Public Policy Lessons from the AIDS Response in Africa 9780367432591, 9781003002130

Table of contents :
Cover
Half Title
Series Page
Title Page
Copyright Page
Table of Contents
List of figures
List of tables
Acknowledgements
Introduction: From intimacy to politics: AIDS in Africa as a moving object
From intimate subjects to public policy object: a journey through AIDS
Problematising public action in Africa from the response to a pandemic
Notes
References
Chapter 1 The international policy response to AIDS in Africa (1986–1996): Empirical bases, theoretical tools
The gradual construction of a theoretical framework to describe and analyse the international response to AIDS in Africa
The construction of a comparative analysis of AIDS public policy in Africa
International frameworks or national convergences? International guidelines and Africa’s national AIDS programs (PNLS/NAC)
Public policy in Africa: an epistemological prelude
From public policy instruments to instrumental public policy: theoretical elements and hypotheses
Access to ARVs in Africa: from the restructuring of the PNLS/NAC to a “therapeutic revolution”?
Notes
References
Chapter 2 AIDS and governance in Africa: Instruments and instrumentalisation of an international policy
Intellectual property and the issue of patents
The international context
Notes
References
Chapter 3 International comparisons in Africa: Socio-political determinants of access to AIDS drugs
A typology of “active” political mobilisation against AIDS in Africa
The “passive adherence” as a particular configuration of AIDS associations
International issues and strategies around ARV access in Cameroon
Notes
References
Chapter 4 Socio-political determinants of access to AIDS drugs in Africa: A paradigm shift
Towards a definition of the State in Africa: preamble
Public action and the State: who governs?
Reconfiguring biomedical oligarchies at the core of transnational public policy networks
Notes
References
Chapter 5 From policies to politics: Policy before the onslaught of politics
NGOs and associations against AIDS in Africa and South: a transnational issue
Conclusion: Towards a trans-sectorial convergence of public policy in Africa?
Notes
References
Chapter 6 Towards a matrix of public action in Africa: Univocal normativity and plural interests
The ambiguous standardisation of international health action in Africa: a diachronic and multi-sectoral reading
Malaria and tuberculosis: clash in the time of AIDS
Education and the environment: contrasting illustrations of the production of standards for transnational public action?
The construction of a new social tie: transnational, differentiated, and flawed
A political anticipation: the Covid-19 reference laboratories in Africa and epidemiological surveillance
Notes
References
Conclusion: The return of the African State?
Resisting the end of AIDS: from daydream to reality
Public action against AIDS in Africa: a distorted mirror image of the world order
The return of the State
Political science at an epistemic crossroads
Notes
References
Bibliography
Index

Citation preview

Public Policy Lessons from the AIDS Response in Africa

Public Policy Lessons from the AIDS Response in Africa examines how the interplay between national state dynamics in Africa and the global political arena has shaped the global AIDS response, and in this context develops a framework for analysing public policy action more broadly in contemporary Africa. By applying comparative political sociology to AIDS public action, this book identifies four political models that are applicable to public initiatives. Fred Eboko goes on to test these in other domains – namely, the malaria and tuberculosis health subsectors, and the education and environment sectors. By articulating global and national connections and contributing a critical perspective grounded in African scholarship and French political science, the author builds a bold and ambitious framework with the potential to enable coherent and effective public policy action in Africa. This book will be of interest to scholars and students of public health, global health, political science, and development studies, as well as policy-level practitioners in the areas of global health and development. Fred Eboko is a member of the Center for Population and Development (CEPED) at the French Research Institute for Sustainable Development (IRD), University of Paris. He teaches “Comparative Politics in Africa” at Sciences Po Paris and “Global Health in Global South” in several universities in France and in Africa.

Routledge Studies in African Development

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Public Policy Lessons from the AIDS Response in Africa

Fred Eboko Translated by Anne M. Lovell

First published 2021 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2021 Fred Eboko Originally published in France as: Repenser l’action publique en Afrique. Du sida à la l’analyse de la globalisation des politiques publiques, by Fred Eboko © Karthala, Paris 2015 The right of Fred Eboko to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Eboko, Fred, author. Title: Public policy lessons from the AIDS response in Africa / Fred Eboko. Other titles: Repenser l’action publique en Afrique. English Description: Abingdon, Oxon ; New York, NY : Routledge, 2021. | Series: Routledge studies in African development | Updated and revised version of the original French publication, Repenser l’action publique en Afrique: Du sida à la l’analyse de la globalisation des politiques publiques (Paris, Editions Karthala, 2015). | Includes bibliographical references and index. | Summary: “Public Policy Lessons from the AIDS Response in Africa examines how the interplay between national state dynamics in Africa and the global political arena has shaped the global AIDS response, and in this context develops a framework for analysing public policy action more broadly in contemporary Africa. – Provided by publisher. Identifiers: LCCN 2020023770 (print) | LCCN 2020023771 (ebook) | ISBN 9780367432591 (hardback) | ISBN 9781003002130 (ebook) Subjects: LCSH: AIDS (Disease)–Government policy–Africa. | Medical policy–Africa. | AIDS (Disease)–Africa–International cooperation. Classification: LCC RA643.86.A35 E2613 2021 (print) | LCC RA643.86.A35 (ebook) | DDC 362.19697/920096–dc23 LC record available at https://lccn.loc.gov/2020023770 LC ebook record available at https://lccn.loc.gov/2020023771 ISBN: 978-0-367-43259-1 (hbk) ISBN: 978-1-003-00213-0 (ebk) Typeset in Times New Roman by Deanta Global Publishing Services, Chennai, India

Contents

List of figures List of tables Acknowledgements Introduction: From intimacy to politics: AIDS in Africa as a moving object

vi vii viii

1

1

The international policy response to AIDS in Africa (1986–1996): Empirical bases, theoretical tools

15

2

AIDS and governance in Africa: Instruments and instrumentalisation of an international policy

48

3

International comparisons in Africa: Socio-political determinants of access to AIDS drugs

80

4

Socio-political determinants of access to AIDS drugs in Africa: A paradigm shift

95

5

From policies to politics: Policy before the onslaught of politics

113

6

Towards a matrix of public action in Africa: Univocal normativity and plural interests

131

Conclusion: The return of the African State?

168

Bibliography Index

181 185

Figures

2.1 2.2 2.3 2.4 2.5 2.6 3.1

Composition of CCMs in six African countries in 2012 Countries’ Global Fund performance before New Funding Model Total sums allocated by the Global Fund Number of applications approved before New Funding Model Number of applications rejected PEPFAR contribution to the Global Fund in 2012 Evolution of the number of patients on ARVs from 2005 to 2008 in Cameroon 5.1 Lesbian and gay rights in the world 6.1 Flowchart of the Public Policy Matrix in Africa 6.2 Disproportion of HIV-TB co-infection cases and TB cases among Africans populations in 2000

56 57 58 58 59 62 90 123 132 146

Tables

1.1 1.2 2.1 2.2 2.3 5.1 6.1 6.2 6.3

Seroprevalence rates (in %) of HIV/AIDS in the 15–49 age group, for selected African countries, 2016 Chronology of the implementation of National AIDS Programs (NAPs) in selected African countries Level of governance and types of organisations in the fight against AIDS Organisation of France’s development agencies African States, Global Fund Assistance and HIV/AIDS, 2012 Prevalence of AIDS in Men Who Have Sex with Men (MSM) and in the 15–49 age group in the general population, in selected African countries A comparison of public action in three sectors: health, environment, and education National and international programmes against the three major diseases Major Education Sector Conferences in Africa

16 21 53 64 67 124 134 139 151

Acknowledgements

This publication benefited from Anne Lovell’s valuable collaboration and assistance and our ongoing intellectual exchanges. I was honoured that she accepted to translate this book, which is an updated and revised version of the original French publication, Repenser l’action publique en Afrique. Du sida à la l’analyse de la globalisation des politiques publiques (Paris, Editions Karthala, 2015). Several institutions provided financial support, especially the Institut de Recherche pour le Développement (Institute for Research and Development (IRD)) and the Editions de l’IRD. I greatly appreciate the interest they showed in this project. My research unit, the Center for Population and Development (CEPED), an IRD–University of Paris mixed research unit (UMR), also provided financial support. The solidarity, warmth, and fruitful exchanges typical of everyday life at the Ceped have nourished this book. I thank the entire CEPED research team and its two successive directors, Etienne Gérard and Rigas Arvanitis, for their support. My children, Iman and William, and my wife, Cathy, are a precious presence in my life. I express my gratitude to them for their patience and sense of humour, including their hilarious comments on my French-accented English: “Dad, can you repeat please?” Many thanks! Finally, my profound thanks go to the Routledge team that accompanied the production of this book. Rosie Anderson, Leila Walker, and Helena Hurd have supported me throughout this process with professionalism, kindness, and consideration.

Political map of Africa

Introduction From intimacy to politics: AIDS in Africa as a moving object

Long the blind spot of Africanist research, policy analysis in Africa has only recently been instituted as the prism through which the emergence, if not the return, of the State can be read. As paradoxical as it may seem, studies of public policy were rare during the first three post-Independence decades (1960–1990), precisely the period when the major architect of planning and public action in Africa was none other than the African State itself. Policy studies only appeared after the State had emerged from the tunnel of the structural adjustment programmes, the quasi-guardianship imposed by the International Monetary Fund (IMF) and the World Bank on countries that had fallen into bankruptcy following the weakening of international trade terms and their failure to repay admittedly disproportionate debts. Thus, although earlier Africanist research had ignored public action, when policy studies research did turn to that world region, it was to study public action of the re-emergent African State. During the post-Independence years, political science research in Africa had been focussed on the ideological essence of postcolonial States and on following their alliances on the world chessboard then dominated by the Cold War. The limited scope and perceptiveness of those studies paralleled the paucity of public policy analysis in Western political science. Both sets of studies followed the classic chronology and geographic patterning of the main currents of social science, and of political science in particular. The wave of public policy studies first appeared in the United States and then Europe before landing in Africa and the rest of the world. This somewhat Pavlovian view of an epistemological process undoubtedly explains the “late” interest in public policy analysis of Africa. Furthermore, there is an irony to this outcome. The burgeoning interest in African studies for policy and concepts derived from the sub-field of public policy analysis coincided with the rebirth and convalescence of a phoenix rising from its ashes – the crisis of the State in Africa. In other words, curiosity about “the State in action” only came into focus after the State had been buried and mourned. But the sudden newfound attention cannot be characterised as eschatological, as since the mid-2000s the world had been hailing the return of the State in Africa by way of a liberal economy obsessed with “economic growth”. In short, it is more the rebirth than the genesis of the phoenix that has engendered the analysis in public policy in Africa.

2

Introduction

In the African case, the research field of public policy and action exists both in continuity with and as a rupture in classical approaches. Because of the internationalisation of public policy and the impact of the supra-national level, policies in Africa are positioned within an a priori framework similar to that observed elsewhere. In a globalised world, all public policies are in this sense homogenous. Yet in the area of internationalised public policy, a political gap remains between, for example, Africa and Europe. The African Union (AU), Africa’s supra-national level, carries little weight and barely impacts the major public policies governing public action in Africa. Moreover, the constellation of actors who systematically accompany African authorities in the design and implementation of public action produces a double-edged prerogative particular to the countries of the global South. The latter are now forced into marriages the benefits of which come at the cost of losing some of their pre-eminence. In Africa and in the developing countries more generally, internationally financed public action is structured through compliance with international standards. These norms and guidelines, and their agendas, exceed the sole function of international regulation. They become public policy instruments, in the most restrictive sense of the term; that is, with many constraints attached. This is the context in which we should read the exceptional international adventure of the fight against AIDS in Africa. It brought together interventions from every level: multilateral action, bilateral relations, national regulation by the State, sub-national de-concentrated organisations, national and local associations, international non-governmental organisations, international and national private–public partnership and foundations, and transnational corporate networks. Over thirty years of international response to AIDS in Africa provide a prime example of cross-cooperation between the actors mentioned above. At several key moments, this type of relationship brought about changes, created tensions, provoked conflict, forged alliances and ultimately shaped some of the most successful coalitions for transnational causes ever realised in the twentieth and twenty-first centuries. Hence the heuristic potential of the policy field has been shaped by the fight against AIDS in Africa and its multiple arenas. This assertion is based on exceptional empirical materials drawn from the social sciences, biomedical sciences, and public health. By comparison, few topics about Europe have exhibited the same potential to make similar connections, at the junction of international relations and public policy called for by Franck Petiteville and Andy Smith 2006). This book builds on the novel circumstances of the international and transnational responses which formed the history of the struggle against AIDS in Africa. It begins with a synoptic view of the field, then proceeds to a panoptic view of the dynamics linking different actors of public action in Africa. The research presented here was constructed through an inductive, diachronic, and, ultimately, syncretic approach, actualised in the application of a typology of the actors who recur in these actions and whose relationships vary by national sector. The foundation of this approach is what I term the “matrix of public action in Africa”, which postulates the function of each type of actor and hypothesises what differentiates

Introduction 3 one sector (health, education, biodiversity) or subsector (AIDS, tuberculosis, malaria) from the others. As will become clear, these sector and subsector differences, and their relationship to the incisiveness, continuity, and discontinuity of public action, depend on whether or not a convergence exists between communities of knowledge and arenas of power, or what Haas calls epistemic communities (1992). This work illuminates the scenario in which the State in Africa rode the wave of international partnerships, through which a public action already prescribed upstream was then recomposed downstream, according to the trajectory of the specific country in which it had landed. This approach, which takes account of the political strategies, social dynamics, international perspectives, and national orientations that condition and direct public action against AIDS in Africa, condenses the crux of the book. My own work is inscribed in the tradition of social science research on AIDS in Africa (Dozon and Vidal, 1993/1995). It draws on six research projects that I coordinated, sometimes in collaboration with colleagues from the global North and global South. These studies focussed on political, social, and public health issues concerning the organisation of public action on AIDS and health, to which I brought my background in three academic areas: sociology, anthropology, and political science. The research connects up national, regional, and transnational issues, while taking into account particular social groups (for example, associations, urban youth, children) and national and institutional actors. Alongside these projects, I developed my own scientific approach by integrating the work of other colleagues with the research I was coordinating. That approach can be summed up in keywords like “health”, “Cameroon”, “global South”, “AIDS”, “social sciences”, “political analysis”, and “comparative approach”. Even more broadly, this book is nourished by social anthropological studies of AIDS in Africa, which I combine with public policy analyses made by Western political scientists. Thus, I translate anthropology into political science (Eboko, 2004; Eboko, 2005a). To do so, I draw on the comparative studies directed by the French anthropologist, Marc-Eric Gruénais (1999), and extend them through my own comparison of AIDS policies in several African countries, once again by juxtaposing political science and social anthropology (Kerouedan and Eboko, 1999; Eboko, 2005b; Eboko, 2005c; Eboko, Owona Nguini and Enguéléguélé, 2009). This two-pronged contribution results in a model for comparative analysis which I call the “dissonant model of public policy”. I subdivide this model according to the four types of responses AIDS-affected African States have made within a configuration marked by the directives of an international institutional polyarchy (Eboko, 2010a, 2010b, 2013). I furthered this interdisciplinary dynamic in projects co-constructed with public health researchers and health economists; these have proved equally important for understanding what is at stake in public health, globally and in Africa. Finally, I have included my studies of programmes to access drugs in the global South. In them, I combined the methods of qualitative political science with quantitative public health and health economics. This has strengthened the interdisciplinary configuration and international scope of the

4

Introduction

final product, which is ultimately designed for operational purposes (Eboko, Abé and Laurent, 2010; Boyer et al., 2010; Moatti and Eboko, 2010).

From intimate subjects to public policy object: a journey through AIDS I made my first field-trip to Africa in 1995, while I was studying for my doctorate at Bordeaux’s Institute of Political Science (Institut d’Études Politiques) and conducting my doctoral research through the University of Bordeaux’s Research Centre on Health, Society and Development. Political science and anthropology, the academic specialities represented, respectively, in the two institutions with which I was affiliated, oriented my doctoral project and the issues it addressed. I had originally planned to examine the social integration of youth in urban settings in Cameroon, during a period when that country was undergoing a severe crisis. But the topic had proved to be too broad. Michèle Cros, an anthropology professor at the University of Bordeaux, first planted the seed of my curiosity about AIDS. She suggested I make AIDS the research object for my dissertation and use it as a key to understanding the urban youth who had interested me in the first place. She eventually oriented me towards another anthropologist, Claude Raynaut, who became my second research director. A few years earlier, any incentive I’d had for working on AIDS had run up against a more or less unconscious wall, and it was a publication by Michèle Cros that had articulated my dilemma. She had written about how AIDS became a symbolic stake and provoked an uncomfortable psychological risk for students developing dissertations on that topic (Cros, 1996). One of her articles especially clicked for me, allowing me to feed an anthropological questioning into the perspective of political science. Not by chance, her text, which concerned patients in Rwanda, was included in the first synthetic edited volume about AIDS in Africa to be published in the French social sciences (Dozon and Vidal, 1995). When I read Raynaut and Muhongayire’s text in 1995 (it had been written before the Tutsi genocide), it took on a highly significant meaning, informed by both private problems and the double historical tragedy of a genocide and an epidemic. The new-found conviction that my initial focus, youth, would not lose its acute potential if I joined it to the issue of AIDS was reflected in a single sentence penned by other researchers at University of Bordeaux Centre: “The AIDS epidemic in Africa is both an agent and a revealer of the dynamics of social change” (Raynaut and Muhongayire, 1995). This credo became the basis for reorienting my research project, under the guidance of Raynaut himself. Between my first field research mission in the winter of 1996–1997 and my dissertation defence in December 2002, my voyages across the disciplines of social anthropology and political science shifted my research perspective from the intimate to the political. The trips I made to Cameroon shifted my focus from the more comfortable sites of my youth – I had lived in Cameroon as a child and adolescent – to those of an epidemiological object made possible by a social and political meandering in the time of AIDS. Cameroon in the 1990s, like most sub-Saharan countries,

Introduction 5 was marked by the acceleration of a crisis of the State (Médard, 1992), coupled with a deep economic crisis, against the backdrop of political and social movements for the liberalisation of political life, or democratisation (Eboko, 1999b).

Problematising public action in Africa from the response to a pandemic My research objective is to analyse and document the configurations of national, local, and international actors involved in the organisation of patient care in Africa, in a context of increasing resource rarefication linked to the international financial crisis, in particular, and to the fears of stagnation and diminishing resources, more generally (Moatti and Eboko, 2010). The implementation of internationally influenced policies and strategies pose the problem of the mechanisms and actors in charge. This book aims to explore the different levels of this implementation (international, national, local) and the different types of actors and institutions which intervene (international organisations, State organs like the National AIDS Councils or Committees, bilateral development agencies, NGOs, international foundations, associations, experts, and so forth). Although the notion of governance is open to numerous interpretations, I use the following definition: an ensemble of means, practices (Giddens, 1987), and institutions produced by actors and consecrated by them in their everyday activities (hence autonomously) that provides frameworks for action (Goffman, 1974), allowing an ensemble of human groups to “make” political society, despite the multiple temporalities in which they are inscribed. (Darbon, 2008, p. 148) Hence, I consider the different levels institutions and the different levels at which research is constructed to be sites that propel “governance”, or the activities of the production of power and meaning and the normative frames and standards that regulate in accordance with predetermined objectives and strategies. This definition of governance, which is neither normative nor prescriptive, has the advantage of taking into account the context of the trans-nationalisation of internationally inspired regulation schemes, strategies, and policies (Hassenteufel, 2005). This context is fundamental to an integrative approach to the dynamics of interactivity between the different levels of action and the mediators and targets of public policy and public action strategies. In this way, I propose to study the framework of action against AIDS and its configurations of actors, or the manner in which the actions of some modify, orient, or determine the actions of others (Elias, 1970). The contemporary situation of the subject: a turning point in the fight against AIDS? The last 35 years correspond to a major turning point in the emergence and international responses to major pandemics. Between 2002 and 2019, the Global Fund

6

Introduction

collected and spent 7 billion U.S. dollars, 50% of which was dedicated to HIV/ AIDS, 32% to malaria, and 18% to tuberculosis. During his meeting with French President Emmanuel Macron last year, Peter Sands, the Global Fund’s Executive Director, estimated that the amount of money to be collected in 2019 alone (US$14 billion for the 2020–2023 period) “could contribute to saving 16 million lives, essentially halving the mortality rate from HIV, TB, and malaria, and to the construction of more solid health systems between now and 2023” (cited in Benkimoun, 2019). Within this configuration, the response to AIDS has provided exceptional leverage, like a plough that opens up a path to the better understanding of pandemics. Since the first AIDS cases appeared in the early 1980s, the AIDS pandemic has proved to be one of the most fatal in such a short time-span – 25 million deaths – in the history of disease, and sub-Saharan Africa has paid a heavier toll than any other world region. Access to ARVs, North and South: an international problem, an African drama During the first two decades of the fight against AIDS (1980–2000), the poorest world regions, including Africa, were the blind spot in the international treatment response. After combination therapies were discovered in 1996, the gap between North and South widened even more. By the 2000s, a series of international initiatives had produced a veritable therapeutic revolution. Several initiatives followed on one after the other, and in so doing created separate poles of action and power constituting what I term an “international polyarchy” (Eboko, 2005a), or “international polycentric governance”. In 2003, less than 2% of African patients in need of treatment had access to it. By the end of 2008, that percentage had risen to 44%; that is, 1 million persons (Eboko, 2005a). In countries like Botswana, more than 90% of eligible patients were able to access drugs. South Africa encompassed the largest number of people infected with HIV in the world. Over seven million people were living with HIV/AIDS in 2019, and the prevalence rate for the 15 to 49 year age group was 19.1%.1 Thanks to the continual increase in treatment coverage, today 3.7 million are now on antiretroviral (ARV) therapy, as opposed to only 630,775 in 2009.2 South Africa’s National Strategic Plan for HIV 2017–2022 has incorporated the UNAIDS target known as the 90-90-90.3 Yet when all African countries are taken together, scaling up turns out to be highly unequal. The overall disparities should not be forgotten as public action against AIDS in sub-Saharan Africa is internationalised or trans-nationalised. This book therefore proposes an aperture onto the political science of public action in one of the world regions most under the sway of decisions made by international organisations. It raises two questions. Are we witnessing an unprecedented historical construction of “post-governmental politics” that signals the arrival of a transnational, structural social relationship for Africa? Or, on the contrary and in accordance with extraversion theory (Bayart, 1999; Bayart

Introduction 7 et al., 2019, pp. 49–53), is this simply the continuation, through multilevel and multi-sectoral public action, of Africa’s dependency, but in a globalised world? To support the first case requires being able to observe a change in the nature of Africa’s relationship to the world. For the second case, the change observed would need to be a matter of degree, associated with the economic situation and trans-nationalisation of public policy. The book is divided into five parts that, taken together, reflect the gradual changes in the analysis of strategies and evolutions in social science and political science research and in my own work. The appeal of the empirically based research I use lies in its potential to enhance the interface of several disciplines. The disciplinary orientation of my research is situated within the political sociology of public action. Thanks to its history and more recent developments, this sociology calls for epistemological interfaces between political science and International Relations (IR). To these, I have added the pivotal contribution of an anthropology informed by a sociology of the subject realised through the observation of individuals and social groups who have mobilised in the AIDS field over time (Eboko, 2004). Few European or African authors have broached the question of AIDS in Africa at the point of intersection of the political sociology of public action and AIDS in Africa. Chapter 1 proposes an analysis of AIDS public policy in Africa, influenced by international organisations and applied at the level of African States. Public policy per se is not treated as a paradigm through which national public policies are mechanically deduced from international guidelines or prescriptions. The differential nature of national trajectories and of concrete responses that one sociologist terms the “political epidemic” of AIDS (Pinell, 2002) requires an approach based on comparison. But “comparaison n’est pas raison”: comparisons do not necessarily produce truths. Thus, my chosen approach has to be justified by systematically examining, for each country, the sequences, processes, and configurations of actors (Hassenteufel, 2005). This involves formulating the approach around the question of the convergence of public policies, understood as “a dynamic process which translates as the fact that, within a same domain and before the same type of issue, an important number of countries with contrasting public policies nevertheless gradually adopt the same public policies (Hassenteufel, 2005, p. 123). To raise the question of the State is to go beyond the formalist and institutionalist approaches that filled the bookshelves of social scientists in the 1960s and 1970s. Jean-François Bayart and Jean-François Médard count among the authors in France who have addressed “the concrete state”. Bayart did so, however, in perhaps a more masterful and iconoclastic manner, by envisaging “the state from below” (Bayart, Mbembe and Toulabor, 1992). Beyond that perspective, it is Bayart’s in-depth understanding of the undercurrents that structure everyday life in African States that has undoubtedly proved most crucial to this work (Bayart, 1979, 1989): Ultimately, the postcolonial State exists like a rhizome, rather than a root system. In order to be endowed with its own historicity, it does not unfold along

8

Introduction a single dimension, starting, like an oak tree, from a genetic trunk […] It is a changeable multitude of networks whose subterranean stems connect points of society. To understand it, we must go beyond the examination of what grows above the surface – the institutional shoots – and seek its adventitious roots, to analyse the bulbs and tubes that with which it secretly nourishes itself and extracts its vitality. (Bayart, 1989, p. 272)4

This is the lineage in which we should place the transnational political awareness of those major stakeholders in public action against AIDS whom I call African “biomedical oligarchies”. Within the chronology of actor participation in this public action, these oligarchies were followed by associations which broke away from their subjugation to biomedical personnel and forced a new type of collective mobilisation, by progressively taking ownership of the imported, syncretic repertoire of collective action. Their mobilisation around promoting the health of men who have sex with men (MSM) and defending their rights, which were far from easily achievable, bear witness to the changes actualised in the political space of AIDS on the African continent. By considering the question of “governance”, this book necessarily broadens the treatment of AIDs public policy to include the broad constellation of actors. Within this logic, the State is a co-actor whose presence is increasingly desired, including by international organisations that had previously argued for and then acted to bring about the relegation of States to a secondary role. In a context in which public policy is depoliticised, is “governance” merely another name for “public action”? Comparisons between several countries (Senegal, Côte d’Ivoire, Burkina Faso, Benin, Niger, and Cameroon), selected because of the partnerships in each, their comparative potential, and the feasibility of doing field research in them, opened the way for a second generation of results, thanks to programmes I had the opportunity to direct (Chapter 2). This second part of my research aims to show how international responses that preside over institutional standards in AIDS policy in Africa were elaborated and embodied in the National AIDS Programs (NAPs). During two distinct periods, 1986–1996, and 1996–present, international public action to fight against AIDS in the sub-Saharan African countries did not unfold in a linear manner. I had to conceptualise the approach orienting my work “less as a science of public policy and more like a sociological research undertaking, so as to understand the governing of political space at various scales beyond the nation-state” (Smith, 2013, p. 2). Compared to European countries, sub-Saharan Africa generally offers a generous opportunity to shed light on the junction of multilevel analysis and the effects of supra-national policies. Such observations take into consideration the economic vulnerability of the majority of African nations and their over-exposure to the power of international organisations implementing structural reforms related to sectoral public policy. The situations that determined the construction of the European Union differ fundamentally from those that explain the weight of international organisations and actors on public action in the countries of the so-called

Introduction 9 South, particularly sub-Saharan Africa. Sub-Saharan African States therefore provide potentially fertile terrains for Public Policy Analysis (PPA). If in Europe, and especially France, “few researchers trained in PPA actually read their colleagues in IR (International Relations) and vice-versa” (Smith, 2013, p. 2), the gap is even larger in the field of political science research in Africa, despite that being one of the geographic areas in which internationalist approaches, let alone IR, could prove particularly fruitful for the AIDS field (Boone and Batsell, 2001). From the first years of the international construction of the response to the AIDS pandemic in Africa (Barnett and Blaikie, 1992; Mann and Tarantola, 1996) up to the turning point represented by the scaling up of access to AIDS treatment, African countries have experienced different trajectories and an internally differentiated development (Chapter 3). Research on the international aspects of the AIDS response, like that on medicines and health security (Biehl and Petryna, 2013; Lachenal, 2009), has led to few alliances between those at the head of national dynamics, even if more recently some such attempts have been made. The potential for crossing IR and PPA approaches by joining them to other methods can only enhance analysis of the trans-nationalisation of public action in Africa through the prism of the fight against AIDS. One example of the use of the political sociology of the State in Africa is alongside a multilevel analysis which clarifies other sectors within health (tuberculosis and malaria, for example) and beyond health (Chapters 4 and 5). The recurrence of actors and institutions forms a typology of public action as a sort of blueprint of the framework or matrix of globalised policies that can then be juxtaposed with the examination of the language of public action across sectors. Whether in educational policy (Lange, 2003) or environmental policy (Smouts, 2001; Bigombe Logo, 2004; Aubertin, 2005; Compagnon, 2005), the content we have identified strongly supports the idea of a matrix of public action in Africa (Chapter 6). In these dynamics, public action choreographs the State as a co-actor of policies implemented under official State coordination. Thus, by exploring “the state of the State”, it is possible to understand how the institutions and instruments proposed for public action are intertwined in processes ranging from appropriation to instrumentalisation. The context of access to AIDS drugs posed, with rare acuity, the issue of State regulation of public action, and especially of the specific structural and conjunctural variables of each State. The methods and results of several projects that I coordinated with French and African research teams are also presented in this book. On the basis of these different projects, it was possible to construct a paradigmatic grid, open up theoretical discussions, and draw on empirical data to support a comparative approach. Ultimately, my desire has been to provide an “Africanist” window of opportunity on the major debates in political sociology and public action (Duran, 1999; Hassenteufel, 2008). These evoke what others, rejecting exceptionalism and exoticism, have already expressed and is worth restating here from a heuristic perspective: “Banal Africa!” in a brutal world (Mbembe, 2020).

10

Introduction

The naked researcher: from intimacy to politics Achille Mbembe’s reference to a “brutal” world reverberates at the moment this book is going to press. “Banal” Africa, with its internal dynamics and external constraints, and despite its strengths and weaknesses, finds itself at the forefront of the world. Banality also provides a personal metaphor of the mirror of the world in which I, the author, see myself. In 2011, the organisers of the First International HIV Social Sciences and Humanities Conference, appropriately entitled “Locating the Social”, honoured me with an invitation to Durban, South Africa, to give the opening talk. The Conference aimed at breaking away from the domination of public health over the social sciences in the HIV/AIDS research field. My talk was entitled “From Intimacy to Politics”. I arrived in Durban from Paris two days before the conference opened. At Durban King Shaka International Airport, after my passport had been checked and I had made it to the last checkpoint, the police began meticulously examining all of my belongings. They looked at my professional calling card, then proceeded to thoroughly search my suitcase, as far as its deepest recesses. The more I would have tried to explain who I was and why I was in Durban, the more I would probably have aggravated my own case. Clearly, I couldn’t possibly be a researcher employed by the French State nor the “Sciences Po” professor pictured on my university ID card. Naturally, I couldn’t be the owner of the two credit cards they had pulled out. The man giving orders was an Indian South African, as were three or so others next to him. Coldly methodical, he instructed the others, without a trace of verbal violence but with the professional self-assurance of someone who is certain he has just caught a wrongdoer. His eyes lit up as his fingers explored the insides of the shoes in my suitcase and the seams of every item of clothing. I told myself they could have checked my identity on the internet in no time, because I was speaking in two days at the very same International Conference Center where illustrious international figures always speak. I even had the official invitation with me, but none of my improvised jailors had bothered to look at it. I even told them they could call the hotel where I was booked and people were waiting for me. In vain. So certain were they of having caught a black version of Al Capone or some trafficker or usurper that the officers could not help but take the next decisive step, to ensure that the rare prey I had become in just 20 minutes would finally squawk. The Giver of Orders politely commanded me to follow him and his colleagues into a room. There, he asked me to undress. I did so, knowing that now they would comb through clothes I was wearing, too. That’s why I kept on my underwear. But my henchmen did not look at my clothes. They looked at me, as if I were a museum piece. I stood in front of them, feeling as if my body were the epilogue of their breathless search. I stared back at them, asking what they were really looking for. The chief asked me to take off my underwear and crouch down. He accompanied my slow descent into hell with a chilling economy of words. Only he spoke.

Introduction 11 When I got up, he told me to get dressed and that I could then leave. In the blink of an eye, the room emptied out, the henchmen scurrying away if they had been caught in some act. Only one remained at my side. The Black policeman. He lowered his eyes. I asked him what was going on. He whispered, “It’s the procedure, it’s part of the procedure, sir, sorry.” He helped me close the gaping, overflowing, and suddenly ridiculous-looking suitcase that had followed us into that room. Five minutes later I was outside. Only one man was waiting in front of the exit, now emptied of all passengers. He was holding a sign with the logo of my hotel and my name written in large letters. I walked up to him. As I pushed the caddy carrying my backpack and suitcase, he asked what had happened, adding that he had been about to leave. I stammered an explanation as I followed him. We took the small bus to the hotel. I had just discovered that in Durban my identity seemed incongruous. I am French, Black, born in Paris, a researcher, a professor in a prestigious institution; but in the eyes of some, I am a dangerous madman, a rare counterfeit. The next day, my colleague and friend, Vinh-Kim Nguyen, who had co-organised the conference, picked me up at the hotel. Meanwhile, I had called the French Embassy in Pretoria. The First Council for the Embassy had verified everything and concluded that, in the absence of physical contact or aggression, I had only been the victim of irresponsible behaviour, not of an illegal procedure. Throughout the rest of my stay, he called me daily, supporting me with his expressions of care, his distress over what had happened, and his solidarity – something that resembled fraternity at its most noble and profoundly human. I had experienced the biggest humiliation of my life, exercised in a legal manner and on that African soil saturated with blood, hardship, and struggle, at the edge of “a past that never passes away”. My colleagues, regardless of nationality, expressed compassion about what had happened. Only the South-African organisers remained silent. When I was going over my presentation with my friend Vinh-Kim, his sense of humour spilled over into the introduction I was adding to my talk to inform my colleagues in the audience about what had happened. When I later took to the podium, it was at the exact same spot where world leaders like Yasser Arafat, Fidel Castro, Nelson Mandela, and Elisabeth II had come to celebrate the end of a horrific era. I began by introducing myself as “The Naked Researcher” and recalling the title of my paper, “From Intimacy to Politics: Social Sciences in the Field of HIV/AIDS Research”. Beyond this small anecdote concerning my humble person, my book presents Africa’s painful route through changes in the contemporary world. With its advances, strategies, and obstacles, Africa circumvents the plurality of trajectories and narratives up against which a few of its daughters and sons collide. Drawing on anthropology and philosophy, Didier Fassin encapsulates the connection between the intimate and the social. He shows how the memory of experiences that we might consider personal and subjective leave traces on the body and in the mind. Yet these individual experiences cannot be reduced to chance circumstances, especially if we are aware of the racialisation of social relations in the contemporary world echoed by South Africa. Fassin elaborates this point:

12

Introduction The moral and the ethical appear to be detachable from the historical framework of the social structure and the political sphere. In my own work, I have chosen to take these dimensions into account by discussing moral questions and ethical issues, facts that, far from depending on a pre-existing morality or ethics, have been constructed by agents through their actions in a specific context. The moral and the ethical should never be seen as mere objects, but rather as historically, socially and politically infused realities. (Fassin, 2018, p. 77)

From the historically saturated pain of the intimate arises the light of a struggle which we should always remember, drawing inspiration from Nelson Mandela: “Do not judge me by my successes, judge me by how many times I fell down and got back up again”.

Notes 1 South Africa’s National Strategic Plan for HIV, TB, and STIs 2017–2022, https://sanac .org.za//wp-content/uploads/2017/06/NSP_FullDocument_FINAL.pdf 2 South Africa’s National Strategic Plan for HIV, TB and STIs 2010/11-2012/13, www .nationalplanningcycles.org/sites/default/files/country_docs/South%20Africa/south_ africa_strategic_health_plan_2010-2013.pdf 3 South Africa’s National Strategic Plan for HIV, TB, and STIs 2017–2022, https://sanac .org.za//wp-content/uploads/2017/06/NSP_FullDocument_FINAL.pdf. The UNAIDS 90-90-90 programme targets 2020 as the year when 90% of all people living with HIV will know their HIV status, 90% of people with diagnosed HIV will receive sustained ARV therapy, and 90% of people on ARV therapy will have viral suppression (Joint United Nations Programme on HIV/AIDS, 2014). 4 With this vivid imagery, Bayart inaugurates a definition of the State “in practice” and of the networks that move within it. His book provoked many reactions, including some that accused him of talking about the State without ever defining it (Sindjoun, 2002b). It was as if the author, having left the classic pathways, provided his readers with something to read that was other than what he was really talking about. But Bayart insists that the “definition” of the rhizome State and its networks takes up ten pages of The State in Africa (Bayart 1989, pp. 270–280).

References Aubertin C., 2005, Éd., Représenter la nature? ONG et biodiversité, Paris, IRD Editions. Barnett T. & Blaikie P., 1992, AIDS in Africa, New York, The Guilford Press. Bayart J.-F., 1979, L’Etat au Cameroun, Paris, Presses de la FNSP. Bayart J.-F., 1989, L’Etat en Afrique. La politique du ventre, Paris, Fayard. Bayart J.-F., 1999, “L’Afrique dans la mondialisation: une histoire d’extraversion”, Critique internationale, 5 (5): 97–120. Bayart J.-F., Mbembe A. & Toulabor C., 1992, Le politique par le bas en Afrique noire, Paris, Karthala. Bayart J.F, Poudiougou G. & Zanoletti G., 2019, L’Etat de distorsion en Afrique de l’Ouest. Des empires à la nation, Paris, Karthala (“Terrains du siècle”), 49–53. Benkimoun P., “Le Fonds mondial fixe ses objectifs financiers pour 2020–2022”, Le Monde du 17 janvier 2019.

Introduction 13 Biehl J.G. & Petryna A., 2013, When People Come First: Critical Studies in Global Health, Princeton, NJ, Princeton University Press. Bigombe Logo P., 2004, dir., Le retournement de l’Etat forestier, Yaoundé, Presses de l’ucac. Boone C. & Batsell J., 2001, “Political science, international relations and aids in Africa”, Africa Today, 48 (2): 2–33. Boyer S., Eboko F., Camara M., Abe C., Owona Nguini M., Koulla-Shiro S. & Moatti J.-P., 2010, “Scaling up access to antiretroviral treatment: the impact of decentralization of healthcare delivery in Cameroon”, AIDS, 24 (Suppl. 1): S5–S15. Compagnon D., 2005, “Gérer démocratiquement la biodiversité grâce aux ONG?”, in Aubertin C., Éd., Représenter la nature? ONG et biodiversité, Paris, IRD Editions: 179–204. Cros M., Éd., 1996, Les maux de l’autre. La maladie comme objet anthropologique, Paris, L’Harmattan. Darbon D., 2008, “Etat, pouvoir et société dans la gouvernance des sociétés projetées”, in Bellina S., Magro H. & de Villemeur V., Éds, La gouvernance démocratique. Un nouveau paradigme pour le développement?, Paris, Karthala: 135–152. Dozon J.-P. & Vidal L., Éds, 1995, (1e éd. En 1993), Les sciences sociales face au sida. Cas africains autour de l’exemple ivoirien, ORSTOM. Duran P., 1999, Penser l’action publique, Paris, L.G.D.J. Durkheim E., 1968, Les règles de la méthode sociologique, Paris, PUF, coll. “Quadrige”. Eboko F., 2013, “Déterminants socio-politiques de l’accès aux antirétroviraux en Afrique: une approche comparée de l’action publique contre le sida”, in Possas C. & Larouzé B., Éds, Propriété intellectuelle et politiques publiques pour l’accès aux antirétroviraux dans les pays du Sud, Paris, ANRS, coll. “Sciences sociales et sida”: 207–224 (publié en français et en portugais). Eboko F., 2004, “De l’intime au politique: le sida en Afrique, un objet en mouvement” in Vidal L., Éd., Les objets de la santé. Autrepart, 29: 117–133. Eboko F., 2005a, “Politique publique et sida en Afrique. De l’anthropologie à la science politique”, Cahiers d’études africaines, XLV (2): 351–387. Eboko F., 2005b, “Patterns of mobilization: political culture in the fight against AIDS”, in Amy S. Patterson, Éd., The African State and the AIDS Crisis, Aldershot, Ashgate Publishers: 37–58. Eboko F., 2005c, “Law against morality? Access to anti-AIDS drugs in Africa”, International Social Science Journal, 186, UNESCO: 713–722. Eboko F., 2010a, “A l'articulation du national et de l'international: bref historique de l'accès aux antirétroviraux au Cameroun”, in Eboko F., Abé C. & Laurent C., Éds, Accès décentralisé au traitement du VIH/sida: Evaluation de l'expérience camerounaise, Paris, ANRS, coll. “Sciences sociales et sida”. Eboko F., 2010b, “La lutte internationale contre le sida, chantier d’une gouvernance mondiale de la santé”, Questions internationales, 43, mai-juin: 76–78. Eboko F., Abé C. & Laurent C., Éds, 2010, Accès décentralisé au traitement du VIH/ sida. Evaluation de l’expérience camerounaise, Paris, ANRS, coll. “Sciences sociales et sida”. Eboko F., Enguéléguélé M. & Owona Nguini M., 2009, “Cameroun Burkina Faso, Botswana, une approche comparée de l’action publique contre le sida en Afrique”, Télescope (Ecole Nationale d’Administration Publique – ENAP- Québec Canada), 15, printemps-été: 52–67.

