIV/AIDS principles and policies, which were agreed by the national government in multilateral forums of negotiation. With the support of the US, faith-based groups were also important securitising actors while instigating, at the grassroots level, the moral agenda of transnational Christian associations. However, due to Botswana’s state-dominated domestic system, with just a few entry points in the policy-making structures, the impact of transnational/domestic winning coalitions in changing the conduct of top decision-makers in the government has been fairly limited when compared with the more influential role played by the US government’s agencies, powerful international donors and UNAIDS.

Notwithstanding Botswana’s positive engagement with HASN leaders, with clear results in terms of the domestic securitisation of the epidemic, the particular manner in which Mogae’s administration has been conducting the implementation of the norm’s prescriptions reveals a preference for the principles and policy ideas supported by the securitising front led by the US government. For example, unlike Mozambique and South Africa, which have approved cheaper generic versions of many ARVs, Botswana adopted a national treatment plan based on the provision of expansive patented AIDS drugs. As shown in chapter 4, the public-private partnership between the Bill and Melinda Gates Foundation, the US pharmaceutical giant, Merck, and the Botswanan government (named ACHAP) was behind the government’s decision to pursue a national treatment programme based on branded AIDS drugs.

Similarly, in 2003, Botswana became the first state in Africa to promote a bold paradigmatic change in its national response, while adopting routine HIV testing in all its public health facilities. This more unilateral form of monitoring the spread of HIV has been criticised by HIV/AIDS NGOs who are concerned with the human rights of PLWHA. As noted earlier, routine HIV testing is, in fact, a recommendation of the US’ CDC without the full backing of UNAIDS and other important transnational HIV/AIDS actors. Concerning HIV/AIDS prevention, after the partial failure of the government’s early strategy, which was in line with the WHO/UNAIDS programme of sexual education combined with the massive distribution of condoms, the US-sponsored “abstinence and faithfulness” (AB) plan gained prominence in a revamped strategy to halt the spread of HIV among Botswanan youngsters.

These examples suggest that the persuasion strategies of the US have been more effective in the Botswanan domestic context vis-à-vis the approach of UNAIDS and its transnational allies. In this respect, the long-term collaboration between the US’ highly-regarded CDC and Botswana’s Ministry of Health (through the BOTUSA project) played a fundamental role in building very strong institutional and knowledge-based bounds between the Botswanan and US governments in the area of public health. Additionally, the openness of the national government to negotiate with a wide range of international actors (free from the ideological constraints verified in South Africa) favoured the establishment of international/national partnerships such as ACHAP. Finally, the stability of Botswana’s economy and political system, allied to the proactive and norm-friendly stance taken by Mogae’s administration, attracted wealthy US donors, as in the case of the Bill and Melinda Gates Foundation, who were willing to invest generous resources in supporting the government’s response to the epidemic.

Mozambique: The Case of Partially Successful Securitisation

Mozambique is the case of an institutionally weak state in Southern Africa. Its many years of civil war led to the destruction of the country’s social fabric as well as its economy and state institutions. The subsequent internationally-led process of state-building created a stable, yet superficially established system of democratic rule. Despite the formal handover of power after the 1994 elections, the Mozambican government is still today highly dependent on external (technical and financial) support to run the country effectively and to exert its sovereignty rights. The ruling elite, Frelimo, has traditionally used its privileged position as the highest (indigenous) authority in the country to engage in tactics of extroversion with international donors and other sources of development aid. This is also the case concerning HIV/AIDS securitising actors.

Therefore, in Mozambique the securitisation of HIV/AIDS did not reach the tipping point in which full normative change occurs. The adoption of HASN was mostly circumscribed to the level of discourse without a clear commitment by the country’s political elites with the norm’s prescriptions. Given the Mozambican elites vulnerability to international pressures, they discursively engaged with securitising actors and appeared to be convinced by their arguments. However, notwithstanding Mozambique’s full participation in all the multilateral agreements which claimed for the securitisation of HIV/AIDS, the government’s strong words were not translated into effective action. As shown in chapter 5, despite Frelimo’s formal declaration that HIV/AIDS represented a national emergency and the subsequent launch of a comprehensive national plan to fight the epidemic, HIV/AIDS activities are still today mostly centralised in the capital city, Maputo. Conversely, in the rural areas controlled by Renamo, which are the most affected by the epidemic, the population have poor access to basic health facilities and, in some places, the government is conspicuous by its absence. In many cases, the provision of HIV/AIDS care and prevention services in those areas is delegated to international actors such as international NGOs and faith-based organisations without the involvement of the Mozambican government.

The government of Frelimo lacks national ownership of HIV/AIDS policies. The initiatives of the public and civil society sectors in tackling the epidemic are completely dominated by the agendas of powerful state donors, multilateral organisations and international HIV/AIDS NGOs. Due to Mozambique’s poorly established indigenous NGO sector, transnational non-profit (both secular and religious) organisations play simultaneously the roles of domestic pressure groups and foreign development partners. Similarly, the CNCS, which is the HIV/AIDS state bureaucracy set up exclusively to deal with the security threat posed by HIV/AIDS, is heavily permeated by foreign individuals and institutions. In this regard, the UNAIDS-led GP plays a central role in policy deliberation and agenda setting. Given the long-term presence of the UN in the country, UNAIDS has been a very influential actor in Mozambique. The very close institutional (and personal) relationship established between Frelimo’s administration and the UN peace-building operation (ONUMOZ) consolidated the latter’s position as a hegemonic institution of truth (Foucault, 1980) within Mozambique’s structure of decision-making.

