Southern Africa’s Persistent Dilemma Coronavirus and the Lost Legacy of the AIDS Epidemic

While SARS-CoV-2 and HIV are different pathogens, comparing the viruses themselves, as well as how southern Africa has responded to them, can help us better understand the region’s current climate and provide insight into whether coronavirus and its aftermath will spur a crisis on a scale comparable to the United States.

Coronavirus is fragmenting the United States of America. With tens of thousands of new infections and several hundred deaths tallied daily, American society is straining under the weight of an eight-month quarantine intended to buy Washington the time it needed to crush the deadly disease. Donald J. Trump’s administration has failed to address the crisis, pivoting instead to fascistic cosplay to distract from the pandemic, suppress the voices of his detractors, and rile up his core base of supporters for an upcoming election that he is openly attempting to undermine. The kidnapping of protestors by unaccountable, unidentified federal officers in unmarked vans; the subversion of global health agencies’ advice; the seeking of electoral assistance from authoritarian foreign administrations—the US government is engaging in the precise activities it has long demanded that African countries cease. For the states of southern Africa, these demands were tied to the provision of US-controlled aid. Now, as the US under President Trump leans into these autocratic behaviours, so too has it begun to extricate itself from its aid obligations to those same countries.

In many ways, this American crisis is a heightened rerun of the HIV/AIDS epidemic in the 1980s. A US president faced with a burgeoning virus, identifying that its initial victims lie outside his electoral base, decides to gaslight the nation and either ignore the disease like Ronald Reagan, or pretend it will disappear on its own. As Trump said during an interview in August, ‘This thing’s going away. It will go away like things go away.’ What White House strategists seem to have forgotten, or, more chillingly, remember, is that Reagan’s necropolitical gambit cost more than 80,000 American lives. As I have written elsewhere, with the US coronavirus death toll above 200,000 and climbing with no end in sight, Americans are paying the ultimate price for their government’s failure to learn the lessons of the HIV/AIDS epidemic.

In southern Africa, the parallels between the coronavirus and HIV/AIDS are even more tangible. The conditions that emerged from the HIV epidemic are now shaping the course of this new pandemic as southern African governments address it using the infrastructure of the HIV response. And as the United States founders under the weight of COVID-19, southern Africa struggles to manage the legacy of America’s extensive involvement in its last major viral crisis. The primarily US-funded World Health Organization (WHO), whose current structure was shaped during the global response to the African AIDS epidemic with the creation of UNAIDS, is attempting to play a role in containing the spread of a deadly disease in the region once again. And while SARS-CoV-2 and HIV are different pathogens, comparing the viruses themselves, as well as how southern Africa has responded to them, can help us better understand the region’s current climate and provide insight into whether coronavirus and its aftermath will spur a crisis on a scale comparable to the United States.

Comparing COVID-19 and HIV

There are two broad determinants for the spread of a disease: biological factors and social factors. Biological factors include whether or not a disease is communicable, how contagious it is, the manner in which it spreads and its lethality. HIV and SARS-CoV-2 are both communicable, zoonotic viruses but the latter is far more contagious. HIV spreads through exposure to select bodily fluids including blood, semen, vaginal and rectal fluid, and breast milk, requiring an act like unprotected sex, sharing of used needles, childbirth, or transfusing HIV+ blood. SARS-CoV-2 primarily spreads via the inhalation of respiratory droplets, which can be transmitted through a brief, face-to-face conversation or a chance in-person encounter. Left untreated, HIV has a much higher fatality rate and can last well over a decade, while coronavirus kills one per cent of those infected.

However, coronavirus often results in little more than mild illness with few detectable symptoms, and untreated HIV remains largely symptom-free for several years until the infected individual’s immune system has undergone significant degradation from the virus’ persistent attacks on their T cells. Both diseases are contagious during these asymptomatic periods. In fact, HIV is at its most viral during the earliest and least detectable acute stage. This characteristic made it easier for HIV to spread undetected throughout sub-Saharan Africa from the 1960s to the 1990s. It has also helped coronavirus thwart containment efforts since its detection in late 2019.