14

Introduction

Elias N., 2003, (éd. Originale en 1970), Qu’est-ce que la sociologie?, Paris, Éditions de l’Aube. Fassin D., 2018, La Vie. Mode d’emploi critique, Paris, Seuil (“La Collection des idées”). Gruénais M.-E., Éd., 1999, l’organisation de la lutte contre le sida en Afrique. Une problématique État / société civile, Paris, Rapport ANRS/IRD. Haas P.M., 1992, “Epistemic communities and international policy coordination”, International Organization, 46 (1): 1–35. Hassenteufel P., 2008, Sociologie de l’action publique, Paris, Armand Colin, coll. “U sociologie”. Hassenteufel P., 2005, “De la comparaison internationale à la comparaison transnationale, Les déplacements de la construction d’objets comparatifs en matière de politiques publiques”, Revue française de science politique, 55 (1), février: 113–132. Kerouedan D. & Eboko F., 1999, Politique publique et sida, Bordeaux, CEAN, coll. “Travaux et Documents”, 61–62, 73 p. Lachenal G., 2009, “Franco-African Familiarities. A history of the Pasteur Institute of Cameroun, 1945–2000”, in Harrison Mark & White Belinda, Eds, Hospitals beyond the West: from Western Medicine to Global Medicine, Orient-Longman, New Dehli: 411–444. Lange M.-F., 2003, “Vers de nouvelles recherches en éducation”, Cahiers d’études africaines, 169–170: 7–17. Mann J.M. & Tarantola D., Éds, 1996, AIDS in the World II. Global Dimensions, Social Roots, and Responses. The Global AIDS Policy Coalition, Oxford, Oxford University Press. Mbembe A., 2020, Brutalisme, Paris, La Découverte, 246 p. Médard J.-F., Éd., 1992, États d’Afrique noire: formation, mécanismes et crises, Paris, Karthala. Moatti J.-P. & Eboko F., 2010, “Economic research on HIV prevention, care and treatment: why it is more than ever needed?”, Current Opinion in HIV and AIDS, 5 (3): 201–203. Petiteville F. & Smith A., 2006, “Analyser les politiques publiques internationales”, Revue française de science politique, 56 (3): 357–365. Pinell P., dir., 2002, Une épidémie politique. La lutte contre le sida en France 1981–1986, PUF, coll. “Science, histoire et société”. Raynaut C. & Muhongayire F., 1995, 2e éd., “Chronique d’une mort annoncée. Problèmes d’éthique et de méthode posés par la démarche anthropologique au suivi des familles touchées par le sida (autour du cas rwandais)”, in Dozon J.-P. & Vidal L., Éds, Les sciences sociales face au sida – Cas africains autour de l’exemple ivoirien, Paris, ORSTOM: 235–252. Sindjoun L., 2002b, L’Etat ailleurs, Paris, Economica. Smith A., 2013, “l’analyse des politiques publiques”, in Balzacq T. & Ramel F., dir., Traité des relations internationales, Presses de Sciences Po: 439–465. Smouts M.-C., 2001, Forêts tropicales, jungle internationale: les revers d’une écopolitique mondiale, Paris, Presses de Sciences Po. Vidal L., 1995, “Les risques du culturalisme”, Le journal du sida, 75–76: 32–34.

1

The international policy response to AIDS in Africa (1986–1996) Empirical bases, theoretical tools

Two goals guide this chapter. First, it aims to demonstrate how public action was constructed at the international level and then at the State level to respond to the spread of AIDS in Africa, and how such action was received. Second, it addresses the epistemological question of which anthropological and political science tools can best contribute to the analysis of the fight against AIDS in Africa. This goal is achieved by creating a theoretical framework which is outlined in the second part of the chapter. The 2000s signalled a turning point in the response to the major pandemics that had emerged during the previous quarter-century. By 2009, global financing for the three major pandemic diseases, AIDS, tuberculosis, and malaria reached US$15.5 billion, half of which came from bilateral and multilateral aid. In this context, the AIDS response carried substantial weight, which led to a better awareness of the other two pandemics. Between the early 1980s, when the first cases of AIDS appeared, and the end of the 1990s, the AIDS pandemic had indisputably become one of the deadliest diseases ever to spread within such a short time period. Globally, sub-Saharan Africa has paid the heaviest price of all world regions, claiming 70% of the cases worldwide, or 25.8 million out of some 36.9 million (UNAIDS, 2015). Any presentation of the struggle against AIDS must take into account the disease’s uneven development across Africa. I do so by beginning with the major thrust of the international response, namely its major benchmarks and directives, from the founding of the World Health Organization (WHO) Global Programme on AIDS (GPA) in 1986 up to the creation of the Joint UN Programme on HIV/ AIDS (UNAIDS) in 1996. The chapter opens with a comparison of the contributions and limitations of each programme through the prism of the African experience and its contribution to public policy analysis (Table 1.1).

The gradual construction of a theoretical framework to describe and analyse the international response to AIDS in Africa Jones’s sequential grid: between black box and blind spot in public policy analysis Sequence analysis of public policy implementation occupies a central place in the political sociology of public action (Hassenteufel, 2005, 2011). Research centred

16

International policy response in Africa

Table 1.1 Seroprevalence rates (in %) of HIV/AIDS in the 15–49 age group, for selected African countries, 2016. Percentage

28–18

17–13

12–10

9–1

Less than 1

Country

Swaziland Botswana South Africa

Zimbabwe Namibia

Zambia Mozambique Malawi

Kenya Cameroon Côte d’Ivoire

Senegal Niger Mauritania

Source: World Factbook, CIA: www.cia.gov/library/publications/resources/the-world-factbook/ Note: For each country in the table, the specific estimates are: Swaziland (27.2%), Botswana (21.9%), South Africa (18.9%), Namibia (13.8%), Zimbabwe (13.5%), Zambia (12.4%), Mozambique (12.3%), Malawi (9.2%), Kenya (5.4%), Cameroon (3.8%), Côte d’Ivoire (2.7%), Senegal (0.6%), Niger (0.5%), Mauritania (0.5%).

on public policies promulgated or influenced by international organisations, such as comparative studies of different “States in action”, falls into the domain of transnational policy analysis. Public policy in which the State theoretically plays a regulatory role tends to fall under the rubric of “public action”, because of the highly diverse actors and multiple centres of power (polyarchies) that guide such policy. Books influenced by social anthropology, like Marc-Eric Gruenais’s Organiser la lutte contre le sida en Afrique [Organising the Fight Against AIDS in Africa] (Gruénais et al., 1999), do not explicitly reference the notions and concepts of Public Policy Analysis (PPA). This is why, elsewhere, I proposed to bridge PPA and social anthropology Eboko, 2005a). Given the richness and diversity of the paradigms and subject matter of each discipline, my intention has not been to critique their shortcomings at the risk of setting up an epistemological stand-off between the two. After all, researchers and research teams who find themselves at the interface of different disciplines often try to work with the paradigms of each. In the field of transnational policy, Andy Smith has attempted to join International Relations (IR) and PPA in the European context Smith, 2013). In his case and mine, the challenge is to find analytic frameworks that not only allow the researcher to understand a given situation, but are also replicable (or not) in similar situations and allow for the generation of falsifiable hypotheses. In other words, such frameworks should be able to contribute to advancing scientific and critical thinking in one or several fields. Within this logic, the process of implementing transnational public policies in the fight against AIDS in African States, first described in one of Gruénais’s comparative studies (Gruénais et al., 1999), can be illuminated through sequence analysis. Although the approach to policy by examining its sequences is usually attributed to Charles Jones, the most cited and critiqued author in this, it actually dates back to Harold Lasswell in the mid-1950s (Hassenteufel, 2011) and was mostly used by Laswell’s students. Among them, Garry Brewer (1974) stands out for having proposed six successive sequences: (1) the definition of the problem; (2) the ranking of problems in terms of preference; (3) the selection of

International policy response in Africa 17 a solution; (4) the implementation of “the solution”; (5) the evaluation; (6) the actualisation of the policy (Hassenteufel, 2011, p. 30). In their comparative study of AIDS public policy in vertical health programs, Gruénais and his team touched on four of Brewer’s six sequences. The team also addressed other conventional ideas developed in Public Policy Analysis. Their studies of Cameroon (Central Africa), Côte d’Ivoire and Senegal (West Africa), and Kenya (East Africa) identify three successive entry-points – processes, institutions, and actors – and draw on anthropology, sociology, political science, and history. Their multidisciplinary approach would undoubtedly have sounded familiar to the tenants of the “3I” model (“ideas”, “institutions”, and “interests”) in PPA (Palier and Surel, 2005). Following in the footsteps of this collective approach and drawing on my dual training (my doctoral thesis was co-directed by a political scientist and by an anthropologist), I have situated my own objectives, research projects, and analyses within Public Policy Analysis. I began by drawing on the classic “Grenoble School” of political science connected to Bruno Jobert and Pierre Muller (Grawitz and Leca, 1985; Jobert and Muller, 1987). To study public policy in the domain of AIDS, I identified the following stages: the emergence of the problem; the construction of solutions according to the guidelines of the WHO Global Programme on AIDS (GPA); standardised implementation and the achievement of transnational policies within a differentiated dynamic (Eboko, 1999c). As a member of the French Institute for Research on Development (Institut de Recherche pour le Développement (IRD)), I was able to expand this theoretical and empirical reflection within a comparative perspective. To do so, I chose to confront PPA with the “political cultures” perspective (Cefaï, 2001), apprehended through a dynamic approach (Eboko, 2005a, 2005b, 2005c). After the lowering of drug prices accelerated access to combination antiretrovirals (ARV), I turned to the institutionalisation of the struggle against AIDS in Africa, almost 20 years after the epidemic had first been acknowledged (Eboko, 2004). Public policy and AIDS in Africa: building an interdisciplinary, empirical, and theoretical contribution to public policy analysis Along with a multidisciplinary team mostly trained in anthropology and political science, I suggested questioning some of the notions and theories of public policy in light of the fight against AIDS in Africa. Our aim was to draw on the experience of researchers from both fields to examine an area of intervention that represented one of the major political challenges for both international relations and contemporary Africa. The project’s two main concerns, theoretical and empirical, led to a series of important questions. Why has political science research on Africa, both French and American, barely addressed public policy? Knowing that anthropology is the social science that has made the most significant contribution to understanding AIDS in Africa, what might it contribute if placed in dialogue with political science? Which public policy concepts and approaches can be reformulated or even enriched by analysing the fight against AIDS in Africa? At an

18

International policy response in Africa

empirical level, why is the case of Cameroon a relevant example for our topic of study? Why does policy analysis teach us about politics? To address these questions has required revisiting the initial anthropological studies on AIDS in Africa, so as to identify what political science can contribute to the AIDS research field. I thus created a new framework by bringing the more conventional concepts and thinking of political science, at least as they are used in the analysis of public policy, to those landmark studies. Rather than enforcing the interests of political science as a corporation, I reconstructed the process by which anthropological research and the critiques it had addressed to the biomedical sciences had become incorporated into a history that reveals as much about the evolution of an epidemic as about the epistemology of the social sciences in research on sub-Saharan Africa. The published and unpublished work of French anthropologists like Laurent Vidal (1996, 2000), Didier Fassin (1996, 1999, 2002a, 2002b), Jean-Pierre Dozon (Dozon and Fassin, 1989; 2001), Marc-Eric Gruénais (1999, 2001b) and many others have inspired this effort. I have drawn on their work to help me articulate the need for a new building block for the edifice of “AIDS anthropology”, moulded from the novel perspective of political science. The AIDS field has undoubtedly been most radically challenged by classic anthropology. In this book, I elucidate this by confronting Laurent Vidal’s research (1996, 2000), in which he moves from the analysis of patient trajectories to a more general anthropology (1996, 2000), with political science studies of policy that did not inform Vidal’s work. From a heuristic point of view, AIDS research is becoming a prism through which it is possible to understand the essential modalities of public policy implementation in sub-Saharan Africa. What one researcher has observed for Central African countries can be generalised to other African countries: What is at stake is how the transformations and tensions currently affecting Central African countries in “transition” are understood. That understanding touches on new paradigms of public action and new mechanisms of citizenship at the intersection of the new ways in which those societies conceive of their relationship to the world. (Enguéléguélé, 2002, p. 249) In this light, the example of Cameroon can serve as an empirical reservoir for international debates and case studies. These have allowed me to reflect on 20 years of social science progress in AIDS research in Africa, while emphasising the novel contribution of political science (Eboko, 2005a, 2005b). Public policies in Africa: multidisciplinary sequences Public policy analysis (PPA) draws mainly from political science. PPA gradually migrated from the United States, its birthplace, to Europe, and particularly to France, where it became a key sub-field from the 1980s onwards. Its choice sites

International policy response in Africa 19 for empirical study were mostly Western countries, where most of its research was ultimately conducted. As for the themes social scientists explored in Africa, they were limited, albeit indirectly, by the policies of international institutions, transmitted by programmes and projects aimed at improving the standard of living of “populations”. Researchers working in Africa nevertheless elaborated their own epistemological and heuristic proposals in response to the issues arising from the implementation of so-called development projects. Their epistemological framework took into account the social, economic, and cultural stakes generated when international policies intersected with the local dynamics these researchers had already been studying. From the 1990s on, Africanist political science prioritised phenomena related to the construction of the newly independent States. As Darbon (2008) notes, Whether because of their tradition or historical heritage, “Africanists” have hardly been concerned with the sociological analysis of administrations, organisations and institutions or with the study of sectorial decision-making processes and procedures. Some exceptions can be found among Anglophone academics […]. For the most part, however, these approaches have remained “peripheral” and strongly rooted in the consulting field and the development of intervention models. As a result, these academics tend to be marginalised in intellectual debates. They tend to show up in management and public administration journals and areas, rather than in the more “legitimate” domain of policy analysis in Africa.

The construction of a comparative analysis of AIDS public policy in Africa Drawing on American and French anthropology, I propose several notions that capture the different types of responses, the dissimilar political contexts in which they were modified, and the successes and failures of social and political mobilisation against AIDS in Africa more generally. I begin by examining the importance of international guidelines promulgated by WHO and later by UNAIDS, which are often standardised despite differences among local contexts. The diversity of local and regional epidemiological dynamics and the plurality of political responses to the magnitude of AIDS in Africa led me to the idea of “political cultures”. This dynamic notion allows me to take into account the in-depth history and trajectory that has shaped each State’s political response to the AIDS pandemic. Generalised access to ARVs marked a turning point in the response to the pandemic. By exploring both diachronic (before-and-after) and synchronic dimensions, I have been able to show the political processes that responded to the pandemic’s emergence in Africa. This further clarifies how different African States responded to the dynamics captured by the epidemiology of HIV/AIDS, from the beginning of the epidemic to the policy on access to combination antiretroviral therapy. Before the discovery of ARVs, the National AIDS Programs (PNLS/

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NCA)1 established according to guidelines emitted by the Global Programme on AIDS (GPA) constituted the foundation of AIDS public policy. The availability of access to ARV treatment later modified political attitudes, international mobilisation, and even the role of associations. To elucidate the responses of African States, I draw on a typology of three models of State action: “active participation”, the activist State”, and “passive adhesion”. Before embarking on the comparative analysis of the interactions of national and international actors, it is necessary to provide a historical overview for each model. This will also allow us to better grasp the confluence of socio-medical and political dynamics that preceded access to ARVs.

International frameworks or national convergences? International guidelines and Africa’s national AIDS programs (PNLS/NAC) During 1986 to 1996 and from 1996 to the present, African States have responded to international development and cooperation in different ways. This timeline is punctuated by the therapeutic, political, and symbolic changes introduced by the discovery of antiretroviral molecules, first announced at the Vancouver AIDS Conference in 1996. Access to ARVs became synonymous with the workings of the PNLS/NACs. In some African contexts, that dynamic led to the State opting out, by default, of the now obsolete vertical Global Programme on AIDS (GPA). This WHO programme was replaced by various international efforts as well as by the Joint United Nations Programme on HIV/AIDS (UNAIDS) which coordinates international public action against AIDS (Nay, 2009, 2010a). After the first AIDS case was discovered in the U.S. in 1981 and the HIV virus was formally isolated in 1983, the AIDS epidemic intensified on the African continent. Two obstacles slowed down the institutional response. The first was the problem of how to assess the epidemiological situation. Diagnostic tools only became available in most countries from 1985 on, with few exceptions, such as Rwanda and ex-Zaire, where international NGOs had already provided them. A second obstacle was the slowness with which some heads of state and governments acknowledged the presence of the disease on their soil. Their hesitancy stemmed from real or perceived racist prejudice that surrounds AIDS and the sensitivity about sexuality, the key mode of AIDS transmission in Africa (Dozon and Fassin, 1989, 2001). After the first HIV screening test, ELISA (Early Linked Sorbent Assay),2 became available in some countries, numerous committees, groups, and networks were set up to discuss prevention and therapeutic responses to HIV. Despite scant resources, doctors in Africa joined networks and interacted with their European and American colleagues. In 1986, Jonathan Mann founded the Global Programme on AIDS (GPA) at the WHO in Geneva. The agency’s goal was to provide an international response to the danger AIDS posed for countries of the South, especially in sub-Saharan Africa, where the pandemic’s epicentre was located. The GPA recommended that individual States, especially African ones,

International policy response in Africa 21 create National AIDS Councils or Committees (PNLS/NAC). These programmes were to develop mechanisms for epidemiological data-collection and monitoring, implement prevention programs for target groups, and, with the support of the European Union, ensure blood transfusion security (Keroudan and Eboko, 1999). Table 1.2 presents the timeline of the establishment of the PNLS/NAC in selected African countries, as reported in the first major social science comparative study (unpublished) of African States and AIDS. The study was conducted under Gruénais’s direction by an interdisciplinary team representing anthropology, sociology, political science, and contemporary history. Its goal was to understand how African States were implementing the guidelines set by international organisations, in particular the WHO’s GPA. The same methodology focussed on actors and institutions was applied to each of the study’s five countries, which represented Central Africa (Cameroon and Congo-Brazzaville), West Africa (Côte d’Ivoire and Senegal), and East Africa (Kenya). Data on international institutions (the GPA and the other international institutions present in each of the countries) provided the basis for an empirical sequence analysis that took into account the processes leading to each country’s implementation of their national aids commission, known as the Programme national de lutte contre le sida (PNLS) in the Francophone countries and the National AIDS Committee (NAC) in Kenya, the one Anglophone country in their study. Next, the relationships between State actors and international actors and the role of associations and international NGOs (later grouped under “civil society”) were identified at the national level. “Civil society” was redefined as “organisations of civil society”, a move supported by international organisations themselves when they were called on intermediary social groups, located between the State and society, to participate in public action against AIDS. Table 1.2 Chronology of the implementation of National AIDS Programs (NAPs) in selected African countries. Country

Year first AIDS Year of founding and name of first case identified or AIDS structure diagnosed

Year NAC* or PNLS** founded

Cameroon Congo

1985 1983

1987 1987

Côte d’Ivoire

1985

Kenya Senegal

1984 1986

1985: Committee for Monitoring AIDS 1985: National Committee for Diagnosis and the Fight Against AIDS 1986: Working Group on AIDS in Côte d’Ivoire 1985: National AIDS Committee 1986: National Interdisciplinary Committee for the Prevention of AIDS

1987 1987 1986

Source: Gruénais M.-E. (ed.), 1999 Notes: * NAC – National AIDS Committee. ** PNLS – Programme Nationale de Lutte Contre le Sida.

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Although Gruénais was not primarily influenced by PPA research and even less so by the comparative literature in this area, his study can nevertheless – if not paradoxically – be considered the first comparative sequential analysis model of AIDS in Africa. Like one of his most knowledgeable contemporaries in the area of international comparisons, the political scientist Patrick Hassenteufel (2000, 2005), Gruénais managed to avoid the major pitfalls of comparison. And as both advocates and critics of sequential analysis might note, he retained only four of seven “classic” sequences of PPA. The collective research Gruénais directed can be read against the following methodological questions posed by Patrick Hassenteufel. A national or sectoral approach? Gruénais examined one sector (health) and one subsector (AIDS) to show the formal convergence of national policies but also the concrete differences linked to the epidemiological, social, and health specificities of each country. Institutions, ideas or interests? His study favoured understanding the institutions and ideas that, at the national level, guided the implementation of AIDS-related institutions, from the GPA to the PNLS/NAC. The approach was then broadened to address the “interests” present and the dynamic of group participation at the forefront of public action against AIDS. These were groups and networks consisting of health professionals, especially physicians. (See Chapters 3 and 4.) A diachronic or synchronic study? The method was diachronic and began at the point in time when the PNLS/NAC were placed on national agendas and actualised (Gruénais, 1999). By incorporating a “before” and an “after”, the diachronic approach provided historical depth to the analysis, situating the dynamics of public action within a perspective rooted in historicity (Laborier and Trom, 2003), for each country confronted with AIDS (Eboko, 2005a, 2005c, 2006). Quantitative or qualitative methods? Although it used quantitative data collected by international-level bodies (WHO, the European Union, bilateral development agencies, and NGOs), the study was essentially qualitative. In each country, participant observation of associations and semi-structured interviews of development agencies and representatives of public institutions like the PNLS/NAC were conducted. Further examination of the crossed methodologies of this pioneering, comparative study reveals how the pitfalls of this type of research were avoided. Patrick Hassenfeutel, drawing on the critiques of Daniel Gaxie and others, has

International policy response in Africa 23 identified four potential pitfalls that, if not avoided, can result in “junk comparisons”. The pitfalls are referred to as “the ‘Canada Dry’, desktop, Jivaro, and ‘ventriloquist” comparisons” (Gaxie, 1997, pp. 34–35). “In each case”, Hassenteufel warns, “a comparison is used to validate a hypothesis without taking into consideration other [possible] hypotheses” (Hassenteufel, 2000, pp. 107–108). For the Gruénais studies, long-term field research, funded entirely by the French Agency for Research on AIDS and Viral Hepatitis (ANRS), was carried out in each country, with local logistical support from the French Office of Scientific and Technical Research Overseas, (ORSTOM), now called the IRD. By remaining attentive of the relationship between the State and Civil Society, insisting on methodological rigour and adequate resources for fieldwork and other aspects of the research process, the Gruénais study was able to avoid all of the above-mentioned pitfalls. Comparative research, Hassenteufel insists, must meet two criteria: adequate resources and empirical fieldwork (Hassenteufel, 2000, p. 107). The Gruénais example and others suggest the need to include Africanist fieldwork in debates about public policy analysis, especially because such methodology can yield a wealth of empirical data and prove interesting for other disciplines, as well. Comparative analyses of certain contemporary issues in France during the same period seem outdated when contrasted with field-based PPA studies of the AIDS field in Africa (Gruénais, 1999; Eboko, 2013; Demange, 2010). Hence, the value of revisiting the manner in which AIDS public action in Africa was designed as well as analysed. Implementing AIDS public policy: the national AIDS programmes (PNLS/NAC), between vertical frameworks and differentiated policies The PNLS/NAC were set up according to modalities proposed by WHO. A National Commission Against HIV/AIDS coordinated activities throughout a national territory, in collaboration with an advisory body. Each country conducted a short-term rapid assessment of the epidemiology of AIDS, developed a first medium-term plan (PMT1), and then a second medium-term plan (PMT2). The plans were spread out over three, four, or five years. WHO provided guidelines and financial resources, which essentially gave it control over national AIDS-related services. National governments were supposed to provide personnel and facilities. National-level AIDS programmes had to intersect with administrative and health structures already weakened by the Structural Adjustment Programmes (SAPs) imposed by the Bretton Woods institutions, namely the International Monetary Fund (IMF) and the World Bank. The PNLS/NAC were thus caught between two opposite, almost simultaneous processes: bureaucratisation (the organisation of the PNLS/NAC) and the undoing of the state (désétatisation or de-statification) (Médard, 1992, 2001). The logic of de-statification impinged on public services in general, given that they were obligated to follow principles of structural adjustment. Health services were especially affected (Médard, 2001; Gruénais, 2001a, 2001b).

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Although most African countries followed the WHO GPA guidelines, some differences in how public policy was implemented arose in the first decade of the institutional struggle against AIDS (1986–1996). These differences can be captured by creating a typology of four models of political mobilisation against AIDS in Africa. Each model takes into account several factors: political leadership, the mobilisation of associations, and the link between the PNLS/NAC, on the one hand, and the dynamics through which associations addressed social issues such as fighting stigma, ensuring the representation of people living with HIV, and defending vulnerable groups, on the other hand. This approach is based on “political cultures” and how they are related to the struggle against AIDS (Eboko, 2005a; see also Chapter 2). Territorial inequalities and the insufficient coordination of bilateral AIDS development projects The presence of an international polyarchy in different countries of the South, especially in Africa, raises numerous issues, particularly about the insufficient coordination between North and South so characteristic of bilateral efforts to fight against AIDS. Action is especially difficult to envision when local demands for them are non-existent. At the country level, national and regional authorities tolerated an arbitrary dividing up of the national territory, as well as the institutional development of actions lacking any cause-and-effect relationship to the epidemiology of HIV/AIDS. Rather than developing responses based on demands on the ground, institutions created a “supply” according to which State agencies, decentralised structures (i.e. those outside the capitals) and potential beneficiaries then positioned themselves. The problem was aggravated when political crises led to the collapse of States, as happened in the Democratic Republic of the Congo in the 1990s, Congo after the 1997 war, Rwanda after the genocide, Burundi, Sierra Leone, and Liberia. Similarly, a lack of economic resources fragilised other States, like Mali, Burkina Faso, and Niger. Thus, the issue of geographic equity went hand-in-hand with survival needs and international solidarity. When States were able to sustain satisfactory if weakened administrative and health systems, the partitioning of bilateral aid posed less of a problem. In other countries, like Cameroon, the issue was more about who was responsible politically for the uneven distribution of resources among regions, which also lacked support, including of the moral kind, from States of the North. French international development (la Coopération française) France opted for a paradigm change in 1998, when it moved its international development programme (officially known as la Coopération française) closer to a multilateral model. France is the second major contributor to the Global Fund, after the U.S. Besides channelling resources in response to requests, France’s ANRS has financed AIDS research in France itself, Latin America, Asia, and, of course, Africa, for over two decades. These bilateral research efforts involve

International policy response in Africa 25 specific projects, including but not limited to financing ARV treatment. The design and organisation of France’s partnerships with countries of the South reflect the growing homogenisation and depoliticisation of bilateral aid. These relatively new phenomena more-or-less signalled the end of France’s postcolonial development model (“la Coopé”, or “Cooperation”) and French development policy’s shift towards a financial and technical centralisation typical of Anglo-Saxon countries. The French Development Agency (AFD) model, which under the Decree of April 4, 1998, became the centrepiece of French international development, is based on a model more akin to older non-French entities such as the U.S. Agency for International Development (USAID), the Canadian Agency for International Development (CIDA), the German Agency for Technical Development (GZT) and the Belgian Agency for Technical Development [Coopération] (CTB). It also resembles other international operators, such as international NGOs from highincome countries (e.g. CARE Canada) (Meimon, 2007). These “development brokers” (Bierschenk et al., 2000) officially construct and/or reinforce the coordination between states, associations, and funders. NGOs make up for the deficit in certain regions and also make strategic choices in response to demands. They develop a de facto supply in relation to which centralised State structures, decentralised structures, and other potential beneficiaries position themselves. A 2008 World Bank Report conveyed the strong concerns of countries that benefit from international assistance to fight AIDS. In the study, which covered several countries and was carried out in collaboration with UNAIDS, the greatest concern emanated from areas where access to ARVs depended on Global Fund financing (World Bank, 2008). For recipient countries, a crucial question was whether their funding would be renewed by wealthy countries in 2010. The collective fight against AIDS, it was assumed, would only intensify, and benefits gained in the fight against AIDS were also of benefit for other pathologies. The need to reinforce health systems was also emphasised. In other words, no one expects miracles when it comes to the health budgets of African countries. Furthermore, it should not be forgotten that the economic survival of these countries was affected by contradictory mandates, oscillating between a “de-statification” regime imposed on African States through the Structural Adjustment Programmes and re-bureaucratisation instituted through AIDS and communicable disease programmes and funds (Boyer et al., 2010, pp. 85–93). Given the rich empirical material on African examples and the research generated by neighbouring disciplines (Enguéléguélé, 2008), the analysis of public action within the above configuration presents a dual challenge for public policy analysis. What might be the added value of political science? Or, at the risk of being provocative, might the notions and concepts offered by the political sociology of public action add something other than a different scientific rhetoric? The superficial answer would involve the nominal summing up of epistemological and geographical bodies of research. But concepts, notions, paradigms, and heuristic orientations comprise more than the words that a particular research profession uses to position itself and bolster its comfort zone. They also comprise a set of

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tools for understanding social reality, and that profession’s expertise must also be brought to bear where relevant. Beyond common sense considerations, political science stands only to gain from socio-anthropology, and scientific reciprocity can only enrich each discipline. Studies of AIDS in Africa illustrate what we call the “dissonant model” of public policy, in reference to the vertical manner through which the AIDS issue emerged and the way it was placed on State-level political agendas. The qualifier, “dissonance”, should not be interpreted as a value judgement. Rather, it constitutes a finding, and not the pre-supposition that the struggle against AIDS in Africa in the mid-1980s constituted a failure, a crisis, an achievement or even a success story. The dissonant model of public policy is defined by the dynamics of globalisation of public action illustrated by the African cases and by the multiple levels of intervention (multilateral organisations, bilateral development agencies, NGOs, etc.) through which such action proliferated. The comparative approach to sectoral politics so central to this book has previously focussed on what happened in Europe. Symmetrical Africanist approaches, however, can increase the analytic potential of that approach by introducing complexity. They can also improve on the reasoning used to identify the construction of new paradigms. Like democracy, political science gains strength from combining unity and diversity (Touraine, 1994). Using the same figure of speech, one might presume that the criss-crossing of concepts and field-sites always generates new ideas (Touraine, 1994).3 Patrick Hassenteufel’s methodological concerns and safeguards resonate with how French research teams bring together different orientations, methods, and approaches, as I noted in the introduction of this chapter. This book will show, among other things, how individual researchers and research teams have combined quantitative, qualitative, diachronic, and synchronic approaches (Moatti et al., 2010; Eboko, Abé and Laurent, 2010). What remains to be seen here are the role, contributions, and perspectives that anthropology, sociology, the political economy of health, and even epidemiology offer when allied with political science. Interdisciplinary alliances involve power plays that alternately enhance and diminish the importance of a discipline’s contribution. Such manoeuvres will depend on how the power of each discipline is constituted and distributed within a research team. Both interdisciplinary exchange and disciplinary separateness are necessary to building a multidisciplinary toolbox for public policy analysis of AIDS – and of other sectors – in Africa. Using anthropology and political science to study public action against AIDS AIDS public policy involves major political stakes for African countries and international relations. To fully benefit from what political science and social anthropology have to offer in this area, it is worth critically examining certain notions and theories about AIDS public policy and linking them to empirical research. The theoretical and empirical concerns that guide such an undertaking can be expressed as a series of questions: why, other than in the AIDS field, have French

International policy response in Africa 27 and American political scientists paid so little attention to public policy in Africa? What might anthropology, given its important contribution to understanding AIDS in Africa, bring to interdisciplinary thinking in the social sciences? Which notions and approaches to the analysis of public policy can be reformulated to improve the study of the fight against AIDS in Africa? Does Cameroon provide a relevant if not sufficient example to study, and if so, in what ways? And finally, what does policy analysis tell us about politics? (Darbon, 2004). In this book, I reconstruct the process through which anthropological research and its critique of the biomedical sciences have become part of a history that teaches us as much about the evolution of an epidemic as about the epistemology of the social sciences when applied to sub-Saharan Africa. As we shall see, the “anthropology of AIDS” has undoubtedly provided one of the most radical challenges to classical anthropology.

Public policy in Africa: an epistemological prelude Presence, absence, and proximity in the social sciences The novel constellation of inter-disciplinarity challenged the unity of anthropology by highlighting its diversity, including when it confronted public health issues. The articles collected in the edited volume, Anthropologies et santé publique (Gruénais and Dozon, 1992), illustrate my point. In them, the authors deconstruct the issues posed by biomedicine and propose instead issues more closely aligned with social reality. In doing so, they take one of the strongest stances in medical anthropology. French medical anthropology in particular made one if the greatest contributions to the renewal of anthropology in the last three decades, when it turned to the policy field, by definition the purview of political science. Until very recently, Africanist political scientists – French Africanist, African, or Anglo-Saxon – were visibly absent from scientific debates on AIDS in Africa. The U.S. published literature on AIDS and Africa in particular is relatively recent, and is indebted to the political science of international relations (Boone and Batsell, 2001; Altman and Buse, 2012). Anthropologists in France have approached the topic using concepts from their own discipline (Gruénais et al., 1999; Raynaut, 2001) and have made the connection between political science and public policy. A theoretical and empirical prerequisite: a critical anthropology of multi-disciplinarity In the late 1980s and especially the 1990s, anthropologists doing fieldwork on AIDS in Africa developed several types of “proximity” to and collaborations with other disciplines. This proximity gave way to critique through exchanges, which varied according to research sites, geography, individual trajectories, and collective concerns. The deconstruction of public health, biomedical paradigms, and biomedical notions stands out in these critiques. “The culture of public health” was elaborated by Jean-Pierre Dozon and Didier Fassin. They began by locating the “habitus” and body of work that have

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influenced this culture (Dozon and Fassin, 2001). They then moved downstream to the level at which concrete cases are embodied (Fassin, 1996). Here, they emphasise the consequences and aporia of the types of thinking and the notions that stem from epidemiology, public health, and the medical and social practices through which African patients travel. Similarly, Laurent Vidal’s research constitutes an essential resource for current thinking: Recourse to anthropology, schematically speaking, takes two forms. In the most frequent case, studies with an epidemiological and clinical component, the anthropologist is solicited to enlighten researchers about the cultural basis of behaviours that doctors characterize as responsible for [a potential subject’s] hesitation to participate in a study or as obstacles to applying the study’s conclusions. […] A second, different type of request comes from practitioners facing […] difficulties they attribute […] to individual representations [of the disease, death, procreation] which have been elaborated in a given family or broader social context […]. In Abidjan, our work corresponded to this second type of collaboration with medicine. It neither distanced itself from medical concerns nor depended on a vast multi-disciplinary undertaking. (Vidal, 1996, p. 7) Using the case of Ivoirian HIV and AIDS patients attending anti-tuberculosis centres in Abidjan, and taking into consideration their idioms of distress and the public health principles governing their health care, Vidal initiated an in-depth deconstruction of presuppositions and preconceptions common in anthropology. By empirically demonstrating the actual problems of people living with HIV/ AIDS, rather than their culture, he positioned himself within the critique of culturalism and its derivations. Vidal emphasised the social position of these patients, hence the economic and other constraints on their therapeutic itineraries, rather than their allegiances to a particular community. In so doing, he created a number of empirical and conceptual inter-mediations between actors and disciplines. He thus conceived of anthropological practice as a bridge between patients and doctors. At the same time, he envisioned critical anthropology as a tool for deconstructing “guidelines” and trends imposed by the medical sciences on the AIDS field in Africa. The independence Vidal exemplified in relation to both what is offered and what is demanded through multi-disciplinarity requires closer examination. First, Vidal and most French anthropologists collaborating with the biomedical sciences never overplay their methodology (i.e. long, detailed observation) or the issues specific to anthropology (e.g. the science of “man” in the world of the ideal and the material). This fits the major critique of culturalism that was more developed in France than in the Anglo-Saxon world, as Didier Fassin has noted (1999). In fact, it is hard to not see in these anthropological critiques of public health an

International policy response in Africa 29 implicit critique of an essentialist view of Africa or even an implicit self-criticism of contemporary French anthropology’s relationship to its early twentieth-century heritage. The rejection of culturalism regarding AIDS by these (Vidal, 1995, 1996; Fassin, 1999) and other anthropologists constituted a healthy and legitimate stance vis-à-vis the biomedical disciplines. Still, until recently, the majority of Africanist studies adopted ethnicity as a determining factor of the object – for example, illness – that they were studying. Rather than a labile construction, ethnicity was taken to be a social fact which overrode every form of social membership. In other words, French critical anthropology of health reacted decisively to the distorted image of itself it saw mirrored in public health, international organisations, and a certain version of epidemiology. It thus joined a long line of critical anthropological and historical research on identity (Amselle, 1990; Amselle and M’Bokolo, 1999). The contribution of the anthropology of AIDS resulted in part from the involuntary infusion of multi-disciplinarity that rightly provoked major advances in medical anthropology. Such debates were able to invoke the conventional if not rudimentary sociological notions of occupation and socio-professional status so often absent from the anthropology of Africa. Some anthropologists, however, did not replace excessive culturalism with the negation of all cultural specificity. For once such specificity was understood dynamically, it became one type of factor among many others (epidemiological, sociological, geographical, relational, and individual), and thus no longer permitted artificial deductions of behaviour from “culture” or “ethnicity”. Vidal drew especially on ethnographic data to show how and why public health used, in the name of evidence and consistency, tautological notions like “vulnerability”, “empowerment” and other unscientific terms derived from quasi-ideological preconceptions like “community”. Far from mere intellectual exercises, these critiques demonstrated how such concepts led to programs that engaged patient experience. Vidal’s research on African women and AIDS provides a remarkable lens through which to understand his work on AIDS in Africa more generally, especially when it aspires towards becoming “an engaged, fundamental anthropology”. As the anthropologist who successfully articulated social inequalities – a vertical dimension – with so-called community belonging – a horizontal dimension – within the dialectic of tradition-modernity, Vidal exhibits a scientific kinship with Balandier (1982, p. 6). As Vidal put it, Along with the redefinition of the issues and the objectives […] of the interdisciplinarity that the problematic of AIDS requires, the acceptance of critical engagement is the first step in the process of elaborating a global research ethic. This follows the principle that before an ethics can be constructed in response to the needs of patients, each scientific discipline concerned must reflect on its own options. (Vidal, 1996, p. 148)

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This recourse to sociology to identify “social reasons” rather than “cultural causes” of the spread of AIDS in Africa signals the first major effect of anthropology’s involvement in this research area as defined by the social sciences. Anthropologists like Vidal (1995), Raynaut, and Muhongayire (1995) examined socio-economic inequalities and constraints in Rwanda, including the political structuring of discourses and programmes destined for Africa. However, like Vidal, Claude Raynaut (1996), Bernard Taverne (1996), and other anthropologists do not think that distancing themselves from culturalism amounts to a refusal to think with “culture”. On the contrary. Using the example of cultural practices like the levirate and polygamy, which were vilified because of their presumed association with AIDS, Vidal (2000) showed that the cause-and-effect relationship between these practices and what “favoured” HIV infection was a mental construction of Westerners and even of certain African socio-professional groups. Seeing the role of the African State in an anthropological light From a different perspective, Fassin, Dozon, Gruénais, and several other anthropologists studied political aspects (States, international positioning, ideological implications, and public action) rarely considered by anthropological research. Whether they were studying African States confronted with AIDS or national programmes against AIDS, their conception, their functioning, or the actors involved, this anthropology engaged the traditional domains of political science, including political sociology. This book does not present Vidal’s work in chronological order, but rather according to its epistemic translation. His studies are based on precise information about patients, individually and as groups, and their respective histories. Fassin’s and Dozon’s thinking on international and “global” modalities through which inequality is structured is also illustrated by Vidal’s later work. Despite different starting points, these works share the idea that AIDS is comprised of a series of hardships which crystallise social inequalities. Some involve the role of African States as actively dominated by their international partners yet aspiring to a “government of life” (Dozon and Fassin, 1989). Other configurations of inequality that connect the global and the local can be gleaned from studies of public health (Dozon and Fassin 2001; Gobatto, 2003). Fassin and his fellow researchers concentrated on the social, health, and political aspects of AIDS in southern Africa. Their observations of the structuring and reproduction of inequalities in the context of epidemiological crisis and political change in the Republic of South Africa generated a coherent analysis of the politics of AIDS. The result was a sort of neo-structuralist paradigm. The AIDS pandemic involved a highly contradictory process. The pandemic revealed social and political inequalities and entailed their embodiment; simultaneously, discursive, ideological, and political responses aimed to produce the opposite effect. Fassin (2000) relates the controversy spawned by President Thabo Mbeki when, in April 2000, he questioned the association between HIV and AIDS, as a paradigmatic storyline. Earlier, Fassin had suggested that the AIDS crisis “embodied” the vicissitudes of the end of political immobility in South Africa and in southern Africa more generally. President Mbeki’s speeches and the

International policy response in Africa 31 international reactions they provoked englobed a double dimension. On the one hand, they clearly indicated an admission of powerlessness and an act of distress in the face of an unprecedented epidemiological crisis. At that time, six million people were living with AIDS in the Republic of South Africa (UNAIDS, 2011), the highest number of any other country. On the other hand, Mbeki’s position reflected the ideological inclination to question the “global” order which the President contrasted with the “African Renaissance” (Fassin 2002a, 2002b; Sindjoun and Vennesson, 2000). By emphasising the researcher’s positionality, Fassin was postulating that the analysis of Mbeki’s discourse needed to be recontextualised in relation to the wounds of the Apartheid past and to the President’s own desire to present an alternative to Western dominance of discourse on African issues. To achieve this, the author proposed situating Mbeki’s dissident proposals as distinguishing the “universal” and the “global” (Fassin 2002a, p. 448). Fassin’s study nevertheless exceeds a mere exegesis of Mbeki’s ideology. The South African case validates the anthropologist’s intuition about cautioning against Manichaean analyses. Beginning in April 2002, Thabo Mbeki distanced himself from the American “scientific dissidents” on whose work he had based his claims about the lack of a relationship between HIV and AIDS. Furthermore, that same month the South African Supreme Court ordered the government to implement general access to nevirapine, a molecule employed to reduce the probability of mother-to-child transmission of the virus by HIV-positive pregnant women. This amounted to a call to look beyond the simplistic visions of Mbeki’s involvement in the access to AIDS drugs in South Africa. Fassin and his co-author proposed instead an approach to discussing AIDS in South Africa that is rooted in political economy and political anthropology. Such an approach will shed light not only on the objective determinants of the epidemic, especially social inequalities, but also on subjective responses, such as those of Mbeki. (Fassin and Schneider, 2003, p. 495) Didier Fassin and Helen Schneider have shown how the dramatic evolution of the AIDS epidemic in South Africa fell along the lines of social inequality. Their observation about South Africa is also applicable to violence in societies where profound transformations facilitate the expansion of epidemics (Fassin, 2000). Fassin and Schneider nevertheless caution that the political economy of AIDS resists superficial, binary positions for or against antiretroviral drugs or President Mbeki (Fassin and Schneider, 2003, pp. 495–496). According to the authors, the causes of the epidemiological crisis lie in a series of objective determinants. These include exposure to risky sexual practices, lack of information about health and disease prevention, a high frequency of sexually transmitted diseases that favour HIV infection, absence or delay of diagnosis and treatment, and finally, a lack of “concern for the self” and a distancing of the “future”, both of which are associated with difficulties in the present.