The prominence of UNAIDS inside the Mozambican HIV/AIDS structures has somehow limited the US’ capacity to influence policy-making. Contrasting to Botswana, in Mozambique the US pressure for a semi-compulsory and more aggressive system of HIV testing was blocked by the firmly established model of precounselling and voluntary testing devised and promoted by UNAIDS and WHO. The financial incentives of PEPFAR have nonetheless had a significant impact on Frelimo’s policy orientations. This was demonstrated by the inclusion of a stronger emphasis on the (US-supported) “AB” prevention strategy in the government’s revised HIV/AIDS Plan for 2004-2009. With regard to HIV/AIDS treatment, the Mozambican government aligned closer with the UNAIDS camp to ensure that the securitisation machinery introduced by PEPFAR would not interfere in the pre-existing treatment plan based on generic AIDS drugs.

However, despite being surrounded and permeated by powerful HASN leaders, Frelimo’s ruling elites managed to negotiate the terms of HASN incorporation in the country. As shown in the cases of ARV treatment and HIV prevention policies, the government rhetorically (and skilfully) manoeuvred inbetween the normative and policy divide separating the US and UNAIDS with clear gains while advancing its own policy preferences. One could argue, in this regard, that the many years of experience in dependency politics have served the interests of Mozambique’s governing party well while dealing with international sources of HASN diffusion. This interestingly illustrates how the so-called audiences of securitisation (or norm takers) can be proactive actors rather than passive recipients of norms (or of securitising moves). In fact, the Mozambican case clearly reveals the centrality of these norm-receiving actors in understanding either the success or failure of securitisation attempts.

Notwithstanding the partial failure of its cascading within Mozambique’s domestic structure, the introduction of HASN into the political discourse of Frelimo promoted substantial change in the government’s policy agenda. The fact that Frelimo’s leadership formally embraced the internationally-proposed securitisation of HIV/AIDS means that this norm has been legitimised inside Mozambique’s domestic politics. According to Cortell and Davis, for example, in these situations “the domestic debate shifts from being concerned with whether the norm is legitimate to one concerning why it should not be consistently applicable” (Cortell and Davis, 2000:77). Similarly, the establishment of the government’s special agencies, such as the CNCS, devoted to the formulation and implementation of policies consistent with the tenets of HASN, is also indicative of its growing (yet still incipient) salience in the country.

South Africa: The Case of Failed Securitisation

South Africa is an exceptional case of (fairly) peaceful democratic transition to black majority rule after the country had been ruled by a racist white minority under the brutal regime of Apartheid. The new regime (referred to as the “Rainbow Nation”) was personified by the emblematic figure of ANC, Nelson Mandela, who became the first black president of the democratic state. Despite the fond allusion to a rainbow to describe the multiracial and inclusive character of post-Apartheid South Africa, the country is still deeply burdened by the legacies of Apartheid. The South African society is, in many respects, as distinct and segregated along racial lines as ever, which leads to increased state-society tensions. This was clearly exemplified by the ardent black nationalism of most ANC leaders. Concerning HIV/AIDS policies, these tensions became apparent due to the racialisation of the epidemic by the country’s political leadership. President Mbeki took a controversial stance while firmly contesting Western scientific knowledge about the epidemic. His rationale is primarily ideological and should be situated in a wider refutation of Western (white) views of Africa.

The rape charges involving former deputy president, Jacob Zuma, who was also the first chair of the National HIV/AIDS Council, are emblematic of the cultural mismatch (Checkel, 1999) between local understandings about the epidemic and the mainstream (scientific) knowledge of international HASN leaders. Similarly, the public support of the health minister, Manto Tshabalala-Msimang, to unconventional methods of HIV/AIDS treatment and prevention shows her disregard for widely accepted Western (white) orthodoxies about how to combat the epidemic. So, in South Africa the internationally proposed securitisation of HIV/AIDS faced a domestic context permeated by strong racial divisions and a political leadership sceptical (even hostile) towards HASN entrepreneurs. Thus, the securitisation efforts of these actors failed to convince decision-makers in the government of the emergencial threat posed by the epidemic.

Both UNAIDS and the US government have faced significant obstacles in attempting to penetrate South Africa’s structures of decision-making. UNAIDS has had more visible progress in this regard nonetheless. Despite fierce policy divergences, UNAIDS’ Theme Group has managed to gradually establish some multilateral channels to improve communication between the government and the international partners, such as the Donor Communication Forum (DCF). Nevertheless, these channels have been circumscribed to the lower levels of policy-making without the engagement of the government’s top leadership. This lack of effective communication has clearly undermined the securitisation moves (or speech-act practices) of the international HASN leaders based in South Africa.

The widespread (mis) representation of the US government as a new form of colonial/imperial power led to a certain degree of suspicion (even hostility) towards PEPFAR’s HIV/AIDS initiatives in the country. The close links between Bush’s administration and the pharmaceutical industry (for example, PEPFAR’s Global Aids Coordinator, Randal Tobias, was a former chief executive officer (CEO) of the US pharmaceutical company Eli Lilly) were interpreted by ANC’s ruling elites as a capitalist plot against black Africans. As shown earlier, the US government’s backing of the Pharmaceutical Manufacturers Association (PMA) in the court case against the South African government have also compromised bilateral relations in the area of HIV/AIDS policies.