However, much like Amartya Sen has argued with regard to the relationship between environment and famine, biological factors constitute only half of the epidemiological whole. Social factors structure human interactions and thereby determine whether a new disease dies off with a single individual or explodes into a global pandemic. HIV demonstrates the importance of the intersection between these factors. SIV crossed over from chimpanzees to humans and mutated into HIV around 1921 in central Africa.  Despite this early inception date, the HIV epidemic did not emerge until the late 1970s. Fifty years is a significant gap, even factoring in HIV’s lengthy asymptomatic period. Yet there is a simple explanation: the disease likely surfaced in a rural, forested community with low population density and mobility. As a result, HIV’s reproduction rate stayed just high enough to sustain itself for its first 30 years. However, once an HIV+ individual moved to the densely populated neighbouring city of Léopoldville (now Kinshasa) in the early 1950s, it took less than ten years for a citywide outbreak and, eventually, a full-blown HIV epidemic to emerge.

HIV and the Legacy of Economic Liberalization

To better understand the historical commonalities between the coronavirus pandemic and the HIV epidemic, we must therefore examine the ways in which biology and social structures intersect. During the peak years of AIDS in Africa, poverty was a powerful predictor of vulnerability. Poverty does not cause AIDS, as Thabo Mbeki infamously proposed, but it does limit a person’s agency, increasing exposure to risky behaviour that could spread HIV and limiting the availability of safe choices. For an unemployed person desperate to feed their family, transactional sex provides a quick, well-trod route to cash in hand. However, given that over 20 per cent of adults were HIV+ in much of southern Africa in the late 1990s and early 2000s, engaging in transactional sex even once posed significant danger to all parties; a danger that rose with each instance.

Additionally, if dire straits force a person to seek income from transactional sex, they have less power to demand that their client follows safe practices. Sex work is illegal in most of southern Africa, deepening this agency disparity. Poverty hastens exposure to HIV in countless other ways: poor communities lack adequate access to social services like healthcare and education; hunger weakens the immune system; and the harsh conditions of poverty can lead to increased rates of alcoholism and drug addiction, further diminishing one’s immune system and the ability to make informed choices. These problems are worsened by the aforementioned limits on access to social services. The HIV vulnerability of the impoverished has proven to be death by a thousand cuts.

The conditions of poverty that facilitated the spread of HIV in southern Africa in the 1990s and early 2000s are a consequence of systemic problems that spanned multiple countries. The legacy of settler colonialism in countries like South Africa, Namibia and Zimbabwe meant that new states were palimpsestic: decolonial projections scratched over blueprints for racial apartheid. After apartheid was abolished in South Africa, the main changes that followed consisted of democratic reform, legal de-racialization and economic liberalization. The structure of governance and the bureaucracy of the apartheid Bantustans were not expressly overhauled. Some countries, such as South Africa and Namibia, underwent liberalization of their own accord in a bid to be treated as members of the global economy in good standing. Others, like Angola, Zambia, and Zimbabwe, implemented Structural Adjustment Programs (SAPs) in order to receive loans from the IMF and World Bank, two organizations in which the United States has sole veto power.

These SAPs mandated that countries privatize, shrink, or increase public-facing costs for social services, deregulate domestic private enterprise, remove import tariffs, and halt the provision of subsidies to sectors of the domestic economy – severe reforms that the US government itself did not abide by. These sweeping changes diminished access to public goods like education and healthcare, increased labour hazards while decreasing wages, flooded the domestic market with cheap foreign goods, and gutted developing industries. As a result, income inequality exploded and national economies shifted from productive industries toward resource extraction industries. Corporate and government corruption ballooned as capitalists and politicians alike fought for the keys to the kingdom: the natural resources driving these economies. This in turn generally resulted in deepening poverty and increased public disillusionment with the political system. Widening economic stratification fit perfectly into the racialized divides of space and access that had characterized settler-colonial society, and class joined race to become the dominant hierarchies dividing the nation.

Coronavirus in the State AIDS Made

When considering coronavirus in southern Africa, the history of HIV/AIDS prompts a few key questions. First, if the spread of disease is determined by the intersection of biological and social factors, does the biology of SARS-CoV-2 mesh with the same social vulnerabilities relevant during the AIDS crisis? The answer is yes, but for different reasons. Poverty, while not the only significant predictor of vulnerability to HIV or coronavirus, is an important driver of the spread of both. For SARS-CoV-2, physical proximity is the main vector for transmission. And while bourgeois urbanites and land-owning farmers may be able to social distance by taking time off or working from home, the millions of southern Africans living in poverty risk starvation if they forgo participation in labour markets—formal or informal. Additionally, quarantining is nearly impossible for the urban poor of cities like Johannesburg, Harare and Windhoek. Their most impoverished—usually informal—townships are crowded with cramped corrugated tin shacks often with poor sanitation. Calls for social distancing ring cruelly hollow in societies in which space is so hierarchically bound.