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In other words, the epidemic itself is linked to diverse historical and political factors anchored in social inequalities ultimately inscribed in the social structure. This perspective on AIDS in South Africa resonates with the notion of “political culture”. It facilitates the understanding of epidemiological crises in relation to the past (before AIDS) and to current processes (the institutionalisation of public policy, the dynamics of political change, the differing degrees of dependency on the international level, etc.). Based on this analysis, the exceptional example of South Africa fits under the category of “active dissidence”. By contrast, most African States fall under what I have called a “passive adherence” to international norms or, more rarely (Uganda, Senegal), under “active participation” (Eboko, 2002a, 2005b; see also Chapter 3). Similarly, in my analysis of AIDS in Cameroon, I had evoked the notion of “an acquired political immuno-depressed syndrome” (Eboko, 2000, p. 235). This reinforces Vidal’s point that structural and political issues should not be confused with cultural factors. When political science examines political responses, collective mobilisation, historical trajectories, and epidemiological configurations particular to a given State, it is able to intersect with anthropology. Paradigms for comparative research that are constructed and operationalised along these lines can offer a better understanding of the AIDS epidemic in Africa, AIDS public policy (Raynaut, 2001), and public policy in development (Baré, 2001). The theoretical contribution of political science Contemporary scholarship has sought to reconcile the differences between the various traditions or schools of French and U.S. political science: The first [tradition] is concerned with carrying out efficient research and generating significant results that can then be applied to improving how public organisations function [cf. Saransk, Edwards 1981]. The second [tradition] addresses key questions, such as representation, legitimacy and the “crisis of the State”. How can policy be examined in any depth without a theory of the State? Or, conversely, how is it possible to think about the place of the State in modern societies without seriously considering the extraordinary development of public policy? (Jobert and Muller, 1987, p. 9) Along the lines of this logic, this book takes the crisis of the State in Africa as the starting point for understanding the diversity of State action when particular situations arise (Patterson, 2005). Similarly, it examines the conditions that pre-existed public health all for proposals to WHO and UNAIDS. This historical context is necessary to understand how the conceptual framework epitomised in AIDS policy was reversed. The crisis of the State, the paucity of resources, and the economic and political crises of the 1980s and 1990s contributed to the unique nature

International policy response in Africa 33 of this policy. Public policy usually originates in negotiations involving social groups who turn to public action after having attempted political negotiation. The AIDS case in Africa suggests a different model, in which public policy originates in the responses to an external solicitation. Following this historical situation, the means had to be found for constructing AIDS as a “social fact” (Durkheim, 1968). The difficulties encountered in doing so, for example, as a prerequisite to developing HIV prevention, illustrate the model of “dissonance”. Anthropologists have reflected on the externalities of the AIDS struggle and debated their social and health consequences. Political science approaches the issue of international frameworks deductively, by examining public policy guidelines. In fact, my analysis of the goal of changing sexual behaviour” that increases the risk for AIDS (Eboko, 2000) called for defining processes that create public policies, both in the political sense (the role of the State in protecting its citizens) and in the sociological sense (institutional mediation between social groups, legitimisation of scientific discourse, regulation of conflict, etc.). A shifting frame of reference The notion of frame of reference (référentiel) in French political science, which refers to the “legitimate” social representations of a social problem and its political management, is applicable to AIDS in Africa and the ideological contradictions that it has generated. AIDS encompasses cultural, political, and social issues, governed by a plurality of concepts and irreducible to any single frame of reference. Health and political authorities lacked a single set of principles or unique “social fact” on which to base their response to the AIDS pandemic. One of the first observations triggered by the AIDS epidemic in Africa was the absence, prior to 1990, of social groups which social policy could target. The cognitive, or référentiel school of French political science, posits a “frame of reference” conceptualised along three dimensions: cognitive, normative, and instrumental (Jobert, 1992). In African countries, however, none of these dimensions were being debated in the construction of public policy. Rather, policy application originated as much in how institutions responded to external, international-level solicitations as to internal negotiations. At the international level, access to treatment mobilised two major groups of local actors. The first group included “double agents”, individuals involved in the local organisation of public policy as well as in the more peripheral programmes of scientific research, associations, expertise, and so forth. The second group was composed of organisations involved in the fight against AIDS (Eboko, Broqua and Bourdier, 2011). These included associations of people living with HIV/AIDS and, from the late 2000s on, homosexual associations. These groups can be characterised as “mediators” situated at the interface of the local and the international. They negotiated and produced the sectoral frame of reference; that is, representations of both the disease and the remedies and resources available.

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To evaluate the cognitivist approach to public policy, I once again draw on anthropology and its essential contribution to AIDS research in Africa. I examine the ideas and discourse that structured public policy as well as the methods and means of “speaking the world” and “rethinking Africa” in the world. In this way, a conceptual frame based on the “cognitive/normative” pair (Jobert, 1992; Enguéléguélé, 2002; Muller et al., 2005) can pave the way for a political science informed by “AIDS anthropology” in Africa. Towards cognitive approaches to public policy The overlap between the political economy and the political anthropology of AIDS (Fassin and Schneider, 2003) draws its inspiration from Michel Foucault. Political scientists might be particularly interested in “the order of things” of power implied by sexuality. According to Foucault: Discourses are not once and for all subservient to power or raised up against it, any more than silences are. We must make allowance for the complex and unstable process whereby discourse can be both an instrument and an effect of power, but also a hindrance, a stumbling-block, a point of resistance and a starting point for an opposing strategy. Discourse transmits and produces power; it reinforces it, but also undermines and exposes it, renders it fragile and makes it possible to thwart it. (Foucault, 1978/1976, pp. 100–101) This citation reinforces the idea that cognitivist approaches to public policy in political science (Muller, 2000) can contribute considerably to AIDS research. This holds true for Mbeki-type “dissidence” in the early 2000s and the “active silence” of many African presidents and leaders prior to then, as much as for the Bill and Melinda Gates Foundation’s discursive and financial authority over international organisations like the WHO and programmes it finances (e.g. the Global Alliance for Vaccines and Immunization (GAVI).4 These examples illustrate Foucault’s idea that “silence and secrecy are a shelter for power, anchoring its prohibitions; but they also loosen its holds and provide for relatively obscure areas of tolerance” (Foucault, 1978/1976, p. 101). These considerations are particularly relevant to the subjective and objective reasons behind the Cameroonian president’s economy of silence before 2011. They also explain why he favoured the considerable cut in the price of ARVs in Cameroon, yet did not try to profit from it electorally. Because only anthropology has so thoroughly studied “social representations” in Africa, it behoves political scientists to use those studies to enhance their own so-called cognitive approaches. Until now, political science has relegated such studies to a minor key, considering them descriptions of the cultural, cognitive, and political canvas from which social questions are articulated and institutional responses constructed.

International policy response in Africa 35 In each African country, the “iron law of biomedical oligarchies” (Eboko 1999a, 1999b, 2005d) responsible for AIDS materialised in part because those specialists had few civil society interlocutors who could bring other perspectives to technical discussions or to the problems of communicating about issues like intimacy. Here, my analysis draws on the critical analysis of cognitive approaches in general. Thus, Pierre Muller has posed a question in another context that is equally pertinent to AIDS policy in Africa: How should we think about the fact that actors act, define strategies, make choices, mobilise resources, in short, are “free” within the framework of global structures in which their possibility to act is at best marginal? This is the question cognitive analysis of public policy raises. (Muller, 2000, p. 193) Several researchers raised this very question in relation to AIDS in Africa in the 1990s, when they analysed the vertical programmes WHO imposed on or proposed to African nations. (Gruénais, 1999, 2001a, 2001b). Anthropological research shed light on the externally imposed “norms” of social regulation that local groups could not appropriate for themselves. It also emphasised the paucity of debate and the poor political and symbolic visibility of African authorities in the AIDS arena. This relative deficiency also revealed how political actors were delegating the AIDS issue to policies put into practice by health professionals. Prevention was not feasible in this context, which spanned the first two decades of the fight against AIDS in Africa. During that time, States and international organisations prioritised prevention to the detriment of treatment while using the issue to illustrate the disconnect between health authorities and the groups targeted by prevention messages. Of course, sexual behaviour, at issue here, is difficult to change everywhere, given its private, intimate nature. On the contrary, the issue of treatment seemed to re-establish the competence of health actors. Although they had failed in the prevention area, they were able to succeed in the area of virological and therapeutic research. In both cases, transnational networks comprised of researchers and doctors in charge of the AIDS issue demonstrated the overriding need to engage social groups who could embody this struggle in all its contradictions, according to specific circumstances and in opposition to institutions. In most African examples, those who mobilised around these issues were “double agents”: agents of the state who provided an interface for invisible and what were later prefabricated “civil societies”, like the first associations of “people infected with …” (Delaunay, 1999; Eboko, 1999a, 1999b; Eboko, Broque and Bourdier, 2011). Here, too, the situation evolved at the end of the 1990s. The emergence of associations with more independence from doctors and who had become more involved in international activist networks than before signalled a “second wave” more likely to engage in “participation” and oppose the guidelines, and sometimes even the abuses, of public action and/or official discourse (Eboko and Mandjem, 2010). South Africa provides the most striking example of civil society mobilisation.

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From public policy instruments to instrumental public policy: theoretical elements and hypotheses In this last section of my chapter, I turn to the theoretical elements and hypotheses that guide the rest of the book. The heuristic process of using empirical data to analyse AIDS public policy, presented above, can be contrasted with the more classical areas of political science and the sociology of public action. This potentially fruitful comparison nonetheless presents an epistemological challenge, which I now take up. This will allow me to translate theoretical and empirical propositions from my research into a number of epistemological propositions stemming from what is often called the French School of public policy, although that label covers a diversity of approaches to public policy analysis (Boussaguet, Jacquot and Ravinet, 2006). From the international to the local Starting with the construction of the international response to the composite issue of AIDS – prevention, treatment, standardised epidemiological data, etc. – I aim to understand the set of instruments for public action that were produced at the international level. These emerged from the polyarchy upon which the “negotiated” and “dissonant” governance of AIDS is based at the international level: the Global Fund to Fight AIDS, Malaria, and Tuberculosis (hereafter the Global Fund); UNAIDS, WHO, and international foundations and NGOs. The transfer to African States of the numerous instruments from these agencies and their translation present a variety of models for scientific inquiry. My research seeks to make them comprehensible and to reveal their logic and historicities with socio-political acuity (Bayar, 1989; Laborier and Trom, 2003). The political inquiry by anthropologists cited earlier showed that the institutional struggle against AIDS in Africa took the form of a public policy which, until 2000, aroused little public debate or specific involvement in the arena of politics. Though the convergence of international mobilisation and the modification of political attitudes in certain African States seemed to suggest change, it actually involved a paradigmatic reversal that merits the interest of political scientists. For since the mid-1980s, the French School of public policy has shown how policies fall into the range of issues addressed by politics (Darbon, 2004). This confrontation with policy and politics generated a number of essential analyses and paradigms, as Jobert and Muller (1987) demonstrated in their now classic collection, L’Etat en action, and in a scattering of decisive studies5 that continue to nourish contemporary debates on public policy. This perspective, along with my own collective research experience (in political science, social anthropology, economics, law, and history) and, above all, certain studies of the politics of AIDS in Africa seem to indicate a new research configuration. Within this body of work, it can be shown that AIDS in Africa was constructed as a public policy by health professionals working on the edge of the political system, even if when they were agents of the State. But the State is only one element of

International policy response in Africa 37 the political system, and its involvement is more of the administrative kind than of the political kind. In fact, the situation in most African countries seemed to indicate that the fight against AIDS had more to do with a “policy of depoliticisation” than anything else (Eboko, 2009). In most States, this public action has been approached as a public health problem for international organisations and local health authorities and limited to the margins of strictly political arenas like political parties, parliamentary debate, and so forth. This hypothesis merits empirical testing with concrete cases, in the light of theoretical works on public policy. Dissonant models of public policy in the African context The first question I tried to answer is how national public policy can be analysed through the proposals of international organisations rather through that of collective intra-national mobilisation (Keroudedan and Eboko, 1999). In other words, how does international public policy appear to be implemented, when seen through the prism of political responses to the AIDS pandemic in Africa? This question situates the debate at two levels. The issue of a framework of reference (référentiel) developed at the level of international organisations and “proposed” to States by way of a set of actors and historical circumstances not limited to the sphere of the State requires an analytic shift from the notion of national public policy to that of public action, regardless of whether it is appropriated at the national level (Eboko, 2005b). Hence the following hypothesis: the encounter between a global frame of reference and the historicity of a given society produces a large diversity of national and local responses worthy of analysis. The global frame of reference is therefore experienced along a range of possibilities that stretch from “active participation” in to “passive adherence” to international directives. Most sub-Saharan African countries fit the latter model of passive adherence. Between the two poles lie weakened States or States in crisis, in which the guidelines “implode”. “Active dissidence” involves questioning all or part of the directives. As we noted earlier, this model, exemplified by South Africa under Thabo Mbeku, raises the issue of the boundary between the “global” versus the “universal” (Fassin, 2002a, 2002b)). We can further hypothesise that global frameworks of reference generate international public policies and transnational public actions that result in convergences as well as divergences (Patterson, 2005, 2006). A political sociology of international public action Whether in health, the environment, or another domain, internationally instigated public action in Africa is reworked at the national and local levels in specific contexts that depend on the historicity of the particular society (Bayart, 1989) and its political culture. Using that perspective, we propose the following hypothesis: a given political culture tests a framework of reference by validating, modifying, or drawing attention to a novel configuration of unequal rival frameworks (Poku and Whiteside, 2004; Eboko, 2005a). What are the configurations of actors and how do

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they influence public action in a specific country? The elaboration of public action against AIDS in Africa, especially after the introduction of combination therapy antiretrovirals (henceforth, antiretrovirals, or ARVs), was accompanied by a series of instruments. These were consubstantial with the organisations that had been created to compensate for the economic and material deficit in access to ARVs in countries of the South. These included the Global Fund against AIDS, TB, and Malaria (established in 2002), the U.S. President’s Emergency Plan for AIDS and Relief (PEPFAR, established in 2003) and the World Bank’s Multicountry HIV/ AIDS programme (founded in 2002). These major international programmes were established after the WHO’s Global Programme on AIDS (GPA: 1986–1996), which UNAIDS replaced in 1996. The emergence of international foundations like the Bill and Melinda Gates Foundation and the Clinton Foundation reinforced this international polyarchy. Each of these organisations plays a specific role in relation to the institutional actors on the international scene. The Global Fund and UNAIDS depend on multilateral aid, PEPFAR involves bilateral (U.S.) aid, and the other organisations are part of an international arrangement. Among the latter, so-called international non-governmental organisations (INGOs) sometimes include certain branches of national NGOs, such as the Doctors without Borders – France and Doctors without Borders – Switzerland. The action of each of these organisations overlaps in a highly variable manner with what Pierre Lascoumes and Patrick le Galès have defined as instruments that constrain the effects of public action. “When applied to the political field of public action, the[se] instruments operate as technical devices for generic purposes that incorporate a specific vision of the relationship between policy and society buoyed by the idea of regulation” (Lascoumes and Le Galès, 2004a, p. 14). The instruments of transnational public action In the context that interests us here, the role and the dynamic of international instrumentation clarify the constellation of resources and constraints that States face when they access health goods at the international level. Lascoumes and Le Galès, citing North, remind us that instruments are institutions in the sociological meaning of the word; that is, “a more-or-less coordinated set of rules and procedures that govern the interactions and behaviors of actors and organisations” (North, cited by Lascoumes and Le Galès, 2004a, p. 16). This definition can be used to deconstruct the relationships and the circumstances whereby international instruments are allocated to different countries through “model transfer”. This process, Darbon reminds us, corresponds most closely to the notions of “best practices” and “benchmarking”, but only if we use them to connect results with the techniques applied in dealing with a particular issue (Darbon, 2010, p. 9–10). In this vein, I offer the following hypothesis: international organisations act through instruments that constitute mechanisms for depoliticising highly political actions (prevention, screening, access to ARVs, categorisation of risks and people). I will show how national and international experts exercise a bio-politics, in

International policy response in Africa 39 the Foucauldian sense of “the right to ‘make live’ or to ‘let die’” (Foucault, 1997: 256). They tie access to international financial resources to specific institutional, structural, and cognitive prerequisites. Although presented in a politically neutral manner, these demands shape the modalities of a “new world government” (Bayard, 2004) which States, in this case African States, must deal with. The ability to draft a funding application to the Global Fund or to PEPFAR and the ability to understand World Bank funding guidelines require a structural conformity to cognitive frameworks that do not allow for a neutral or ideological axiology (Demange, 2009; Nguyen, 2010). African countries bring to these processes a vast heterogeneity of trajectories that this book analyses. Any understanding of the health, epidemiological, political, and economic variables that might determine whether a model is adapted must be informed by the “public policy networks” that compete to implement AIDS public policy. As Patrice Duran notes: In a polycentric world, public action is increasingly defined as a joint action involving particular coordinating mechanisms. These are further and further removed from hierarchical and bureaucratic solutions that lead us to question the capacity of institutional frameworks to generate appropriate collective action, in combination with the stable government institutions and greater flexibility of action. (Duran, 1999, p. 23) Within this logic, coalitions vary in stability, depending on the country and the international networks in which State authorities and social actors (associations, health professionals’ networks, etc.) are embedded at the national level. Public policy instruments and networks The instruments mentioned above are used in interventions by multiple actors who constitute, direct, and shape the AIDS field in African countries. The notion of “public policy networks” is particularly relevant here. The most widely accepted definition is summarised by Le Galès and Thatcher: “in a complex environment, public action networks result from more-or-less stable, non-hierarchical co-operation between organisations which know or at least acknowledge one another, negotiate, exchange resources and may share norms and interests” (Le Galès and Thatcher, 1995, p. 14). More so than European countries, African States are caught up in the logics of institutionalisation at the supra-national level of “processes of globalisation in all their diversity and contradictions, circumvention of social groups and economic flows, and formation of transnational actors who work around the borders and injunctions of their own governments” (Lascoumes and Le Galès, 2004a, p. 22). In the same vein, my own studies in Africa validate and considerably extend the observations of authors who have scrutinised European configurations. The proliferation of actors and instruments for coordination has “facilitated the emergence of

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a paradigm. In this ‘new negotiated governance’, public policies tend to be less hierarchised, less confined to bounded sectors, and less structured by powerful interest groups” (Lascoumes and Le Galès 2004a, p.23). Rather, these “interest groups” or actor networks (e.g. associations of people living with HIV, health professionals, political authorities) are structured in response to international “demands” for public action and hierarchised according to their status and connections to international partners, which are unstable and at some moments may be reversible. Here and elsewhere, the “regulatory” State, which Emile Durkheim thought of as the counter force to society, is given the role of co-directing public policy. However, “the State has not had the last say. Research on these new instruments allows us to understand certain aspects of the State’s restructuring” (Lascoumes and Le Galès, 2004b, p. 169). Yet from one country or context to another, same force, power, or resonance of the State’s last word will vary according to whether the outcomes are at the national level or the international level. What are the repertoires of collective action? What differences emerge in a diachronic perspective, between the time of AIDS and what went on before? What repertoires emerge in synchronic perspective, or how is the fight against AIDS embedded in collective dynamics of a more general kind? With these questions in mind, I have opened up several lines of research. The first required that I position myself at the interface of “political culture”, dynamically understood, and the public policies which may or may not have been influenced and changed by collective action. To capture these differences, I have developed a typology of countries, models of national political responses according to power relations between actors (international organisations, State actors, international non-governmental actors, national and local associations, private sector actors like the pharmaceutical industry), and various types of configurations. These “models” take into account the historicity of repertoires of collective action and the history of the fight against AIDS in selected countries; namely, Cameroon, Côte d’Ivoire, Senegal, Uganda, and South Africa (Eboko, 2005b). Criss-crossing disciplines or inter-disciplinarity? Earlier, I asked what might, in epistemological terms, be the role and contribution of political science. How might we read the political issues concerning AIDS in Africa from the standpoint of a political science in confrontation with other disciplines, notably an anthropology that already has examined these issues? (Eboko, 2005c). How might political scientists collaborate with specialists from health economics, political economy (Moatti and Eboko, 2010), and public health, within an interdisciplinary research context focussed on AIDS? What might be the heuristic value of such a collaboration, once we get beyond the ritual refrain about “inter-disciplinarity”? This perspective has enabled me to see how States became co-actors, through public action, in the very policies for which they were originally responsible. Similarly, it is the institutions and instruments that accompany a public action that are involved in processes ranging from appropriation to instrumentalisation in enacting the “state of the State”.

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Access to ARVs in Africa: from the restructuring of the PNLS/NAC to a “therapeutic revolution”? Harbingers of change between Vancouver (1996) and New York (2001) When the International AIDS Conference held in Vancouver in 1996 announced the discovery of tri-therapies and their efficacy, the first and major beneficiaries were patients from wealthy countries. For example, in public hospitals in France’s capital (Assistance Publique – Hôpitaux de Paris), the mortality associated with HIV/AIDS fell by 80% within only one year. In the global South, Brazil became the first country to tackle the survival of its patients after President Cardoso allowed the copying of ARVs still on patent, evoking the right of Brazilian patients to benefit from treatment. The initial results proved significant; mortality dropped by 50% within the first year that Brazilian patients were able to benefit from Cardoso’s decision. But what of patients in Africa? The African convergence of a global approach In Africa, the problem of access was first articulated around the problem of a lack of the biomedical skills necessary for patient care. The first training meeting to help African physicians address this issue was held in Dakar, in late 1997. Shortly afterwards, French President Jacques Chirac and his then-Health Minister, Bernard Kouchner, launched the idea of an International Therapeutic Solidarity Fund (FSTI) at the International Conference on AIDS and Communicable Disease (CISMA). At that stage, no one was calling into question the monopolies, control, and constraints connected to the costs of treatment in African countries. Rather, under the coordination of GPA/WHO’s successor, UNAIDS, the focus was on negotiating with the big pharmaceutical companies in order to obtain so-called branded medicines. This pilot programme, the UNAIDS Initiative, was aimed at benefiting two African countries, Côte d’Ivoire and Uganda. However, the selection of patients and the onerous procedures demanded by health ministries, UNAIDS, and the pharmaceutical labs tempered initial expectations. The following year, Senegal opted for another method. It negotiated directly with the same pharmaceutical companies, thereby eliminating the UNAIDS step. A low HIV prevalence rate (at the time, 1%), the political will of its leaders, and the international interconnectedness of its biomedical elites explains the relative speed with which Senegal implemented its Initiative to Access ARVs (ISAARV). Here, too, patients were selected according to their ability to pay for treatment, the price, which had been lowered through negotiations. The situation remained dire, with the patent-holders in command. The start of the third millennium spawned negotiations between some countries, including Cameroon, and the companies manufacturing ARV copies. These initiatives hatched in the margins of the Trade-Related Aspects of Intellectual Property Rights (TRIPS), the international agreement between the World Trade Organization (WTO) and its member states. When the big pharmaceutical companies took the government of Brazil to court at the WTO and the same companies

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sued the government of South Africa directly, the degree of controversy and mobilisation that resulted brought hope to an unprecedented high. The strategic error committed by the pharmaceutical companies unleashed such a massive international mobilisation among the NGOs that in 2001 the charges against Brazil and South Africa were dropped. Even better, this power struggle cleared the way for other African countries to seek recourse to “generics” without having to go through the preliminary legal step of obtaining a compulsory licence from the drug company. Thus, a first phase in lowering the cost of treatment began in Africa, although resistance was widespread at the international level. In 2001, a high-level USAID director speaking at the kick-off event for the Global Fund6 provoked the ire of the associations present by expressing a doubt, which he couched in culturalist terms, that Africans had the “capacity” for undergoing treatments whose efficacy depended on scheduled dosage (“Africans don’t wear watches”). This faux-pas, news of which reached all of the groups involved in the fight against AIDS, should have instead provided activists with an additional reason to challenge a priori culturalist assumptions. The year 2001 became a turning-point and a symbol that condensed the international aporias of that moment as well as the earlier ones. The Bush Administration’s bilateral if not actually “unilateral” momentum opposed the endorsement of the UN’s multilateral response, developed under SecretaryGeneral Kofi Annan (Eboko, 2005a; Demange, 2010). The American President responded to the founding of the Global Fund in 2001 by creating the President’s Emergency Plan for AIDS Relief (PEPFAR). This situation at once set off and symbolised the dynamics and contradictions of what political scientists call a “polyarchy”, or a multiplicity of powers that are independent of one another and work towards a same cause without ever becoming a “common cause”. This chapter has attempted to show how the convergence of public policies implemented in response to the AIDS pandemic in Africa was constructed and promoted at the international level. The chapter opened with the methodological prerequisites for addressing questions posed by international comparisons (Hassenteufel, 2000, p. 2005). It then engaged a rereading of the theoretical and epistemological tools that established the basis for broadening the sociology of public action to include African study sites. By evoking “dissonant public policy models”, I hope to have exemplified the unique nature of a novel process whereby a public action already decreed at the supra-national level is constructed at the national level. This dissonance, which is not solely an African prerogative, sets off sequences and modalities of a public action that is not “state-centred”. Rather, this action is conceived and proposed without involving the social groups and political bodies responsible for its implementation in the debates that eventually result in its placement on the political agenda. The so-called “dissonant” model elucidates how the international–national interface can clarify and stimulate the “interests”, “ideas”, and “institutions” (Palier and Surel, 2005) of highly unequal transnational groups and networks, which vary by country. The evolution of the collective studies which I have had the opportunity to coordinate and present in the chapters that follow attests to interdisciplinary

International policy response in Africa 43 cross-fertilisation between sociology and political science (Hassenteufel, 2011) and between International Relations (IR) and political science (Smith, 2013). In this context, it is crucial to highlight how the African State is restructured, in a situation that increasingly reinforces its role as a co-actor of polyarchical public action. This is the goal of the next chapter.

Notes 1 This book uses the French and English acronyms for the national programs: PNLS (Programme national de lutte contre le sida) and NCA (National Council on AIDS, National Committee on AIDS). The English, but not the French, names for these programs vary. Translator’s note. 2 This enzyme immunoassay technique is used to detect HIV antibodies. 3 Alain Touraine created a metaphor from the statement, “happiness is always a new idea”, proffered by St. Just. 4 GAVI is a public–private platform for the protection of children and health through vaccination programmes. It finances governmental and international programmes, including those at the WHO. 5 See in particular two syntheses of cognitive approaches to public policy (Muller, 2000; Sabatier and Schlager, 2000) and the critical review of the historicity of public action (Laborier, 2003). 6 During the United Nations General Assembly Special Session (UNGASS) on AIDS, held in New York in June 2001.

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Gruénais M.-E., Éd., 2001a, “Un système de santé en mutation: le cas du Cameroun”, Bulletin de l’apad, 21. Gruénais M.-E., Éd., 2001b, l’organisation locale des politiques de santé en Afrique centrale, Convention MIRE/IRD, n° 10/99, Marseille, IRD, SHADYC, août. Gruénais M.-E., Delaunay K., Eboko F. & Gauvrit E., 1999, “Le sida en Afrique: un objet politique?”, Bulletin de l’apad, 17, juin: 9–36. Gruénais M.E. & Dozon J.P. Eds., 1992, Anthropologie et santé publique, Cahiers des sciences humaines, 28, n°1. Hassenteufel P., 2000, “Deux ou trois choses que je sais d’elle. Remarques à propos d’expériences de comparaisons européennes”, in CURAPP, Éd., Les méthodes au concret, Paris, PUF: 105–124. Hassenteufel P., 2005, “De la comparaison internationale à la comparaison transnationale, Les déplacements de la construction d’objets comparatifs en matière de politiques publiques”, Revue française de science politique, 55 (1), février: 113–132. Hassenteufel P., 2011, 2e éd. Revue et augmentée, Sociologie de l’action publique, Paris, Armand Colin, coll. “U sociologie”. Jobert B., 1992, “Représentations sociales, controverses et débats dans la conduite des politiques publiques”, Revue française de science politique, 42 (2): 219–234. Jobert B. & Muller P., 1987, L’État en action. Politiques publiques et corporatismes, Paris, PUF, coll. “Recherches politiques”. Kerouedan D. & Eboko F., 1999, Politique publique et sida, Bordeaux, CEAN, coll. “Travaux et Documents”, 61–62, 73 p. Laborier P. & Trom D., 2003, dir., Historicités de l’action publique, Paris, PUF. Lascoumes P. & Le Galès P., 2004a, “l’action publique saisie par les instruments”, in Lascoumes P. & Le Galès P, dir., Gouverner par les instruments, Paris, Presses de Science Po: 11–44. Lascoumes P. & Le Galès P., 2004b, “De l’innovation instrumentale à la recomposition de l’Etat”, in Lascoumes P. & Le Galès P., dir., Gouverner par les instruments, Paris, Presses de Science Po: 357–369. Le Galès P. & Thatcher M. Eds, 1995, Les réseaux de politique publique. Débat autour des policy networks, Paris, L’Harmattan, coll. “Logiques politiques”. Médard J.-F., Éd., 1992, États d’Afrique noire: formation, mécanismes et crises, Paris, Karthala. Médard J.-F., 2001, “Décentralisation du système de santé publique et ressources humaines au Cameroun”, Bull. APAD, 21/2001. http://apad.revues.org/35. Meimon J., 2007, “La fin du pacte colonial? La politique africaine de la France sous J. Chirac et après”, Politique africaine, 105 (1): 7–26. Moatti J.-P. & Eboko F., 2010, “Economic research on HIV prevention, care and treatment: why it is more than ever needed?”, Current Opinion in HIV and AIDS, 5 (3): 201–203. Moatti J.-P., et al., 2010, “Recherche opérationnelle sur l’accès au traitement du VIH/sida dans les pays à revenus limités, in Eboko F., Abé C., Laurent C., l’accès décentralisé au traitement du VIH/sida. Evaluation de l’expérience camerounaise, Paris, ANRS, coll. “Sciences sociales et sida”: 297-311. Muller P., 2000, “l’analyse cognitive des politiques publiques: vers une sociologie politique de l’action publique”, Revue française de science politique, 50e année, 2: 189–208. Muller P., et al., 2005, “l’analyse politique de l’action publique. Confrontation des approches, des concepts et des méthodes”, Revue française de science politique, 55: 5–6. www.cairn.info/revue-francaise-de-science-politique-2005-1-page-5.htm.

International policy response in Africa 47 Nay O., 2009, “Administrative Reform in International Organizations: the case of the Joint United United Programme on HIV/AIDS”, Questions de Recherche, 30, octobre, Centre d’études et de recherches internationals, Sciences Po. Nay O., 2010a, “Policy Transfer and Bureaucratic Influence in the United Nations. The case of AIDS”, Questions de Recherche/Research in Question, 33, septembre. Centre d’études et de recherches internationales, Sciences Po. Nguyen V.-K., 2010, The Republic of Therapy. Triage and Sovereignty in West Africa Time of AIDS, Duke University Press. Palier B. & Surel Y., 2005, “Les trois I et l’analyse de l’Etat en action”, Revue française de science politique, 55 (1): 7–32. Patterson A.S., Éd., 2005, The African State and the AIDS Crisis, Aldershot, Ashgate Publishers. Patterson A.S., 2006, The Politics of Aids in Africa, Boulder, Lynne Rienner. Poku N. & Whiteside A., Éds, 2004, Global Health and Governance, Durban, Heard. Raynaut C., 1996, “Quelles questions pour la discipline? Quelle collaboration avec la médecine?”, in Benoist J. & Desclaux A., dir., Anthropologie et sida. Bilan et perspectives, Paris, Karthala: 31–56. Raynaut C., 2001, “Comment évaluer les politiques de lutte contre le sida en Afrique”, in Baré J.-F., Ed., l’évaluation des politiques de développement. Approches pluridisciplinaires, Paris, L’Harmattan, coll. “Logiques politiques”: 318–354. Raynaut C. & Muhongayire F., 1995, 2e éd., “Chronique d’une mort annoncée. Problèmes d’éthique et de méthode posés par la démarche anthropologique au suivi des familles touchées par le sida (autour du cas rwandais)”, in Dozon J.-P. & Vidal L., Éds, Les sciences sociales face au sida – Cas africains autour de l’exemple ivoirien, Paris, ORSTOM: 235–252. Sabatier P.A. & Schlager E., 2000, “Les approches cognitives des politiques: perspectives américaines”, Revue française de science politique, 50 (2): 209–234. Sindjoun L. & Vennesson F., 2000, “Unipolarité et intégration régionale: l’Afrique du Sud et la “renaissance africaine””, Revue française de science politique, 50 (5): 915–940. Smith A., 2013, “l’analyse des politiques publiques”, in Balzacq T. & Ramel F., dir., Traité des relations internationales, Presses de Sciences Po: 439–465. Taverne B., 1996, “Stratégie de communication et stigmatisation des femmes: lévirat et sida au Burkina Faso”, Sciences sociales et santé, 14 (2): 87–104. Touraine A., 1994, Qu’est-ce que la démocratie? Paris, Fayard. UNAIDS, 2015, Global AIDS Response Progress Reporting 2015, Geneva. https://www .unaids.org/sites/default/files/media_asset/JC2702_GARPR2015guidelines_en.pdf Vidal L., 1995, “Les risques du culturalisme”, Le journal du sida, 75–76: 32–34. Vidal L., 1996, Le silence et le sens. Essai d’anthropologie du sida en Afrique, Paris, Anthropos/Economica. Vidal L., 2000, Femmes en temps de sida. Expériences d’Afrique, Paris, PUF, coll. “Politique d’aujourd’hui”. World Bank, 2008, West Africa. HIV/AIDS Epidemiology and Synthesis. Implications for prevention, The Global HIV/AIDS Program. Global AIDS Monitoring and Evaluation Team (GAMET), The World Bank, Washington DC.

2

AIDS and governance in Africa Instruments and instrumentalisation of an international policy

At first glance, any attempt to delineate the notion of “governance” involves the recognition that it refers to practices, norms, and actions situated beyond government. The word “governance”, which comes from language of management, found its way into the institutional field of international relations with the publication of a 1989 World Bank Report (World Bank, 1989). Because the Bank attributed the responsibility for African economic crises to “poor governance”, the governance notion came to light in relation to Africa, before being extended to other areas. Beyond its managerial connotation, the term shows up in the social sciences of the 1960s, but only ephemerally. In political science, American authors have used this notion to mean the matrix through which international partners supported African governments in implementing the first postcolonial public policies, in the early years of independence (Hyden and Bratton, 1992). These authors also note that the rapid Africanisation of managers in the public sector mitigated recourse to the governance notion, which was then referred to as policy building. From political arenas and the field of public policy, the governance came to be qualified in epithets like “good governance”, “poor governance”, and so forth, before it was expanded to the area of “globalisation” and the acceleration of transnational public action, captured in the term, “global governance”. As Joseph Laroche has noted, “the concept of global governance that appeared in the 1980s emphasized, first of all, the multiplicity of transnational actors and the negotiations in which they are engaged” (Laroche, 2003, p. 19). From this point of view, “governance” can be considered a synonym for “international public policy”, given that it is elaborated by international actors (Hassenteufel, 2011, p. 19). Following this reasoning, we can distinguish the notion of “governance” when it is related to politics (Hyden and Bratton, 1992) from its use in connection with policy (Darbon, 2008). Both uses are concerned with modalities of management that both include and go beyond the national context as a result of the trans-nationalisation of the actors at hand. In this context, the notion is conducive to the comparative approach, as the following definition illustrates: 1. Governance is a conceptual approach that, when fully elaborated can frame a comparative analysis of macro-politics.

AIDS and governance in Africa 49 2. Governance concerns “big” questions of a “constitutional” nature that establish the rules of political conduct. 3. Governance involves creative intervention by political actors to change structures that inhibit the expression of human potential. 4. Governance is a relational concept, emphasising the nature of interactions between state and social actors themselves. 5. Governance refers to particular types of relationships among political actors; that is, those which are socially sanctioned rather than arbitrary. (Bratton and Rothchild, 1992, p. 267) This chapter reviews the question of AIDS governance in Africa, beginning with the international instruments that were put into place. It draws on the first results of a study I coordinated in six African countries, selected on the basis of their national partnerships and the feasibility of conducting field research in them. A diachronic approach to capture the changes in international governance brought about by “institutional complementarity” (Lafaye de Micheaux and Ould-Ahmed, 2007, p. 16) in a context of polyarchy. The diachrony is anchored in the issue of ARVs, and related publications beginning in 1996.

Intellectual property and the issue of patents Before 2000, the tendency was to endorse the discoveries of ARVs and to adopt therapeutic protocols that met the emerging standards of the new clinic. Few questions were raised about the prices proposed by the pharmaceutical companies who owned the ARV patents, including the particularly high price of protease inhibitors. From Dakar to Abidjan to Yaoundé, the focus was on the therapeutics. In the margins, African States positioned themselves as advantageously as possible to access tri-therapies. The Senegalese programme was innovative in this respect. Thanks to conventions it signed with an oligopoly of five pharmaceutical companies long before generics became an issue, the cost of treatment per Senegalese patient dropped by about 90%. The Senegalese Initiative to Access ARVs (ISAARV) (Desclaux et al., 2002) developed social and clinical criteria to select candidates for tri-therapy. Senegal also built on the dynamic of local scientists in international research networks (Eboko, 2005). The UNAIDS Initiatives were launched at the 1997 International Conference on AIDS and Transmittable Diseases in Africa (CISMA), held in Côte d’Ivoire. These agreements between the global programme, States (Côte d’Ivoire and Uganda for Africa, Viet Nam for Asia and Chili for Latin America) and pharmaceutical companies permitted access to lower-cost ARVs, without having to turn to generic drugs manufactured in countries like India and Brazil (Orsi et al., 2007). Despite numerous problems concerning patients (meeting social and clinical eligibility criteria), the organisation of therapeutic networks (training practitioners, managing drug stocks) and regulating demands (which proved to be easier for the most active members of associations), the UNAIDS Initiatives did materialise. Nevertheless, in Côte d’Ivoire and

50 AIDS and governance in Africa Uganda, the number of patients on ARVs was lower than expected. The implementation process appeared to have been slowed down by problems related to the broad range of people intervening (Msellati, Vidal and Moatti, 2001). At the end of 1997, at the instigation of a pharmaceutical lab, MSD, Cameroun organised the first training session for practitioners responsible for patients with HIV or AIDS. The company used its familiarity with certain very engaged, local personalities to organise this meeting, which had two goals. First, MSD sought to promote its molecule and to train Cameroonian doctors (from a local group already trained in treatment with ARVs) to use therapeutic protocols for ARVs. The situation was similar to that faced by Senegal when it had signed an agreement with companies which owned patents. The “elective affinities” between local doctors and Western pharmaceutical companies also highlights the dominance doctors exercised over associations of people living with HIV/AIDS in Africa, which lasted until the emergence of an “activist project” capable of countering institutional norms. The promotion of the “AIDS Industry” in a context of globalisation (Altman, 1999) held sway until the controversy associated with the lawsuits against Brazil and the Republic of South Africa. Through their transnational networks, African physicians took part in his “inversion of the world” (Badie and Smouts, 1999). A problem with these networks lay in the “double agents”, who straddled the public and private spheres (Eboko, 1999). How, then, was it possible to transform the power of the pharmaceutical companies in the early 2000s? What circumstances provoked the change in perspective and the novel debates between activists and these companies? Transnational civil society against economic liberalism: public action forum and cognitive controversy By the end of the 1990s, competition between pharmaceutical companies manufacturing generics, and legal problems connected to the international Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), sent the pharmaceutical industry on the offensive. Some 39 pharmaceutical companies joined together to impose legal standards favouring their interests (Dixneuf, 2003). International mobilisation through petitions launched by NGOs, Doctors without Borders (MSF) in particular, transformed the context and created an internationallevel forum for public action that opposed issue-based networks that promoted or at least respected the primacy of patents in the diffusion and commercialisation of access to ARVs. Here, I use Eve Foulleux’s definition of forums as “more or less institutionalised arenas, regulated through particular dynamics within which actors debate public policy, directly or indirectly, that affect the public policy being studied” (2000, p. 278, cited by Boussaguet, 2006, pp. 228–229). This forum, with Doctors without Borders – France as its spokesperson, used internet to mobilise very different actors on every continent, including French NGOs. In a previously unheard of opportunity, MSF and Act Up Paris were able

AIDS and governance in Africa 51 to merge their repertoires of collective action directed against the pharmaceutical companies and summed up in the Act Up slogan, “Merchants of Death”. The pressure being exerted on the big pharmaceutical firms and the appeals to companies manufacturing copies of the ARV molecules reached a high point in 2001. In April of that year, the 39 companies withdrew their legal complaints against South Africa and Brazil. Activists and international organisations accompanied and counselled African countries which began to import “generic” drugs, despite the TRIPS agreements. In this manner, the new configuration of actors (African States, international NGOs, local associations, pharmaceutical firms involved in generics, etc.) facilitated the emergence of generic copies that in turn fostered the drop in drug prices. Cameroon and Burkina Faso, for example, benefited from importing copies from Indian pharmaceutical companies, especially CIPLA. Note that these same countries were signatories to the international conventions and were members of the WTO, where TRIPS originated. International civil society thus introduced a hybrid juridical area between international law, ethics, and public health. The Brazilian example and the pioneering efforts of those countries around compulsory licensing (which allow the copying of even patented molecules when public health is endangered) reinforced this stance. Nonetheless, at the beginning of the 2000s, these same international NGOs were not in unanimous agreement about mass access to ARVs in Africa. It took a series of intense debates and above all the strategic “mistake” made by the pharmaceutical companies (their lawsuit against countries in the South, where public health was endangered) to achieve the irreversible turn towards access to combination therapy. MSF launched pilot projects of access to ARVs for hundreds of patients as a way of demonstrating that the pharmaceutical company arguments against access was culturalist. The various projects produced results exceeding all expectations. In fact, as patients received intense medical and especially psychosocial support from doctors, psychosocial counsellors, pharmacists, psychologists, and social workers, treatment follow-up was superior than or equal to that of patients in Western countries. The pharmaceutical companies’ argument that health-care services and the “cultural” laxity of patients worked against proper access to treatment fell apart. Not only did the treatments work, but the obsolescence of health services could be mitigated by the material and human resources allocated to fight against AIDS. This was also the idea behind the WHO’s launching of its 3 by 5 Initiative. Even if the goal of putting another three million people on ARVs by the end of 2005 was never reached, it provided the impetus for the view that patients had the capacity to access and adhere to these powerful drugs. The massive training of psychosocial and community counsellors also seems to have played a key role in this international collective dynamic. Likewise, malaria and tuberculosis were not ignored. In fact, health actors in Africa began to ask whether wealthy countries were ignoring diseases that did not affect them. All of these issues were incorporated into international responses aimed at integrating into the fight against AIDS other diseases that affect Africans on a massive scale.