The US recommendations concerning HIV prevention and testing have also faced persistent resistance within South Africa. Notwithstanding the engagement of a significant number of Christian organisations at grassroots levels, the “AB” strategy was supplanted by the more pragmatic view of UNAIDS and its partners. Since very early on in the national response, both government officials and HIV/AIDS NGOs realised that deep-rooted gender imbalances in South African society would create significant barriers to abstinence practices of women and girls. According to HIV/AIDS activists, in this type of male-dominated social environment, the use of condoms would be more easily negotiated between sexual partners (Interview Nukeri 23.07.2004). With regards to HIV testing, the US/CDC’s lobby for the introduction in South Africa of routine semi-compulsory testing has also been fairly ineffective given the ANC’s strong emphasis on the individual human rights of the South African citizens.

Transnational advocacy networks have been more success-ful than other securitising actors in promoting normative/policy change within South Africa’s domestic structure. HIV/AIDS NGOs, such as the Treatment Action Campaign (TAC), aligned their political agendas with those of their transnational counterparts with significant results in terms of forcing the South African government to reassess its policy options. In 2002, for example, TAC sued the government given its refusal to roll-out ARV treatment (even after the advent of cheaper generic drugs). Despite the Mbeki administration’s reluctance to accept the benefits of ARVs, the government was forced by the South African Constitutional Court to provide AIDS drugs through the public health system. Similarly, after 2002, Mbeki began to distance himself from the views of the so-called denialists. This slight change in the confrontational language of South Africa’s leader was due to the intense transnational/domestic mobilisation led by TAC. Through a global campaign of shaming (Keck and Sikkink, 1998) and sustained criticism against Mbeki’s response to the epidemic, TAC managed to embarrass the government vis-à-vis the wider international community. However, the row involving the South African government, TAC and most of the international community of HASN leaders persisted, becoming even more virulent over the years.

3. Assessing Results and the Implications of Case Findings to Theory

In understanding processes of HIV/AIDS norm incorporation in the three Southern African states, this study proposed an association between postulates of the securitisation framework and the constructivist scholarship on international norms. In what follows, I further explore some contributions that the case studies brought to the theoretical refinement of this proposed merge.

One general empirical finding of this thesis with clear theoretical implications is that similar transnational/international pressures for the socialisation of international norms can have very dissimilar results in terms of domestic policy outcomes. In this respect, differences in the domestic social, political and cultural structures of the three case studies were proved to be essential elements in understanding their distinct responses to HASN. This finding is in line with some constructivist domestic structure approaches in international relations which produced research on domestic variation in state responses to international influences and norms (e.g., Barnett, 1990; Katzenstein and Okawara; Berger, 1993; Risse, 1994; Klotz,1995; Katzenstein, 1996; Cortell and Davis Jr., 1996). It contradicts, on the other hand, structural explanations, whether realist or liberal, that do not account for domestic influences in state behaviour. It also disconfirms the (rather ethnocentric) notion put forward by some constructivist authors (e.g., Risse, Ropp and Sikkink, 1999) affirming the indistinctive universal effectiveness of socialisation processes across a wide range of domestic social and cultural systems. This view sustains the fact that, given the intrinsic universal value of certain types of international norms (such as international human rights norms), violator states under similar socialisation pressure will eventually move towards positive change.

On the contrary, what this thesis’ case studies revealed is that, depending on variations in the domestic structure of states, international norms can be integrally accepted (Botswana), instrumentally used (Mozambique), or totally rejected (South Africa). Although the proposed securitisation of HIV/AIDS is not per se a good international norm given that it is an extreme measure outside normal politics, it is seen by its proponents as a necessary one given the magnitude of the challenges posed by the epidemic. But what is a good international norm in the first place? These normative understandings are in fact negotiated between advocates and recipients of a particular norm. In this regard, there is no such thing as an absolute good or perennially desirable norm. Rather, the domestic acceptance/desirability of a particular international norm has to be constructed through intersubjective processes of convincement and persuasion. Risse asserts in this respect that “transnational promoters of foreign policy change must align with domestic coalitions supporting their cause in the “target state” to make an impact” (1994:187). What this thesis’ empirical study found is that the transnational promoters of HASN not only aligned with already in place domestic sympathisers of their cause, but also engaged in argumentative processes to build these domestic “allegiances”.

In an important constructivist work on the socialisation effects of international human rights norms, Risse and Sikkink (1999) stressed the strategic influence of social activism in pressuring decision makers in national governments. In situations whereby the communication channels between local advocacy groups and the government are broken or significantly reduced, these domestic groups directly link up with transnational advocacy networks to bring combined pressure on their states from “above” and from “below”. As the aforementioned authors note, “international contacts can amplify the demands of domestic groups and then echo these demands back into the domestic arena” (Risse and Sikkink, 1999:18). Their representation of transnational protest mechanisms as pathways for domestic normative change held some truth in the case of South Africa’s incorporation of HASN.

As noted in chapter 6, TAC engaged in a dual strategy of organising mass protests at home and, at the same time, raising international awareness about the norm-violating South Africa. In the face of increasing civil society and transnational mobilisation, some members of ANC’s political leadership, mostly at the provincial level of decision-making, began to realise that complacency over the HIV/AIDS epidemic could bear high political costs. However, the central administration in Pretoria fiercely resisted HIV/AIDS social mobilisation. As already noted, it was only by judicial means that the federal government moved towards the implementation of a nationwide HIV/AIDS treatment plan. In this sense, what the South African case has shown is that, rather than engaging in direct argumentative practices with intransigent ANC authorities, local HIV/AIDS groups used alternative forms of social pressure that transcended the limits given by the domestic arena of decision-making.