Second, if poverty facilitates the spread of SARS-CoV-2 as it did HIV, we must ask whether the conditions that created and sustained poverty during the AIDS epidemic persist today. The answer to this is also an unfortunate, resounding yes. The strongest evidence of this sad truth is the ongoing prevalence of HIV in southern Africa 40 years later with no clear end in sight. In fact, many of the global, social and economic structures that facilitate poverty and vulnerability to health crises were erected in response to the AIDS epidemic. In the early 1980s, before independence and the darkest days of HIV, the South West Africa People’s Organisation (SWAPO)—the future governing party of Namibia—designed a national healthcare system with a structure more similar to the program proposed by the Nicaraguan Sandinistas than to the US public-private insurance system. Healthcare was to be bottom-up, community-based and government-run. Private medicine would be abolished and foreign aid handled with caution.

However, by the late 1980s, the US-backed WHO was organizing a response to the HIV epidemic, effectively restructuring African healthcare systems to deemphasize national health regimes and instead rely on foreign aid and the expertise of foreign advisors. In Namibia, when presented with the chance to construct and legitimize the new government on the back of a fully sponsored global HIV response, SWAPO discarded their aspirations for socialized medicine and instituted the WHO plan. Much of southern Africa made a similar decision.

Across these countries, a patchwork system of public health NGOs and charities grew in lieu of a welfare system. However, these organizations would never achieve the coverage, authority or utility of national healthcare. Funded largely by the United States, US-influenced international institutions and western aid organizations, NGOs in southern Africa were constantly torn between the interests of their donors and the needs of the people they served. If necessary, groups would go as far as to overhaul their raison d’être overnight to secure funding. Certain areas were saturated with redundant services from competing organizations, while other areas went entirely unserved. The healthcare sector gradually shifted outside the purview of national politics and into the depoliticized hands of foreign experts. NGOs instituted programs that satisfied donors’ desire to do ‘good work,’ while the local mediators who enacted these schemes, as well as the communities meant to benefit, retooled them to fulfil their own idiosyncratic needs—a system that Ann Swidler and Susan Cotts Watkins describe as a ‘fraught embrace’.

As a result, the response to HIV in southern Africa was articulated through a series of ‘working misunderstandings’ in which both parties achieved their own ends, but HIV persisted largely unabated. In the midst of this, the embattled public-private health care systems resulting from this arrangement (also funded largely by foreign aid) struggled to stay afloat under the weight of the austerity measures that followed the aforementioned economic liberalization of the 1990s. This pastiche coalition of mismatched systems has created a world where HIV testing and care are free across most of southern Africa, yet HIV adult prevalence rates remain well above ten per cent in many countries and over ten per cent of HIV+ persons are unaware of their status.

This is the environment into which coronavirus arrived, and southern Africa has struggled to cope with the pandemic. As Zimbabweans worked to manage August’s caseload spike, Emmerson Mnangagwa’s government began siphoning off foreign-sourced COVID-19 funds and arresting journalists and citizens who criticized their tactics. In South Africa, both the likelihood of infection and likelihood to be punished for violating lockdown orders ran along the familiar divides of race and class. Namibia saw over 100 new cases per day between June and September, and now, as numbers begin to decline, Hage Geingob’s government is considering admitting foreign travellers not because it is epidemiologically advisable but rather to prevent the collapse of its tenuous and economically critical tourism sector.

A Paradoxical Crossroads

Southern Africa is standing at a paradoxical crossroads. Partially American-imposed economic liberalization efforts coupled with the global response to HIV/AIDS left countries in the region overly reliant on a permeable, externally funded, ad hoc health care system lacking the capacity to manage large-scale crises. However, that same system has sustained southern Africa’s ability to maintain American-supported policies of neoliberal austerity without experiencing total epidemiological collapse. And now, as this ramshackle infrastructure undergoes a rigorous stress test, the US government—in the throes of its own breakdown—is backing away from funding the aid programs that prop it up. For example, the United States government announced it would suspend payments to the WHO, which accounted for a substantial proportion of WHO funding in 2019.

Perhaps by vacating its responsibility to southern Africa—a region the US has inadvertently constrained—America is turning the page on non-governmental healthcare. Indeed, this may leave the door open for southern African nations to enact new governance agendas in healthcare and beyond as long envisioned by critical thinkers across the region. These agendas could reformulate the very definitions of value that, in turn, determine who gets to live and die in southern Africa. For now, though, southern Africans are stuck trying to fix a new health crisis with the rusty neo-colonial tools that never quite managed to repair the last one

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