52 AIDS and governance in Africa Moreover, the major laboratories reorganised their “response” to the offensive by generic manufacturers in relation to the TRIPS and WTO agreements. As of January 1, 2005, Indian laboratories, the main suppliers of ARV copies to African countries, were no longer allowed to reproduce future molecules. Yet, clinical and therapeutic responses to HIV infection must be continually modified to respond to the periodic emergence of resistant viruses. One type of response is to introduce new molecules into treatment, which result in other “lines” of tri-therapies. African patients who faced resistant viruses would not be able to access tri-therapies. International and local mobilisation, particularly in Burkina Faso, demanded that the Indian government, a signatory to the new WTO agreements that benefited patent holders, review its position. Their efforts were in vain. Despite what was at stake, the outcome reaffirmed the political power of the major drug companies, which adopted the economic strategy of acquiring shares in some Indian laboratories to strengthen their legal protection. The 2007–2009 international financial crisis and the subsequent decline in international funding, particularly from the Global Fund, might seem to call into question the exceptional progress in the fight against AIDS due to international solidarity and to African countries facing AIDS, beginning with Senegal, Burkina Faso, Côte d’Ivoire, and Cameroon. The first decade of the twenty-first century was carried by mounting hope. The following decade began in an international environment overwhelmed by the most serious economic crisis the world had experienced since 1929. The implementation of internationally inspired policies and strategies raises the question of their mechanisms and of the actors in charge of them. Here, I turn to the exploration of the different levels of implementation (international, national, local) and the type of actors and institutions involved (international organisations, State bodies, bilateral development agencies, non-governmental organisations and international foundations, associations, experts, etc.). The first step in my analysis is to construct a typology, to map the actors involved in the policy of combating HIV/AIDS and six French-speaking African countries (Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Niger, and Senegal). In doing so, the different levels and institutions taken into account turn out to be sites of governance, or the activities of production of power, meaning, normative frameworks and standards, which are regulated according to the strategies and objectives defined. This definition, which is neither normative nor prescriptive, has the advantage of taking into account the context of the trans-nationalisation of regulatory schemes for internationally inspired strategies or policies (Hassenteufel, 2005).

The international context AIDS in a multilateral and multipolar world: global challenges, global and national responses AIDS governance is both fragmented and tightly integrated. Its fragmentation is due to the diversity in the types of actors (public, private, etc.) involved in the

AIDS and governance in Africa 53 fight against AIDS and the spaces (international, national) of their involvement. Its tight integration comes from the recurring presence of the same actors across different spaces. International organisations as well as non-governmental organisations, for example, are present in both the production of international AIDS policies and AIDS assistance in Africa. They are involved in both the production and the implementation of AIDS responses at the national level. Many of them circulate between these levels and participate in holding together this vast configuration of actors. The context is that of a fragmentation of governance, that we must first understand at the highest level, through the most important actors (Table 2.1). Levels of governance and types of actors in the fight against AIDS The growing involvement of international health actors is reflected in the multiplication of financing mechanisms for fighting against AIDS, which generates a complex global architecture. Three main global health initiatives are worth highlighting: the World Bank’s Multi Country AIDS Programme (MAP), established in 1999; the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM, or Global Fund), established in 2001 by UN Secretary General, Kofi Annan; and the President’s Emergency Plan for AIDS Relief (PEPFAR), established in 2003 by President George W. Bush.1 “Between the three of them”, Nkoa and colleagues have noted, these organisations “provide more than 80% of international AIDS assistance, which has grown dramatically from less than US$1 billion a year at the end of the last century to 7.7 billion dollars’ worth of disbursements in 2008 (with 8.8 billion dollars in commitments)” (Nkoa et al., 2010). Table 2.1 Level of governance and types of organisations in the fight against AIDS. Type of organisation

Level International

Transnational National*

Public

Private not-for-profit

International organisations (e.g. WHO) European Union

Multinational International NGOs companies (e.g. MSF) International foundations (e.g. Bill and Melinda Gates Foundation) Association networks Consulting firms (e.g. Coalition Plus) (e.g. ZeGoGroup) NGOs (e.g. Ruban Companies rouge; SOLTHIS)

Bilateral aid (e.g. PEPFAR) State agencies, ministries (e.g. CNLS, Ministry of Health)

Source: Project Governance, Demange, 2012 Note: * May intervene nationally or internationally.

Private for-profit

54 AIDS and governance in Africa Besides these three, the UNITAID initiative was launched in 2006 by France’s President Jacques Chirac and Brazil’s Luis Inàcio Lula da Silva (“Lula”) and several private funding sources, such as the Clinton Foundation and the Bill and Melinda Gates Foundation, whose financial contribution to the fight against AIDS now exceeds that of the World Bank. For all of these actors, the international financial and economic crisis rekindled the question of the prospects, methods of allocation and management of resources at the international level, as well as in the beneficiary countries, especially the poorest and/or most affected ones, including the countries of sub-Saharan Africa. As a consequence, concerns about the decline in contributions to financing access to AIDS treatment coming from wealthy countries (World Bank, 2008), particularly from the Global Fund, the main provider of resources for African countries to purchase medicines, pointed to catastrophic scenarios of massive disruption in care (Eboko, 2009, 2010). THE GLOBAL FUND: TRANSFORMING AN “INNOVATIVE MECHANISM” OF THE NEW DEVELOPMENT ASSISTANCE PARADIGM INTO AN INTERNATIONAL BUREAUCRACY

Around 2001, the economic paradigm that had questioned the possibility of efficient and “cost-effective” scaling-up was changing (Moatti, 2011). In 2001, the Secretary-General of the United Nations decided to launch a Global Fund to fight the AIDS pandemic, with the support of international, European, and African personalities. Building on this momentum, African Heads of State met on April 26, 2001 in Abuja, Nigeria, for a special session of the Organisation of African Unity (OAU) to discuss AIDS and other infectious diseases. Present were high level international leaders, namely UN Secretary-General Kofi Annan, the Executive Director of UNAIDS and the Director-General of WHO. In 2002, the Global Fund was officially launched and its initial funding was formalised at the G8 Conference in Okinawa that same year. In 2003, the first African movement for access to medicines (PATAM) was launched at the International Conference on AIDS in Africa in Nairobi; it was inaugurated at the conference by several demonstrations led by African patients. In 2004, patients in Burkina Faso demonstrated for the first time in favour of maintaining the importation of generics from Indian pharmaceutical companies. A new cycle was beginning, which would bring exceptional hope and progress over the next ten years, but also new challenges and obstacles aggravated by the then current economic and financial crisis. The main problem was sustainability of access to care and to prevention programmes in sub-Saharan Africa. Understanding this logic requires us to analyse each level of international, national, and local response in order to shed light on their interactions. The Global Fund is at the heart of this logic. In just a few years, the Global Fund established itself as a central and essential player in the global fight against AIDS. The second largest funder of the AIDS response, just behind PEPFAR, the Global Fund contributed to the financing of antiretrovirals for about half of the patients in

AIDS and governance in Africa 55 treatment in low- and middle-income countries (Kerouedan, 2011). Its importance also grew in countries like Benin, Burkina Faso, Cameroon, Niger, and Senegal that did not benefit from PEPFAR. THE GLOBAL FUND, BETWEEN EFFECTIVENESS AND THE NATIONAL APPROPRIATION OF POLICY: FROM FUNDING MECHANISM TO AD HOC INSTITUTION

At its creation, the Global Fund presented itself as an “innovative mechanism”, flexible, lightweight, and able to distance itself from international organisations and the criticisms they faced. The Fund also personified the “new paradigm” of international development assistance, as set out in the Paris Declaration: effectiveness, ownership, participation, and alignment with the needs and demands of countries rather than with the offer of assistance (Nantulya, 2004). These principles are reflected in the Fund’s organisation and operating procedures. Ownership of AIDS strategies by inclusive partnerships of stakeholders was expressed both at the international level, by the Fund’s Board of Directors, and at the level of the national coordinating bodies, or the Country Coordinating Mechanism (CCM). The Fund’s Board has 20 members, representing the governments of the donor countries (eight seats), recipient countries (seven seats) and civil society and the private sector (five seats). The Board of Directors therefore consists of an inclusive partnership and a “demand-driven” mechanism, in that it includes representatives of the Fund’s beneficiaries (Garmaise, 2009). The Fund’s Board of Directors is a site of power, comparable to the United Nations Security Council. Balances and alliances between representatives lead to sometimes contested decisions, such as the decision to cancel the eleventh round, or call for funding proposals, in 2011. This decision raised questions about the decisionmaking process within the Board of Directors and the real reach of voices from countries of the South (Global Fund Observer, 2012/02). The entire structure of the Fund ensures it is demand-driven. Funding requests submitted to the Fund are developed at the level of countries by national multisectoral partnerships through the national CCMs. The CCMs, and through them all national stakeholders involved in the three targeted diseases, submit grant applications to the Global Fund based on national priorities and strategies. With the goal of effectiveness, independent assessments take on importance. Proposals are evaluated by a technical review committee (a panel of independent experts) who make recommendations to the Board of Directors. The Fund itself is subjected to an individual evaluation by a “technical reference group for evaluation”. “Local Fund Agents” verify and validate the financial and programmatic reports submitted by the principle beneficiaries. Examining the principles and operating methods of the Fund can provide a clear understanding of AIDS governance and the importance of actors both at the international level (secretariat, board of directors) and at the national level (the role of the CCMs and the relationship between its members and other AIDS actors).

56 AIDS and governance in Africa THE GLOBAL FUND AS A PRODUCER OF GOVERNANCE INSTRUMENTS: FROM FORMATTING THE DEMAND TO A MECHANISM FOR RESPONDING TO THE OFFER

More than a simple funding mechanism, the Fund is also a producer of norms, especially the instruments (Lascoumes and Le Galès, 2004) that shape AIDS governance at the global and national levels. The two main instruments promoted by the Fund are the CCM and performance-based funding (PBF). The concept of PBF comes from the New Public Management. Its goals are to improve the results of development projects and to demonstrate the validity of the strategies implemented through international cooperation. The two key elements of PBF are rationale development and “accountability”. Designed and presented as the most “neutral” and “effective” way of allocating funds, the Global Fund imposes a particular, external type of governance on countries through the CCMs. Like the Global Fund’s Board of Directors, CCMs are inclusive, multi-sectoral partnerships, which include government and international representatives as well as representatives of people living with the diseases, NGOs, and religious, scientific, and private sector actors. The CCM is responsible for putting together funding applications for the Global Fund, but also for identifying the Global Fund beneficiaries and monitoring grant implementation. More than “jurisdictions”, CCMs are real institutions that are intended to be at the centre of national AIDS governance. These institutions are also shaped by the Fund, which issues guidelines, recommendations, and incentive schemes (CCM self-assessment grids, etc.), all of which help determine the eligibility of applications. Ownership of this governance modality seems to be uneven across countries, and dysfunctions in the CCMs create obstacles to the effective functioning of the Fund. The CCMs’ composition is extremely variable (see Figure 2.1), and

CCM Composition 50 45 40 35 30 25 20 15 10 5 0

KAP EDU FBO PS PLWD NGO ML/BL Benin

Burkina

Cameroon

Cote d'Ivoire

Niger

Senegal

Figure 2.1 Composition of CCMs in six African countries in 2012. Source: Demange (ANRS projects 12251 and 12266)

GOV

AIDS and governance in Africa 57 its members are not always the same people who actually produce the country’s national AIDS response. In what follows, we aim to understand how this governance instrument is invested or not by national AIDS actors, and to what extent it really promotes collaboration in the production of public action. Performance-based funding (PBF) is implemented through a multi-phase financing process: development of appropriate national-level applications; grant negotiation; major target seeking and determination of quantifiable performance indicators; gradual disbursement of funds in instalments based on regularly reported results. The five-year funding cycle is divided into a two-year phase and a three-year phase. The second phase is dependent on the global evaluation of the first phase of grant implementation. Each grant receives a performance score. This has practical effects, including the suspension of funding, and contributes to taking stock of the “good”, “average”, and “poor” implementers of the Fund (see Figures 2.2 to 2.5). The number of applications the Fund accepted and rejected in the Rounds presented in Figures 2.4 and 2.5 contributed to the interpretation of dissonance between the international level and the national level as a problem of “failure” or problem of capacity. The failure or success of an application or of a grant’s implementation seems to have been due less to a problem of capacity than to the difficulty countries experienced in complying with the issues and the programmes the Fund was likely to finance. Rather than expressing their needs, the grant-writers sought to identify with those issues and programmes (Brugha et al., 2005). The heavy demand for international consultants specialised in grant-writing confirms this argument. Rather than merely shaping the demand, the Fund seems have envisioned a partial return to a mechanism of responding to the offer, or supply. The Fund’s reform, which the Technical Evaluation Reference Group (TERG) had called for,

Performance Ratings (as of 2012/02/20) Number of grants reviewed

8 7

A1

6

A2

5

B1

4 3

B2

2

C

1

N/A

0

Benin

Burkina

Cameroon

Cote d'Ivoire

Niger

Senegal

Figure 2.2 Countries’ Global Fund performance before New Funding Model. Source: Demange (ANRS projects 12251 and 12266)

58 AIDS and governance in Africa Cumulative Amounts of Disbursements for HIV component 180

Amount (in million US$)

160 140 120 100 80 60 40 20 0

Burkina

Benin

Cameroon

Niger

Cote d'Ivoire

Senergal

Figure 2.3 Total sums allocated by the Global Fund. Source: Demange (ANRS projects 12251 and 12266)

Applications Approved (rounds 7 to 10) 6

Rcc

5

Round 10

4

Round 9

3 2

Round 8

1

Round 7

al Se

ne g

r Ni ge

Iv oi re d’ Co te

Ca m er oo n

rk i Bu

Be

na

0

ni n

Number of Applications

7

Figure 2.4 Number of applications approved before New Funding Model. Source: Demange (ANRS projects 12251 and 12266)

and the nomination of a new executive director, Gabriel Jaramillo (former director of the commercial Sovereign Bank), could lead the Fund to define not only the issues (such as vulnerable populations), but also the priority countries, thus moving the Fund closer to classic development aid mechanisms, like PEPFAR and the Gates Foundation, which are guided by the funding supply.

AIDS and governance in Africa 59 Applications Rejected 6 5

Round 10

4

Round 9

3

Round 8

2

Round 7

1

l ga ne Se

r ge Ni

re Iv oi d’ Co te

Ca m er oo n

in rk Bu

Be

a

0

ni n

Number of Applications Rejected

7

Figure 2.5 Number of applications rejected. Source: Demange (ANRS projects 12251 and 12266)

THE BILL AND MELINDA GATES FOUNDATION: DOES THE CHARITY BUSINESS SHAPE AIDS GOVERNANCE?

The Gates Foundation, founded in 1994, is currently the third largest funder of global health, after the U.S. and the Global Fund. Its financial impact has greatly increased since 2006, when Warren Buffet donated about 10 million shares of his company, Berkshire Hathaway, Inc. to the Foundation. This gift, estimated at about US$31 billion, doubled the total endowment (about US$61 billion) of the Bill & Melinda Gates Foundation Trust. The Trust’s role is to manage the endowment, invest it, and allocate the return to the Gates Foundation, according to its needs.2 In 2007, the grants awarded by the Foundation amounted to US$2.1 billion. The budget allocated to global health was US$1.22 billion (McCoy et al., 2009). In 2010, the grants awarded amounted to US$2.37 billion, of which US$1.48 billion went to global health (Gates Foundation, 2010). The Gates Foundation’s weight in the AIDS fight only increased when the Global Fund ran into financial trouble. It initially pledged US$500 million for 2010–2025. It has as of this writing contributed US$2.23 billion to the Global Fund and pledged another US$760 million for the 2020–2022 period.3 The Gates Foundation allocates its money to a limited number of global organisations and initiatives: 65% of its funding has gone to only 20 organisations, 40% goes to international organisations, and about 50% to beneficiaries based in the United States (McCoy et al., 2009). The Foundation also funds private-for-profit organisations, like the International Finance Corporation (US$6 million) and is reticent about financing and supporting public actors (McCoy et al., 2009).

60 AIDS and governance in Africa THE WORLD BANK, A LABILE ACTOR IN THE INTERNATIONAL RESPONSE TO AIDS

The World Bank first entered the AIDS fields as a partner of UNAIDS, when it was established in 1996. But it really changed its involvement in this area in 2000 (Coriat, 2008). It began a reorganisation of the finances it was allocating to AIDS by creating, in 2001, the Multi-Country AIDS Programme (MAP), its global programme for AIDS. The programme’s goal is to reinforce the coordination of AIDS action at the level of States. To achieve this, it relies on the National AIDS Committees or their equivalent. Another goal is to draw on all of the key AIDS actors in each country, including by supporting “civil society” and “communities”. In fact, the World Bank chooses a precise interlocutor for each country, who is expected to boost and coordinate all prevention actions and capacity strengthening of actors and health systems, with a lesser emphasis on access to ARVs compared to, for example, the Global Fund. Since 2000, the World Bank’s involvement in AIDS has fluctuated. UNAIDS AND THE UN SYSTEM: THE PRIMARY STANDARD-SETTERS

The UN response to AIDS was at first fragmented, despite the leadership of the Global Programme on AIDS at the WHO. Different representations of the fight against AIDS emerged and generated conflict between international institutions (Garbus, 1996). The structuring and stabilisation of international AIDS governance began “in the second half of the 1990s (Patterson, 2006). The UN’s common AIDS programme was created in 1996, after the dissolution of the WHO Global Programme on AIDS (GPA). UNAIDS brought together ten UN agencies plus the World Bank. The programme’s goals are aims to coordinate the actions of other agencies and to guarantee the implementation of standards for the collection and dissemination of data concerning the epidemic on the five continents. Olivier Nay has conducted an in-depth study of the UNAIDS reforms since 2005 (Nay, 2009). He illustrated three different ways of characterising the influence of international bureaucracies like those of the UN. First of all, they have a prescriptive influence, that is “the capacity to elaborate rules and standards having an impact on the process of elaboration of public action, instruments for action, and rules of management”. Next, they possess a technical influence that “results in the development of instruments and specific technical competencies through which the administration increases its capacity to help its partners” define programmes and implement decisions. Finally, they have a cognitive influence, that is, a capacity to gather, integrate, shape, generate, and diffuse knowledge (Nay, 2010). Nay’s analysis raises several major questions: in what way are international institutions mechanisms of constraint? How do these institutions exert pressure on African countries? Which actors are vehicles for these standards? To what extent do technical devices carry standards, and can they be considered mechanisms of constraint?

AIDS and governance in Africa 61 Bilateral responses: between foreign policy and domestic policy objectives The rise in the power of multilateral policies is linked to the identification of “global public issues” or “global public goods”, such as the environment or epidemics (Gabas and Hugon, 2001). Yet international development is still a stakeholder in the foreign policy of States. The global North’s response to AIDS in Africa fits into the larger context of the evolution of bilateral development and geostrategic stakes since the fall of the Soviet Union. Despite the development of the Global Health Initiatives and international organisational partnerships like the Global Fund, in the countries of the North tension continues to exist between multilateral policy and bilateral policies for development assistance. While the United States has always prioritised bilateralism over multilateralism in its involvement with AIDS in Africa, France has almost exclusively invested in multilateral involvement since the creation of the Global Fund. Nevertheless, today France has engaged a new bilateral mechanism, in support of the Global Fund, which raises the question what is currently at stake in international relations. U.S. foreign policy: PEPFAR, the Global Fund, and the primacy of the bilateral over the multilateral When the Global Fund was established, the President of the United States responded by creating PEPFAR (the President’s Emergency Plan for AIDS Relief) in 2003. Two elements in particular illustrate the official positions of the U.S. since 2000. In April of 2000, President Clinton declared that AIDS constituted “a threat to American national security”. The same year, the American ambassador to the UN, Richard Holbrooke, pushed the question of AIDS in Africa before the UN Security Council, as a “threat to international security” (Chabrol, 2002). The US government then set the goal of limiting the epidemic’s spread in and from low-income countries, including African countries. To achieve this, it turned to lines of reasoning that seemed most convincing to the public and to the American political class. The report produced by U.S. intelligence indicated that one-fourth of the population in southern Africa was doomed to die of AIDS, but that Asia and the former USSR were also probably threatened with a similar catastrophe. To avoid such carnage, the White House decided to create an inter-agency working group and announce it was doubling the budget for AIDS around the world (US$254 million). In 2003, George W. Bush, Bill Clinton’s successor, launched PEPFAR, forcing a consensus between the Democratic and Republican Parties on the validity of fighting against AIDS in the global South. With this initiative, Bush broached his foreign policy on five fronts. (1) He played a welcome humanitarian card, to counterbalance the international image of tough American imperialism at a time when American troops were just invading Iraq. (2) He asserted his administration’s unilateral option in international affairs, thereby confirming American distrust and suspicion of multilateral jurisdictions embodied by the UN. (3) He rallied to the previous administration’s position by becoming involved with the struggle against

62 AIDS and governance in Africa AIDS in Africa. (4) He appeased American multinationals because to benefit from PEPFAR financial support, countries were required to buy only brand name pharmaceuticals. (5) He satisfied his own conservative electorate through his international promotion of moral policies (abstinence, disapproval of abortion) that he only supported moderately at the national level (Eboko, 2009, 2010; Demange, 2010). This bilateral mechanism gave the United States both international visibility and the possibility of reinforcing its position in the response to AIDS. But it also allowed for a greater accountability to American voters for how money allocated to international aid was being used. In some ways, all of PEPFAR was constructed like the Global Fund. Money was allocated on the basis of the beneficiary programme’s performance. Thus, the newly established policy followed the intended logic of its creators, including in domestic policy. But the policy also imposed a new set of constraints on African countries who would have to adapt to new complications and contradictions. The importance the U.S. bestowed on the bilateral option is discernible primarily in financial terms, as about 83% of American aid was allocated bilaterally, rather than multilaterally. For AIDS, the amount allocated through a multilateral mechanism, namely the Global Fund, came out of PEPFAR’s budget and is deliberately capped. The original PEPFAR legislation stipulates that the American contribution to the Global Fund must not exceed 33% of all contributions to PEPFAR or 33% of PEPFAR’s budget. Public Law 108-25s further limits U.S. contributions to the Global Fund by requiring justification of any supplementary amount allocated at the expense of a bilateral mechanism. The balance between bilateral and multilateral funding by the U.S. action has remained stable over the last few years (see Figure 2.6).

55,000

50,005

50,000 45,000

45,605

40,000 37,081

35,000 29,198

30,000 23,838

25,000 20,000

28,403

17,156 20,393

15,000

Figure 2.6 PEPFAR contribution to the Global Fund in 2012. Source: Demange (ANRS projects 12251 and 12266)

M 20 arch 08

Ju 20 ne 07 De ce 20 mb 07 er

M 20 arch 07

Ju 20 ne 06 De ce 20 mb 06 er

M 20 arch 06

11,769 J 20 uly 05 De ce 20 mb 05 er

10,000

AIDS and governance in Africa 63 French AIDS policy in Africa: renewing bilateralism? THE PARADOXICAL EFFECTS OF REFORM: THE COOPÉRATION FRANÇAISE

The reform of the Coopération française, formalised in 1998, signalled both a break with the past and an attempt to normalise France’s development policy. This change was the outcome of several years, if not decades, of aborted attempts at redefining France’s relationship to its former colonies, by re-inscribing it within a “healthier” framework more in alignment with international relations after the “colonial pact”.4 Despite continuity and sustainability in France’s relationships with its African “preserve” (pré carré), or zone of influence, the country never perceived its development policy to be monolithic and unambiguous (Eboko, 2008). The first reports calling for reform were published almost contemporaneously with the African Indépendances of the 1960s. Resistance to the urge to reform lasted almost 40 years. A new political generation, in France and in Africa, and the will of a network of French political actors overcame these divisions. Their efforts culminated in the Decree of December 10, 1998, which centralises French policy on Africa within the Ministry of Foreign Affairs. This decree spelled the end of the Coopération, whose services were transferred from the Ministry of Development to the Quai d’Orsay, as the French Ministry of Foreign Affairs is called. In this context, France chose the multilateral option, which implied going through the European Union to implement the major lines of its foreign policy. According to the new French-African development framework, economic exchanges and aid were now under the aegis French Development Agency (AFD). Since its founding in 1999, this agency is expected to coordinate the economic aspects of development. In Africa, French development services follow the logic of this new coordinating mechanism. The Ambassador heads the system. The 31 missions for development and cultural affairs that represented the Ministry of Foreign Affairs (MAE) abroad and managed the Fund for Aid and Cooperation (FAC) were dissolved and transformed into the Service for Development and Cultural Action (SCAC), under the authority of the Embassy. This reform was intended to simplify development mechanisms, reduce the decision-making sites and reinforce the potential for coordination. The Minister of Foreign Affairs and the AFD were the two institutions strengthened by the reform (Table 2.2). THE DEVELOPMENT DEBT-RELIEF CONTRACT (C2D): AN INNOVATIVE TOOL FOR DEVELOPMENT PROGRAMMES5

The so-called “Heavily Indebted Poor Countries” (HIPCs) were a product of the global strategy to reduce the debt of African countries under the impetus of the Paris Club and then the IMF. Under the reform, the HIPCs faced new challenges. Unlike other donor countries, which simply cancelled the debts of African States, France decided to implement partnership agreements. These aimed to transform the debts into contracts which stipulated that the amount owed was to be invested in development projects, in accordance with the debtor country’s own priorities and

64 AIDS and governance in Africa Table 2.2 Organisation of France’s development agencies. Administrative organisation of French development Interministerial Committee for International Development and Cooperation High Council on International Cooperation Ministry of Foreign Affairs Ministry for the Economy, Finance and Industry French Agency for Development (AFD)

Policy organisation for stimulating and orienting development Advisory body

•• Defines priority areas for solidarity •• Orientates the overall program •• Evaluates whether objectives have been met •• Concerted action between public and private actors

Administrative structures •• Definition, management, control for steering, and monitoring of aid monitoring and control Principal organ

•• Implements projects and programmes

Source: A. Barrau report on the “Reform of cooperation”, Committee on Finance, General Economy and Planning

in the sectors of its choice. The Development Debt-Relief Contract (C2D) operates primarily through the AFD.6 The health sector benefited from C2D support in countries like Cameroon, but the process of accessing ARVs was also supported by HIPC funds that predated the C2Ds. In 2002, it was therefore the so-called HIPC funds that led to a further reduction in the price of ARVs in Cameroon, via government grant. Other African States in France’s former zone of influence (e.g. Côte d’Ivoire) benefitted from similar moves. Furthermore, the C2Ds could be mobilised if the Global Fund, which arrived about the same time, cut back its funding. As we noted, in reforming its development apparatus, France chose to strengthen its multilateral exchanges. This was accomplished through France’s contribution to the Global Fund to support countries with limited resources for fighting against the major pandemics. However, 12 years after the reform, several factors seemed to have influenced France’s decision to repositioned itself within a dynamic of bilateral action. Exactly which factors depends on the types of actors involved (the Ministry of Foreign Affairs, experts, consultants, associations, researchers, etc.). The synergetic effect of these French actors led to the success of their joint demand that 5% of French funds allocated to the Global Fund be used to strengthen “Francophone”, and particularly French, “expertise”. THE “5% INITIATIVE”: THE RE-LATERALISATION OF A MULTILATERAL PROCESS

In October 2010, France announced that 5% of its financial contribution to the Global Fund would henceforth be channelled through a bilateral technical

AIDS and governance in Africa 65 assistance funding stream dedicated to Fund projects. The goal of this technical assistance was to strengthen the skills of French-speaking countries in order to enable them to better implement projects financed by the Fund and to better meet the Fund’s requirements, particularly around the application process. Another goal was to strengthen France’s visibility and influence in the fight against AIDS. In fact, because France channelled all of its financing for AIDS through the Global Fund’s multilateral mechanism, not only was French investment not identified as such on the ground, but it was no longer identified through a staff carrying out “French technical assistance”. In fact, technical assistants themselves experienced the discomfort of invisibility in the field. The 5% Initiative allowed France’s commitment to become visible once again at ground level. Furthermore, it provided an opportunity to strengthen the formal and informal networks of Francophone countries. By fortifying these networks, France seemed to be seeking allies to influence the Board of the Global Fund, and even international public health, in power struggles with the United States, which had intensified when the French physician and diplomat, Michel Kazatchkine, resigned as Director of the Fund. Thus, French diplomacy activated the 5% Initiative mechanism in order to exert more weight at the Global Fund, particularly on the Board and in the strategic decisions it made. However, the 5% Initiative, like the Global Fund itself, was also a “demanddriven” mechanism. Actors in French-speaking countries eligible7 for grants from the 5% Initiative could send a request to the French Embassy, which would then forward it to the Regional Advisor for Health Development, for an opinion. The proposal also had to be validated at the level of the Fund secretariat by the portfolio manager in charge of that country’s files. A steering committee then decided whether or not to accept the request for technical assistance. Technical assistants, all Francophone, were solicited by the 5% Initiative. They might be individual experts or organisations, “partners” of the “5% Initiative Network”. Moreover, demands for medium-term (more than 12 months) technical assistance were incorporated into calls for proposals tailored to specific topics. These topics were determined according to country need, but also as a function of the availability of French technical expertise on the subject. Like the Global Fund, these technical devices seemed to be shaping the demands emitted from countries of the South. Even more so, the technical expertise process seemed to hasten a return to a practice driven by supply, hence to the very paradigm of international aid that France was defending elsewhere, such as on the Board of the Global Fund. In what follows, I examine these contradictions and the ways in which its technical mechanisms, similar to those of UN organisations, are actually mechanisms of constraint (Nay, 2010). Ultimately, the 5% Initiative allows us to comprehend the French technical assistance market. Older networks – the French Red Cross, Coalition Plus – have capitalised on the Initiative to identify funding. This in turn reactivates the older networks and gives new visibility to what had been informal alliances. This sometimes translates into the creation of new partnerships and organisations, like the consulting firm, Serogroups. The Initiative also has the effect of side-lining other technical assistance actors, like the members of Association of

66 AIDS and governance in Africa Health Professionals (ASPROCOP). With its annual budget of €18 million, the 5% Initiative has turned into a major stake for French organisations involved in technical assistance to developing countries (consulting firms, associations, public interest groups, etc.). We will see how the mechanism has been invested by these actors, and how its principles have been circumvented (e.g. through funding requests from partners in non-eligible countries). The 5% Initiative can also be compared to similar mechanisms. In fact, within the larger context of international development, the Initiative is not really an innovation. Earlier examples include the Grant Management System (GMS) in American aid and the GTZ Back Up Initiative in German development assistance. How the three mechanisms are coordinated on the ground would be worth further examination. TRANSNATIONAL PUBLIC ACTION NETWORKS AND FACTORS AFFECTING THE HOMOGENISATION OF TRANSNATIONAL PUBLIC ACTION

A mechanism like the 5% Initiative underscores the role of transnational networks in governance. Political science brings to light the different types of networks involved in governance issues: public action networks, issue networks, public policy communities, epistemic communities, movement coalitions, and so forth. By analysing a network’s composition, the integration of its components and their power relations, it becomes possible to identify a set of actors who collaborate regularly.8 The qualifier “transnational” refers to the various nationalities represented by the actors. French networks may be formally involved in bilateral development (the ESTHER9 public interest group, for example, brings together French and African hospital professionals), focus on collaboration among associations (such as Africa 2000, led by AIDES10), or be made up of a variety of actors (the association, Solthis,11 and its partners) (Table 2.3). UNDERNEATH THE FINANCIAL CRISIS: LOSS OF CONFIDENCE AND AN INSTITUTIONAL AND IDEOLOGICAL PARADIGM SHIFT

Crises and dysfunction brought an end to what had been a remarkable period of massive access to ARVs in Africa. What came to be known as the “crisis of Global Fund” affected the organisation’s action at every level. The crisis can be boiled down to a number of tensions that affected every level in the allocation of the Fund’s resources. A crisis of governance at the Global Fund Secretariat in Geneva was paralleled by a string of controversies over how funds were being used at the country level. After the misappropriation of funds in some countries came to light in 2009, certain donor countries began pressuring the Secretariat’s executive to exert stricter control over financing. Mauritania became the emblematic case of state corruption and proven misappropriation of funds by African leaders, and the Islamic Republic of Mauritania (IRM) was forced to reimburse the amount stolen. THE MAURITANIAN SYNDROME

An audit requested by the Global Fund revealed irregularities in Mauritania of such serious nature that in September 2009 the Fund suspended its grant to that

1.2% 1.2% 5.3% 3.4% 0.8% 0.9%

Benin Burkina Faso Cameroun Côte d’Ivoire Niger Senegal

58% 49% 38% 37% 29% 50%

Rate of ARV coverage

780 550 1,180 1,160 370 1,090

GDP/capita (US$)

Source: Demange (ANRS projects 12251 and 12266), according to AIDSInfo data

60.2 110.2 606.6 447.6 61.2 59.2

Prevalence Number of HIV-positive in thousands

Country

Table 2.3 African States, Global Fund Assistance and HIV/AIDS, 2012.

77.17 62.73 46.47 155.90 28.04 61.08

Total HIV funds disbursed by the Global Fund (million $)

1,281/pers 569/pers 78/pers 348/pers 458/pers 1,031/pers

Amount disbursed by the Global Fund per the number of HIVpositive people ($/pers)

AIDS and governance in Africa 67

68 AIDS and governance in Africa country. Out of €11 million approved over five years, the inquiry had identified the misappropriation of €1.6 million, in addition to €2 million of expenditures for which documentation was missing – in all, the equivalent of 3.6 million U.S. dollars. The Fund demanded legal proceedings, which the Mauritanian authorities carried out. Just days after the affair was made public, the Permanent Secretary of Mauritania’s CNLS was arrested along with his deputy. Mauritania’s government returned the entire amount under question to the Global Fund. On February 7, 2012, the Nouakchott court requested a ten-year prison sentence for the Secretary, and three years for his deputy. As a result, certain Global Fund donors pulled out, authorities brought more actors suspected of corruption to trial, and criticism was directed against the Global Fund’s governance. According to Global Fund evaluations, the “Mauritanian syndrome” turned out to be limited. Less than 1% of the Fund’s grants since 2002 had been diverted, which equalled the average for misappropriated funds in public affairs management across the world. As a former Global Fund consultant put it, “that’s a lot less corruption than the port of Marseille”. This affair nevertheless added more confusion to the concatenation of facts and circumstances that resulted in the Global Fund’s paradigm shift in governance. This transformation was incarnated in the Global Fund’s New Financial Model so sought by the Americans but denounced by the Global Fund’s former director, who was French. In the global North, countries confronting the international financial crisis justified their withdrawal from the Fund with arguments that were not supported by the audits. Still, the consequences for the Global Fund were dire, in that it was also facing a major financial crisis. In 2011, the Fund suspended Round 11 of its financing, which was perceived as endangering patients in poor countries. The threat was minimised thanks to a transitory mechanism for continuing the treatment of patients already on ARVs. At the level of governance, the insidious conflict between Paris and Washington for “control” of the Fund veered in favour of the largest donor. Deprived of a major amount of grant funds, and despite support from Paris, Michel Kazatchkine (or “Kaza”, as he was nicknamed in those circles), was forced to accept the Global Fund’s liberal turn. Just as he had feared, the blueprint being drawn up amounted to nothing less than the transformation of the institution into an “AIDS World Bank”, imposing the same constraints countries “helped” by the Bretton Woods institutions had already experienced. “KAZA”’S EXIT AND GATES’S RETURN

Just three days after the French Director’s resignation, Bill Gates announced a US$750 million gift to the institution. In the Associated Press dispatch, the announcement was made at the Davos World Economic Forum on January 27, 2012. Gates emphasised that the new amount was in addition to the US$600 million the Bill and Melinda Gates Foundation had already contributed to the Fund over the past ten years. The press release mentions the suspension of contributions from several countries for reasons of “problems in how funds were being

AIDS and governance in Africa 69 used and corruption in several beneficiary countries” and the Fund’s cancellation of one billion dollars in funding. It ends with the simple statement: “The Fund’s Executive Director, Professor Michel Kazatchkine, who is French, announced his resignation, effective mid-March”.12 THE FRANCE–U.S. COMPETITION: AN AMERICAN VICTORY

Professor Kazatchkine justified his resignation by explaining, in clear terms, his disagreement with the American position on future governance of the Global Fund. On January 9, 2012, he told the French daily, Libération, Until now, applicant countries would draw up a programme, then submit it to the Fund, and we would respond according to criteria like quality and relevance. Now there’s a plan for the Fund to become more like the World Bank and decide a lot more. This is what happened last November, in Accra (Ghana), when the board decided to name a “general manager” [to work] alongside me to promote this reform. The manager reports directly to the Board, which troubled me. So, on December 22 I wrote to the Board to tell them that in the next few months, I would be examining these new changes they were planning to implement, and that I would think about the Fund’s future, and mine.13 A banker was appointed to head the Global Fund in the interim and implement the New Funding Model’s institutional and accountability framework. Under this model, funding is no longer based on a country’s request; rather, the Fund decides beforehand on an amount which the country must agree on. In the subsequent phases, the country develops a “Third Generation” strategic plan (PSN3G), writes a concept note and submits the request. In Geneva, a Global Fund portfolio manager assigned to the particular country accompanies each phase of the process. This mechanism is supposed to reduce the number of rejected applications, or the “institutional coup d’Etat” typical under the previous funding model. In other words, with the American victory, the Global Fund now conformed with the New Public Management model. Statistical predictions and accountability replaced the humanitarian protocol; patients were considered statistical units rather than individuals with health care needs, affected by a poverty not captured by statistical tables. This is the same period when shock waves from the U.S. subprime crisis hit Europe. Because of problems they anticipated regarding their ability to contribute and their general suspicion of recipient countries, several countries suspended their contributions. Germany justified ending its financing with the argument that resources were being poorly used. Italy evoked problems with its own domestic economy, despite the strong mobilisation by Italian associations who summoned Silvio Berlusconi’s government to continue participating in the Global Fund.

70 AIDS and governance in Africa All of these tensions highlighted the contingencies set in motion by the Global Fund’s contributors – with the exception of France – and by the NGOs – with the exception of French ones. Thusly was the Frenchman Michel Kazatzkine, Executive Director of the Global Fund, obliged to resign in 2012.14 THE GLOBAL FUND’S NEW FINANCIAL MODEL: A METHODOLOGY FOR ALLOCATING RESOURCES (2014–2016)

After the interim period ended, the fund’s leadership fell to an American immunologist, clinician, and former head of PEPFAR, Mark Dybul.15 The U.S.’s ideological, political, and financial victory was now complete. The Global Fund as a demand-based mechanism was defunct; a new Fund had come to life. It was founded on performance-based financing, the pedestal on which the New Public Management stood. African countries who accepted the New Funding Model began training in the first trimester of 2014. A brief history of access to ARVs in Africa, with attention to several countries The forms of care and political responses to AIDS in Africa are based on several different models (Darbon, 2008; Moatti and Eboko, 2010). In the late 1990s, a series of events changed international opinion in favour of “universal” access to AIDS treatment in African countries, and consequently in Cameroon. In September 1997, Senegal hosted an international meeting to discuss the preconditions for using ARVS and therapeutic protocols to treat people living with HIV. The development and implementation of the Senegalese, Ivoirian, and Cameroonian programmes, which were independently evaluated with support from the French ANRS and the American Centres for Disease Control (CDC), contributed to the demonstration that ARV treatment in poor countries was feasible, a possibility which international experts had until then denied. The experiences also uncovered numerous difficulties, especially tensions around available resources (Muller, 2000; Samb et al., 2009; Nguyen, 2010). SENEGAL: A PRECURSOR COUNTRY

In 1998, Senegal became the first African country to launch its own programme for access to ARVs, the Senegalese Initiative for Access to ARVs (ISAARV) (Desclaux et al., 2002). Although the Senegalese case is special because compared to other African countries, prevalence of HIV/AIDS is low – 0.7% for the 15–49 age group at the time of the Initiative – the country’s actions illustrated the political possibility for direct negotiation by African countries. Under the WHO’s Global Programme for AIDS (GPA), most African countries had implemented a National Programme Against AIDS. It 1986, Senegal became one of the first countries to do so. Burkina Faso, Côte d’Ivoire, Benin,

AIDS and governance in Africa 71 Niger, and Cameroon were among the countries that followed suit, starting in 1987. Between that date and the achievement of access to ARVs, African countries experienced highly different epidemiological trajectories and institutional/ political responses. While Senegal is recognised, in retrospect, for its “active” response and proactive adherence to international strategies, three of the countries mentioned above adopted positions of “passive adherence”. Cameroon, Côte d’Ivoire, and Burkina Faso, like most of the African homologues, went through a latency period in terms of policy (1987–2000) even though they were formally implementing their national programmes (Kerouedan, 2011). The “therapeutic revolution” that followed the beginning of access to ARVs has since modified this situation. The introduction of antiretroviral molecules in the form of generics distributed mainly by Indian pharmaceutical companies, with Global Fund and, in Côte d’Ivoire, PEPFAR assistance, led to an exponential growth in the number of eligible patients actually treated with ARVs. CAMEROON: FROM THE DYNAMICS OF SUCCESS TO THE BEGINNINGS OF AN ARV CRISIS?