Conversely, in the cases of Botswana and Mozambique, despite the existence of active domestic-transnational linkages engaged in the transmission of HASN prescriptions, socialisation processes occurred in the absence of strong social pressure. In those states, domestic-transnational articulations had only a marginal impact on policy change. The ruling elites of these countries engaged directly with the securitisation “speech-act” of the US, UNAIDS and other transnational HIV/AIDS actors with clear variations in the outcomes of socialisation. Therefore, unlike South Africa, the Mozambican and Botswanan governments’ interactions with international sources of HASN diffusion were not strongly mediated by winning coalitions between national and transnational HIV/AIDS groups. However, the reasons behind these states’ more direct relationship with international HASN leaders were quite distinct.

In Mozambique, the lack of a truly indigenous domestic civil society sector favoured the Frelimo government’s strategies of extraversion. This means that the massive penetration of international actors into Mozambique’s domestic structure since the end of civil war resulted in a symbiotic (or interdependent) type of relationship between those actors and local political leaders. If, on the one hand, the government relinquished to foreign agents a substantial share of its sovereignty rights, on the other, these same international actors maintained and reinforced traditional patterns of domestic political control by Frelimo. In this regard, chapter 5 has shown how the Mozambican government skilfully manipulated the securitisation language of the international community to keep donors onboard, albeit without demonstrating a clear engagement in the actual domestic securitisation of HIV/AIDS.

Botswana, in turn, presents a state-controlled domestic structure with a highly centralised decision-making system. As already noted in chapter 4, the corporativist character of the Botswanan state led to the creation of a civil society sector highly dependent on the government for financial support and policy guidance. Good, for example, attested that in Botswana’s domestic system, “regarding liberties of expression and association in general, the national leadership has a definite preference for the depoliticisation of issues” (Good, 1992:85). Hence, HIV/AIDS local groups, notwithstanding their important connections to transnational HASN leaders, have been more reactive than proactive actors in influencing the national response to the epidemic. This granted the national government a fairly autonomous capacity to negotiate the domestic entry of international HASN’s actors and their securitising ideas concerning HIV/AIDS.

In fact, the location of agency in the personal leadership of key decision-makers was a common feature of the three case studies. Given that all investigated countries presented (with important qualifications nonetheless) a centralised system of decision-making with power concentrated in a few individuals, the prior convincement of the top political leadership in the government about the need to securitise HIV/AIDS was an essential precondition for the domestic cascading of HASN. In effect, those ruling elites were the actual gatekeepers controlling the penetration of international norms in their respective states. Botswana is an interesting example in this regard. The positive engagement of Mogae with the securitisation ideas of international norm leaders triggered substantial domestic change after he took office in 1998. Accordingly, Frelimo’s political leadership in Mozambique adapted the imported principles of HASN to traditional patterns of these leaders’ relationship with international actors. Finally, South Africa under Mbeki’s rule rejected the interference of HASN leaders in the country based on the President’s, and his Minister of Health’s, ideological preconceptions about Western domination and race. Therefore, the struggles, consistencies and contestations over the domestic acceptance of HASN concern, to a large extent, the social identity of these actors.

By discussing the particular (mis) perceptions and reactions of national leaders (and their close supporters) towards international HIV/AIDS norms, the present argument analytically exposed a very important locus of normative change in these three polities. In several important respects, therefore, the personalist nature of these African states provided an important empirical contribution to the cumulative understanding of how international norms impact states’ domestic structures. It is important to emphasise, however, that top decision-makers do not behave in a complete political vacuum. As already seen, they are exposed to and constrained by the particular configuration of domestic forces, the values and principles that define the specific political culture of their countries and the limits given to their power by the states’ political institutions.

The unfolding of these dynamics of HASN’s incorporation in Botswana, Mozambique and South Africa provided an important contribution to the ongoing securitisation debate in international relations. As chapter 2 has demonstrated, Buzan and Wæver, as well as other members of the Copenhagen School, have attempted to provide a theoretical foundation for rethinking the processes by which issues become securitised. Notwithstanding their sustained efforts to accomplish such an endeavour, they have been quite unsuccessful in actually demonstrating when and how a speech-act removes a particular issue from the realm of normal politics to that of an existential threat. These authors concentrated mostly on meta-theoretical assumptions about the intersubjective security articulations between securitising actors and their audiences rather than on the actual (and variable) empirical circumstances which determine the success of a securitisation attempt. I believe that the focus of this study on domestic processes of HASN incorporation expanded the capacity of the securitisation theory to empirically understand the ways in which states (or the audiences of securitisation) absorb and respond to the securitisation claims of the so-called securitising actors.

Therefore, the pendulum analogy used in chapter 2, by which issues are moved from the realm of politicisation to that of securitisation and back, makes sense only when the analyst clearly identifies the location of agency in securitising processes and the domestic structural features that either enable or constrain the argumentative practices (or speech-acts) of securitising actors. In this regard, and as already noted, the understanding of the actual mechanisms whereby securitisation attempts are internalised by domestic actors, and how they respond to them, is the foremost shortcoming in securitisation analysis. So, the study of the differential impact of HASN in Botswana, Mozambique and South Africa has widened the scope of the securitisation research agenda to include a strong emphasis on the (usually neglected) audiences of securitisation. Indeed, I have argued at the beginning of this thesis that to convincingly demonstrate that an issue has been securitised requires a thorough examination of the acquiescence of an audience. The governments of the three case studies were likened here to the idea of “the national”, meaning those who objectively and legitimately speak security for their respective societies (MacSweeney, 1996). As such, they were the main target audiences of the international securitising actors described in chapter 3. This does not mean, however, that these governments were isolated political entities disconnected from the wider social dynamics and shared political culture of the states they represent and are supposed to protect. Rather, they were immersed in and constituted by the particular cultural/social environment of these states. To open up the black box of these complex audiences, this study employed theoretical insights from the constructivist scholarship on international norms, which concentrates mostly on the variations in state compliance with externally devised norms. In so doing, it identified three models of state behaviour towards HASN, which corresponded to the particular domestic political processes of Botswana, Mozambique and South Africa.