Numerous developments in the international and national contexts had an effect on the Cameroonian programme and modified the conditions under which access to ARVs was achieved. The first notable development was the Cameroonian government’s adoption, in May 2007, of free ARVs for everyone, which was intended to reinforce universal access to treatment (Gilks et al., 2006; Souteyrand, Collard and Moatti, 2008). This measure resulted in a significant increase in the number of patients benefitting from ARVs, from 23,800 in September 2006 to 37,000 in September 2007 and 102,000 at the end of 2011. The analysis in this section draws on the EVAL study and related research (Eboko, Abé and Laurent, 2010). In 2010, WHO revised its recommendations on eligibility for treatment initiation on ARVs in low-income countries. The Organisation recommended raising the eligibility-for-treatment-initiation threshold to 350 CD4/mm, gradually withdrawing stavudine from first-line treatments, replacing stavudine with zidovudine or, in anaemia cases in Hepatitis B co-infection, with tenofivir (World Health Organisation, 2010). The recommendations had the dual effect of increasing the need for treatment and the cost of first-line treatment. These developments took place in an international context marked, as we saw above, by an important economic crisis with repercussions on public development assistance, and hence on resources allocated to HIV. After a dramatic rise in funding over the previous decade, resources from international donors began to drop in 2010. Two years later, the Permanent Secretary of the national coordinating committee against AIDS (CNLS) expressed serious qualms at a meeting of the Partner Coordinating Group for Operations (GCOP-Cameroon): The first Round 10 [Global Fund] disbursement [€12 million for the first nine months of activity] is expected in June 2012, which means there will probably be a disruption in the ARV supply, because COST [which assures

72 AIDS and governance in Africa therapeutic continuity] ended last December and the active queue keeps getting longer. Plus, there is a real possibility of raising eligibility to 400, even 500 DC4, which probably won’t help things.16 Without presuming this is a legitimate fear about future goals, this citation sheds light on the risks faced by African countries during the global economic crisis. The Permanent Secretary also reminded everyone that Round 10 covered only 36% of the needs for ARVs in Cameroon. Cameroon’s leaders were already on the job looking for other financial sources (PPTE Funds for buying ARVs, the Clinton Foundation for paediatric and second-line ARV treatment). According to the Secretary, four to six million dollars were still needed to meet the need for ARVs. Besides these funding sources, PEPFAR had brought a US$24 million project for activities in the Cameroonian regions of Adamaoua, the East, and the two Anglophone regions of the Southwest and Northwest. NIGER: FROM ONE FUNDING SOURCE TO THE ANOTHER

With less than a 1% a prevalence rate of HIV infection for the adult population, Niger was among the last countries in West Africa to access antiretrovirals. The Niger Initiative for Access to ARVs (INAARV), inspired directly by the Senegalese Initiative, was implemented in 2004. It marked an important turning point in the fight against AIDS in Niger, namely, a manifest will to begin scaling up and to gradually decentralise the fight against AIDS. Treatment was centred on the regional capitals, with no coverage at the district level. By the end of 2011, 9,407 patients (out of 29,000 people in need) were in treatment, which amounted to coverage rate of 32%, according to WHO. After Niger implemented its PNLS/NAC in 1987, it adopted the “multisector” principle. The fight against AIDS was coordinated by the Inter-Sectoral Committee to Fight AIDS (CISL), established in 2002, which was attached to the Presidency of the Republic beginning in 2007. Although civil society groups, notably the national NGO “Living Better with AIDS”, played a clear role in intensifying the fight against AIDS, the associational movement remained relatively fragile in Niger. After a Multi-Country AIDS Project (MAP) funded by the World Bank, the Global Fund rapidly became the main funder for HIV/AIDS, providing Niger with an unprecedentedly high level of funding. In 2011, the World Bank decided to begin financing AIDS again, despite several years of pause, but focussing on populations at risk. Niger also benefitted from UN agencies, as well as from Solthis, ESTHER, and a few international NGOs (CARE, CCISD, KFW) working in the area of prevention.

CÔTE D’IVOIRE: OVERCOMING ONE CRISIS AND FACING ANOTHER ONE

As one of the four countries selected to implement the UNAIDS Initiative in 1998, Côte d’Ivoire was one of the pioneers in ARV treatment programmes. It

AIDS and governance in Africa 73 achieved the scaling up and decentralisation of treatment for people infected with HIV, although the political and military crises it experienced in the previous decade could have easily stymied implementation. Côte d’Ivoire is the only Francophone country that the United States selected in 2003 to benefit from its PEPFAR programme. At that time, 87% of U.S. foreign aid was bilateral aid, of which 74% was allocated to HIV/AIDS (UNGASS, 2010). Despite Côte d’Ivoire’s political instability, the massive U.S. support allowed the number of patients on ARVs to increase from 2,000 in 2004 to almost 75,000 in 2010. In 2008, ARV treatment became free for patients. Nevertheless, ARV coverage in Côte d’Ivoire stopped rising at 37%, although the HIV prevalence rate rose to 3.4%. By the next decade, Côte d’Ivoire was complaining that it lacked US$20 million to implement its national programme. By that time, although the Global Fund’s Round 9 funding had been disbursed and in 2009 the World Bank had restarted the very PUMLS programme it had suspended six years earlier because of late loan repayments, Côte d’Ivoire was affected by both the world economic crisis and a violent post-electoral crisis. After the elections, the health system fell apart because of looting, deterioration of its material, and a several-month exemption from paying for health care. Eligible individuals could no longer access treatment, and certain partners pulled out. Health facilities, NGOs, and associations were facing layoffs of their medical and technical personnel, buyouts of their equipment, and other serious problems. This was the time to think about new strategies for sustainable financing, like France’s Debt Reduction and Development Contracts (C2D) mechanism, the African Development Bank’s low-interest rate loans, and taxation of mobile phones. Côte d’Ivoire also had to address the challenge of institutional reorganisation. To simplify coordination, the technical agencies in charge of decentralisation (CTAILS) were shut down. For the first time, the AIDS Ministry was merged with the Ministry of Health, leaving public actors in the lurch until new measures were decreed. BENIN: A MIDDLE GROUND

With a national sero-prevalence rate at less than 2%, Benin is classed as having a low-prevalence epidemic. The Beninese Initiative for Access to Antiretroviral Drugs (IBA-ARV) was established in 2001 with the support of the French International Therapeutic Solidarity Fund (FSTI). Round 2 financing from Global Fund in 2003, and the establishment of a free minimum treatment package (ARV drugs, medical appointments, follow-up testing, and treatment for opportunistic infections (OI)) in 2004 facilitated the scaling up and multilevel decentralisation of treatment. Today, more than 80 treatment centres exist at every level, with more than 300 centres for the prevention of mother-to-infant HIV transmission (PTME). More than 70% of adults and 34% of children in need of treatment have been able to access it. Despite such encouraging results, however, breaks in the ARV and screening test supply chain, and problems with implementation

74 AIDS and governance in Africa of second-line treatment and high-quality biological and virological monitoring remain. Coordination is penalised by constant redefinitions, at the presidential and ministerial levels, of the role of the national HIV/AIDS coordinating council, and by the shortage of financial and human resources. Most AIDS financing in Benin comes from the Global Fund. The country obtained Round 9 Global Fund financing. For the first time, the main beneficiaries were the PNLS, a Public Works company representing the private sector, and a community-based component, Plan Benin. The World Bank’s MultiCountry AIDS Programme (MAP) allocated substantial funding for prevention, based on satisfying results associated with its earlier grant to Benin. Numerous other international actors (Doctors of the World, Doctors without Borders, Solthis, the Danish International Development Agency (DANIDA), the Clinton Foundation, the African Development Bank, and SIDA 3) have ended their programmes in Benin. The French public interest group ESTHER made important contributions to AIDS treatment in Benin through the “twin hospital” programme, a UNITAID project which benefitted from Global Fund financing and USAID’s Population Services International (PSI). CARITAS was also involved in the nutritional and psychosocial treatment of patients. Finally, the World Bank’s Abidjan-Lagos Corridor Programme set up its permanent headquarters in Benin’s economic capital, Cotounou. However, limited resources and relative inaction keeps on the civil society actors and patient associations from playing a major role in developing health policy. BURKINA FASO: HUMANITARIAN AND INTERNATIONAL SOLIDARITY

In Burkina Faso, 25% of HIV/AIDS patients were being treated with ARVs by international associations and NGOs even before ARVs were made available to patients at no cost. Associations thus played a more important role in Burkina Faso than in other countries. This involvement nevertheless attests to the weakness of the State’s resources, even compared to other African countries (see Chapter 3). Burkina Faso was facing a generalised epidemic, but one with a gradual decline in the prevalence of AIDS, currently estimated at 1.2% (Système des Nations Unies pour au Burkina Faso, 2011). In the first decade of the epidemic, the country’s national programmes assimilated the international response. In the second decade, associations created a strong associative dynamic, in a country already accustomed to collective mobilisation (Otayek, 1997). Yet despite pressure from civil society and particularly from patients, who often belonged to them, ARVs did not become available for free in Burkina Faso until 2010. After some rough starts, including the placement of technical committees under the supervision of the public authorities until 1995, the organisation of the fight against AIDS was strengthened by the Population and AIDS Control Project (PPLS) (UNDP, 2008).17 Subsequently, regular programmatic frameworks were established. The Strategic Framework for the Fight against AIDS (CSLS) was put into place for

AIDS and governance in Africa 75 three periods: 2001–2005, 2006–2010, and 2011–2015. Operationally, this strategic tool is used by the Permanent Secretariat of the National Council to Fight HIV/AIDS and STIs (SP/CNLS) (created in 2001) to ensure the coherence and coordination of AIDS interventions at the institutional and community levels. The State is very much a part of the platform (the President of the State of Burkina Faso has chaired the CNLS since its creation) and is involved in mobilising funds from foreign partners to fight AIDS. A new, community-based organisation, PAMAC (Support Programme for Communities and Associations) also became a space for regulating the activities of associative organisations in the fight against AIDS. PAMAC has been described as dismembering of the National Council (CNLS), which was placed under the authority of Burkina Faso’s Permanent Secretary (SP) and Ministry of Finance. Public action is now focussed on the objective of universal care, in a context in which economic crisis threatens the sustainability associations struggle to ensure. On the contrary, preventive, social, and biomedical care schemes are responding to the goal of normalising the AIDS pandemic, especially through systematic screening and the continuation of health service components for the prevention of mother to child transmission of HIV (PMCTP). The objectives of universal care and HIV prevention are connected to reproductive health (RH), gender issues, human rights (rights of people living with HIV), decentralization of the response, and strengthening of multi-sectoral mobilisation. When this last point is evoked, it is with an emphasis on the political leadership embodied in the involvement Burkina Faso’s Head of State. The current strategic document (CSLS 2011–2015) opts for again framing AIDS response according to the principle national and international development guidelines concerning accelerated growth strategy for sustainable development (SCADD), the national health development programme (PNDS 2011–2020), and the National Gender Programme (PNG). The 2011–2015 CSLS objectives also pay attention to the Millennium Development Goals (MDGs), in particular the major challenge of bringing effective health care to all world populations. Moreover, the objectives reflect a strong willingness to absorb the recommendations of the Global Fund (United Nations System, 2011). In the next chapter, I present the national and comparative dimensions of transnational public action. The chapter adopts an empirical approach. Countries are analysed and grouped according to the “type” of their socio-political responses to AIDS. Each type is illustrated by a “model” representing a country, while the overall typology seeks to capture the different national trajectories within the prescribed space of international convergence of public action against AIDS in Africa.

Notes 1 In her doctoral thesis, Elise Demange has extensively analysed the development of PEPFAR and its implementation in Uganda (Demange, 2010, pp. 313, 388–342, 506–569).

76 AIDS and governance in Africa 2 www.gatesfoundation.org/ 3 www.theglobalfund.org/en/private-ngo-partners/resource-mobilization/bill-melinda -gates-foundation/ 4 See the special issue of Politique Africaine (no. 105), “Exiting the Colonial Pact”, edited by R. Banégas, R. Marchal, and J. Meimon. 5 In the 2000s, bilateral development agencies commissioned studies on the perception of the impact of bilateral and multilateral aid in Africa (Eboko, 2008; Lavigne-Delville and Abdelkader, 2010). 6 For example, in Cameroon the C2D equalled €537 million for 2006–2011 and €326 million for 2011–2016. 7 The French Ministry of Foreign Affairs originally listed 17 priority countries, and eventually added 34 more countries. 8 Recall from Chapter 1 that public action networks are defined as those which “result from more-or-less stable, non-hierarchical co-operation between organisations which know or at least acknowledge one another, negotiate, exchange resources and may share norms and interests” (Le Galès and Thatcher, 1995, p. 14). 9 ESTHER stands for “All together for a network of therapeutic solidarity”. It is a French public interest group (Groupement d’Intérêt publique) founded in 2001. In 2015, ESTHER became one of six groups incorporated into Expertise France, a French public agency for designing and implementing international technical development projects. Expertise France is currently under the supervision of the Ministry for Europe and Foreign Affairs and the Ministry of the Economy and Finance. 10 A French community-based non-profit founded in 1984. “AIDES” is a play on two words, aide (“help”) and AIDS (in French, SIDA). 11 An international NGO founded in Paris in 2003 to improve prevention and access to quality care. 12 www.essential drugs.org/emed/archive/201201/msg00082.php 13 www.liberation.fr/societe/2012/01/24/michel-kazatchkine-quitte-le-fonds-mondialcontre-le-sida_790791 14 The positions taken by several NGOs are illustrative of the type of critique directed at the Global Fund Secretariat, during the international contest between the Funds two principal financial contributors, the U.S. and France. For example, AIDSPAN, a Global Fund watchdog, suggested measures to remedy the “hypertrophy” of the Fund’s Executive Board, which prevents “fresh, sincere conversation” and resembles more a political body than an executive board. www.aidspan.org/fr/gfo_article/modifier-gouve rnance-fonds-mondial-reforme-possible-necessaire 15 www.theglobalfund.org/fr/about/organisation/executivedirector/ 16 Minutes of the Meeting of the Partner Coordinating Group for Operations (GCOPCameroon), February 7, 2012. 17 Report on Human Development – Burkina Faso, 2001, p. 150.

References Altman D., 1999, “AIDS and questions of global governance”, Pacifia Review: Peace, Security & Global Change, 11 (2): 195–211. Badie B. & Smouts M.C., 1999, 3e éd. Revue et mise à jour, Le Retournement du monde. Sociologie de la scène internationale, Paris, Presses de la FNSP et Dalloz. Boussaguet L., Jacquot S., Ravinet P., dir., 2006, 2e éd. Revue et corrigée,Dictionnaire des politiques publiques, Paris, Presses de Sciences Po, coll. “Gouvernances”. Bratton M. & Rothchild D., 1992, “The institutional bases of governance in Africa”, in Hyden G. & Bratton M., Éds, Governance and Politics in Africa, Boulder & London, Lynne Rienner Publishers: 263–284.

AIDS and governance in Africa 77 Brugha R., Donoghue M., Cliff J., Ssengooba F. & Ndubani P., 2005, “Global fund tracking study: a cross-country comparative analysis”, London School of Hygiene and Tropical Medicine, August 2. Chabrol F., 2002, “Le sida en Afrique subsaharienne: perceptions d’un enjeu de sécurité internationale”, Revue Internationale et Stratégique, 2 (46): 129–136. Coriat B., Éd., 2008, The political economy of HIV/AIDS in developing countries. TRIPS, Public Health Systems and Free Access, London, Edward Elgar Publisher. Darbon D., 2008, “Etat, pouvoir et société dans la gouvernance des sociétés projetées”, in Bellina S., Magro H. & de Villemeur V., Éds, La gouvernance démocratique. Un nouveau paradigme pour le développement?, Paris, Karthala: 135–152. Demange E., 2010, La controverse “Abstain, Be Faithful, Use a Condom”. Transnationalisation de la politique de prévention du VIH/sida en Ouganda, Thèse de doctorat: science politique, Science Po Bordeaux, Univ. Montesquieu Bordeaux 4 (dir. D. Darbon). Desclaux A., Lanièce I., Ndoye I. & Taverne B., 2002, L’Initiative sénégalaise d’accès aux antirétroviraux. Analyses économiques, sociales, comportementales et médicales, Paris, ANRS, coll. “Sciences sociales et sida”. Dixneuf M., 2003, “Au-delà de la santé publique: les médicaments génériques entre perturbation et contrôle de la politique globale”, Revue française de science politique, 53 (2): 277–304. Eboko F., 1999, “Logiques et contradictions internationales dans le champ du sida au Cameroun”, Autrepart, 12: 123–140. Eboko F., 2005, “Patterns of mobilization: political culture in the fight against AIDS”, in Amy S. Patterson, Éd., The African State and the AIDS Crisis, Aldershot, Ashgate Publishers: 37–58. Eboko F., 2008, “Botswana, Cameroun: deux approches dans l’accès aux antirétroviraux”, Transcriptases (France), numéro spécial Compte-rendu de la XVII conférence internationale sur le sida, Mexico, 3–8 août, ANRS, 138: 51–54. Eboko F., 2010, “La lutte internationale contre le sida, chantier d’une gouvernance mondiale de la santé”, Questions internationales, 43, mai-juin: 76–78. Eboko F. & Nemeckova T., 2009, “AIDS-challenge to health security in Africa: politics in Africa and case study on Botswana”, in Brauch H.G. Éd., Globalisation and Environmental Challenges: Reconceptualising Security in the 21st Century, Berlin/ Heidelberg/New York, Springer-Verlag: 539–562. Eboko F. & Mandjem Y.P., 2010, “ONG et associations de lutte contre le sida au Cameroun. De la subordination vers l’émancipation à l’heure de l’accès au traitement anitirétroviral”, in Eboko F., Abé C. & Laurent C., Éds, Accès décentralisé au traitement du VIH/sida. Evaluation de l’expérience camerounaise, Paris, ANRS, coll. “Sciences sociales et sida”: 269–285. Gabas J-J. & Hugon P., 2001, “Les biens publics mondiaux et la coopération internationale”, L’Economie Politique, 12, 4e trimestre: 19–31. Garbus L., 1996, “The UN response”, in Mann J.M. & Tarantola D., Éds, AIDS in the World II. Global Dimensions, Social Roots, and Responses. The Global AIDS Policy Coalition, Oxford, Oxford University Press: 369–374. Garmaise D., 2009, Guide d’initiation au Fonds mondial, Version intégrale, Nairobi, New York, Aidspan, Juillet. Gates Foundation, 2010, “Progress and partnerships”, Annual Report, CEO Letter. Gilks C.F., Crowley S., Ekpini R., et al., 2006, “The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings”, Lancet, 368: 505–510.

78 AIDS and governance in Africa Global Fund Observer, 2012, “Gates foundation increases its investment in the global fund”, Global Fund Observer Issue, 175, 6 February. Hassenteufel P., 2005, “De la comparaison internationale à la comparaison transnationale, Les déplacements de la construction d’objets comparatifs en matière de politiques publiques”, Revue française de science politique, 55 (1), février: 113–132. Hassenteufel P., 2011, 2e éd. Revue et augmentée, Sociologie de l’action publique, Paris, Armand Colin, coll. “U sociologie”. Hyden G. & Bratton M., Éds, 1992, Governance and Politics in Africa, Boulder/London, Lynne Rienner Publishers. Kerouedan D., 2011, Santé internationale. Les enjeux de santé au Sud. Presses de Sciences Po. Lafaye de Micheaux E. & Ould-Ahmed P., 2007, “Les contours d’un projet institutionnaliste en économie du développement”, in Lafaye de Micheaux E., Mulot E. & Ould-Ahmed P., Éds, Institutions et développement, Rennes, Presses Universitaires de Rennes: 9–37. Laroche J., dir., 2003, Mondialisation et gouvernance mondiale, Paris, IRIS-PUF, coll. “Enjeux stratégiques”. Lascoumes P. & Le Galès P., 2004, “l’action publique saisie par les instruments”, in Lascoumes P. & Le Galès P, dir., Gouverner par les instruments, Paris, Presses de Science Po: 11–44. Lavigne-Delville P. & Abdelkader A., 2010, “A cheval donné on ne regarde pas les dents”, Les mécanismes et les impacts de l’aide vu par les praticiens nigériens, Niamey, Lasdel, Etudes et Travaux, 83, 113 p. McCoy D., Kembhavi G., Patel J. & Luintel A., 2009, “The Bill & Melinda Gates Foundation’s grant-making programme for global health”, Lancet, 373: 1645–53. Moatti J.-P., 2011, “Lutte contre le sida, mobilisations politiques et changements de paradigme: l’exemple de l’économie de la santé dans les pays en développement”, in Eboko F., Broqua C., Bourdier F., Éds, Les Suds face au sida. Quand la société civile se mobilise, Marseille, IRD Éditions: 371–394. Moatti J.-P. & Eboko F., 2010, “Economic research on HIV prevention, care and treatment: why it is more than ever needed?”, Current Opinion in HIV and AIDS, 5 (3): 201–203. Msellati P., Vidal L., & Moatti JP, Éds, 2001, l’accès aux traitements du VIH en Côte d’Ivoire – Evaluation de Initiativea/ministère ivoirien de la santé publique, Paris, ANRS. Muller P., 2000, “l'analyse cognitive des politiques publiques: vers une sociologie politique de l'action publique”, Revue française de science politique, 50e année, 2: 189–208. Nantulya V., 2004, “The global fund to fight AIDS, tuberculosis and malaria: what makes it different”, Health Policy and Planning, 19 (1): 54–56. Nay O., 2009, “Administrative Reform in International Organizations: the case of the Joint United United Programme on HIV/AIDS”, Questions de Recherche, 30, octobre, Centre d’études et de recherches internationals, Sciences Po. Nay O., 2010, “Policy Transfer and Bureaucratic Influence in the United Nations. The case of AIDS”, Questions de Recherche/Research in Question, 33, septembre. Centre d’études et de recherches internationales, Sciences Po. Nguyen V.-K., 2010, The Republic of Therapy. Triage and Sovereignty in West Africa Time of AIDS, Duke University Press. Nkoa F., Eboko F. & Moatti J.-P., 2010, “Coopération Internationale et financements de la lutte contre le sida en Afrique: le cas du Cameroun”, in Eboko F., Abé C. & Laurent C., Éds, Accès décentralisé au traitement du VIH/sida: Evaluation de l'expérience camerounaise, Paris, ANRS, coll. “Sciences sociales et sida”: 13–27.

AIDS and governance in Africa 79 Orsi F., d’Almeida C., Hasenclever L., Camera M., Tigre P. & Coriat B., 2007, “TRIPS post-2005 and access to new antiretrovirals treatements in southern countries: issues and challenges”, AIDS, 21 (15): 1997–2003. Otayek R., 1997, “Démocratie, culture politique, sociétés plurales: une approche comparative à partir de situations africaines”, Revue française de science politique, 47 (6): 798–82. Patterson A.S., 2006, The Politics of Aids in Africa, Boulder, Lynne Rienner. Samb B., Evans T., Atunir R., Moatti J.-P., et al., 2009, “An assessment of interactions between global health initiatives and country health systems”, Lancet, 273: 2137–2169. Souteyrand Y.P., Collard V., Moatti J.P., et al., 2008, “Free care at the point of service delivery: a key component for reaching universal access to HIV/AIDS treatment in developing countries”, AIDS, 22 Suppl 1: S161–8. Système des Nations Unies pour le Développement, 2011, Programme conjoint d’appui des Nations Unies à la lutte contre le VIH et le Sida au Burkina, période 2011–2015, 38 p. UNDP, 22 May 2008, UNDP Strategic Plan 2008–2011, UNDP, Geneva. https://digital library.un.org/record/628583#record-files-collapse-header World Bank, 1989, From crisis to sustainable growth – sub Saharan Africa: a long-term perspective study (English), Washington, D.C., World Bank Group. http://document s.worldbank.org/curated/en/498241468742846138/From-crisis-to-sustainable-growthsub-Saharan-Africa-a-long-term-perspective-study World Bank, 2008, West Africa. HIV/AIDS Epidemiology and Synthesis. Implications for prevention, The Global HIV/AIDS Program. Global AIDS Monitoring and Evaluation Team (GAMET), The World Bank, Washington DC. World Health Organization, 2010, Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach, Geneva, World Health Organization.

3

International comparisons in Africa Socio-political determinants of access to AIDS drugs

This chapter aims to describe the political processes that constituted the response to the arrival of the AIDS pandemic in Africa. It clarifies the heterogeneity of responses by African States as they faced the dynamics of the pandemic, from its beginnings until the access to combination antiretrovirals (ARVs). Before the discovery of ARVs, the national programs against AIDS (PNSL/NAC), which were under the aegis and leadership of the WHO’s Global Programme on AIDS (GPA), constituted the foundation for AIDS public policy in Africa. Once access to treatment became a reality, political attitudes, international mobilisation, and the role of associations changed. The response of African States can be illustrated by three models: active participation, the activist State, and passive adhesion. A comparative analysis of the strategies employed by national and international actors must first take into account the historical background of each model. Only then can the weight of dynamics pre-existing the arrival of ARVs, especially the intersection of the socio-medical and political domains, be understood. The epidemiological patterning of HIV/AIDS in sub-Saharan Africa can be ascertained from prevalence rates across the subcontinent, from north to south. Yet the political responses of African States have not been structured according to a relationship of cause (the severity of the epidemic) to effect (the construction of public action). These responses can be described according to provisional “models” constructed using data from several studies. Each model represents the particular situation of a given country as it faces the AIDS epidemic. Four country-specific variables were identified: the state of the health system, macroeconomic indicators, the degree of political stability and political leadership, and social movements or mobilisation. The elements of each country’s response are drawn from a combination of qualitative variables and from the country’s history, before and after the epidemic. Hence, for each country, the four variables are examined at two points in time: when the pandemic was nationally recognised and then during the period when the political, administrative, social, and health response was constructed. The models presented in this chapter correspond to the main types of response to the HIV epidemic in sub-Saharan Africa. They should be considered to be constantly evolving, rather than definitive and fool-proof. They offer

International comparisons in Africa 81 a socio-political tool for understanding how, over time, countries can shift from one type or response to the other, or even be positioned at the intersection of different responses. Before access to ARVs, the three models were: active participation, passive adhesion, and, at a later point, the “militant state” (illustrated by the emblematic case of Botswana (Eboko and Chabrol, 2005; Eboko, 2008; Eboko and Nemeckova, 2009; Chabrol, 2012)). The construction of these “models” take into consideration several factors: political leadership, the mobilisation of associations, and the connection between the national AIDS organisations (PNLS/ NAC) and social issues that emerge from the epidemic (fighting stigma, the representation of people living with HIV, advocacy in favour of vulnerable groups, etc.). These processes are described on the basis of “political cultures” and how they are articulated in the fight against AIDS (Eboko, 2005b, 2005c). The socio-political determinants presented here are based on a comparative synthesis of well-documented literature, published elsewhere (Eboko, 2005a, 2005b) I begin here with a description of the diversity of contexts of access to ARVs. I then take a more in-depth look at one country, Cameroon. This case clarifies and summarises the possibilities of and the limitations to the decentralisation of access to ARVs under limited resources and against the backdrop of the UN Millennium Development Goals promulgated in 2005. Within this perspective, the models analysed provide the basis for a typology of political mobilisation against AIDS in various African countries.

A typology of “active” political mobilisation against AIDS in Africa “Active participation”: Uganda, Senegal Active participation refers to countries that envisioned and constructed their own AIDS policy beyond the formal acceptance of international guidelines. Even before ARVs had become available, these countries were implementing original prevention programmes based on epidemiological surveillance information. Uganda and Senegal are examples of countries in which the fight against AIDS was actualised through the mobilisation of local forces. Each country was facing a different epidemiological configuration. Senegal’s sero-prevalence rate for the 15 to 49 years age group had been assessed at less than 1%, whereas in Uganda it was over 6%. Yet both countries demonstrated the political willingness to control the course of the epidemic. As a result, they were among the countries which most successfully fought AIDS, especially through prevention, in the pre-ARV years. Both were early initiators of public policies compatible with international guidelines yet specifically geared to local political and epidemiological dynamics. Very early on, Senegal oriented its health and social campaigns towards sex workers. At the same time, Senegalese health authorities developed preventive measures through the regulation of sexuality, by relying on the country’s religious and cultural background. While this approach was socially and medically

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coherent, it was disadvantaged by the lack of attention to sexualities, especially male homosexuality, that did not fit mainstream social representations. In Uganda, when Yoweri Museveni became President in 1986, he inherited a nation affected by 20 years of “military ethnocracy”, including a decade of pathological violence led by Idi Amin.1 In the mid-1980s, AIDS statistics for Uganda were already alarming. In the economic capital, Kampala, the sero-prevalence rate was almost 30% among the so-called sexually active population. By the late 1990s, Uganda’s sero-prevalence rate had fallen. For example, the sero-prevalence rates for women under 20 in pre-natal services fell from 28% in 1990 to 6% in 1998. Uganda was the first African country for which the fall in rates of HIV/ AIDS sero-prevalence was recognised by international organisations, the media, and institutional and research observers (Demange, 2010). This success story owes much to political engagement and the mobilisation of communities. An important social mobilisation The AIDS Support Organisation (TASO) best symbolises the involvement of associations in Uganda’s AIDS struggle. Founded in 1987 by Noreen Koleba, a young woman whose husband had died of AIDS, TASO and its president turned the organisation into an icon of Uganda’s community-based mobilisation effort. TASO’s primary mission was to help people living with HIV/AIDS. Because in the 1980s Ugandans were so affected by the disease (30% of pregnant women in pre-natal services were sero-positive), Koleba’s mobilisation rapidly increased TASO membership among families affected by the epidemic. TASO received funding from British and U.S. NGOs and the political support of the Ugandan State. Ten years after its founding, TASO had already spent one million U.S. dollars for the treatment of opportunistic diseases of its members. By the end of the 1990s, TASO included 2,000 volunteers throughout the country and 150 permanent employees working with some 16,000 people seen at home and in the centres the association had created (Demange, 2010). TASO’s success had a bandwagon effect on other associations in Uganda. It was also able to position itself as the interlocutor of the State and its international partners in the AIDS fight, both before and after the turn to ARVs. Although the epidemic took a heavy toll on Uganda in the 1980s and 1990s, the country gained distinction because of its deliberate prevention policy and widely recognised coordination between the State and local and international NGOs. Another reason for success lay in the will to involve all government sectors in the AIDS fight of the mid-1980s. Thus, Uganda was a precursor of multi-sectoral AIDS policy long before UNAIDS established international guidelines. To their credit, Uganda and Senegal furthered the fight against AIDS through multi-sectoral engagement, work with NGOs, and even with faith-based associations. The leadership issue Senegal and Uganda are also connected through their respective histories of political leadership: that of Abdou Diouf, Senegal’s President from 1981 to 2000,

International comparisons in Africa 83 and Yoweri Museveni, Uganda’s president since 1986 (Putzel, 2006; Demange, 2010). In both cases, “the State played a decisive role by giving the associations the necessary space for action, but also by spurring the mobilisation of the fight against AIDS” (Putzel, 2006, p. 261). In both countries, national and local political authorities strongly encouraged involvement in fighting AIDS and implemented prevention strategies based on their respective socio-cultural context. In the case of Uganda, different administrative levels were mobilised to multiply prevention and treatment activities (Demange, 2010). In 1998, Senegal became the first African country to launch its own public initiative for access to antiretrovirals, known as the Senegalese Initiative for Access to ARVs (ISAARV) (Seytre, 1993). Even if the case of Senegal was somewhat unique because of a low sero-prevalence rate compared to other African countries, the country’s actions sent the message that African countries could negotiate directly with their interlocutors. By late 2009, 75% of eligible patients in Senegal were being treated with ARVs. After 1997, Uganda became involved in protocols for access to combination drug therapy, thanks to UNAIDS. By the end of 2009, 53% of eligible patients in Uganda were being treated with ARVs, as the result of a dynamic that joined earlier community mobilisation to support from the international community (Demange, 2010). The political leadership of Uganda’s presidential couple, Yoweri and Janet Muveni, was acknowledged through numerous AIDS Awards. The couple received eight awards between 1998 and 2004 for the major role they played in the fight against AIDS. The leadership of President Museveni and Senegal’s President Abdou Diouf was consecrated by their joint award from the Society for Women and AIDS in Africa, in 1998. The co-discovery of the HIV-2 virus in 1984 by the research team led by Senegal’s Professor Souleymane M’Boup added to the country’s scientific success internationally (Seytre, 1993). In Uganda, what was rewarded, if not celebrated, was above all the persistence of political and community-based efforts for prevention, screening, and de-stigmatisation of people living with HIV. From 2004 on, support from the U.S. PEPFAR programme greatly improved access to drugs. The arrival of Global Fund financing in 2006 intersected with the strong presence of the American programme. The synergy was so successful that the Global Fund suspended its second round of funding to Uganda on the rationale that financial resources had been underutilised. This illustrates the contrast between the strong footprint of U.S. bilateral transactions in Uganda and Uganda’s weaker political connection to multilateral AIDS partners (Demange, 2010). The “activist State”: Botswana’s voluntary political response to southern Africa’s epidemiological crisis Although in the 1980s and early 1990s, sero-prevalence rates were already extremely high in East Africa (including Uganda, Rwanda, Burundi, and Kenya), by the end of the 1990s the epidemic was peaking in southern Africa (Republic of

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South Africa, Botswana, Swaziland, Zimbabwe, Namibia, Mozambique). From then on, the highest HIV/AIDS rates would be concentrated in this part of Africa. At that time, one out of five adults infected with HIV/AIDS was living in southern Africa. Botswana has often been presented as a model of economic success (Benkimon, 2001). Once the AIDS sero-prevalence rate in Botswana passed the symbolic 30%, a rate unheard of until then,2 the State’s leaders began to mobilise in an unprecedented manner. It should be recalled that when Botswana declared Independence in 1964, it was one of the poorest countries in the world. Over the next 40 years, it became one of sub-Saharan Africa’s “richest” countries, with an estimated GDP per capita of US$3,500. During the same period, the international community praised its political stability. Botswana has been based on a two-party democratic system since 1966 (Médard, 1999), long before the rest of the continent liberalised its political regimes, beginning in the 1990s. Botswana’s first AIDS case was diagnosed in 1985, the year screening tests became available. Starting in 1987, the Health Ministry established two plans recommended by the WHO Global Program on AIDS. It displayed a high-quality epidemiological surveillance programme, attached to a high-performing health system. Nevertheless, the prevention efforts did not meet expectations, and the sero-prevalence rates exploded. The most commonly cited explanatory factor was the mobility of diamond mine workers. Paradoxically, the good quality roadway infrastructure and the ease with which workers could travel weekly between their family home and the diamond sites partly explains why they became sick. Low condom use and contact with sex workers in the diamond mining area were thought to explain the dynamics of the Botswana’s epidemic, which official moralising discourse barely affected (Eboko and Nemeckova, 2009). Until the mid-1990s, the AIDS epidemic did spur the involvement of political leaders. This changed after 1998, when Festus Mogae, a former deputy of the party in power and executive at the International Monetary Fund, was elected President. His mandate coincided with national and international media reports on Botswana’s AIDS epidemic. He became the country’s first important figure to declare a national AIDS emergency and to take control of the fight against AIDS as the president of the National AIDS Council (NAC) (Chabrol, 2002). The AIDS programme was structured around the African Comprehensive HIV/ AIDS Partnership (ACHAP), a platform established in 2000 in collaboration with the Bill and Melinda Gates Foundation and Merck. The ACHAP partnership was preceded, accompanied, and then replaced by a series of agreements that provided the basis for a coalition of international actors in the AIDS field in Gaborone, the capital. Among them were BOTUSA (an agreement between the Botswanan government and the Centers for Disease Control - CDC in Atlanta), the Botswana Harvard Institute, and Secure the Future (the Botswanan government and BristolMeyers Squibb) (Chabrol, 2002). The programme for access to ARVs, called MASA (which means “dawn” or “new beginnings” in Tswana language of southern Africa), was launched in 2002.

International comparisons in Africa 85 From the start, the Botswanan authorities made ARV treatment free and available to eligible patients who were Botswanan citizens (Chabrol, 2002). In promoting access to HIV/AIDS treatment, political mobilisation thus achieved a major goal. But between 2002 and 2005, the number of patients on ARVs and the acceptability of the screening promoted by public health authorities nevertheless failed to meet the expectations of the country’s leaders. At this point, President Festus Mogae took an exceptionally symbolic and media-savvy step. In November 2005, Botswana Television (BTV)’s audience witnessed a new episode in both the country’s spectacular fight against AIDS and the relationship between politics and the citizenry. On live TV, President Festus Mogae underwent an HIV/AIDS screening test. This gesture heralded the willingness of high-level state health authorities to provide something of a salutary shock in favour of a massive screening campaign and the powerlessness of the same State to persuade the public to accept what had been offered: free and comprehensive multiple-drug treatment for patients afflicted with HIV/AIDS (Eboko, Enguéléguélé and Owona Nguii, 2009). This action falls under what I have called the “strategic State”. Although the same concept has been used to analyse States in the West, it is applicable to Botswana in that “The strategic State can be understood as a discourse in both the analytic and prescriptive sense […]. The reality of the strategic State and its representation mutualise each other” (Chevallier, 2007, p. 184). As a leader, Festus Moge was a vector of the “activist” and “strategic” State. He harnessed power for precise ends, favouring a dynamic – the process of awareness-raising, screening, and therapeutic and social care – which eventually resulted in care for people infected with HIV/AIDS. Three years after his “spectacular” television appearance, Mogae made a presentation at the opening of the 2008 International AIDS Conference, in Mexico City. He declared, without fanfare, that more than 90% of infected pregnant women were being cared for under the Prevention of Mother to Child Transmission (PMCT) programme. With the same modesty, he added that more than 80% of treatment-eligible patients in his country were on ARVs – a record for sub-Saharan Africa. The limits of this model lie in the weak collective mobilisation of associations. Hence, the difference between Botswana and Uganda models, and the poorer results for prevention in Botswana. From “passive adherence” to a “therapeutic revolution” The “passive adherence” to international guidelines (1986–2000) Passive adherence is the style followed by most African States (e.g. Côte d’Ivoire and Burkina Faso) when they formally adopted the international recommendations of the WHO’s Global Programme on AIDS, between 1986 and the end of the 1990s. Two main criteria underlie this positioning: an absence of political leadership and the subordination of AIDS associations to health personnel and international development agencies present in a particular country. The disconnect

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between civil society actors and AIDS public policy is one of the first effects shown in social science research. The dominance of associations by “medical oligarchies”: from ambivalence to therapeutic action In most of the above-cited countries, biomedical professionals, particularly those in charge of AIDS, served as an entry point for traditional pharmaceutical companies. They were able to play on the visibility they had gained in the international AIDS field in the 1980s and 1990s to join transnational networks that included the pharmaceutical companies. Through their strategic positioning between the local level and the international level, they were transformed into what I call “biomedical oligarchies” (Eboko, 1999a).

MINIMAL LEADERSHIP

Before the discovery of ARVs, most of the African countries discussed here established a separation of power by delegating the responsibility for fighting against AIDS to doctors, by way of the national programmes (PNLS/NAC). In this context, the political space was occupied by the doctors responsible for implementing the programmes recommended by the WHO’s GPA, specifically its short-term programs (STP1 and STP2). In various examples I studied, the heads of state and heads of government were barely involved with the media, even when the national programme was directly under the President or Prime Minister. Even when Senegal’s President Abdou Diouf solemnly exhorted his counterparts at a top summit meeting of African leaders in Dakar to take charge of the fight against AIDS in their own countries, his call had little effect. A relative political and collective apathy clearly distinguishes “passive adherence” from “active participation” models like the “activist State”. Most countries discussed here used the AIDS issue as a modality for their transactions with international partners and organisations. In these cases, although development agencies and UN organisations declared AIDS to be a “national priority”, the countries themselves exerted a certain degree of inertia. Burkina Faso, for example, fell into an “epidemic of silence” about the fate of its children (Desclaux, 1997); it has been characterised as “A State against public health” (Desclaux, 1995). In Cameroon, a similar situation was stigmatised as an “acquired political immunodepressive syndrome”, a formulation that could apply to most of sub-Saharan Africa (Eboko, 2000). In all of these cases, African political authorities engaged double-talk, for example, through adherence to discourses on the danger of AIDS and absence from “active participation”. In fact, some groups that mobilised in favour of political change and democracy in Africa were noticeably absent from the public fight against AIDS, in keeping with the broader double-dealing that characterised African authorities.

International comparisons in Africa 87

The “passive adherence” as a particular configuration of AIDS associations Associations fighting against AIDS: from subordination to gradual emancipation Why English-speaking African countries have been more prone to collective activism than French-speaking countries is undoubtedly explained in part by the different political cultures of collective action and the respective colonial pasts. Socio-epidemiological factors have nonetheless played a decisive role, as well. The first English-speaking countries to mobilise collectively (Uganda, Zambia, and a little later, the Republic of South Africa) were also some of the African countries with the highest prevalence of HIV/AIDS in the 1980s. The cities where mobilisation was most visible and long-lasting after the 1980s are the very ones which faced true epidemiological crises. They include Kampala in Uganda (Prolongeau, 1995) and Kinshasa in ex-Zaire before the civil war. Even in the French-speaking countries, the most dynamic and active associations emerged in Côte d’Ivoire,3 the country most affected by the epidemic when compared to West African and Central African countries (Cornu, 1998). Hence, its is important to examine the epidemiological variable in relation to the history of civil society mobilisation around common causes versus the sole intervention of the State. In addition to epidemiological determinants and the social history of collective mobilisation, configurations of social action need to include the diversity of political dynamics. The specific way in which the State was organised, like the country’s specific political and economic situation, could produce different outcomes. The mobilisation of associations was facilitated when the State was too weak to organise the fight against AIDS or, inversely, was slowed down when the role of public authorities was paramount (Eboko, 2008). The capacity of international organisations (international NGOs, bilateral and multilateral development agencies, etc.) to intervene also played a significant role in several countries. Partners made an effort to lean on NGOs as a way of avoiding what they perceived to be the bureaucratic rigidity of agencies. In these countries, whether or not they were strongly affected by the epidemic, people living with HIV (PLWH) had trouble mobilising, except in Côte d’Ivoire (Cornu, 1998). However, in all of the French-speaking countries, including Côte d’Ivoire, these associations were not founded because of a spontaneous movement or self-organisation by PLWH. Rather, they were prompted by biomedical personnel or AIDS NGOs run by such personnel; or they were established at the request of international organisations like UNAIDS and UNDP. Only in Côte d’Ivoire did the associations become autonomous very early on, thanks to their integration into international and, especially, French NGOs (Cornu, 1998). Cameroon is representative of the three types of models discussed above. PLWH associations were initially set up under the initiative of hospital physicians who played a sort of “double agent” role, as both clinicians and as presidents of the major AIDS associations (Eboko and Mandjem, 2010). In a second phase, these associations gained more autonomy from the medical sphere, thanks

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to support from international connections they had made beginning in the 2000. Paradoxically, while access to ARVs loosened the influence of physician networks on associations, it increased the medicalisation of patient care. Cameroun: from passive adherence to active decentralisation of access to ARVs The genesis of access to ARVs in Cameroon The history of the access to ARVs in Cameroon illustrates the convergence of several dynamics: social, scientific, and political. After the first results on the effectiveness of combination ARVs on mortality and morbidity associated with HIV infection were presented at the 1996 World AIDS Conference in Vancouver, Cameroon set up therapeutic and social care, in several stages. In what follows, the major steps in establishing the policy of access to ARVs are presented, with emphasis on their originality, perspectives, and works-in-progress. CHANGING PACE AND CHANGING SCALE

May 1, 2007 marks the successful outcome of a long process. From that moment on, ARV drugs for AIDS have been available free of charge for patients in all AIDS treatment centres, known as the Unités de Prise en Charge (UPEC) and the Centres de traitements agrées (CTA) in Cameroon). The country’s epidemic profile had followed the tendency in most other Francophone West and Central African countries, beginning with a low prevalence rate (0.5% prevalence in 1988) and then accelerating to higher rates after 1990 (5.5% in 2004 and 4.8% in 2014). As AIDS spread throughout the country, people eligible for treatment, according to national criteria based on those of the WHO, were theoretically able to access combination antiretroviral therapy “for free”. But the transformation of the WHO’s GPA and the quasi-vacuity of leadership in Cameroon’s national AIDS programme seemed to indicate that Cameroon had distanced itself from post-Vancouver issues. In fact, in 1997, when the President’s slot was vacant, the PNLS was directed by the Division of Community Health (later transformed into the Division for Disease Control). Although UNAIDS was founded in Geneva in 1996, it did not send a representative to Cameroon’s capital, Yaoundé, until 2000. A MULTINATIONAL ENTERS THE PUBLIC HEALTH ARENA

In 1999, Alucam-Socatral, Cameroon’s largest company, took the debate on access to ARVs in a new direction. Two years earlier, the company, which was based in the littoral region of Edéa, had initiated an HIV prevention programme for its employees and the surrounding community and medical care free of charge for employees and family members living with HIV. Now Alucam-Socatral was asking the government to launch a pilot programme to provide those eligible employees and family members with access to ARVs. The Ministry of Health suddenly faced a dilemma: equity. How could they support free treatment for

International comparisons in Africa 89 people connected to a private company without providing the equivalent to the rest of population? After much discussion, Alucam finally received the authorisation for its project; the Minister of Health himself attended the launching ceremony for the new programme, Tritherapies in Cameroon (Tricam). Tricam was the result of a scientific and technical collaboration between the Health Centre for the Sanaga Companies (the Alucam Clinic) and the research team headed by Professor Willy Rozenbaum at Rothschild Hospital, in Paris. At this point, Alucam completely reversed its public relations policy on AIDS, which had been perceived as potentially stigmatising for the company’s image. Now, with the Tricam project, the company claim could that it was putting everything into preserving its “human capital”. A subsidiary of the Péchiney group (which had sent its Number 2 to the opening ceremony), Alucam would soon inject a new momentum into the private sector and raise the awareness of numerous companies in Cameroon. International mobilisation around the lowering of ARV prices The beginning of the new millennium presented new opportunities Cameroon, especially for access to ARVs. Rather than concentrating exclusively on the Access initiative established through a partnership negotiated with UN organisations (WHO, UNAIDS, etc.) and multinational pharmaceutical companies, Cameroon became one of the first African countries to take advantage of the arrival of generic drugs. Retrospective economic analyses have shown they made the right decision. The massive decrease in cost of first-line ARVs became the obligatory passage point for AIDS treatment at a scale that could never have been reached in Africa merely through negotiations with the firms which owned the patents. The arrival of the generics market introduced the necessary competitive pressure. At the same time, the then-Prime Minister presented a Strategic Emergency Plan for 2000–2005 to the government and its partners, in particular UNAIDS and the World Bank. Cameroon thus began the practical process of decentralising access to ARVs. The Minister of Health appointed in 2000 transformed the presidency of the Central Technical Group (GTC) for the country’s national committee against AIDS into a permanent Secretariat. Similarly, the minister created and designated approved treatment facilities (CTA) for ARV treatment of people living with HIV.4 Between 2000 and 2001, the introduction of generics and the availability of ARVs at cost in the hospital pharmacies of Laquintinie Hospital in Douala and Central Hospital in Yaoundé led to a strong increase in the number of patients. The Yaoundé hospital alone saw a 50% increase per month in 2001. By the end of 2001, the number of patients at the hospital had quadrupled (Commeyras, 2001; Commeyras et al., 2006). At Laquintinie Hospital in Douala, over 500 patients had initiated treatment. Before the first price decrease, several hundred patients were officially on ARVs, at a cost of about US $1,000 per month per capita. In April 2001, the reduction in ARV prices linked to the Access initiative went into effect in Cameroon. The residual costs for patients varied between 23,000 and 68,000 FCFA (roughly €35 and 104) per month per capita– a fivefold to tenfold reduction.