These models were, in fact, the actual outcomes of the securitisation attempts of international HASN leaders in each one of the three case studies. Therefore, the fully successful, partially successful, or totally unsuccessful securitisation of HIV/AIDS in Botswana, Mozambique and South Africa, respectively, were a function of both the argumentative (and other negotiation) practices between securitising actors and their audiences and the facilitating structural factors that shaped (and were shaped by) the social interaction among them. Thus, the empirical measurement of HASN’s strength (or salience) in the domestic political arena of these states has contributed to a more comprehensive understanding of the securitisation process, which gives a stronger and more systematic role to the audiences of securitisation and their social contexts.

Moreover, the study was crucial in identifying the domestic empirical conditions which either facilitated or hampered the successful transposition of HIV/AIDS from the area of politicisation (normality) to that of securitisation (exceptionality). Four main factors (or variables) were identified in this respect: 1) the form of state-society relations; 2) the type of state institutions (either strong or weak) and the format of the decision-making process (either centralised or decentralised); 3) the long-term values and principles that defined the political culture of the three states and, finally, 4) the personal characteristics of key leaders in the government.

State-Society Relations

Decision-making process

Match between HASN and Pre-existing Political Cultures

Political Leadership on HIV/AIDS After Securitisation Move

Outcome

Botswana

Close with dependent/weak civil society (co-opted by government)

Centralised decision-making (Developmental State)

Close

Assertive

Successful

Securitisation

Mozambique

Distant with dependent/weak civil society (co-opted by transnational actors)

Centralised decision-making

(Patrimonial State)

Contingent

Instrumental

Partially Successful Securitisation

South Africa

Distant/conflictive with independent/strong civil society

Centralised decision-making

(Black Nationalist/Ideological State)

Distant

Absent/Erratic

Unsuccessful

Securitisation

Table 1: Analytical Variables and Case Studies

Finally, the argument put forward in this thesis has claimed that the semantic practice of securitisation should be analytically integrated within larger normative/historical processes at the global level. As demonstrated in chapter 2, through the explanation of the first (holistic) dimension of HASN, the domestic incorporation of this norm’s postulates makes sense only if one recognises broader historical, ideological and material divisions in the inter-state system/society. As noted by Ayoob (2002:35), the emergence of new states as a result of rapid decolonisation after the end of WWII brought along significant normative tensions in the international society. Alongside the bipolar geo-strategic division of the global order, an equally conflictive North-South divide redefined material and ideological relations among states. This unprecedented expansion of the international society and the normative changes it brought about are today still influencing the foreign policy decisions of a number of African political leaders. In this respect, the South African case suggests that Mbeki’s ideological resistance to HASN should be placed within the larger political agenda of the so-called “South”. By challenging Western institutions (which, in his view, would represent a kind of Gramscian historic bloc) Mbeki’s government has sought to buttress South Africa’s international identity as a key representative (and aspiring leader) of the developing world. As a general case, the constructivist scholarship on international norms and the securitisation framework have neglected this very important structural element while understanding how international norms are socialised within states as well as in shedding light on the interaction between securitising actors and their audiences. Instead, both perspectives have focused exclusively on the domestic and circumscribed impact of particular international norms and securitisation moves without fully acknowledging the wider ideational/material structure within which norms are created, promoted and also resisted.

It is worth noting that, among existing analytical perspectives in international relations, (neo)realist theories have also offered a structural ( and rather sceptical) interpretation of how, under what circumstances, and why states abide by international (mostly security) norms (e.g., Gilpin, 1981; Waltz, 1979; Krasner, 1995; Mearsheimer, 1990, 1993). According to these authors, anarchy prevails in international relations and norms, when enforced, are just epiphenomenal to the power politics logic that dictates relations between states. Although the study of the impact of international norms in the behaviour of states is not a key issue in theoretical debates among realist authors, they emphasise very strongly the role of powerful states in the international system in leading (or blocking) processes of normative change. The US economic and political weight was indeed an important factor in understanding normative change towards HASN in the three case studies. The huge economic incentives of PEPFAR have undoubtedly influenced policy decision-making in Botswana, Mozambique and South Africa. However, this was not the crucial factor in understanding the incorporation of HASN in these three countries. Botswana, the country who least needed the PEPFAR money, was the one which complied more closely with the demands of the US. Conversely, Mozambique, who most dramatically required US support, managed to articulate alternative views at the same time as keeping the US financial channels open (see, for example, the cases of generic AIDS drugs and HIV prevention campaigns in chapter 5). South Africa, which is also a recipient of PEPFAR, constantly denounced the interference of US economic interests in Africa and actively resisted HASN interference in the country.

4. Conclusive Thoughts: The Way Forward

Although substantial research is still needed to devise an empirically useful securitisation theory, these three models of state reaction to HASN suggested that the way forward lies in a more in-depth study of real-world securitisations. In this regard, the understanding of states (and the governments they represent) as complex audiences of securitisation would significantly improve the explanatory power of the securitisation framework. As chapter 2 has shown, this could be done by drawing upon the work of constructivist scholars who have argued (and showed how) international norms impact state behaviour through domestic political systems.

Besides, the exposition of the differences in the domestic reception of HASN in those three Southern African states can also shed some light on issues concerning regional security relations. As noted in this thesis’ introduction, regional attempts to securitise HIV/AIDS at SADC were undermined by inward-oriented states, lacking common understandings about how to respond to the epidemic. Buzan and Weaver (re)defined regional security complexes (RSC) as “a set of units whose major processes of securitisation, desecuritisation, or both are so interlinked that their security problems cannot reasonably be analysed or resolved apart from one another” (Buzan and Weaver, 2003:44). For them, “a RSC depends on there being significant levels of security interdependence among a group of states or other actors” (2003:229). What this thesis has revealed is that inside the SADC area, major processes of securitisation towards HIV/AIDS only took place within states rather than among them. Hence, a systematic analysis of processes of HASN incorporation at this regional institution would provide some further empirical evidence to challenge the idea that the Southern Africa region is an example of an RSC, as Buzan and Weaver claimed in their book (Buzan and Weaver, 2003:233).

In addition to these theoretical contributions, the research developed here can also help to bridge the (rather wide) void between scholarly knowledge in international relations and governments’ policy-making. While systematically thinking about distinct state responses to the proposed securitisation of the HIV/AIDS epidemic, this thesis can be particularly helpful in laying the ground for a critical assessment of the normative underpinnings (benefits and shortcomings) in securitising global epidemic diseases, such as HIV/AIDS, Avian Flu and SARS. Ultimately, this should provide some extra leverage to policy-makers and enable them to influence outcomes in a more enlightened fashion.

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2.2. Journal Articles and Other Materials

Acharya, A. (2004) How Ideas Spread: Whose Norms Matter? Norm Localization and Institutional Change in Asian Regionalism. International Organization 58 (2):239-275.

Ala, J. (2004) Is South Africa Meeting the Challenge of HIV/AIDS Ten Years into Democracy? Unpublished Manuscript.

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Allen, C. (1999) Ending Endemic Violence: Limits to Conflict Resolution in Africa. Review of African Political Economy 26 (81):317-322.

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“South African Health Ministry Sees AIDS Pandemic Stabilising”. Agence France Press, 23.09.2004.

“Africa’s Success Story, Botswana Gears up for Elections”. Agence France Press, 24.10.2004.

“Controversy Dogs AIDS Forum”. BBC News, 10.06.2000. Available at <http://news.bbc.co.uk/1/hi/world/africa/826742.stm> (accessed on 21.01.2003).

“AIDS Kills 50% in Botswana”. BBC News, 07.11.2000. Available at <http://news.bbc.co.uk/1/hi/world/africa/1011639.stm> (accessed on 22.02.2003).

“Delivery Remains Stumbling Block in Anti-AIDS Drive”. Business Day, 28.07.2004.

“US Criticised for Cutting Its Own Deals with Makers of AIDS Medicines”. Business Report, 15.07.2004.

“Routine HIV Testing Project Launched in Francistown”. Daily News, 30.08.2004.

“HIV/AIDS Fight Pays Dividends”. Daily News, 07.02.2006.

“Botswana Loses Out”. DailyNews, 16.02.2006.

“World Bank Warning: Economic Collapse in South Africa Without Action on AIDS”. Financial Times, 11.07.2003.

“A Man in a Hurry: Thabo Mbeki Pushes for Jobs at Home and Peace Abroad”. Financial Times, 22.02.2005.

“Four Ways to Fix America’s Failure on Africa”. International Herald Tribune, 27.06.2005.

“US$ 35 million boost for anti-AIDS effort”. IRIN News, 09.03.2005. Available at <http://www.irinnews.org/report.asp?ReportID=46019> (accessed on 30.05.2006).

“TAC: We Want to Help”. Mail & Guardian, 19.09.2002.

“Global AIDS Coordinator Tobias Defends U.S. Policy Not To Use Generic Fixed-Dose Combination Antiretroviral Drugs” Kaiser Daily, 29.04.2004. Available at <http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=23445> (accessed on 23.06.2004).

“Bush administration AIDS czar fails to win over critics”. Los Angeles Times, 11.07.2004.

“South Africa’s AIDS doubts baffle the experts”. Mail & Guardian, 17.03.2000.

“ANC Puts Party Before Democracy”. Mail & Guardian, 06.02.2001.

“A Decade of Democracy in the Fight Against AIDS”. Mail & Guardian, 14.04.2004.

“Slow Road to Drugs Roll-Out”. Mail & Guardian, 09.07.2004.

“Row Over “Mutant” AIDS Drug”. Mail & Guardian, 23.07.2004.

“No One Forced Government to Use Nevirapine”. Mail & Guardian, 19.12.2004.

“Africa Should Beware of Forces of Liberal Imperialism”. Mail & Guardian, 07.04.2006.

“TAC: Zuma Should Speak Out on HIV/AIDS”. Mail & Guardian, 31.05.2006.

“SA Govt Under Fire at AIDS Conference”. Mail & Guardian, 19.08.2006.

“Zuma Camp Lashes Out at “Old” Tutu”. Mail & Guardian, 01.09.2006.

“Seropositivos Beneficiam de Assistência em Maputo”. Notícias, 09.08.2004.

“Alemanha Financia Orçamento do Estado”. Notícias, 11.08.2004.

“Prevalência do HIV/SIDA Tende a Aumentar no Norte”. Notícias, 17.08.2004.

“Brasil Mantém Fidelidade ao Protocolo Acordado”. Notícias, 18.08.2004.

“Problemática da SIDA no Mundo Actual”. Notícias, 20.08.2004.