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International issues and strategies around ARV access in Cameroon Subsequently, four important political and economic decisions facilitated the scaling up of ARV combination therapies at the beginning of the 2000s. The first decision, on April 4, 2001, concerned a protocol accepted by a representative of Merck, Sharpe and Dhome (MSD), which had also been delegated to represent four other pharmaceutical companies. The protocol and its modalities, which remained confidential, led to a public declaration that prices for triple combination drugs were being lowered by more than 90%. Furthermore, besides importing generics for the Indian company, CIPLA, Cameroon was able to achieve some sort of balance between the TRIPS agreements, which it had signed, and the public health priorities it had set for itself. The monthly cost borne by patients for first-line treatment dropped below 70,000 FCFA (€107). Ministerial decisions made in connection with international partners allowed further drops of the treatment cost for patients, on a regular basis. Within the context of the Global Fund Rounds, public funding of ARV drugs finally allowed ARV treatment to be free of cost, beginning May 1, 2007. Government funding was then supplemented by funding from the socalled Unitaid initiative. By the end of 2009, Cameroon had an estimated 75,000 persons living with HIV and eligible immediately for ARV treatment, according to WHO criteria (a CD4 count less than or equal to 200mm). The national programme had managed to achieve 46% coverage of these estimated needs, slightly higher than the average for sub-Saharan Africa. In June 2010, coverage of patients on ARVs reached 50%. Cameroon’s particular model was later brought into the larger economic and political debate at the international level (Moatti et al., 2010; Boyer et al., 2010) (Figure 3.1). PShare of PEPFAR Budget Allocated to the Global Fund (%) 30 25

24.02

20

16.56

16.02

% 15 10

13.92

14.97

15.29 14.30

12.82

5 0 2004

2005

2006

2007

2008

2009

2010

2011

Source: Demanage [projects ANRS 12251 and 12266]

Figure 3.1 Evolution of the number of patients on ARVs from 2005 to 2008 in Cameroon. Source: National AIDS Control Committee, Towards Universal Access to Treatments and Healthcare for Adults and Children, N° 10, Yaoundé, 2008

International comparisons in Africa 91 Future strategies The Cameroonian example illustrates the transition from one model of political response to another model. But it also reminds us that the decentralisation of access to ARVs was fuelled by the mobilisation of physician networks, more than by large-scale social mobilisation or assertive political leadership. There are but few similar cases, notably Botswana, Uganda, and Senegal. The case of Cameroon also illustrates the adaptation of an already strong political response to the strategy of access to ARVs. Hence, it fits the “active participation” type, alongside countries like Senegal and Uganda, where broad public action existed prior to scaling-up. Botswana, however, presents an unusual case, caught between an indecisive and proactive offensive leadership and a rather weak mobilisation among associations. But the degree to which coverage of access to ARVs is achieved does not simply reflect the number of years of mobilisation. Access to ARVs obviously represents a continuity in the fight against AIDS. But it also, and above all, constitutes breaks with past strategies. In fact, the state of the health system played a more crucial role during the period of access to ARVs than in the period of “prevention above all” (1986– 1996). The health system variable moves the cursor of public policy closer to actors both inside and outside the health system. The latter include “surplus facilitators” (Eboko et al., 2009), such as local private enterprise, pharmaceutical companies, national and/or international associations and high-level political personalities who provide firm leadership, like Festus Mogae in Botswana (Chabrol, 2002). On a different note, during the first two decades of the fight against AIDS, Cameroon’s decentralisation programme for access to HIV/AIDS treatment was driven by an unprecedented impetus (Eboko, 2000). The redistribution of strategic resources in public action against AIDS brought to the fore factors related to the country-wide health care network. Countries where government structures collapsed were the same ones in which different actors (associative, private, public, national, international, etc.) proved to be inconsistent in their provision of care for patients on ARVs. The challenges at the international level and predicted cuts in international financing called for extreme caution. Slowing down coverage for access to ARVs in the region of the world most affected by the epidemic would provoke a disaster in Africa and beyond. Mobilisation is less a question of solidarity than of common sense and pragmatism. This chapter has shown how the international convergence of AIDS policy in Africa generated three types of national responses, none of which were fixed once and for all. By examining the historical background of public action in each country, it has been possible to understand what differentiates one type from one another. The outcomes allow us to grasp how the transformation of inputs from international bodies could have resulted in something less than expected (“passive adherence”), something beyond expectation (“the activist State”), or even something that broke symbolically with international guidelines (“active dissidence”). It would have been possible to add to this typology those countries in which the State had

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collapsed or was in the process of reconstruction (Sindjoun, 2007) and where UN organisations and NGOs intervened to compensate for the State’s absence or minor role. Examples include severe, discontinuous crisis during which the State’s action is marginalised for a specific period, such as in Côte d’Ivoire, Congo-Brazzaville, Burundi, or Rwanda, or a structural crisis that transforms a country into a “regime under humanitarian government” (Fassin, 2010; Agier, 2010; Atlani-Duault and Vidal, 2009), as happened in the Democratic Republic of Congo (RDC), the Central African Republic, Somalia, Sierra Leone, Tchad, and other countries. In this context, influenced by the power wielded through international interventions, public action produces a sociology of the State in Africa, where policies are influenced by new linkages between international organisations, international NGOs, national associations, and public–private partnerships framed by bilateral and multilateral development. The next chapter will illustrate these configurations.

Notes 1 On the social and political changes in Uganda, see Prunier and Calas (1994). For an analysis of the social and political management of AIDS in Uganda, in a political and historical context, see Verboud (1994). 2 The means for calculating sero-prevalence have evolved. Using the older methods based on extrapolation of data from sentinel surveillance sites, especially prenatal clinics for pregnant women, the rate for young adults in Botswana in 2003 was estimated at over 37%. Later, when representative household surveys were conducted in most of the country, the estimated sero-prevalence rate fell to around 25%. For a more precise discussion of the issues and improvements in estimation of prevalence, see Larmarange (2008). 3 The HIV prevalence rate in Côte d’Ivoire was estimated at 10% of the adult general population in the 1990s. It was as high as 20% in and around Abidjan, the capital. The prevalence rate began to fall in the 2000s, as it did in most African countries (Larmarange, 2008). 4 Ministerial Decision n° 0178/DMSP/CAB and Ministerial Decision n° 0190/MSP/ CAB.

References Agier M., 2010, Managing the Undesirables. Refugee Camps and Humanitarian Government, Cambridge, Polity Press, 300 p. Benkimoun P., 2001, “Botswana: une “success story” économique assombrie par le sida”, Le Monde “Economie”, “L’Afrique noire revendique sa renaissance”, numéro spécial, juin: 3. Boyer S., Eboko F., Camara M., Abe C., Owona Nguini M., Koulla-Shiro S. & Moatti J.-P., 2010, “Scaling up access to antiretroviral treatment: the impact of decentralization of healthcare delivery in Cameroon”, AIDS, 24 (Suppl. 1): S5–S15. Chabrol F., 2002, “Le sida en Afrique subsaharienne: perceptions d’un enjeu de sécurité internationale”, Revue Internationale et Stratégique, 2 (46): 129–136. Chabrol F., 2012, Prendre soin de la population. Le sida au Botswana, entre politiques globales du médicament et pratiques locales de citoyenneté, Thèse de doctorat: sociologie, Paris, EHESS, octobre 2012 (dir. D. Fassin).

International comparisons in Africa 93 Chevallier J., 2007, “L’héritage politique de la colonisation”, in Smouts Marie-Claude Éd., La situation postcoloniale. Les postcolonial studies dans le débat français, Presses de Sciences Po: 360–377. Commeyras C., 2001, “Cameroun: situation sur la mise en place des antirétroviraux”, Remed, 25: 15–20. Commeyras C., Rey J.-L., Badre-Sentenac S. & Essomba-Ntsama C., 2006, “Determining factors of observance of antiretroviral treatments in Cameroon during the start-up period (2000–2002)”, Pharmacy Practice, 4 (3): 117–122. Cornu C., 1998, “Émancipation et engagement des personnes atteintes, réduire l’écart”, Genève, ANRS, Le Journal du sida, Transcriptase, Special Issue: 30–39. Demange E., 2010, La controverse “Abstain, Be Faithful, Use a Condom”. Transnationalisation de la politique de prévention du VIH/sida en Ouganda, Thèse de doctorat: science politique, Science Po Bordeaux, Univ. Montesquieu Bordeaux 4 (dir. D. Darbon). Desclaux A., 1995, “L’Etat contre la santé publique”, Sociologie Santé, 13: 85–91. Desclaux A., 1997, l’épidémie invisible. Anthropologie d’un système médical à l’épreuve du sida chez l’enfant à Bobo Dioulasso, Burkina Faso, Thèse de doctorat: Anthropologie, Université Aix Marseille 3 (dir. Jean Benoist). Eboko F., 1999a, “Logiques et contradictions internationales dans le champ du sida au Cameroun”, Autrepart, 12: 123–140. Eboko F., 2000, “Risque-sida, pouvoirs et sexualité. La puissance de l’Etat en question au Cameroun”, in Courade G., Éd., Le désarroi camerounais. L’épreuve de l’économiemonde, Paris, Karthala: 235–262. Eboko F., 2005a, “Politique publique et sida en Afrique. De l’anthropologie à la science politique”, Cahiers d’études africaines, XLV (2): 351–387. Eboko F., 2005b, “Patterns of mobilization: political culture in the fight against AIDS”, in Amy S. Patterson, Éd., The African State and the AIDS Crisis, Aldershot, Ashgate Publishers: 37–58. Eboko F., 2005c, “Law against morality? Access to anti-AIDS drugs in Africa”, International Social Science Journal, 186, UNESCO: 713–722. Eboko F. 2008, Perceptions et représentations de la coopération française par les acteurs et les décideurs au Cameroun, Paris, FPAE (Yaoundé) et Ministère des Affaires Etrangères et Européennes. Eboko F. & Chabrol F., 2005, “Réappropriation du paradigme de la sécurité face au sida en Afrique: diffusions, confusions, inversions”, in Bagayoko-Penone N. & Hours B., dir., Etats, ONG et production des normes sécuritaires dans les pays du Sud, Paris, L'Harmattan, coll. “Questions Contemporaines”: 193–216. Eboko F. & Mandjem Y.P., 2010, “ONG et associations de lutte contre le sida au Cameroun. De la subordination vers l’émancipation à l’heure de l’accès au traitement anitirétroviral”, in Eboko F., Abé C. & Laurent C., Éds, Accès décentralisé au traitement du VIH/sida. Evaluation de l’expérience camerounaise, Paris, ANRS, coll. “Sciences sociales et sida”: 269–285. Eboko F. & Nemeckova T., 2009, “AIDS-challenge to health security in Africa: politics in Africa and case study on Botswana”, in Brauch H.G. Éd., Globalisation and Environmental Challenges: Reconceptualising Security in the 21st Century, Berlin/ Heidelberg/New York, Springer-Verlag: 539–562. Eboko F., Enguéléguélé M. & Owona Nguini M., 2009, “Cameroun Burkina Faso, Botswana, une approche comparée de l’action publique contre le sida en Afrique”,

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Télescope (Ecole Nationale d’Administration Publique – ENAP- Québec Canada), 15, printemps-été: 52–67. Fassin D., 2010, La raison humanitaire. Une histoire morale du temps présent, Paris, Gallimard/Seuil, coll. “Hautes Etudes”. Larmarange J., 2008, “HIV prevalence estimates: the new deal in Sub-Saharan Africa since 2000”, in Coriat B., Éd., The Political Economy of HIV/AIDS in Developing Countries. TRIPS, Public Health Systems and Free Access, London, Edward Elgar: 169–189. Médard J.-F., 1999, “Consolidation démocratique et changement des élites au Botswana. Du parti dominant au bipartisme”, in Daloz J.-P., dir. Le (non-) renouvellement des élites en Afrique subsaharienne, Bordeaux, Centre d’Etude d’Afrique Noire: 187–215. Moatti J.-P., et al., 2010, “Recherche opérationnelle sur l’accès au traitement du VIH/sida dans les pays à revenus limités, in Eboko F., Abé C., Laurent C., l’accès décentralisé au traitement du VIH/sida. Evaluation de l’expérience camerounaise, Paris, ANRS, coll. “Sciences sociales et sida”: 297–311. Prolongeau H., 1995, Une mort africaine. Le sida au quotidien, Paris, Seuil. Prunier G. & Calas B., Eds, 1994, L’Ouganda contemporain, Paris, Karthala. Putzel J., 2006, “Histoire d’une action d’Etat: La lutte contre le sida en Ouganda et au Sénégal”, in Denis P. & Becker C., Éds, l’épidémie du sida en Afrique subsaharienne. Regards d’historiens, Paris, Karthala, coll. “Espace Afrique”: 245–270. Seytre B., 1993, Sida: les secrets d’une polémique, Paris, Presses Universitaires de France. Sindjoun L., 2007, “Démocratie et liberté: tension, dialogue, confrontation”, in du Bois de Gaudusson J., Claret P., Sadran P. & Vincent B., textes réunis par, Mélanges en l’honneur de Slobodan Milacic, Bruxelles, Bruylant: 969–1011. Verboud M., 1994, “Ouganda: le sida dans sa seconde décennie”, in Prunier G. & Calas B., Eds, L’Ouganda contemporain, Paris, Karthala: 275–297.

4

Socio-political determinants of access to AIDS drugs in Africa A paradigm shift

Beginning in the 1980s, African States underwent a series of deep structural changes, known as Structural Adjustment Programmes (SAPs), under pressure from international organisations, especially the International Monetary Fund (IMF) and the World Bank (WB). The sectorial reforms States agreed to were under the aegis of UN organisations and bilateral development agencies. They involved health, education, agriculture, and other sectors, as well as State government. The degree to which these reforms complemented the SAPs depended on whether the sectorial public policy was ultimately targeting those areas from which the State had been forced to pull back. This chapter retraces the main stages in the construction of the State from the 1960s on and shows how public policies designed and initiated by the African States were replaced by multilevel policies, with multiple actors, as the previous chapter illustrated with the case of AIDS governance. Here, the deployment of networks of transnational actors, professionals (“medical oligarchies”) and voluntary sector actors is described in the context of global public policy. This chapter further demonstrates that despite the exceptionalism of international mobilisation against AIDS in Africa, most public policies were subject to the same matrix – one constituted by international organisations; international, national and local NGOs; and bi- and multilateral development agencies. Before detailing this maze of paradigms and notions, it is useful to attempt a definition of the State in Africa. Public policy in the first three decades of African independence might have benefitted from careful study and analysis. A State-centred, hence “classic” approach might have easily grasped the process through which sector-level policies emerged, were implemented, and found a place on the political agenda. In fact, for the majority of African countries, access to independence in the early 1960s led to the dual phenomena – the Africanisation of administrations and the formal construction of States – thus both following and partly breaking with colonial era policies that began with the Berlin Conference of 1884. Three phenomena characterise State action at the end of colonialism and differentiate it from the present era. First, and most salient, is the relative flexibility political authorities exercised in planning public policy during the period from independence to the early 1980s. The major partnerships developed to strengthen public action tended to involve bilateral cooperation with the former colonial

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powers, but as these were now linked to Cold War accommodation, political orientations also played a role. For example, the former USSR developed bilateral partnerships with countries that opted for the “socialist model” (the Democratic Republic of the Congo, today the Republic of Congo; the Republic of Benin, formerly Dahomey). Other countries, such as Cameroon, chose Non-Alignment1 by negotiating partnerships with countries on both sides of the Cold War. Second, some countries, like Guinea, which declared independence in 1958, broke ties with the old colonial powers. The resounding “no” of Guinea’s President, Sekou Touré, to General Charles De Gaulle effectively ended the Deferre legal framework,2 crafted in the French metropolis to grant independence to most of the territories under French colonial rule by 1960. The third phenomenon was the development of public action programmes, or what came to be known as the fiveyear plans (Plans Quinquennaux), which correspond to today’s State-structured public policy packages. The re-assemblages, splits, ruptures, and continuities brought about by independence and then by bilateral partnerships constituted the building blocks of public policy, whether their inspiration came from French, British, Portuguese, “socialist”, or other sources. Public policies at the dawn of independence have been referred to as types of “model transfer” or as “the imported state” (Badie, 1992). However, these concepts mischaracterise the period. Catherine CoqueryVidrovitch’s (1992) chronology offers a more apt description: the African State begins with colonial domination and the establishment of a territory, borders, and an administration. Following this logic, independence can be understood as the purveyor of continuity in the construction of the State, which itself underwent significant changes in order to construct public action programmes on which its “national unity” was founded and national citizenship hinged. This postcolonial State was no longer subject to the impositions coming from the metropolis but was inspired by its common colonial past. Hence, the shift away from domination/colonialism and toward cooperation inspired national policy “models”, particularly in the areas of education, training, and public policy planning. Each country’s history can thus be written and retold independently of the history of the colonial empires. Such narratives involve the ideology of the founding fathers (Fôte-Harris, 1991) and in some cases have contributed to falsifying historical facts through what Achille Mbembe terms “State-historian” bias (Mbembe, 1989). The idea of continuity in the formation of “states in action”, more than in “the imported state” (Badie, 1992), finds support in how national public policy was planned as a function of the needs of national, social, and economic development. Political regulation of the “construction of national unity” within States, characterised by a more-or-less important geographical, ethno-regional, and economic diversity, constituted the major argument used by those in power to justify freezing the multi-party competition born under colonialism, especially between the end of World War II and beginning of independence of African States. Public policy plans implemented in the 1960s, notably those concerning land-use development, sought a balance between political factions, especially

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those originating in the last years of colonialism (the post-war years). The political history of postcolonial Africa and the evolution of public policy are linked by a bijective relationship. The process of State institutionalisation is jointly constituted with “the action programmes pursued by State authorities; that is, the ‘polity’s policy’”, through which public policy is defined (Hassenteufel, 2011, p. 7). In what follows, I trace the process through which African States were constructed, both during and after colonialism, by relating the dynamics of State formation to health policy. How should we conceptualise the African State?

Towards a definition of the State in Africa: preamble A Durkheimian vision of the State Although the major authors who have analysed the State in Africa were inspired by the Weberian definition of the rational-legal state, I have proposed to reorient this analysis using a Durkheimian perspective (Eboko, 1997). This choice in no way denies the theoretical and practical import of Max Weber’s theory. In fact, my approach retains the Weberian definition of the State’s vocation: “the State is a political enterprise whose administrative leadership successfully vindicates the legitimate monopoly of physical violence” (Weber, 1971, p. 51). The reasoning behind my proposal is simple. The contemporary State in Africa resembles the one Durkheim observed under the Third French Republic, inasmuch as the state he was studying was a state-in-the-making, at the stage of ongoing institutionalisation and defined by its practices and by the autonomisation of its action. Emile Durkheim defined the State as: a sui generis group of officials, within which representations and acts of volition involving the collectivity are worked out, although they are not the product of collectivity. […] The State, like the individual, is often mistaken as to the motives underlying its decisions, but whether its decisions be ill motivated or not, the main thing is that they should be motivated to some extent. (Durkheim 1950/1986, p. 40) In this citation, the State is defined in terms of its agents, the determinants of their actions (“motives”), and the fact that they act in the name of the collectivity. In this context, the State, according to Durkheim, “must be present in all spheres of social life, so that its action can be felt” (Durkheim 1950/1986, p. 40). In this way, Durkheim implicitly distinguishes his definition of the State from the Weberian one, although he never actually cites the German sociologist. In fact, we can almost discern his desire to propose a positivist definition of the State, beyond that of Max Weber. Durkheim writes: Hence, history seems to have proved that the State was not created and does not have the mere role of preventing the individual from being troubled in his

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Determinants of access to AIDS drugs exercise of natural rights. Rather, it is the State which creates these rights, organises them according to reality. (Durkheim 1950/1986, pp. 95–96)

This is the register in which the postcolonial State built its authority, in opposition to past colonial domination and as an attempt to avoid the risk of anomie or anarchy that the absence of a command centre for society – to paraphrase Durkheim – would have caused. There are three types of analysis of the State in Africa. The first, legal formalism, defines the African State in terms of its constitutional, administrative, and organisational prerogatives. The second was first charted by Jean-François Bayart’s study of the State in Cameroon (Bayart, 1979). He examined what could already have been termed “the concrete State” in an African context. Breaking with functionalist (or functional) approaches to the State, Bayart proposed a processual understanding of the State through the hegemonic construction of its power. The mutual assimilation of the two segments of the elite, the modern and the traditional, into the legitimation process of State action was captured by studying the action of the State’s “agents”, which opened a fertile if not unprecedented analytic path at the end of the 1970s. Later, Durkheim adds: There is nothing negative about the role of the State. It tends to assure the most complete individuation possible while allowing the social state to exist. Far from being the tyrant of the individual, the State redeems the individual from society. (Durkheim 1950/1986, p. 103) Although the State is also defined by what it regulates, especially in terms of its territory and population, importance must be given to the construction and enactment of its administration, as well (Sindjoun, 2002a). While Africa is barely acknowledged in administrative sciences, noteworthy analyses of public administration in Africa have been carried out for international organisations like the World Bank, the OECD, and UNDP. As Darbon and Crouzel (2009) explain: These analyses of power and the State are highly sophisticated. They rely on concepts like governmentality, neopatrimonialism, appropriation; treat topics like political culture and the mutual assimilation of elites; and include theories of the failed / collapsed/ fragile/ shadow/ suspended/ changing state, MPAs and bottom-up analysis (Médard, 1991a; Bayart, 1989/1993; Hibou, 1999). Such approaches contribute to the analysis of public administration in Africa by shedding light on certain characteristics of the State, in dramatic contrast with the usual platitudes about administrative organisation in Africa. These limited, simplistic, and constantly recycled commonplaces make assumptions about over-administration, under-administration, bloated

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bureaucracies, colonial legacy, administrative inefficiency, imported models, institutional mimicry, and social lag. (Darbon and Crouzel, 2009, p. 78) The above assessment suggests that AIDS policy in Africa can constitute a rare if not privileged site of inquiry. In fact, national and international responses to AIDS everywhere depended on the support, involvement, skills and/or leadership of administrations and health agents. Where the response to the AIDS crisis was limited or poor in quality, re-bureaucratisation followed, contrary to the erroneous ideas Darbon and Crouzel evoke. Tracing the public policy and actions deployed against AIDS in Africa requires understanding the background of administrative agents, health experts, and public administrations in each of the countries covered in this book. Thus, we need to consider how the emergence of organisations of people with HIV alongside NGOs fighting against AIDS in the 1990s introduced and delineated a plural field of institutions and actors seeking to achieve new social status. Political science recognises this as: a pluralistic process, internal to a system of relevant actors, through which the merits of public interventions, in particular their stance and means of implementation, are evaluated by relating the resulting effects to the value system at hand. (Duran and Monnier, 1992, p. 245) In fact, the contradiction arising from the relative absence of interest groups able to compete with the biomedical sector and transform AIDS in Africa into a political issue changed somewhat after the mid-1990s. Public policy on AIDS was inspired by the need to debate ideas. The role played by such a debate is often indirect. According to the political scientist, Bruno Jobert, it creates “an ideological climate that influences the decision-makers’ selection criteria, giving shape and legitimacy to what until then had resembled an ensemble of partly-bricolaged solutions” (Jobert, 1992, p. 233). Following if not concomitant with this process, other research examined both the denial and the acceptance of the reality of AIDS as a political issue in different States. The three main research poles – international organisations, the African State, and civil society – can be examined together to detect repertoires of collective action that might (or might not) explain the conditions of social and political mobilisation against AIDS in Africa. Claude Raynaut claims at the end of his article on the evaluation of AIDS policy in Africa that his hypothesis “would require us to closely analyse the line of argument presented by the international organisations through those responsible for the various options” (Raynaut, 2001, p. 22). Yet he seems to leave off at the very place political science approaches and research on international organisations might begin. Such research could undoubtedly deepen an already productive field of study. It is within this context of negotiations over “identifying” intermediary bodies and representatives of the social groups targeted by these programmes that

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so-called communities were engaged. Often such groups originated at the initiative of the health authorities. Observers at the time witnessed the acceleration of an effort already underway to develop a particular type of community model. Biomedical personnel (the social body that controlled the AIDS field) were the first to react by urging HIV-positive people to form associations in sync with the terms set by the funders. Doctors responsible for AIDS in Africa preempted this grass-roots orientation by founding their own NGOs. Some of these organisations acted as intermediaries between funders and people with HIV/ AIDS, and even with “target groups” in general, following a dynamic already under way in Francophone Africa (Kerouedan and Eboko, 1999). By contrast, Anglophone Africa had already made serious gains in this area compared to other parts of the continent. Anglophone African associations of people with HIV and/ or AIDS started in the 1980s, were politically engaged, and clearly displayed their independence.

Public action and the State: who governs? Transactional operators in a polycentric coordination According to Pierre Muller, in theory, “those who succeed in embedding a sectorial standard within a global standard are in some ways constructing the foundation of a public policy” (Muller, 2000, p. 59). In several African examples, when administrators and health actors in the AIDS sector carried out the theoretical operation of “monopolisation” within general public health and so-called development policy areas, they generated a disconnection. In fact, the national programmes to fight AIDS (PNLS/NAC) quickly turned into relatively autonomous administrations, with specific budgets fuelled by international organisations and bilateral and multilateral development agencies. This observation fits what we have called the “dissonant model of public policy”, and for two reasons. First, it reminds us that the PNLS/NAC are ex-cathedra creations of the World Health Organisation. By implication, internal transactions that had managed to bring public action to the political agenda were in this case replaced by demands external to the States themselves. In turn, institutional actors engaged in the struggle against AIDS gradually became disconnected from the objectives they had been assigned. The lack of control exerted by “civil society” further favoured the enrolment of these actors in international networks. This observation is valid for a number of countries in the global South, including African States. Socio-anthropological research in the last 20 years can be qualified as inductive, whereas, as noted above, the classic public policy analysis in political science tends to embrace a deductive approach, shaped by certain analytic models that incorporate various levels and types of research, as well as the production of knowledge itself. Here I seek to understand whether the two approaches can be brought together to complement one another, if the scientific reasons for such convergence are made clear, beyond the usual nod to interdisciplinarity. Although anthropology was in dialogue with medicine (Raynaut, 1996) and public health

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during the AIDS research years, such exchanges were not pursued between anthropology and political science. Political science has in fact collaborated with sociology, and for such a long time that in the United States it has generated a specific subfield: political sociology. The question of institutionalisation Public policies to fight AIDS have provided a promising opportunity for political science and anthropology to collaborate on a new terrain. Policy specialists have tended to turn to anthropology when they wish to emphasise the symbolic dimensions of the processes of power. Here, however, the convergence of political science and anthropology interests me as a means of understanding public policy in the context of the weak institutionalisation of the State and of its relative non-differentiation as a central organ of society in Africa.3 It can also help us to grasp general factors and unknowns inherent to all public policy, regardless of geographical area, to better apprehend the specificities and particularities of African States. In social science research on AIDS in Africa, anthropologists have “practiced” political science more than has any other discipline, although they have done so using anthropological concepts. The present study engages political science and its concepts in debates that for the most part began without them. Furthermore, over two decades of recent research, researchers’ positions have shifted radically. The political dimension of international AIDS management in Africa arose somewhere between the regressive epistemological and culturalist turn in the anthropology of AIDS of the 1980s and the critical studies that began in the 1990s.4 The issue of access to new drugs heightened the critical turn. Whether British, North American, or French, these studies increasingly involved a double radical critique: that of public health as a discipline and, more generally, of “politics”, local and international.

Reconfiguring biomedical oligarchies at the core of transnational public policy networks In most of the countries mentioned above, biomedical professionals, particularly health officials involved in the fight against AIDS, served as bridges between different types of partners, including pharmaceutical laboratories; multilateral international organisations (especially WHO, UNAIDS, and UNDP); bilateral development agencies and financial institutions (the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and PEPFAR); international non-governmental organisations (the various national sections of Doctors without Borders); public interest groups (Groupes d’Intérêt Public or GIPs, including, in the French context , the ANRS5 and the Esther GIP)6; and even older networks like those of the Pasteur Institute. In this way, global priorities changed and were translated, networks made up of African and European doctors and other clinicians from both the North and the South were able to join networks developed to implement public policy, at the

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national level, involving patient care, access to drugs, access to funding, and clinical, social science, public health, and other research. Beginning in the mid-1980s, these professionals positioned themselves within so-called issue networks, which split apart and were recomposed, made alliances and broke them, and evolved in tandem with international debates and issues. Although the public policy literature makes a formal distinction between two types of policy network, “interest groups” and those related to “policies and the administration of others” (Boussaguet, Jacquot and Ravinet, 2006 , pp. 386–388), the trajectories we analyse below show how African biomedical authorities in fact straddle the two network types. Straddling career tracks: “double agents” within transnational dynamics The double dynamic of health practitioners straddling different positions and institutions (for example, as president of an NGO and head of a national programme to fight AIDS; as the representative of a French GIP and operations director at the Health Ministry of an African country, etc.) and the paths shaped as they move from one status to another, characterises the matrix of networks of biomedical professionals who were in charge of the institutional response to AIDS in their respective countries. In each national context, depending on the issues and subsectors involved, groups falling under the rubric of biomedical oligarchies are spread across public policy networks along a typology. Actors who built networks in the area of prevention (1986 to 1996) must be distinguished from those who sought access to drugs and treatment in Africa from 1997 on, and from those who faced later challenges from institutions financing access to treatment and prevention, notably the Global Fund and PEPFAR. From national programmes to fight AIDS to international organisations: a variety of career tracks In general, the administrative figures and biomedical professionals who took charge of the AIDS issue when the epidemic was first acknowledged in their respective countries initially benefitted from a combination of circumstances. Expansion of the availability of the ELISA test for detecting HIV allowed doctors from very different specialties to constitute networks for exchanging ideas, and this well before the implementation of the Global Programme on AIDS directives that led to the creation of the national programmes to fight AIDS (PNLS/NAC). How these doctors were able to attain top positions in their respective PNLS/ NAC in 1986 and 1987 can be explained by variables such as their administrative position, their status as a physician (specialist, professor of medicine) and/or their involvement in patient care. STABILISATION, DURABILITY, AND PROFESSIONAL MOBILITY IN THE FIGHT AGAINST AIDS: THE CASE OF SENEGAL

In certain cases, directors and board presidents of national programmes were able to achieve great longevity in office, often because of a separation between the

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PNLS/NCA and political arenas. This was the case in Senegal. Delaunay (1999) describes three medical personalities who emerged from the AIDS field in Senegal and were able to establish themselves within transnational networks: Professor S. Mboup, director of the Bacteriology and Virology lab at Le Dantec Hospital in Dakar earned his reputation as a partner in the research teams from the Global North whose work allowed the HIV2 retrovirus to be isolated and studied […]. ‘Naturally’, he became the President of the Research and Epidemiological Monitoring Group at the CNLS (Senegalese National Council to Fight AIDS). Professor Awa Marie Coll-Seck first faced the problem of AIDS when she headed the infectious medicine department at the university hospital of Fann, in Dakar. It’s in that very department, incidentally, that the first Senegalese Association for People Living with AIDS was founded, in 1991 […]. As President of the Clinic and Counselling Group at the CNLS, she participated in the development of a counselling manual, published in 1991 […]. At the same time, she took over the Senegalese affiliate of two international NGOs, the Society for Women and AIDS in Africa (SWAA) and the Pan-African Organisation to Fight Against AIDS (OPALS). Dr. Ibra Ndoye, originally trained as a gynaecologist, first appeared on the scene as a typical actor who had occupied a marginal position in the health system and whose involvement in the fight against AIDS assured him of a promotion. [He] knew what it took […] to direct the PNLS and coordinate the programme. (Delaunay, 1999, p. 103) To date, Dr. Ibra Ndoye holds the distinction of being the longest-serving director of an AIDS programme in Africa, having held that position from 1986 to 2014. He has also coordinated the Senegalese site of the ANRS (French National Research Agency on AIDS) since its establishment as the first bipartite structure of its sort in Africa. He also started the ISAARV, the first public programme for access to ARVs in Africa (Desclaux et al., 2002). In 2001, Professor Awa Coll-Seck became the first African candidate for Director-General of the WHO. Although she was supported by European networks, especially French ones, she did not win the election. However, she became Executive Director of Roll Back Malaria, the first international programme of its kind. In between her WHO candidacy and international appointment, she served as President Abdoulaye Wade’s Minister of Public Health and stayed on after Macky Sall was elected president, in 2012. Elsewhere, other events similarly affected professional trajectories. In Ivory Coast, Professor N’dri, the ANRS’s Ivory Coast coordinator for the South, was named Minister of Public Health in President Alassane Ouattara’s first government, at the end of the country’s crisis, in 2011. At the end of this chapter, we present in detail the trajectory of Dr. M’Pelé. Cameroon’s situation is slightly different. The first major figure in this country’s fight against AIDS was pushed

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out when he was at the height of his fame, after having organised the Seventh International Conference for AIDS in Africa (CISA). Networks and scientific research: the case of Cameroon Those among Cameroon’s principle partners with real presence in the country participated to different degrees in the struggle against AIDS. Beginning in 1987, the European Union established a youth project, refurbished the blood banks for safer transfusions, and developed a training programme for lab personnel. This last programme relied on the Director of the Research Section at the PNLS, Dr. P.N., who later became the go-to person in Cameroon for the European Union’s AIDS policy. Recognition of the experience and competence in the AIDS sector of this immunology expert bolstered his reputation. Not unexpectedly, he went on to Camdiagnostic, a production unit for HIV screening kits founded in 1995 with Canadian and Cameroonian funding. At the same time, Dr. P.N. became an Associate Professor. He directed the PNLS for nine months in 1998, until he was named head of the Faculty of Medicine and Biomedical Sciences at the University of Yaoundé (Cameroon’s capital), after which he accepted the position of Dean of the Faculty of Medicine at Buéa, in the English-speaking southwest region of the country. He still holds that position. Elsewhere, I have described the path to prominence taken by the founder of Cameroon’s first national AIDS council: In 1985, Professor L.K. founded the first national council to fight AIDS (CNLS), two years after the WHO released its directives. At the time, he was Inspector General for Public Health and a haematologist at the university teaching hospital. In 1987, with the WHO’s intervention, he rose to the rank of director of the country’s national AIDS programme. The 1992 International Conference on AIDS gave his status its most important visibility until then. As the conference’s organiser, this national programme director proved himself to be a key interlocutor for Cameroon’s foreign partners. In 1993, he left the PNLS. Without giving up his position at the university hospital, he became the local president of an international NGO, Sidalerte International, based in Lyon. He was supported in this endeavour by a physician and biologist, Dr. L.Z., who served as local Secretary-General of the same NGO and Executive Secretary of the above-mentioned international conference in Yaoundé. Since 1993, when he resigned from his position as head of the PNLS […], Professor L.K.’s name has remained closely identified with the fight against AIDS in Cameroon. After all these years, he is still Cameroon’s “Mr. AIDS”, in the eyes of the media and a poorly informed public. The delicate process of bringing anti-retrovirals (ARV) to Cameroon illustrates the ambiguities of transnational rationality and the career paths the AIDS crisis fuelled and even reproduced. In November 1997, one month after the Dakar meeting on ARVs in Africa, Cameroon hosted an

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international platform of specialists “caring for people with HIV/AIDS”. The initiative originated with Merck Sharp and Dohme’s pharmaceutical laboratories, which financed the “training sessions”. The event’s sponsor was none other than Professor L.K., and not the national programme he had headed four years earlier. The reason for this choice, according to the French representative of the British pharmaceutical laboratory, was irrefutable: the “Professor’s” name is the one which came up in his roster of contacts. The Cameroonian physician gave legitimacy to the event and strengthened it by organizing it under the auspices of the Faculty of Medicine and Biomedical Sciences, of which he is a member. Yet the initiative was marked by the absence of two major stake-holders: the PNLS and representatives of people with HIV/AIDS. Despite the high level of the meeting – participants were highly-acclaimed, scientifically competent specialists from three countries (Cameroon, Ivory Coast and France) – the principle stakeholders had been left out, “forgotten” because of the collusion of interest groups and the particularities of international recognition. (Eboko, 2002b) Viruses and career tracks in the AIDS field: a scramble for Africa How Cameroonian researchers were able to construct and integrate transnational networks is explainable at two levels: the administrative organisation of Cameroon’s institutional response to AIDS and the field of virology research. Neither domain was impermeable. Conflict and crossovers between clusters organised on the basis of a particular expertise accounted for promotions at the international level as much as for marginalisation and ejection at the national level. After the first AIDS cases were diagnosed at the end of 1985, doctors and biologists were spurred by the presence of an “atypical serology” to make further investigations. Some patients were presenting with the clinical features of AIDS yet tested negative when classical diagnostic tools were used. Elsewhere, I have analysed parallel and competing transnational networks (Eboko 1999a). Guillaume Lachenal, a historian of science and specialist in the history of the discovery of the two HIV-1 sub-types in Africa, has since dissected what was at stake (2002, 2006): Between 1990 and 2000, more than ten international teams started research projects in Yaoundé […]. The projects, which were explicitly concerned with sampling and analysing strains from the retrovirus that was circulating throughout Cameroon, mobilized private companies, international disease control centres and university laboratories in France, Germany, Belgium, Japan and the United States. This unprecedented fascination with Cameroonian biological material – blood products from patients and monkeys – often took the form of what in the researchers’ words amounted to a race to extract a scientific “raw material” […]. The conflicts it engendered

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Determinants of access to AIDS drugs suggest a race akin to a scientific version of the Scramble for Africa between former colonial powers. But there is one difference: what political scientists term “tactics of extraversion” were superimposed upon and adapted to the logic of extraction. Half a dozen Cameroonian scientists managed quite skilfully to use and even build this lopsided relationship. As gatekeepers of a promising site for extraction, they were the catalysts and major local beneficiaries of the international enthrallment with this Cameroonian field-site. (Lachenal, 2006, pp. 275–276)

In the beginning, two institutions, the Pasteur Centre of Cameroun and the CEAC (Organisation for the Coordination and Fight Against Endemics in Central Africa) controlled the discovery pipeline for groups and subtypes of HIV-1. Between 1986 and 1990, these two institutions churned out publications from Cameroon, which one scientist called “a paradise for virologists” (Lachenal, 2002). Professor Lazar Kaptué, a French-trained haematologist, alumnus of the Pasteur Institute of Paris and pioneer in Cameroon’s fight against AIDS, contributed to the research dynamic under way from 1986. He appointed Dr. Leopold Zékeng, a Dakar and French-trained pharmacist specialised in medical biology, to head serological screening. From 1990 on, Kaptué collaborated on the discovery of the HIV-1 sub-type, Group O, thanks to a residency at the Max von Pettenkofer Institute in Munich, Germany, where he provided blood samples from patients presenting with a so-called atypical serology. In this way, he was able to position himself at the centre of internationally recognised networks. At the same time, the Antwerp (Belgium) research teams directed by Peter Piot and Guido Van der Groen continued investigating other strains. They were joined by Eric Delaporte and Martine Peeters, former aid workers in Gabon, who chose Cameroon to conduct “an initial survey of the circulation of these viruses” (Lachenal, 2006, p. 291). Eric Delaporte then developed a project with Cameroon’s new CNLS Director, the physician and Colonel, Eithel MpoudiNglolé. Their collaboration spawned a succession of projects as well as a veritable research enterprise which has continued since then and includes the International Mixed Research Unit (UMI) of the French Institute for Development Research (IRD), with sites in Dakar, Yaoundé, and Montpellier (France); the Institute for Medical Research and the Study of Medicinal Plants (IMPM); and the Military Hospital of Yaoundé and the ANRS site in Cameroon. Léopold Zékeng, formerly Professor Kaptué’s Number Two, found himself side-lined when his mentor’s leadership ended. In fact, when Kaputé organised the International Conference on AIDS in Africa in 1992, the opening notes had already been sounded for the swan song of Professor Kaptué’s institutional networks. Dr. Zékeng re-emerged only in 2002, becoming director of the CNLS Permanent Secretariat, which he then left voluntarily in 2004 to join UNAIDS as the Coordinator for Sierra Leone and Liberia, and later for Ghana. Since 2012, he has served as Deputy Director of the Regional Bureau for UNAIDS in West Africa and of its centre in Dakar.

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From 1993 to 1994 Professor Kaptué’s successor at the CNLS was a member of his staff. Dr. Roger Salla-Ntounga became head of the PNLS in 1993. This young doctor, with a good AIDS publication record, was recruited in 1994 by the German development agency (GTZ) and given a position in an Anglophone African country. When UNAIDS was created, the agency hired him for its Geneva office, where he has continued to hold high office since 1998. Colonel Dr. Mpoudi Ngolé left the CNLS in 1997 and returned to the military research institute for infectious disease, where he continues to collaborate internationally with Eric Delaporte. He was replaced by Professor Peter Ndume, a former European Union intermediary for the AIDS field in Cameroon. Ndumbe’s principle networks are the WHO and the University of Kansas. With his American partners, he conducted a trial on the combination of two protease inhibitors, saquinavir and indinavir, the results of which were never published. As we mentioned earlier, today he is the highest ranking dean of the Buéa medical school, in Cameroon. In 1997, Professor Mondekosso, the former WHO Regional Director for Africa (1986–1996), became Cameroon’s Minister of Health. This former dean of the Medical School in Yaoundé and a graduate of King’s College London, he made the important decision of stopping the constant turnover at the head of the CNLS. Consequently, it was decided that the Minister of Health would be the de facto president of the CNLS, alongside a Permanent Secretary (SP). This is how a Professor of infectious diseases, Sinata Koulla Shiro, came to occupy the SP role at the CNLS from 1999 to 2002. She was also the Coordinator for the South of Cameroon’s ANRS site at the time Eric Delaporte served as Coordinator for the North, and she doubled as Chief Operating Officer at the Ministry of Public Health, after serving as the “number 1 technical advisor” at the Ministry and then as Vice-President of the CNLS until 2007. Once he retired from civil service, Professor Kaptué became President of the private university, the Montagnes, in his home region in western Cameroon, Mayor of his village of birth, and president of Cameroon’s National Ethics Committee for Research in Public Health. The exit option: female, single, young and competent The young female physician, Dr. Mbouni Seeomba Marie-Thérèse Gioria, was only 28 when she was hired in 1993 to became interim director of the CNLS. She stayed in that position until 1995. Among the actors I have interviewed since 1995, it was her competence, dynamism, and management skills that stood out the most. Why was she never tenured, despite her wishes? After triangulating the results of two long interviews I conducted with her in 1995 and 2000 with information from other sources, my conclusion is that she was a “victim” of the triad that sums up the ethos of social and political reproduction in Cameroon, namely “masculinity, notability, and seniority” (Eboko 2000, 2004). She chose the “exit option” and ex-patriated to the United States. In a dramatic re-orientation of her medical career, she returned to medical school in Detroit, Michigan

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to specialise in anaesthesiology and intensive care medicine. Currently, she practices in North Dakota, where her name can be found in all of the “Intensive Care” directories. The loyalty option: a Cameroonian pioneer’s voice After finishing medical school at the Faculty of Sciences in Brazzaville, Republic of Congo, Dr. Pierre M’Pele went to France to specialise in infectious medicine and tropical diseases. At la Salpêtrière Hospital in Paris, he joined the Department of Tropical Medicine and Public Health, just as the first AIDS cases were appearing in France. Working under Professor Marc Gentilini, he was confronted with this “new” disease for which the department’s activities and training had not prepared him. He thus learned how to treat AIDS at the same time as his physician peers and Professor “bosses” (patrons). His recollection of this period has much to teach us about a professional adventure that lasted close to 40 years. When AIDS first showed up, the transition was harsh. It changed the life of a once calm medical service where men and women worked. This new disease had symptoms found in tropical cancers like Kaposi’s sarcoma, various parasitic and bacterial illnesses, tuberculosis, toxoplasmosis and meningitis […] The forty beds, rapidly occupied by AIDS patients from the U.S., Africa, France and Europe, were no longer sufficient. We had to rethink the hospital. AIDS transformed the ward day after day, its architecture but also its staff. Today that hospital service is at the forefront of AIDS treatment and clinical research. (M’Pele, 2019, p. 18) Dr. M’Pelé thus became involved in medical research on tissue samples from the patients at the facility. What he was seeing was the appearance of well-known and lesser-known realities in the formal discovery of HIV-1; today these facts have all been validated. Willy Rosenbaum is unequalled as a clinician, an idea broker who will try anything. He was really the one at the origin of the discovery of the new retrovirus, first called Lymphadenopathy Associated Virus (LAV), a virus that affected the ganglia and that would become the Human Immunodeficiency virus (HIV). […] It was Willy who, in January 1983, ordered a swollen lymph node removed from Monsieur Bru, a 33-year-old homosexual who had resided in New York in 1979. It’s Willy who guided the biologists at the Pasteur Institute towards etiological research on the viral origin of what they called Bru disease. The name comes from the first three letters of the patient’s name, the young French man, febrile, exhausted but nice, who had been on the ward for several weeks and whose lymph node allowed Professor Luc Montagnier’s team to discover the LAV-BRU retrovirus responsible for AIDS, in 1983. In fact,

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the newly discovered retrovirus came from a patient in the Laveran Pavillon in Professor Gentilini’s department. The history of the virus’s discovery has never acknowledged this episode; only Professor Luc Montaigner is acknowledged. Later the Nobel Prize for medicine was awarded to him and Françoise Barré Sinoussi. But there are others who have been forgotten, like Jean-Claude Chermann, whose contribution to the discovery of the virus was never recognized by the Nobel Academy – what a pity! (M’Pele, 2019, pp. 21–22) Dr. M’Pelé began gathering cases of HIV infection in patients coming from Africa, especially Congo. Patients from Africa started being admitted to another service, this time at Claude Bernard Hospital, and directed by Professor JeanPierre Coulaud. The two hospitals began to collaborate. Along with another French colleague, Michel Rosenheim, Dr. M’Pelé began to distinguish symptoms specific to patients coming from Africa, or more precisely from Zaïre (now the Democratic Republic of Congo – DRC) and Congo Brazzaville. Compared to other patients, these turned out to have a high likelihood of co-infection with tuberculosis, but low likelihood of a pulmonary infection, Pneumocystis carinii, common in other patients. The world’s leading medical journal, the Lancet, refused to publish M’Pelé’s article, although the symptoms he identified would later come to be known as “African AIDS” and be presented in 1985 at a conference in Bangui, Central African Republic, organised under Françoise Barré Senoussi and Peter Piot (the Belgian doctor who discovered the Ebola virus in the 1970s) (David, 2013). M’Pelé suggests that the Lancet did not publish his article “perhaps because the first author was an unknown African. The paper was the first to observe that the AIDS afflicting Africans was different from that seen in Americans and Europeans. That it wasn’t published is a shame and an injustice” (M’Pele, 2019, pp. 23). Armed with this this experience, Dr. M’Pele returned to Brazzaville in June of 1986 and joined the Department of Internal Medicine and Gastroenterology directed by Professor Itoua N’Gaporo. “Out of 120 beds, one out of five patients had AIDS and three out of five were seropositive” (M’Pele, 2019, pp. 28). Dr. M’Pele soon became the “Mr. AIDS” of Congo and the Central African mainstay for Professor Gentilini, who still considered him his protégé. M’Pele represented one of the many strongholds in the competition launched by French research networks involved in discoveries and activities relevant to HIV/AIDS in Africa Lachenal, 2006, 2009, 2011). Through these networks, M’Pele had ELISA HIV diagnostic tests at his disposal and could diagnose and care for patients. It seems logical, then, that he eventually became the first director of Cameroon’s national AIDS programme (PNLS), which was the first such programme WHO’s Global Programme for AIDS (GPA) ever established in Africa and in the Global South. He directed Congo’s PNLS from 1987 to 1988. He also directed the Society for AIDS in Africa from 1995 to 2005. UNAIDS and the WHO recruited him, as they did other pioneering doctors in the AIDS area

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in Africa. Dr. M’Pele was named the representative of UNAIDS in Nigeria, Benin, and Côte d’Ivoire, and the WHO representative in Ethiopia. In 2017, he became an African ambassador for Mercy Ships, the Christian faith-based NGO. His highly original autobiography retraces the untold history of the fight against AIDS in Africa, through interlocking and highly revelatory transnational networks that stretched from Paris to Brazzaville, from Cotounou to Abuja, from Abidjan to Addis Ababa. This is the context in which the oldest actors in the AIDS field in Africa were able to exploit their international visibility in the AIDS struggle the 1980s and 1990s to join transnational networks connected with the pharmaceutical industry (see Chapter 1).

Notes 1 The Non-Aligned Movement was created at the Bandung Conference in 1955 by a group of countries of the South and Tito’s Yugoslavia, under the leadership of India, Egypt, and Cambodia. Its principle aim was “projetceon” from the influence of the USSR and the U.S. during the Cold War. The founding countries for Africa were Sekou Toure’s Ghana, Nkrumah’s Ghana, Nasser’s Egypt, and Boumédiène’s Algeria. The phrase “Non-Aligned” was coined by India’s Prime Minister, Jawaharlal Nehru, in 1956, during a speech in Colombo (Sri Lanka). Today the non-aligned movement has 120 Member States; 17 countries, including Brazil, have Observer status. 2 Translator’s note: Also known as the Deferre Reform Act, this law was passed by the French National Assembly on June 23, 1956, in response to the independence movements in France’s African colonies. The Act transferred many powers from France to the elected territorial governments and established universal suffrage. These were considered first steps towards the establishment of the French Community, which included overseas territories, departments, and Member States, the latter constituted by former African colonies. 3 On the weak institutionalisation of the State in Africa and its effects, see Médard (1983, 1991a, 1991b). On similar questions specific to Cameroon, see Médard (1977). For a critique of Bayart (1989/1993) based on the argument of the neo-patrimonial, weakly institutionalised State , see Médard (1981, pp. 120–139). 4 For English-language work, see Boone and Batsell (2001) and especially the important synthesis by Schoepf (2001). For a critical evaluation of the anthropology of AIDS since the 1980s, see Fassin (1999, pp. 41–65), particularly his notion of the “decivilisation of research” (p. 53), which describes the culturalist and essentialist drift that marked the first period of these studies. 5 The French National Agency for Research on AIDS and Viral Hepatitis (ANRS) was founded in 1988. It is represented in countries of the South at “ANRS Sites”, each of which is coordinated by a French researcher and a researcher from the country of the site. ANRS sites exist in the African countries of Egypt, Senegal, Ivory Coast, Burkina Faso, and Cameroon; in Southeast Asia (Cambodia) and in Latin America (Brazil). 6 See Chapter 2, endnote ix.

References Badie B., 1992, L’Etat importé, Paris, Fayard. Bayart J.-F., 1979, L’Etat au Cameroun, Paris, Presses de la FNSP. Bayart J.-F., 1989, L’Etat en Afrique. La politique du ventre, Paris, Fayard.

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Boussaguet L., Jacquot S., Ravinet P., dir., 2006, 2e éd. Revue et corrigée, Dictionnaire des politiques publiques, Paris, Presses de Sciences Po, coll. “Gouvernances”. Coquery-Vidrovitch C., 1992, Afrique Noire. Permanences et ruptures, Payot, 1985, 2e éd. Révisée, Paris, L’Harmattan. Darbon D. & Crouzel I., 2009, “Administrations publiques et politiques publiques des Afriques”, in Gazibo M. & Thiriot C., dir., Le politique en Afrique. Etat des débats et pistes de recherche, Paris, Karthala: 71–101. Delaunay K., 1999, “Des groupes à risque à la vulnérabilité des populations africaines: discours sur une pandémie”, Autrepart, 12: 37–51. Desclaux A., Lanièce I., Ndoye I. & Taverne B., 2002, L’Initiative sénégalaise d’accès aux antirétroviraux. Analyses économiques, sociales, comportementales et médicales, Paris, ANRS, coll. “Sciences sociales et sida”. Duran P. & Monnier E., 1992, “Le développement de l’évaluation en France. Nécessités techniques et exigences politiques”, Revue française de science politique, 42 (2): 235–262. Durkheim E., 1950/1986, Leçons de sociologie, Paris, PUF, coll. “Quadrige”. Eboko F., 1997, “Durkheim et l’Afrique contemporaine. Une relecture de Durkheim et de la sociologie africaniste”, Polis. La revue camerounaise de science politique, 4 (2): 115–142. Eboko F., 1999a, “Logiques et contradictions internationales dans le champ du sida au Cameroun”, Autrepart, 12: 123–140. Eboko F., 2002b, Dynamiques sociales, action communautaire des jeunesses urbaines face au sida au Cameroun (1998–2001), Paris, ANRS, Rapport final. Fassin D., 1999, “l’anthropologie entre engagement et distanciation. Essai de sociologie des recherches en sciences sociales sur le sida en Afrique”, in Becker C., Dozon J.-P., Obbo C. & Touré M., Éds, Vivre et penser le sida en Afrique, Paris/Dakar, CodesriaKarthala-IRD: 41–65. Fotê-Harris M., 1991, “Des ancêtres fondateurs aux Pères de la nation. Introduction à une anthropologie de la démocratie”, 123, XXX-3: 263–285. Hassenteufel P., 2011, 2e éd. Revue et augmentée, Sociologie de l’action publique, Paris, Armand Colin, coll. “U sociologie”. Jobert B., 1992, “Représentations sociales, controverses et débats dans la conduite des politiques publiques”, Revue française de science politique, 42 (2): 219–234. Kerouedan D. & Eboko F., 1999, Politique publique et sida, Bordeaux, CEAN, coll. “Travaux et Documents”, 61–62, 73 p. Lachenal G., 2002, Le Centre Pasteur du Cameroun. Trajectoire historique, stratégies et pratique de la science biomédicale postcoloniale (1959–2002), DEA: Epistémologie, Histoire des sciences et techniques, Université Paris VII, 171 p. Lachenal G., 2006, “Scramble for Cameroon: Virus atypiques et convoitises scientifiques au Cameroun, 1985–2002”, in Charles Becker & Phillipe Denis, Éds, Le sida en Afrique, regards d’historiens, Paris, Karthala: 273–307. Lachenal G., 2009, “Franco-African familiarities. A history of the Pasteur Institute of Cameroun, 1945–2000”, in Mark Harrison & Belinda White, Ed., Hospitals Beyond the West: From Western Medicine to Global Medicine, New Dehli, Orient-Longman: 411–444. Lachenal G., 2011, “The intimate rules of the French “Coopération”. Morality, race and the post-colonial division of scientific work at the Pasteur Institute of Cameroon”, in Wenzel Geissler & Sassy Molyneux, Éds, Evidence, Ethos and Experiment: The Anthropology and History of Medical Research in Africa, Oxford, Berghahn: 373–402.

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Mbembe J.A., 1989, “L’Etat historien”, in Um Nyobé, Ed., Ecrits sous maquis, Paris, L’Harmattan: 10–42. Médard J.F., 1977, “L’Etat sous-développé au Cameroun”, L’Année africaine, 33–84. Médard J.F., 1981, “L’Etat clientéliste transcendé?”, Politique africaine, N°1: 120–124. Médard J.F., 1983, “La spécificité des pouvoirs africains”, Pouvoirs, N° 25: 5–22. Médard J.F., Ed, 1991a, États d’Afrique noire. Formations, mécanismes et crises, Paris, Karthala. Médard JF., 1991b, “Étatisation et désétatisation en Afrique noire”, in Médard JF, Ed, États d’Afrique noire. Formations, mécanismes et crises, Paris, Karthala: 355–365. Muller P., 2000, “l'analyse cognitive des politiques publiques: vers une sociologie politique de l'action publique”, Revue française de science politique, 50e année, 2: 189–208. Raynaut C., 1996, “Quelles questions pour la discipline? Quelle collaboration avec la médecine?”, in Benoist J. & Desclaux A., dir., Anthropologie et sida. Bilan et perspectives, Paris, Karthala: 31–56. Raynaut C., 2001, “Comment évaluer les politiques de lutte contre le sida en Afrique”, in Baré J.-F., Ed., l’évaluation des politiques de développement. Approches pluridisciplinaires, Paris, L’Harmattan, coll. “Logiques politiques”: 318–354. Schoepf B.G., 2001, “International AIDS research in anthropology: taking a critical perspective on a crisis”, Annual Review of Anthropology, 30: 335–361. Sindjoun L., 2002a, Sociologie des relations internationales africaines, Paris, Karthala. Weber M., 1971, Economie et société, Tome 1, Paris, Plon.

5

From policies to politics Policy before the onslaught of politics

From one country to another, the relationships between political arenas and public policy networks vary considerably. The description of the dynamics that shape the policy field by Darbon and his colleagues (Darbon et al., 2008) partly clarifies the axiological matrix of States. Our earlier examples have shown how actors move from public policy to governmental or para-governmental positions to the international level. Senegal offers a good example of professional curricula including technical and then political positions at the national level, followed by international positions, such as with the WHO, Roll Back Malaria, and other programmes. The same holds true for Côte d’Ivoire. The connections in this type of trajectory are even stronger in Uganda and Botswana, where heads of government have played a widely acknowledged leadership role in the institutional and symbolic response to AIDS. Elsewhere, we have already described the Cameroun case, its de-politicisation of the fight against AIDS and the parallels between policies and politics (Eboko 2002; 2004). Government authorities have monitored the leaders of the fight against AIDS, out of fear that it serves as a springboard to political power. Ever since public health ministers have been automatically appointed to the presidency of the CNLSs, with responsibility for their country’s progress in the AIDS field, their actions in that area are no longer linked to approval or promotions. The last Health Minister with a medical background was Professor Monekosso, who was let go after he lost the municipal elections in his home town, in 2001. He was replaced by a judge who was close to the head of state, Laurent Esso, who negotiated the agreements with pharmaceutical companies in 2001. He was replaced in turn by a civil servant and administrator, Urbain Olanguena, from the Ministry of Finance, who led Cameroon’s “Scaling Up” effort for ARVs. After inaugurating the ANRS site in Cameroon and joining the Global Fund’s Board of Director, he started the programme for decentralising access to drugs and treatment. He then brought in the ANRS to conduct an independent evaluation of this programme (Eboko, Abé and Laurent 2010). On May 1, 2007, with funding from the Global Fund, he decreed the gratuity of ARVs throughout the country, much to the general relief of patients and health professionals. That September, Olanguena was relieved of his functions, and three months later he was indicted and jailed for “misappropriation of funds”. The Executive

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Director of the Global Fund publicly declared that he had no problem with the way the resources allocated to Cameroon had been managed. It’s quite possible that, beyond the judicial affair itself, Olanguena was being sanctioned for his visibility and his success in a country where governance oscillates between a form of “perpetual government” (Owona Nguini, 2004, political anomie (Eboko, 1999, 2000), and an evasiveness that ultimately serves the system President Paul Biya has controlled since 1982 (Pigeaud, 2011). Here, political indifference to even the most visible public policies is indicative of the presumed divorce between Real Politik (preservation of power through the management of clientist networks) and what we might term a “post-governmental” public policy (Vasseur, 2011).

NGOs and associations against AIDS in Africa and South: a transnational issue When the AIDS pandemic entered its third decade, the social and political history of the response to the disease included institutional struggles and numerous episodes at the international level but connected to local structures. The extraordinary landscape of collective struggles and transnational mobilisation tapped by this history is unique in the political history of epidemics. These actions, carried out in public space on every continent, were neither uniform nor linear nor timeless. This collective mobilisation can be characterised according to different historical contexts: the discovery of the syndrome and the identification of the virus in the 1980s; the tragic inequality between rich and poor countries, in the 1990s; the discovery of multi-therapies in 1996; and, finally, projects for universal access, in the 2000s. Geographic differentiation further complicates this reality, by identifying the disparities and inequality between sub-regions and social groups (Eboko, Bourdier and Broqua, 2011). Glocalisation and its subjects How groups responded hinged as much on classical organic forms of solidarity in contemporary society, such as peer groups bound by a common threat, as on repertoires of collective action against a deadly communicable and/or congenital disease whose very exceptionalism nourished universal fear. AIDS is war, European and American activists declared in the 1990s. The metaphor was not so far-fetched, given that the disease did retreat, even if only partially and unequally, thanks to the political action of the most engaged activists. Because of their actions, preconceived notions were attacked and questioned, inequalities emphasised, and common objectives imposed on everyone, regardless of the concrete results. These activists and their collective action recall Durkheim’s observation a century ago: It is a banal truth that the current war doesn’t in any way resemble those of the past. But even if everyone parrots this truth, it is not always with an awareness of its scope. The new conditions of war require not only profound

From policies to politics 115 changes in tactics and strategy; they also obligate everyone, especially the non-combatants, to take on new duties we should all be aware of. (Durkheim and Lavisse, 1916, p. 21) The actors in the AIDS field whom we now turn to were aware of the social, cultural, demographic, human, and political stakes at hand. Their actions were all the more remarkable because of how they characterised AIDS as a “social fact”; that is, as a process that is “external to the individual” yet imposed on the consciousness of everyone (Durkheim, 1968, p. 4). It is less the classical analytic tools than the strong intuition of sociology’s founding fathers that helps us understand the collective action. The activists who engaged and resourced the battlefield of AIDS brought to it an institutional insubordination which provided the fertile soil for new approaches and official standards. The result goes to the crux of two sociological realties: concern for the individual and globalisation. This dual transformation allows the limits of geographic, scientific, and intellectual borders to be overcome, to envision “subjects of globalisation”. Alain Touraine provides the clearest articulation of this idea, at least in France: By ‘subject’ I mean the construction of individuals (or groups), through the association of their affirmed freedom and of their lived experience as it is accepted and reinterpreted. The subject is the effort to transform a situation experienced through free action. (Touraine, 1994, p. 23) From this vantage point, we can trace effort to construct subjects in a struggle where borders are crossed but not abolished. The case studies presented below show how the transformation of private experiences into collective action can be understood as a function of the inequality and solidarity that distinguishes wealthy countries from countries with few resources, which just happen to be those most afflicted by AIDS. In keeping with this analysis, we borrow JeanFrançois Bayart’s neologism to capture the link between “globalisation” and more locally and historically situated dynamics. He uses “glocalisation” to refer to local modes of appropriation of globalisation (Bayart, 2004, p. 83). Thus, the connection between the analytic tools used in the nineteenth and early twentieth century (Durkheim, 1895; Durkheim and Lavisse, 1916) and those used today (Touraine 1994; Wieviorka, 1995, 2008; Bayart 2004) is less to do with heuristic differences than with historical continuity between what we call globalisation/mondialisation and its historical roots. In this global context, the AIDS epidemic triggered an exceptional process of subjectivation of the mobilised (Delor, 1997). There is a simple lesson to be learned from observing the forms of collective mobilisation in the global North. Specifically, NGOs fighting AIDS in the countries of the North gradually moved towards strengthening their activities in international relations and their support for patients and other actors in the South. With the transformation of AIDS into a chronic disease and normalisation of the diversity of bisexual and homosexual orientations, social and “sexual”

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minorities modified the demands they had so strongly formulated in the 1980s and 1990s. They came to embrace a more therapeutic and less socially oriented process. Thus, the state of emergency experienced by Western Europe and North America in the 1980s and 1990s was replaced by new problems posed by longterm treatment and the continual therapeutic innovation to which patients were exposed. At the same time, many NGOs turned their attention to migrants from the most affected countries, namely sub-Saharan Africa. While this collective mobilisation did not exhaust all forms of action against AIDS globally, it was indicative of essential tendencies around the world, from North to South and South to North. On the one hand, resources, action models and standards were transferred and re-appropriated throughout a world now thought of as “global” (Poku, 2001; Gobatto, 2003; Poku and Whiteside, 2004). On the other hand, the actors involved were not simply a reflection of North–South exchanges and international solidarity. The social movements emerging here and there in civil society bore witness to the inadequacy of public policies and multilateral interventions, insufficiently adapted to the expectations of a local population poorly embedded in socio-cultural and economic realities. Some collective responses to the evolution of AIDS nevertheless transcended the North–South divide. Civil society struggles in the North and the South influenced, supported, and disputed the official paths drawn through the field of AIDS. Thanks to these policies, transnational solidarity between activists from the North and the South became apparent. Also brought to light were local collective forms of mobilisation that correspond to the specific repertoires of collective action. To borrow a felicitous expression from Edgar Morin, the epidemic brought to light what had until then remained endemic. Out of a disease that had primarily afflicted mainly certain groups, and as a consequence resulted in a stigmatisation often rationalised under the guise of science, activists were able to produce different effects. They challenged the inequalities associated with the disease, influenced and reoriented public policy, and contributed to lowering the stigmatisation and marginalisation of people who were homosexual, and even fostered a greater visibility and identity of previously marginalised groups. Even if, then and now, the recurrence of risk behaviour among young homosexual men required urgent attention, particularly in situations of precarity (including in wealthier countries like France), progress was made in both the North and in countries of the South, like India, Brazil, and Cambodia. From the late 1990s on, the fall in AIDS-related mortality due to ARVs, the “normalisation” of certain sexual orientations, and the legitimation of patients’ experiences in areas of decision-making allowed the AIDS struggle to expand to other areas, particularly prevention and treatment efforts for migrants. Similarly, beginning in 2003, the UN, primarily through UNAIDS, spurred international policy to increase participation among local populations, thereby clearing the way for the growing involvement of patient-experts and community-based organisations in prevention, screening, and access to treatment. These modalities of

From policies to politics 117 participation and mobilisation cannot simply be linked to universal definitions; rather, the specific content and re-appropriation of these broad trends must be understood within their specific contexts. Mobilisation in wealthier world regions faced a fluid situation, in which routinisation around the benefits gained converged with the prospect of new struggles, particularly in connection with international solidarity. Access to ARVs, decreased mortality, and the idea that, in the late 1990s, AIDS had been transformed into a chronic disease, at least in wealthy countries, were testimony to the impressive results of two decades of struggle against AIDS (Pinell, 2002). Now, it was possible to envision new areas for action: young heterosexuals, the growing risk in gay settings, the exposure of mobile populations to the epidemic in the North. It is worth pondering whether internal mobilisation, especially in the poorest areas of the world, was decreasing as mobilisation beyond borders was increasing. This new configuration reflected a certain homogeneity among globally diversified trajectories and national-level practices, particularly in the mobilisation of support for organisations of people living with HIV in the global South. Beginning in 2000, access to ARVs in low-income countries became a collective goal. In fact, the negotiations over pharmaceutical patents and access to generic drugs reflected both hope and underlying tensions. The interests of patients in the South and transnational civil society contrasted with those of the large pharmaceutical companies, which were supported by government authorities in certain wealthy countries, particularly the United States. The judiciarisation of the issue of ARVs at the World Trade Organization (WTO) and the pressure exerted by the accelerated liberalisation of the international economy demonstrate the seriousness of what was at stake. Yet the bitter struggle between the “moralisation of capitalism” imposed by NGOs working in the South and the political and financial power of the pharmaceutical industry had barely begun, as the new, more effective therapies on the horizon suggest. Access to drugs still remains problematic, if not illusory, for poor populations. Compared to the power asymmetry which separated the two poles of the conflict in the early 2000s, the ensuing struggle moved more towards a balance. The readjustment between actors was fragile, but real. Networks were constituted, ties formed, alliances solidified. Media attention to the lawsuits in Brazil and above all South Africa transformed the reputation of pharmaceutical companies at a cost they could no longer ignore. After a period that hinted at a normalisation of the competition between the laboratories manufacturing generic drugs and the big pharmaceutical companies, which basically lowered the price of ARVs, new challenges appeared on the horizon. The most powerful laboratories in the North decided to bring financial and legal pressure, despite the new intellectual property agreements regarding trade (Agreement on Trade-Related Aspects of Intellectual Property Rights, or TRIPS). The Indian laboratories, whose successful commercialisation of generics benefitted African and Asian countries in particular, were forced to accept capital from “Big Pharma” (to use the activists’ terminology),

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thereby joining in an alliance with the giant laboratories. With the laws stiffening within a purely neoliberal logic pursued solely for economic profit, the Indian government was forced to adopt new regulations forbidding the reproduction of new molecules after January 1, 2005. The stormy political negotiations they found themselves in bypassed by far matters of health. Given that the lifespans and viral resistance of the molecules necessitated constant biomedical innovation, activists in the North and the South could expect further uphill battles in the courts and the political arena, on behalf of patients in the poorest countries. In other words, access to better, more adaptive drugs in the future posed (and continued to pose) new challenges and new resources for African countries confronted with AIDS (Patterson, 2005), as they did for countries on other continents. The irony, of course, is that the relevant clinical trials have taken place mostly in the South (especially sub-Saharan Africa), where access to treatment remains greatly inadequate. It is in this world region that collective mobilisation was initially and deeply tied to international organisations and eventually to associations in the North. From subjugation to emancipation: Cameroon as a case study In sub-Saharan Africa, the Republic of South Africa is undoubtedly the country most recognised for its mobilisation and political opposition around better access to treatment. Through the Treatment Action Campaign (TAC), this country, with its six million HIV-positive people, maintained an active if not aggressive (in the positive sense of the term) network of people living with HIV. Their struggle has not been easy, because they have had to fight both for access to ARVs and against the contradictions of the South African government, some of whose leaders adopted a stance of denial and refusal to acknowledge the link between HIV and AIDS (Mbali, 2005). Cameroonian associations in light of African dynamics To understand the socio-political and health antecedents of the rupture associations experienced when they faced the issue of access to ARVs, we must retrace the major steps in the genesis of political arenas where these associations developed. Cameroonian associations, with their different structures, degrees of influence and unequal resources, can be useful for understanding what happened in sub-Saharan Africa. This example opens a window on the commonalities between African and international trends, as well as on local and national specificities. In sub-Saharan African countries most affected by the epidemic (the central east and southern countries, and Uganda), the collective mobilisation of associations against AIDS dates back to the second half of the 1980s. Central-West African countries like Cameroon, however, experienced a different time-line. Political cultures linked to specific colonial pasts, particularly historical differences between Anglophone and Francophone countries, partly explain why the

From policies to politics 119 former were more inclined to produce a particular type of collective action. But the role of socio-epidemiological factors probably played a determining role in these differences, as well. The Anglophone countries in which collective mobilisation first arose (Uganda, Zambia, and a little later, South Africa) were those among those in which the highest HIV/AIDS prevalence rates were observed, beginning in the 1980s. Among the cities where the most visible and long-lasting mobilisation emerged after the 1980s, some had undergone veritable crises because of the epidemic. Kampala, in Uganda (Fabing, 1998; Demange, 2010) and Kinshasa, in former Zaïre before the civil war, stand out. Similarly, the most dynamic and long-lasting associations in so-called Francophone countries started in Côte d’Ivoire1 (Cornu, 1996), the West and Central African country most affected by the epidemic. The capacity for action of international partners, like international NGOs, bilateral and multilateral development agencies, etc., likewise played a significant role in most countries. In those, international actors deliberately depended on national NGO action to counterbalance what they perceived to be the “bureaucratism” of government services (Desclaux et al., 2010). Elsewhere, we have described the reconfiguration of associations and NGOs fighting AIDS in Africa, as another, equally rich example of local–international connections (Eboko and Mandjem, 2011). After demonstrating the onerous subordination of these structures to biomedical actors, we described the process through which they emancipated themselves. The example of Cameroon allowed us to explore this reconfiguration of the fight against AIDS in the era of antiretroviral drugs. While early Cameroonian associations were made up of members who were socially deprived, subjugated to supervision by doctors, and dependent on subsidies from so-called development agencies, new types of associations emerged at the beginning of the 2000s. As in South and Southeast Asia, the sociological characteristics changed first, with new members more likely to be female and from the “elite” classes and the leadership more likely to be professionalised. The structural and material nature of these changes was shaped by international and state funding, which reinforced the actions and forms of autonomy of the organisations, to the point of where they shifted from models of solidarity to an activism which had earlier seemed beyond their grasp. With the support of French NGOs, like AIDES and Sidaction; bilateral organisations, like Germany’s GTZ; and local NGOs working on ethical questions, like the Ethics Network on Rights and AIDS (REDS), Cameroon experienced an unprecedented degree of collective mobilisation. Having suffered immense isolation from international collective actions, Cameroonian associations were now entering a new phase of action at several levels: State, associational, NGO, and international partnerships. The most spectacular outcome of these multiplecentred actions was free access to ARVs. With its successes and controversies, traversed by international-level logics and contradictions, the Cameroonian case both symbolised and contributed to the diversity of African contexts.

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The renewal of associations through North–South partnerships A second turning-point followed in the footsteps of the access to treatment accelerated by the gratuity of ARVs starting in May 2007. It involved a greater local appropriation of collective mobilisation, but tended towards organisational scissiparity.2 Unlike in the period before ARVs became available, this organisational vitality contributed to the takeover of leadership positions by elites, whom we define, following Busino (1992), as “a minority which, at a given moment in a given society, possesses prestige and a set of privileges flowing from socially valorised natural qualities (for example, race, blood, etc.), as well as from acquired qualities (culture, merit, aptitudes, etc.) (see also Coenen-Huther, 2004). From then on, an academic degree became an essential resource for obtaining a leadership position in an association, as the kernel of leaders of SUNAIDS and many other organisations we encountered in the Douala coastal region (Littoral) attest to.3 Our observations of various organisations converge in showing that as professionalisation increased, the structure began to require academic (or at least specialised) backgrounds and professional experience as the entry ticket to a management position. Educational level4 skills and past professional experience became necessary requirements for involvement in the professionalised activities of these associations. Starting in the 2000s, organisations of people living with AIDS (PLWA) gained an institutional prominence that reinforced the autonomy of their collective mobilisation vis-à-vis the State, on the one hand, and vis-à-vis medical authorities, on the other hand. The distinctive mark of being a “depoliticized and somewhat inert imported civil society” connected to AIDS no longer corresponded to the reality of collective mobilisation in Cameroon. According to the president of Recap+, the lower costs of biological tests and the free availability ARVs were made possible thanks to “the work of organizations of PLWAs”, beyond international guidelines. Members of civil society were now intervening in political and social debates around HIV/AIDS in Cameroon and were becoming progressively more aware not only of their rights and obligations, but also of their fundamental role as the go-between the grassroots and the summit. The capacity of PLWA associations to move beyond merely acquiescing to the objectives imposed by outside actors is attested to by how their members were able to appropriate discourses, formulate proposals and make suggestions during organised events, and participate in workshops where guidelines and recommendations were elaborated. Furthermore, although these organisations continued to depend on international networks to strengthen their position nationally, they largely escaped the subjugation so often characteristic of the relationship between early Cameroonian NGOs and corresponding NGOs elsewhere. Nevertheless, grass-roots organisations achieved these gains at a cost; namely, the take-over by “elites” facing a new epidemiological pattern, in which the most educated classes were contributing as much if not more to HIV/AIDS rates than the rest of the population. Of course, because AIDS transcended the differences in social hierarchy, upper-class involvement in collective mobilisation against AIDS

From policies to politics 121 in Cameroon could not be explained in the same way as elite take-over in other areas of Cameroon society. The AIDS example thus differed, for example, from what happened in the management of royalties from forests, when “unproductive and disloyal elites” took over the resources (Bigombe Logo, 2006). It is too early to qualify the take-over process as the mere reproduction of elites through “recycling or conservative renewal” (Highley and Paluski, 2000). Members of some organisations emphasised that from that period on, “the charisma of the presidents of these organizations is so strong that it is hard to replace them” and that elections for these positions had become “mere formalities because the incumbent’s challengers were just pawns”. Nevertheless, the pressure for transparent and democratic management of the organisations resulted for some in a significant renewal of leadership, beginning in 2007–2008. Elite involvement nevertheless nurtured organisational splitting – the scissiparity evoked earlier – by exacerbating competition for the most important positions, which opened the way to new sites of power.5 This undoubtedly also contributed to downgrading the former leaders, whose social backgrounds were more modest, and by marginalising the most destitute patients, who during an earlier period had held counselling positions in treatment services. The “classic” social inequalities of Cameroonian society had resurfaced. Another powerful trend introduces nuances in this analysis, namely the rise of women to positions of power within collective mobilisation, which counterbalanced the organisational takeover by the elite. Women comprised the majority, and often the totality, of members in PLWA organisations,6 even if men from both sero-concordant and sero-discordant couples began to join. The massive presence of women within these organisations can be explained not only by the fact that, at a population level, females were more likely to be HIV positive then men; but also by the fact that women tended to be more economically deprived than men. Despite the changes described above for organisational leadership, the sociological profile of members continued to be mostly single women with dependent children, no stable employment, and surviving on work in the informal sector. Their participation in organisations for People with HIV/AIDS continued to be motivated by the desire to lessen their economic vulnerability by undertaking activities linked to their membership status, such as counselling, giving out information on prevention, testifying, and providing home aid for others living with HIV/AIDS. This sociological reality provided a foundation and a springboard for women to take over the direction of the organisations, even if it was often those from more privileged backgrounds who succeeded in doing so. In 2008, 14 of the 28 organisations of People Living with HIV/AIDS in the coastal province were headed by women. Six out of nine members of Recap+’s Executive Board were also women, including the President. While men, such as the presidents of Afsupes and Colibri, an organisation in Bafoussam (western Cameroon), cannot be ignored, in general, the collective mobilisation against HIV/AIDS in Cameroon shows the indelible fingerprint of female activism and political itineraries. Such impressive figures as Madame Lucie Z., Madame Josephine B., Madame Marlyse B., Madame Pauline M., all

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members of the Association of Activist Women in Solidarity (Afaso), are wellknown and respected by the public, who refer to each of them as “Madame AIDS”. Only the future can tell the degree to which this feminisation of the fight against AIDS brought about, beyond the disease itself, the reduction of gender inequality so deeply anchored in African societies, as elsewhere (Desgrées du Loû and Ferry, 2006; Desclaux et al., 2009). The emergence of homosexuality as an issue in the mobilisation of associations Connecting “African gays” to the international AIDS cause: between resources, constraints, and postcolonial tensions The issue of male homosexuality entered the arena of collective mobilisation against AIDS in Africa under the label of Men Having Sex with Men (MSM) (in French: HSH). The epidemiological pattern in low-prevalence countries like Senegal showed prevalence rates for MSM to be over 20 times higher than that for the general population, unlike the case in the rest of sub-Saharan Africa. This finding opened a window on transnational responses, an opportunity rich with aporia. Associations, however, found themselves up against two sets of constraints. The most deplorable obstacle was the judicial and social context of so-called homophobia (see Figure 5.1). The second, non-negligible set of constraints associations faced was the poor access to specific prevention tools and, even more so, the hetero-centred nature of education campaigns in a context where exposure to risk of infection from HIV/ AIDS affected homosexual men, too (Gueboguo, 2007). Table 5.1 compares the HIV/AIDS sero-prevalence rates of MSM and the HIV/AIDS sero-prevalence rates in the 15 to 49 age group of the general population, in selected African countries. This table suggests an example of reductio ad absurdum in which the political and social construction of public policy is not based on a straightforward causal relation between problems that need solving and the solutions that can be proposed. In Africa, homosexuality became a public issue only recently. Homosexual organisations emerged in South Africa at the end of the period of political struggle. It was the first African country to experience gay political activism, which culminated in a law allowing same-sex unions. The movement then spread throughout “Anglophone” Africa. Gay organisations were founded in Francophone African countries only much later, as a researcher observed in 2007: Collective mobilisation is taking place in Francophone West African countries, which have tended towards discretion [about homosexuality]. This is the case in Côte d’Ivoire, where a few organizations have recently cropped up, even though an article published by two French researchers twenty years ago reported that Abidjan homosexuals lacked the desire to affirm any identity whatsoever related to their sexual practices. (Broqua, 2007, p. 135)

Figure 5.1 Lesbian and gay rights in the world. Source: The Overview map – sexual orientation laws (2017) was published by ILGA in 2017’s State-Sponsored Homophobia report www.neonmag.fr/comment-les-droits-lgbt-evoluent-ils-dans-monde-514694.html

From policies to politics 123

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Table 5.1 Prevalence of AIDS in Men Who Have Sex with Men (MSM) and in the 15–49 age group in the general population, in selected African countries. Country

N(MSM)

Prevalence (%) Prevalence (%) general (MSM) population, 15–49 age group

Senegal South Africa Zambia Kenya Tanzania Malawi Nigéria Sudan Egypt Total

943 574 641 1,125 509 201 1,961 1,119 340 6,470

21.6 15.3 32.9 15.6 12.4 21.4 13.5 8.8 5.3 15.7

0.88 15.0 15.7 7.5 5.6 11.5 2.9 1.3 0.02 5.0

Source: Baral, PLOS One, cited in Bruno Spire, Presentation, IMEA, November 2011

In Africa, for 20 years, AIDS was considered a resolutely heterosexual issue. The first epidemiological studies of MSM in Dakar began to change the positions taken by researchers and institutional actors. These studies, whose authors included the leaders of the National Committee to Fight AIDS (Comité national de lutte contre le sida), shed light on the disjuncture between the infection rate in MSM and in the general population (Niang, 2010). Following these studies, researchers from the North who engaged in transnational (North–South) association networks (especially the French organisation AIDES) initiated research in various African capitals. One entity, Coalition Plus, included public health research on MSM in its studies. Its community-oriented research protocols, developed with and for men who have sex with men, met no institutional resistance from African countries. On the other hand, contradictions emerged once activists began expressing their sexual orientation in public space, because of the repressive laws against homosexual practices typical of most African countries. The transnational composition of the networks of organisations against AIDS (notably between France’s AIDES and Francophone African organisations) and the awareness of gay issues that organisations in the North had developed beginning in the 1980s (Altman, 1996, Pollak, 1993; Pinell, 2002; Broqua, Souteyrand and Lert, 2003; Broqua, 2005) provided an opportunity to mobilise against “institutional homophobia”. When research results on MSM and AIDS were presented at the International Conference on AIDS in Africa in Senegal in 2009, they didn’t make waves. But several days after the Conference ended, some MSM activists were arrested on the sole charge of “homosexuality”. After pictures of men parodying an MSM marriage ceremony were published in the local press, the people involved were subpoenaed. As a result, a response including AIDES and the President of France was organised in Paris to put pressure on the Senegalese authorities. As a result, the MSM activists were freed, albeit in the midst of popular demonstrations generally hostile to “homosexuals”.