“New Volunteers Arrive in Swaziland with HIV/AIDS Focus”. Peace Corps Press Release, 17.09.2003.

“Maputo Hosts Partnership Forum”. Panapress, 19.04.2004. Available at <http://www.panapress.com/newslatf.asp?code=eng038655& dte=16/04/2004> (accessed on 22.06.2005).

“Manto Blazes Away Over AIDS Drug: Combative Minister Has a Go at UN Envoy”. Sunday Times, 18.07.2004.

“Mbeki’s HIV Stand Angers Delegates, Hundreds Walk Out on His Speech. San Francisco Chronicle, 10.06.2000.

“Leaders Fighting AIDS “Ashamed””. Saturday Star, 17.07.2004.

“A Battle Line in Botswana AIDS Fight”. The Boston Globe, 24.10.2003.

“Mozambique’s Misery”. The Economist, 02.03.2000.

“Stop denying the killer bug”. The Economist, 21.02.2002.

“Who Killed the Fly?”. The Economist, 21.11.2002.

“South Africa and AIDS: No More Denial”. The Economist, 05.12.2002.

“In Mandela’s Shadow”. The Economist, 12.12.2002.

“Help at Last on AIDS. Yet the Worst is Still to Come”. The Economist, 29.12.2003.

“The Menace that Wasn’t: The Human Rights Act Has Not Lived Up to Expectations”. The Economist, 11.11.2004.

“Just a Few Bad Apples?”. The Economist, 20.01.2005.

“Thabo Mbeki, A Man of Two Faces”. The Economist, 20.02.2005.

“The End of the Beginning?”. The Economist, 15.07.2004.

“The Triumph of the Religious Right”. The Economist, 11.11.2004.

“You Ain’t Seen Nothing Yet”. The Economist, 23.06.2005.

“Too Much Morality, Too Little Sense”. The Economist, 28.06.2005.

“The Row about the Bushmen”. The Economist, 16.02.2006.

“Botswana: A Beacon of Hope in Africa”. The Guardian, 15.07.2004.

“Malawi Counts the Cost of America’s Policy for Funding anti-Aids Drugs”. The Independent, 16.09.2005.

“Author Shatters Taboo to Claim AIDS Death Figures Are Based on False Surveys”. The Observer, 21.12.2003.

“The World: The US and Africa: Extending a Trembling, Hesitant Hand”. The New York Times, 07.05.2000.

“Early Tests for US in Its Global Fight on AIDS”. The New York Times, 14.07.2004.

“TAC Accuses Health Officials of Undermining Agreement. The Star, 15.07.2004.

“Botswana on the Way to 5.5% Growth as Economy Diversifies”. The Star, 30.07.2004.

“Bush Using AIDS As a Lever to Take Africa’s Resources”. The Sunday Independent, 18.07.2004.

“AIDS Conference Demands Access to Drugs for All”. The Sunday Independent, 18.07.2004.

“Lewis Taking Africa’s AIDS Battle to the World”. The Sunday Independent, 01.08.2004.

“Call to Hasten Microbicides as HIV Rate Climbs Towards 50%”. The Sunday Independent, 01.08.2004.

“SANDF Unveils Shock AIDS Data”. The Sunday Independent, 01.08.2004.

“Brazil Rejects U.S. AIDS Funds Over Antiprostitution Pledge”. The Wall Street Journal, 02.05.2005.

“AIDS is Declared Threat to Security: White House Fears Epidemic Could Destabilise World”. The Washington Post, 30.04.2000.

“US Rule on AIDS Drugs Criticised: Ban on Using Aid to Buy Foreign Generics Hinders Treatment, Experts Say”. The Washington Post, 14.07.2004.

“Botswana’s Gains Against AIDS Put U.S. Claims to Test”. The Washington Post, 01.06.2005.

“How AIDS in Africa was Overstated”. The Washington Post, 06.04.2006.

“Botswana’s Leader Defends AIDS Testing”. The Washington Times, 10.04.2004.

“UN Report Critical of Donor Countries Still Giving “Tied Aid””. This Day, 08.07.2004.

“Prevention Better Than Cure: AIDS Vaccine Eludes Scientists”. This Day, 08.07.2004.

“Curing AIDS Patience”. This Day, 12.07.2004.

“SA HIV Rate Out by 33%, World Told: Health Minister Says State Has Helped to Reduce Infections”. This Day, 12.07.2004.

“SA Has the World’s Third-Largest Market for Generic Medicines”. This Day, 12.07.2004.

“Achmat’s Utterances “Irresponsible””. This Day, 14.07.2004.

“Battle AIDS as You Do Terror, US Urged”. This Day, 14.07.2004.

“Death by Mosquito: Malaria, Like AIDS, Is Killing Millions. But Unlike AIDS, It Can Be Cured. Why Isn’t That Happening?”. Time Magazine, 26.07.2004.

Appendix: List of Interviews in Alphabetical Order

ALA, Jacqui

Department of International Relations, School of Social Sciences, University of the Witwatersrand – HIV/AIDS Academic. Interview conducted in Johannesburg, South Africa, 23.07.2004.

BAGGIO, Ombretta

UNAIDS – Programme Officer. Interview conducted in Maputo, Mozambique, 11.08.2004.

BALFOUR, Thutula

Head of International Health Liaison, National Department of Health and former Director of SADC Health Sector Coordinating Unit. Interview conducted by phone in Pretoria, South Africa, 23.08.2004.

BARBOSA, Clarisse

Embassy of Norway – HIV/AIDS Programme Official. Interview conducted in Maputo, Mozambique, 11.08.2004.

BORTOLOT, Gabriella

Comunidade de Sant’Egidio – Programme Officer, DREAM Project. Interview conducted in Maputo, Mozambique, 05.08.2004.

CAESAR, Mary

IDASA – Research Facilitator, Governance and AIDS Programme. Interview conducted in Pretoria, South Africa, 08.07.2004.

CREWE, Mary

Centre for the Study of AIDS, University of Pretoria – Director. Interview conducted in Pretoria, South Africa, 28.07.2004.

CESSAMO, Teodora

MONASO – Institutional Capacity Officer. Interview conducted in Maputo, Mozambique, 16.08.2004.

CHAMBULE, Jonas

Irish Embassy – Assessor de Saúde. Interview conducted in Maputo, Mozambique, 13.08.2004.

DRAGE, Mona

UNAIDS – Programme Officer. Interview conducted in Gaborone, Botswana, 15.02.2006.

DUCE, Pedro

INE – Técnico de Demografia e HIV/SIDA. Interview conducted in Maputo, Mozambique, 13.08.2004.

HAMAZ, Bekume

NACA – National AIDS Coordinating Unit. Interview conducted in Gaborone, Botswana, 30.08.2004.

HEMBE, Antonia

SADC – HIV/AIDS Manager. Interview conducted in Gaborone, Botswana, 27.08.2004 and 08.02.2006.

HUMPHRIES, Richard

Southern African Regional Poverty Network (SARPN) - Senior Researcher. Interview conducted in Pretoria, South Africa, 07.07.2004.

JOHANNSEN, Philipp

GTZ – Coordenador Provincial, Programa de Desenvolvimento Rural. Interview conducted in Maputo, Mozambique, 18.08.2004.

LETSHWITI, Dikitso

YOHO – Programme Officer. Interview conducted in Gaborone, Botswana, 14.02.2006.

LOEWENSON, René

Training and Research Support Centre (TARSC) – Director. Interview conducted in Benoni, South Africa, 27.07.2004.

MACUANE, José Jaime

Unidade Técnica da Reforma do Sector Público – Consultor. Interview conducted in Maputo, Mozambique, 10.08.2004.

MAGONGO, Bongani

CADRE – Senior Research Manager. Interview conducted in Johannesburg, South Africa, 20.07.2004.

MALEKIA, Erica

SADC – Senior Officer, Public Health. Interview conducted in Gaborone, Botswana, 27.08.2004.

MEISSNER, Richard

South African Institute of International Affairs (SAIIA), University of the Witwatersrand – Research Fellow. Interview conducted in Johannesburg, South Africa, 03.08.2004.

MILAGRE, Diogo

CNCS – Secretário Executivo Adjunto, Director de Projecto. Interview conducted in Maputo, Mozambique, 19.08.2004.

MODISAOTSILE, Innocent

SADC – HIV/AIDS SADC/EU Project Manager. Interview conducted in Gaborone, Botswana, 11.02.2006.

MOTHUSI, Lorato Leatlhama

YOHO – Senior Programme Officer. Interview conducted in Gaborone, Botswana, 30.08.2004.

NACHTIGAL, Georg

GTZ – Assessor de Projecto, Projecto Saúde – HIV/SIDA. Interview conducted in Maputo, Mozambique, 12.08.2004.

NEGRÃO, José

Cruzeiro do Sul – Senior Researcher. Interview conducted in Maputo, Mozambique, 09.08.2004.

NUKERI, Cedric

TAC – Senior Programme Manager. Interview conducted in Johannesburg, South Africa, 23.07.2004.

PALHA DE SOUSA, César

Cruzeiro do Sul – Medical Doctor and Senior Researcher. Interview conducted in Maputo, Mozambique, 09.08.2004.

PHARAOH, Robyn

Institute for Security Studies (ISS) – Senior Researcher, AIDS and Security Project. Interview conducted in Pretoria, South Africa, 24.08.2004.

PINTO, Stella

UNDP – Assistant Resident Representative, Head of Poverty Eradication and HIV/AIDS Unit. Interview conducted in Maputo, Mozambique, 18.08.2004.

RAJARAMAN, Divya

Botswana Harvard AIDS Institute – Social and Behavioural Sciences. Interview conducted in Gaborone, Botswana, 30.08.2004, and Oxford, England, 28.01.2006.

RALPH, Ian

Delegation of the European Commission in South Africa – Health Advisor. Interview conducted in Pretoria, South Africa, 25.08.2004.

ROELS, Thierry

CDC – Associate Director, Global AIDS Programme, The Botusa Project. Interview conducted in Gaborone, Botswana, 12.02.2006.

SAÍDE, Mouzinho

Ministério da Saúde (MISAU) – Director da Unidade de HIV/SIDA. Interview conducted in Maputo, Mozambique, 11.08.2004.

SOARES LUZ, Francisco

Embassy of Brazil – First Secretary, Multilateral and Public Affairs Section. Interview conducted in Pretoria, South Africa, 07.07.2004.

TSELAYAKGOSI, Monica

NACA – Programme Planning Manager. Interview conducted in Gaborone, Botswana, 16.02.2006.

UANE, Doris

Irish Embassy – Assessora para a Área de HIV/SIDA. Interview conducted in Maputo, Mozambique, 17.08.2004.

VAN NIEUWKERK, Anthoni

Centre for Defence and Security Management, University of the Witwatersrand – Senior Lecturer. Interview conducted in Johannesburg, South Africa, 30.07.2004.

WATSON, Diana

Delegation of the European Commission in South Africa – Development Attaché. Interview conducted in Pretoria, South Africa, 25.08.2004.