From policies to politics 125 In Cameroon, a weekly newspaper published a list of personalities, “denouncing” their “homosexual practices”. This provoked a controversy that soon extended beyond the country’s borders. In early 2006, certain privately owned newspapers thought it was their duty to denounce a situation, described as follows in an editorial in the January 24 issue of the Anecdote: Men who make love with each other using the most disgusting of orifices, women who tenderly lick one another. These are indeed ghastly acts against social decency. […] From the lowest level to the top echelons of the State, in culture as in sports, in [government] administration as in business, even in the clergy, homosexuality makes its way in Cameroon, sometimes with the very same people whose position demands they fight it. Should we be complicit and remain silent before this waltz of incessant invasions that are polluting society? […] The Anecdote refuses to abet the civic and moral decay of the young. (Njiengwé, 2007) For several months, the publication of the names of political personalities, including current ministers, mobilised national debate and inspired international-level reactions. Most of the Cameroonian press and the majority of public opinion reduced the issue of homosexuality to practices used for social and political advancement, mirroring a society that had lost its bearings. A small minority of journalists and intellectuals attempted to foreground respect of individual liberties and the private sphere. Various youth, political, associational, and other groups organised demonstrations “against homosexuality” in a climate where the threats were increasing and the stakes were high. It is in this context that a Cameroonian activist, sitting next to a historical figure of French AIDS activism at the International Congress on AIDS in Mexico in August 2008, called out Cameroon’s Minister of Public Health. He stigmatised the homosexual climate in his country and asked the Minister if he intended to pass measures to protect homosexuals. This scene, rife with meaning, illustrates the public concatenation of a series of transnational dynamics. The Cameroonian law (art. 347 bis of the Criminal Code) denounced by the activist is not the responsibility of the Minister, even if he belongs to a government that supports it. The Agence national de recherche sur le sida (ANRS), France’s AIDS research agency, had invited this Minister to Mexico, to a gathering where even the hint of homophobic attitudes could incur virulent, collective wrath. The French and Cameroonian researchers had come to present the preliminary results of their joint evaluation study of the decentralisation of access to HIV/AIDS treatment in Cameroon. The Minister of Health did not have the time to respond. On the stage following my own presentation, I argued that the Cameroonian authorities had not opposed the research the ANRS had financed in Cameroon on homosexuality and AIDS. The head of the Cameroon ANRS office picked up the ball, emphasising that she had never encountered any institutional barriers concerning AIDS and homosexuality. The two of us pleaded for the necessity of fighting AIDS and

126 From policies to politics respecting individual rights. The Minister in question had in fact not opposed these principles, and hence we could not accuse him of something that concerned all of Cameroonian society. In between the excuses, improvisation, and hesitancy, this scene brought into play every level of public policy and mobilisation in the AIDS field in Africa. By speaking up, we not only avoided embarrassing a Minister, but also the Cameroonian militant who would soon be on a flight back to his country and would have had to explain himself in court and face a state of disgrace from which the French activist seated next to him could have extricated him only with great difficulty. Coalitions built around a cause can be contradictory, despite the best intentions. Transnational networks do not travel through equivalent spaces. The consequences in Paris of the stance taken by the French gay activist lie at the opposite extreme of those that would follow the same stance if taken in Douala. What appear to be homologous roles reveal an underlying structural antagonism. The social, political, and historical context of an almost anomic African country contrasts with that of a country that has gained the social and relational benefits of 30 years of struggle against AIDS and the recognition of the “Gay Cause”. This collision of “repertoires of collective action” (Tilly, 1978, 1984) between the public confrontation of a Minister in the Act Up mode and the subordination of “social underlings” in the politics of public space in Africa lead to two hypotheses: that of change (the transnationalisation of a repertoire) and that of the invention of new modes of political action in Africa. “Africagay”: Francophone response or “African solution”? The Africagay network was founded in 2006 to respond to the exclusion, discrimination, and sanctions MSM faced in Africa. It leaned explicitly on the experience of the French organisation, AIDES, to build a federation of 18 African associations seeking to unite their national struggles in a transnational network (Awondo, 2012). The decision to depend on a French organisation turned out to be an Achille’s heel, because the AIDES’s leaders soon created a certain discomfort among African members, especially those from Cameroon. In fact, some activists made the argument that the fact that the nerve centre of the African network was in France reinforced the popular perception of extraneous motives and sexual orientations and forms of intimacy that were not their own lay behind their struggle. Besides this postcolonial ideological explanation, other reasons can be found in classic leadership conflicts. In fact, another organisation opted for moving beyond a “Francophonie” (the area of French-speaking countries) saturated with historic colonial representations. The result was the founding of a new network, the African Men Who Have Sex with Men Initiative for Health and Human Rights (AMSHER). The network was composed of members from Francophone and Anglophone countries and Portuguese-speaking Mozambique, hence incorporated highly diverse colonial histories (Awondo, 2012). The aim here, as elsewhere, was to end the representation of French postcolonial domination of France’s

From policies to politics 127 traditional partners. This new French configuration differed from the older gay networks in Africa. Anglophone African networks, such as the Global Forum on MSM and HIV and Pan-Africa ILGA, an African offshoot of the International Gay and Lesbian Association, had been directly assimilated into Western networks.

Conclusion: Towards a trans-sectorial convergence of public policy in Africa? Despite its exceptionalist dimension, the destiny of the AIDS struggle in Africa resembles that of public policies directed to African States. These begin with the implementation of international recommendations emitted by a UN agency and directed at African State structures. At the level of the States, platforms are established, comprised of international non-governmental organisations and local and national associations supposedly representative of “civil society” and so-called communities. Whether the domain is health, education (Lange, 2003), or environmental (Smouts, 2001; Compagnon, 2005; Aubertin, 2005), the same configuration can be found, with variants in specific sectors. This also holds for the domain of sports (especially soccer) in which the nation-state is reputedly the alpha and omega of the conception and implementation of a decision (Boniface, 2006). In general, an important international conference signals the beginning of encounters between different partners after a problem or issue has been placed on the international agenda. A framework of international recommendations and standards concerning the modalities of action soon follows. At the national level, committees are set up, usually led by the State, but actually driven by international and/or national experts. The latter work with non-governmental actors, who structure the actions between associations in the North and South. The following chapter outlines the regularities in terms of the types of actors and processes that currently constitute what we might call the “matrix of public policy in Africa” in the shape of a critical political sociology.

Notes 1 In Ivory Coast, the prevalence rate for HIV was estimated to be 10% in the adult population in the 1990s, and peaked at 20% in Abidjan, the capital. It was re-estimated to be about 5% in the 2000s, a drop that characterised most African countries (Larmarange, 2008). 2 Hence, Douala’s AFSU association, a local branch of Youandé’s AFSU, the “dean” of Cameroon’s associations of people living with AIDS (PPVS), split into several local, autonomous associations, namely AFSUPES, Espoir+, Merenso, and Aasmero. 3 Recap+’s president holds a degree from the University of Cameroon and the University of Benin. The president of Fondation Espoir et Vie (FEV) was at the time a second-year law student at the University of Douala. The president of Apas, who was also Recap+’s delegate for the coast (Littoral) and member of the AFSU network’s governing board, was a senior administrator in the executive branch of AES-Sonel in Douala-Koumassi. The President of Capolias held a graduate degree in accounting sciences, taught in a private university in Douala and was preparing a doctorate. The president of NewWay+ was pursuing a professional degree in journalism.

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4 For example, the minimum requirement to become a counsellor in an association of people living with AIDS was a Brevet d’ études du premier cycle (a junior university degree). 5 An example was the Recap+’s split into two organisations, resulting in competition with Canep+. 6 In 2010, we counted only seven men among the 42 members of Actlus+. Out of 100 members of Sunaids, 90 were women, as were 111 of 121 members of Afsupes+. In Espoir+, 98% of the 106 members were women. Among FEV’s 169 members, 64 were people living with HIV/AIDS, 50 of whom were women.

References Altman D., 1996, “Rupture or continuity? The internationalization of gay identities”, Social Text, 14 (3): 77–94. Aubertin C., 2005, Éd., Représenter la nature? ONG et biodiversité, Paris, IRD Editions. Awondo P., 2012, Homosexualités, sida et constructions politiques. Ethnographie des trajectoires entre le Cameroun et la France, Thèse de doctorat: anthropologie sociale et ethnologie, Paris, EHESS, 466 p. (dir. M.-E. Handman). Bayart J.-F., 2004, Le gouvernement du monde. Une critique politique de la mondialisation, Paris, Fayard. Bigombe Logo P., 2006, Les élites et la gestion décentralisée des forêts au Cameroun. Essai d’analyse politiste de la gestion néopatrimoniale de la rente forestière en contexte de décentralisation. Communication présentée au colloque GECOREV, Université Versailles Saint-Quentin en Yvelines. Boniface P., 2006, Football et mondialisation, Paris, Armand Colin. Broqua C., 2005, Agir pour ne pas mourir! Act Up, les homosexuels et le sida, Paris, Presses de Sciences Po. Broqua C., 2007, “Compositions silencieuses avec les normes sexuelles à Bamako”, in Eboussi Boulaga F., Éd., l’homosexualité est bonne à penser, Terroirs, revue africaine de sciences sociales et de philosophie, 1-2/2007: 133–147. Broqua C., Souteyrand Y. & Lert F., 2003, dir., Homosexualités au temps du sida. Tensions sociales et identitaires, Paris, ANRS, coll. “Sciences sociales et sida”. Busino G., 1992, Élite (s) et élitisme, Paris, PUF, coll. “Que sais-je?”. Coenen-Huther J., 2004, Sociologie des élites, Paris, Armand Colin. Compagnon D., 2005, “Gérer démocratiquement la biodiversité grâce aux ONG?”, in Aubertin C., Éd., Représenter la nature? ONG et biodiversité, Paris, IRD Editions: 179–204. Cornu C., 1996, Les Associations des personnes vivant avec le VIH-sida à Abidjan, Côted’Ivoire: le malade du sida, réformateur social en Afrique subsaharienne?, Mémoire de DEA, Iedes, Université Paris I-Panthéon-Sorbonne (dir. D. Fassin). Darbon D., 2008, “Etat, pouvoir et société dans la gouvernance des sociétés projetées”, in Bellina S., Magro H. & de Villemeur V., Éds, La gouvernance démocratique. Un nouveau paradigme pour le développement?, Paris, Karthala: 135–152. Delor F., 1997, Séropositifs. Trajectoires identitaires et rencontres du risque, Paris, L’Harmattan, coll. “Logiques sociales”. Demange E., 2010, La controverse “Abstain, Be Faithful, Use a Condom”. Transnationalisation de la politique de prévention du VIH/sida en Ouganda, Thèse de doctorat: science politique, Science Po Bordeaux, Univ. Montesquieu Bordeaux 4 (dir. D. Darbon). Desclaux A., Kouanda S. & Obermeyer C.M., 2010, “Stakeholders’ participation in operational research on HIV care: insights from Burkina Faso”, AIDS, S1 (S 1): S79–S86.

From policies to politics 129 Desclaux A., Msellati P. & Walentowitz S., 2009, “Women, mothers and HIV care in resource-poor settings”, Social Science & Medicine, 69: 803–806. Desgrées du Loû A. & Ferry B., Éds, 2006, Sexualité et procréation confrontées au sida dans les pays du Sud, Paris, Ceped. Durkheim E., 1968, Les règles de la méthode sociologique, Paris, PUF, coll. “Quadrige”. Durkheim E. & Lavisse E., 1916, Lettres à tous les Français, Préface de M. Maffesoli, Paris, Armand Colin. Eboko F., 1999, “Les élites politiques au Cameroun: le renouvellement sans renouveau?”, in Daloz J.-P., Éd., Le (non-)renouvellement des élites en Afrique subsaharienne, Bordeaux, CEAN: 99–133. Eboko F. & Mandjem Y.-P., 2011, “ONG et associations de lutte contre le sida en Afrique. Incitations transnationales et ruptures locales au Cameroun”, in Eboko F., Broqua C. & Bourdier F., Éds, Les Suds face au sida. Quand la société se mobilise, Marseille, IRD Editions: 201–226. Eboko F., 2000, “Risque-sida, pouvoirs et sexualité. La puissance de l’Etat en question au Cameroun”, in Courade G., Éd., Le désarroi camerounais. L’épreuve de l’économiemonde, Paris, Karthala: 235–262. Eboko F., 2002, Pouvoirs, jeunesses et sida. Politique publique, dynamiques sociales et constructions des Sujets, Thèse de doctorat: science politique, CEAN, Institut d’Études Politiques de Bordeaux, Université Montesquieu Bordeaux 4. Eboko F., 2004, “De l’intime au politique: le sida en Afrique, un objet en mouvement” in Vidal L., Éd., Les objets de la santé. Autrepart, 29: 117–133. Eboko F., Abé C. & Laurent C., Éds, 2010, Accès décentralisé au traitement du VIH/ sida. Evaluation de l’expérience camerounaise, Paris, ANRS, coll. “Sciences sociales et sida”. Eboko F., Broqua C. & Bourdier F., Éds., 2011, Les Suds face au sida. Quand la société se mobilise, Marseille, IRD Editions, 400 p. Fabing D., 1998, Peut-on vaincre une épidémie sans traitements?, Mémoire DESS ‘Coopération et Développement’: Université Paris I – Panthéon Sorbonne, Département de Science politique dir. Richard Banégas et Fred Eboko. Gobatto I., dir., 2003, Les pratiques de santé dans un monde globalisé, Paris, Karthala-MSHA. Gueboguo C., 2007, “Sida et homosexualité”, in Eboussi Boulaga F., Éd., l’homosexualité est bonne à penser, Terroirs, revue africaine de sciences sociales et de philosophie, 1-2/2007: 113–130. Highley J. & Paluski J., 2000, “Jeux de pouvoir des élites et consolidation de la démocratie en Europe centrale”, Revue Française de Science Politique, 50: 4–5. Lange M.-F., 2003, “Vers de nouvelles recherches en éducation”, Cahiers d’études africaines, 169–170: 7–17. Larmarange J., 2008, “HIV prevalence estimates: the new deal in Sub-Saharan Africa since 2000”, in Coriat B., Éd., The Political Economy of HIV/AIDS in Developing Countries. TRIPS, Public Health Systems and Free Access, London, Edward Elgar: 169–189. Mbali M., 2005, “La TAC dans l’histoire de l’activisme du VIH/sida basé sur le droit des malades en Afrique du Sud”, Face A Face. Regards sur la santé, 7. http://faceaface .revues.org/301. Niang C., 2010, “Understanding sex between men in Senegal: beyond current linguistic and discursive categories”, in Aggleton P. & Richard P., Éds, The Routledge Handbook of Sexuality, Health and Rights, London, Routledge.

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Njiengwé E.F., 2007, “Malentendus sur le “phénomène homosexuel” au Cameroun”, in Eboussi Boulaga F., Éd., l’homosexualité est bonne à penser, Terroirs, revue africaine de sciences sociales et de philosophie, 1-2/2007: 183–199. Owona Nguini M.E., 2004, “Le gouvernement perpétuel en Afrique centrale: le temps politique présidentialiste entre autoritarisme et parlementarisme dans la CEMAC”, Enjeux, n°19: 12–19. Patterson A.S., Éd., 2005, The African State and the AIDS Crisis, Aldershot, Ashgate Publishers. Pigeaud F., 2011, Au Cameroun de Paul Biya, Paris, Karthala, coll. “Les terrains du siècle”. Pinell P., dir., 2002, Une épidémie politique. La lutte contre le sida en France 1981–1986, PUF, coll. “Science, histoire et société”. Poku N., 2001, “AIDS in Africa: an overview”, International Relations, 15: 5–14. Poku N. & Whiteside A., Éds, 2004, Global Health and Governance, Durban, Heard. Pollak M., 1993, Une identité blessée. Etudes de sociologie et d’histoire, Paris, Métaillé. Smouts M.-C., 2001, Forêts tropicales, jungle internationale: les revers d’une écopolitique mondiale, Paris, Presses de Sciences Po. Tilly C., 1978, From Revolution to Mobilization, Addison-Wesley, 349 p. Tilly C., 1984, “Les origines du répertoire de l’action collective contemporaine en France et en Grande Bretagne”, Vingtième Siècle, Revue d’histoire, 4 (4): 89–108. Touraine A., 1994, Qu’est-ce que la démocratie? Paris, Fayard. Vasseur B., 2011, La démocratie anesthésiée, Paris, Les Editions de l’Atelier. Wieviorka M., 1995, “Plaidoyer pour un concept”, in F. Dubet, & M. Wieviorka, Éds, Penser le sujet. Autour d’Alain Touraine, colloque de Cerisy, Paris, Fayard: 209–220. Wieviorka M., 2008, “Sociologie postclassique ou déclin de la sociologie?”, Sociologies inactuelles, sociologies actuelles?, Cahiers internationaux de sociologie, CVIII, janvier-juin 2000: 5–35.

6

Towards a matrix of public action in Africa Univocal normativity and plural interests

Transnational public action against AIDS, particularly in Africa, illustrates more general political processes. These tend to reveal what constitutes, in the sociological language of Norbert Elias, a relatively standardised configuration of actors (Elias, 2003). Two entry-points provide support for this reasoning. The first focuses on the types of actors involved in multilevel public action since the 1980s, while the second centres on the sectors in which procedures for standardising this public action are put into place, at the international, national, and regional levels of the countries in question. This necessarily synoptic view of the structural recurrences of transnational public action in Africa characterises specific types of actors, presented below. Their relations, strategies, statuses, and their recurring presence in very different sectors – in this case, health, education and the environment – form the basis of what I have chosen to present as the matrix of public action in contemporary Africa. Figure 6.1 presents these actors and institutions in the form of “agencies”, networks, or “epistemic communities”. The actors and institutions in the matrix of public action in Africa are as follows: ••

••

One or more UN or international multilateral organisations. These are the standard-setting and/or standardisation agencies. On the African continent, they mobilise the “international quotas imposed by standardisation agencies and standardisation of social management modes relayed by the interplay of African and non-African actors” (Darbon, 2010, p. 201). One or more Western bilateral development agencies (European or North American). These are the agencies involved in adjustment that repositioned themselves following the fall of the Berlin Wall. They formally accept the New World Order and international directives while trying to redeploy spheres of influence under standard-setting agencies imposed at the multilateral level. In this respect, France, through the now-defunct coopération française, is among the last major industrialised countries to have adopted multilateralisation of public action in Africa. Conversely, the United States, through the American Agency for International Development (USAID), has adapted its will to dominate to the desiderata of multilateral agencies. These

132 A matrix of public action in Africa

Standardisation/ Main epistémic communities (Transnational networks)

Normalisation Agencies International Organizations

Adjustement Agencies Biltateral Agencies/ Foundations

Regulation Agencies

Additional mediations /

Government of˜ices

Main lobbies, private sector

Concertation Agencies /

Implementing, poposal or countr-propossal Agencies International ONGs / Local NGOs

Stakeholders platforms

Figure 6.1 Flowchart of the Public Policy Matrix in Africa.

••

••

“adjustment agencies” correct, emphasise, and support a particular country and its social and political actors in the implementation of international guidelines, often in new ways. A coordination platform for national and international actors present in a particular African State. Coordinating agencies work on administrative and technical procedures for organising the bureaucratic implementation of the public action in question. Depending on the sector, these agencies may follow an agenda defined on the spot, in the African countries of interest. A state structure officially in charge of the implementation of public action in the sector concerned. These are the national regulatory agencies. They are made up of national actors, appointed by presidential or ministerial decree, according to the logic of national and international politics. Depending on the country, this structure may be attached to the relevant ministry (i.e. health, education, or environment), to the Presidency or Prime Ministry of the republic. They are called National Programmes, National Committees, or National Councils and in some cases (e.g. health) they are inspired by the framework of the National AIDS Programmes/Councils/Committees.

A matrix of public action in Africa 133 ••

••

••

••

A so-called “public–private partnership” between State and international structures on the one hand and the companies or foundations involved in the promotion, management, and sustainability of the sector in question, on the other hand. National, or in some cases regional, African associations representing individuals and groups directly concerned by public action in a specific sector. These are implementing agencies which originated as structures created by international or national actors to “make civil society”. Some of them have evolved into counter-proposal agencies. They include patient associations, associations for the defence of the rights of local populations (environment), and parent associations (education). They are national stakeholders linked to international non-governmental organisations with whom they form transnational networks for collective action/mobilisation. A multilateral donor with private donors, such as international foundations in the United States and Public Interest Groups (GIP) in France (e.g. Esther,1 founded in 2001). Each accompanies and supports the work of adjustment and/or implementation agencies, as additional mediators. Public and private networks of experts (universities, consultants, etc.). It’s in this context that one finds epistemic communities, famously defined by Peter M. Haas as follows: “An epistemic community is a network of professionals with recognized expertise and competence in a particular domain and an authoritative claim to policy-relevant knowledge within that domain or issue area (Haas, 1992, p. 4). Bossy and Evrard (2006, p. 140) add that “The notion of epistemic community refers to the channels through which new ideas circulate from societies towards governments and from one country to another”.

This classification, or better, “configuration”, leads to what I have called the matrix of public action in contemporary Africa, inspired by several research questions, two of which are particularly relevant to my argument: •• ••

Which phenomena lead to the gradual construction of the nomenclature? Beyond the communalities underlying the epistemic communities of each sector that have led to a transnational public action in Africa, how do sector variables differ from the modalities and visibility of collective action?

The first question is consubstantial with the historicity of each sector. In the case of health, a socio-historical reading makes it possible to see how the fight against HIV/AIDS helped bring to light the devaluation of pathologies at least as important as AIDS. It also reveals how HIV infection contributed, through collective global mobilisation, to “reclassifying” malaria and tuberculosis on the international health agenda and, as a result, to restructuring the national agendas themselves. Table 6.1 synthesises this matrix, which is constructed on the basis of public action in Africa since the early 1990s. The major mechanism for financing the fight against AIDS in the South, and especially in Africa, is symptomatic

Idem

USAID (United States) – ACDI (Canada) – GIZ (GTZ, KFW) & DED (Germany) – AFD (France), DFID (UK) – JICA (Japan)

Bill & Melinda Gates Foundation − Clinton Foundation

National programmes for the fight against AIDS (PNLS, NAC, etc.) National programs for other diseases

MSF – Act Up – The Union (IUATLD) – GNP+

Adjustment agencies: principle agencies for bilateral development

Major foundations

Regulatory agencies: state structures “Focal points”

Operations agencies for proposals and counterproposals: international NGOs

Ministry of Education and assimilated programmes (Ten Year Programmes for Education and Training)

World Wildlife Fund (WWF) – Plan International (education for girls) – Greenpeace – Conservation Aide et Action (France) International (CI)

Ministerial departments dedicated to environmental issues

Ford Foundation − Rockefeller Fondation Orange (Sonatel in Senegal) − Foundation, etc. Ecobank Foundation, etc.

Idem

UNESCO – World Bank – Islamic Educational, Scientific and Cultural Organisation (ISESCO) – African Development Bank (ADB) – Islamic Development Bank (IDB) – UNICEF

Forest protection The fight against desertification

Malaria Tuberculosis

Access to “quality” mass education Prioritisation of secondary education Cultural adaptation of programmes Scolarisation of girls

Education

Standard-setting / WHO – The Global Fund – The World UNEP – FME – UNFCCC – normalisation agencies: Bank – UNAIDS – UNGASS World Bank international organisations

Biodiversity

AIDS

Subsector

Environment

Health

Sector

Table 6.1 A comparison of public action in three sectors: health, environment, and education.

134 A matrix of public action in Africa

Pharmaceutical companies

Intergovernmental Panel on Harvard School of Public Health Climate Change (IPCC) (U.S.) − London School of Hygiene and Tropical Medicine (U.K.) − Institut Pasteur (network of the Instituts Pasteur) − Agence nationale de Recherche sur le sida et les hépatites virales (ANR) (France) IRD (France) − INSERM (France) − Global Health Initiatives (GHI), etc.

Additional mediators: major interest groups, private actors

Major epistemic communities (transnational networks)

Research Department of the World Bank UNESCO Regional Bureau for Education in Africa – CONFEMEN Programme for the Analysis of Education Systems (PASEC)

Publishing houses – Multinationals (oil industry, Private establishments nuclear industry), Multinationales (industries du pétrole, industrie nucléaire), Commercialisation of timber and non-timber products, etc.

Africa Network Campaign on Education For All (ANCEFA) − World Partnership for Education

The Global Fund Country Coordinating Mechanism

Coordinating agencies: multi-actor, multilevel platforms CNUE

Teachers unions, Parent associations, etc.

National and local associations

A matrix of public action in Africa 135

136 A matrix of public action in Africa of how public action is differentially configured in international power relations. Here, the example of the New Financing Model of the Global Fund represents the achievement of a framework for the contemporary African State.

The ambiguous standardisation of international health action in Africa: a diachronic and multi-sectoral reading So-called “modern” medicine’s answers to health problems in Africa precede the colonial foray by a few decades, as European missionaries brought medical care to the continent beginning in the mid-nineteenth century. The evangelisation project of Protestant and Catholic churches was accompanied by plans for education and health care. Following the carving up of Africa by the European powers at the Berlin Conference (1884–1885) coordinated by the German Chancellor Otto von Bismarck, colonisation accelerated the health imperative through what today would be called “bilateral modalities”. The postcolonial turning-point in the fight against AIDS: rupture and continuity With the exceptional response to the AIDS pandemic, political science finds itself at the centre of efforts to understand the policy issues which the discipline has elucidated for over three decades. The political scope of the fight against AIDS has much to teach us about the downgrading of sub-Saharan Africa. Advances in clinical and therapeutic research on HIV, and then their practical translation (lowering the price of antiretrovirals (ARVs), negotiations with manufacturers of copies of drugs and patent-holding laboratories, subsidies granted to governments and, ultimately, patient care) have made it possible to denounce the downgrading of other public health issues. These critiques of the preferential and quasi-discriminatory nature of the response to the AIDS pandemic in Africa compared to that of more common and equally fatal pathologies have been extended to all of the so-called vertical programmes, i.e. those enacted at the international level and whose agenda is imposed on African States through a top-down perspective. Moreover, accusations about the allegedly deleterious effects of these vertical programmes have made it possible to “reclassify” certain diseases (tuberculosis, malaria) and to expose the failure of health systems that predated the HIV/AIDS epidemic. However, these criticisms and debates, as interesting as they may be from an intellectual point of view, reveal above all the presence of several epistemic communities whose historical, corporatist, and cognitive differences remained hidden under the veil of the “international community” that intervenes in the field of public health. Indeed, the actors at the forefront of the fight against the exponential spread of HIV were among those who were influential in the expansion of the Global Fund to include tuberculosis and malaria. From this point of view, AIDS provided a new window on a plural Africa where international health actors were not the first to denounce the decline hastened by contradictory international injunctions.

A matrix of public action in Africa 137 One such set of injunctions, the Bamako Initiative (1988) led by the WHO to establish “cost recovery” attests to the fairly liberal and counterproductive public health perspective of the World Health Organization’s cognitive matrix with regard to the health of Africans. This WHO perspective preceded the cognitive revolution brought about by the international mobilisation against AIDS throughout the world and then Africa. The resurgence of tuberculosis, the decline in malaria prevention and the rise in infant and maternal mortality during the years of the crisis of the State (1980–2000) are unrelated to the priority given to the response to the AIDS pandemic. As they did in the area of education, the Structural Adjustment Programs (SAPs) callously contributed to the deterioration of the entire field of health in Africa. The SAPs were the first programmes to slow down investments in health and education, under the pretext of rebalancing Africa’s national pocketbooks and in keeping with the neoliberal ideology of “return to growth”. To this day, economists and the media alike, including non-specialists of Africa, hail the positive growth rates in the majority of African countries (Hibou, 2011; Commission Economique de l’Afrique, 2011) compared to the West, whilst the inverse has been true. This “return to growth” is one of the heaviest costs the region has had to pay for international decisions, outside the context of armed conflict. When health specialists outside the arena of AIDS activists blame the fight against AIDS for the devaluation of the importance of other health problems, they are mistaken – or at least prone to misinterpretation. In 2001, it was activists at the first United Nations General Assembly Special Session (UNGASS) on AIDS who successfully demanded that the Global Fund – the idea developed by Kofi Annan and the international community to ensure access to AIDS treatment in the poorest countries – be expanded to include malaria and tuberculosis.2 In the case of tuberculosis, formal access to treatment was not the problem, because treatment had been free since the 1990s. Rather, what changed with the Global Fund were resources and community engagement (as had happened in the fight against AIDS) and a more active monitoring and evaluation process, which in turn enhanced the circulation of information. The contribution of political science A decade of analyses of AIDS public policy, first research in Cameroon and then a comparative approach to several countries, reveals how public action against AIDS can illuminate the web of problems in which States are caught up. In 2001, a synthesis of the social science literature that contributed to understanding these problems was published in the Annual Review of Anthropology (Schoepf, 2001). The author summed up his results by citing a phrase I had coined to describe what I saw in my own comparative research: “AIDS is an acquired political immunodeficiency syndrome” (Eboko, 2000). Ten years later, political scientists repeated the synthesising exercise, by devoting a special issue of Contemporary Politics (Altman and Buse, 2012) to the question of politics in the social science of AIDS. They, too, contributed to a synoptic perspective, in taking AIDS as a political

138 A matrix of public action in Africa object sheds light on other objects. This is especially clear in cross-country comparisons. Hence, as one political scientist noted: The different policy regimes that various African states undertook based on political culture – “the dynamic and heterogeneous ground of collective identities, ideologies, and historical pathways of different political forces” – explains a large part the differing paths Cameroon, Côte d’Ivoire, Senegal, South Africa and Uganda took. (Eboko, 2005, p. 38)3 These two borrowings from political science emphasise the importance of situating the struggle against AIDS within its historical context, both internationally and nationally. Doing so allows us to separate out analyses so partial (in both meanings of the word) and, sometimes, teleological that they identify that struggle as the source of the weakness of other public policies. On the contrary, our reasoning and that of a few others (Moatti, 2011, 2012) consider public action against AIDS a project that should inspire reflections and responses in Africa more generally, other than in health and humanitarianism. Within this paradigmatic situation, we consider that all social sciences who adopt this perspective (of moving from the particular to its political implications), then as now, to be social sciences of the political. They include the political sociology of public action (Hassenteufel, 2011), political anthropology (Dozon and Fassin, 1989, 2001; Fassin, 1996, 2002a, 2002b) and the political economy of AIDS and health (Moatti and Eboko, 2010; Moatti, 2011). Table 6.2 and the paragraphs following it analyse the dissonance between etiological and epidemiological knowledge, on the one hand, and the responses of institutions that have opposed AIDS, tuberculosis, and malaria, at every echelon of multilevel of governance. This table illustrates the place of collective mobilisation in transnational public action. For most African countries, neither the incidence of the disease nor the number of deaths explains the novel status of responses to the AIDS pandemic, compared to other pathologies. Rather, it is the place AIDS occupies in the “transnational world order” that explains this importance. The political history of HIV and its rapid transmission across borders represent essential criteria for understanding the factors which led to AIDS becoming the priority for public action in health in the world, and in sub-Saharan Africa, where the epidemic spread the most. Stakeholders who make a difference Few examples of transnational public action validate the role of “concerned parties” or “stakeholders” in the field of AIDS as much as does that of the so-called “sero-concerned”. These include groups of people living with HIV as well as individuals and groups who are aware of or make explicit claims about the danger of AIDS. Unlike tuberculosis and malaria, familiar to scientists for more than a century, transnational public action against AIDS was shaped, modified, and called

A matrix of public action in Africa 139 Table 6.2 National and international programmes against the three major diseases. Disease

AIDS

Tuberculosis (TB)

Malaria

Scientific discovery of pathogen/ cause of the disease Date of implementation of international programmes

HIV: 1983

Mycobacterium tuberculosis: 1886

Plasmodium: 1880/1897

1986: Global Programme on AIDS (GPA/ WHO) 1996: UNAIDS

Main coordinating bodies

UNAIDS

Organisation and date of first national programmes (in Africa) World Day (date first celebrated)

PNLS − 1986 (Senegal, Uganda)

1998 : Roll Back 2000: Stop TB Malaria (RBM) Partnership Partnership (WHO, 2006: Stop TB UNICEF, UNDP, Partnership and World Bank) (WHO and World Bank) RBM – WHO Stop TB Strategic Initiative 1920: International Union against Tuberculosis and Lung Disease (IUTBLD) 1956: WHO PNLT − 1995 (Côte PNLP − 1995 d’Ivoire) Senegal (1985)

December 1, 1988

March 24, 2008

April 25, 2007

Total number of cases in 2018

1.7 million

9 mill/year (stable) 2 million/year

217 million

Deaths

770,000 (2018)

881,000 (2011) 435 000 (2017)

Proportion of all cases in subSaharan Africa (SSA)

68% of all cases 80% and 70% of new infections

Principle donors

Global Fund World Bank PEPFAR (The President’s Emergency Plan For AIDS Relief) (−) in 33 countries (22 are in SSA) since the mid-2000s 33% decline in deaths since 2000

90% (212 million/247 million) and 91% of deaths (801,000/881,000) in 2017 World Bank Global Fund

Rise (+) or decline (−) in incidence since 2000 in subSaharan Africa (SSA)

World Bank European Union Global Fund

(+) since 1980−1990

Sources: UNAIDS, WHO, UICTMR, Roll Back Malaria, Stop TB

(−) since beginning of 2000

140 A matrix of public action in Africa into question by collective mobilisation. This was built through a social movement, in the sociological meaning of the term (Touraine et al., 1984; Mann, 1991; Fillieule and Péchu, 1993) in the global North, and then more gradually in the global South (Eboko, Broqua and Bourdier, 2011; Patterson and Stephens, 2012). The matrix of these mobilisations is embodied in the struggle against stigmatisation of homosexual individuals, who were doubly victimised by the disease when the epidemic began. Their struggles (Broqua, 2005) constitute the basis of successive and simultaneous transformations of collective mobilisation and public action against AIDS. In other words, the response to AIDS, more than to any other disease, was constructed in the global North as “a political epidemic” (Pinell, 2002). The fact that in many countries, and in all of the developed countries, the agents who built the major AIDS organisations share the status of belonging to a historically stigmatized social minority [homosexual] is a first in the history of epidemics. This particularity determines the character of the social responses to the scourge, because at the political level, it connects de facto the problem of AIDS to the issue of the place of homosexuality in society. (Pinell, 2002: 9) Africa, between a global priority and a lowered status in the world Reception of the translation of this mobilisation on the African continent was different than in the West because from 1985 AIDS was described in Africa as a “heterosexual” epidemic. Nonetheless, in representations of AIDS as a global emergency, Africa was the weak link, the most vulnerable and weathered, in the worldwide chain of transmission of the epidemic. THE GLOBAL FUND’S NEW FINANCIAL MODEL: BETWEEN TUTORING AND GUARDIANSHIP?

The international financial crisis and the crisis of governance in the executive branch of the Global Fund (Pizarro, 2012; Global Fund Report, 2012) created a counter-current to a period that had been full of hope for sub-Saharan Africa, the world region most affected by the HIV/AIDS epidemic. The paradoxical juncture of international uncertainty, the “return to economic growth” in African States and the exceptional progress of international and national responses to HIV/AIDS depicted a completely novel context after the 2000s. The international financial crisis happened at a time when Africa had reached the end of the tunnel of the economic crisis (strictly speaking) and during the period when, along with its international partners, it had made remarkable progress in the fight against the three priority diseases. Between 2002 and 2012, “a record number of 2.3 million people (in sub-Saharan Africa) gained access to HIV treatment” (UNAIDS, 2012), with an attendant gradual increase in cost (Pizarro, 2012, p. 12). In this context, the World Fund had faced the concurrence of two types of crisis since 2009: the embezzlement of almost 75% of the funding for Mauritania (sub-Saharan Africa)

A matrix of public action in Africa 141 and the crisis in governance at the Global Fund Secretariat in Geneva, against the backdrop of the international financial crisis. Wealthy countries justified their decreased donations (a more-or-less 30% drop) by the poor use of Fund resources, although audits showed a generally small loss of financing in most of the donoree countries (less than 1%). This period of institutional crisis at the Global Fund was met with some procrastination. Following the suspension of Round 11 in 2009–2010 the resignation of the Executive Director (the Frenchman, Michel Kazatchkine) in 2012, and the rejection of a series of funding applications, the New Financial Model was finally established in 2014. After a year of elaboration, the model was proposed to the different actors responsible for letting grants. These were assembled under the Global Fund’s Country Coordinating Mechanism (CCM) in each beneficiary country. These became the “matrix of public action” and assembled different types of actors and institutions. This very tight accompaniment of the grant process was manifested, from start to finish, through the most developed version of a framework for the African State. The New Public Management is conceptually framed as a model of public action founded on “performance-based financing” and a minimal bottom-line risk of failure, given that the funding agency is a partner in the preparation of the application, has inspired it and has validated it throughout the process. Since its inception, the Global Fund has been led by four prominent individuals. Two medical professors succeeded each other as Director: the American Richard Feachem (2002–2007) and the Frenchman Michel Kazatchkine (2007– 2012). The Briton Peter Sands was appointed Executive Director of the Global Fund on November 17, 2017. He succeeded the American physician, Mark Dybul and officially took office in March 2018. Sands, an international finance specialist and graduate of Harvard University,4 was the first non-physician to lead the Global Fund, if we except another financier, the Brazilian Gabriel Jaramillo, who held an interim position between 2012 and 2013, the period corresponding to the beginning of the New Funding Model (NFM) implemented in 2014 (Tchiombiano, 2019). Since 2002, the Global Fund has raised and spent US$27 billion (€23 billion), of which 50% has been spent on HIV/AIDS, 32% on malaria, and 18% on tuberculosis. It is estimated that this money has saved 22 million lives and resulted in a 30% reduction in HIV-related mortality. Between 2017 and 2019, the Fund invested US$14 billion to “save 14 million lives”. While France maintained its contribution above €360 million over this period, the Reconstitution Conference is of crucial importance, particularly because of the 18% drop in funding from the United States of America, the largest contributor.

Malaria and tuberculosis: clash in the time of AIDS By creating the Global Fund against HIV/AIDS, tuberculosis, and malaria in 2002, the international community was trying to reduce over a century’s worth of contradictions brought to light by the discovery of and responses to the AIDS pandemic. Malaria and tuberculosis were thoroughly identified on the African

142 A matrix of public action in Africa continent by the end of the nineteenth century. But it was the international architecture of the fight against AIDS that spelled the official end of the AIDS exceptionalism, internationally and in Africa, and allowed for the construction of a global response that “integrated” the other two diseases, at least formally. The fight against malaria: from demotion to promotion Malaria represents the exemplar of the relationship between health and the environment. It affects principally those areas that are at once hot and humid. It is worth recalling that malaria’s eradication in the countries of Europe, especially France, was achieved only in the 1950s. The marshes of Poitiers, like those of Corsica, were fertile grounds for malaria; it took environmental actions (the draining of swamps, spraying of insecticide in malaria-infested zones, etc.) to eradicate the disease in France. In African countries, colonial-era campaigns focus on the environment and only partly on the treatment of patients (Bado, 2004, 2007). Chloroquine-based treatment, which constituted the basis of the therapeutic response throughout most of the twentieth century, was hampered by two obstacles. The most important was – and remains – the development, over several decades, of plasmodium’s chemical resistance. The resistances rendered chloroquine-based treatment ineffective in endemic transmission zones. The second type of resistance lay in the vector itself, which developed chemo-resistance to domestic and industrial insecticides. Urbanisation is one of the factors that contributed to reducing the presence of the anopheles mosquito, which requires shelter (vegetation) and humidity (bodies of water, stagnant water, etc.). In fact, regions can be divided according to several “epidemiological profiles”. Certain inter-tropical countries of Africa contain several “epidemiological profiles” that change from the North to the South of their respective territory. For example, Cameroun sits at the convergence of several geographical areas: the Sahel, the savannah, forests, and the Atlantic coast. The extreme North, in the Sahel, is characterised by a short malaria transmission period of three months, and the population, for this reason, possesses only a weak immunity to the parasite. During this period, the most vulnerable individuals (pregnant women and children under age five) are exposed to the risk of severe forms of malaria, even though the exposure rate to anopheles bites is relatively low compared to the rest of the country (an average of 20 stings per person per month). The classification of the exposure to stings and immunity to the parasite changes the further South one goes. The savannah region and the plateaux (the Adamawa) experience a seasonal transmission of the risk for malaria, with an average of 50 stings per month per individual over a six-month period, and a moderate parasitic immunity. In the country’s South, so-called perennial transmission (over 12 months) and parasitic immunity are strong, despite an average of up to 100 stings per person per month, throughout the year (Eboko, 2006). Thus, the major issues surrounding the fight against malaria were: the obsolescence of chloroquine-based treatments, weak environmental measures, and the change in care following the WHO-led Bamako Initiative (1988) strategy of

A matrix of public action in Africa 143 recuperating costs by forcing patients to pay for care in African health facilities (Gruénais, 2001). In fact, after the independence of African States, malaria represented about 40% of public health expenditures in sub-Saharan Africa. At the same time, 20 to 50% of patients entering health facilities in the region were suffering from malaria, and the disease consumed more than 10% of household expenditures every year.5 This is very different from the responses to AIDS and tuberculosis, whose recurrence is linked to the process of deterioration of African States and their health systems. The malaria specialist Muriel Same-Eboko notes the following: From the moment AIDS was no longer considered a marginal illness, the perception of the new global pandemic affecting societies in the global North and South took on dramatic proportions. But although malaria constituted a chronic disease in Africa and Asia, it was perceived as a trivial issue, just one widespread disease among many others in the Third World. In addition, the irreversible character of HIV infection was contrasted with the transitory character of a malaria episode which, if treated correctly, could lead to a definitive cure, with no repercussions. (Same-Ekobo, 2010, p. 3) However, it was the institutional modalities of the fight against AIDS that restructured the fight against malaria in Africa, by creating previously unheard-of national programmes almost a century after the disease was formally identified on the continent. As Same-Eboko (2010, p. 3) stressed, the fight against AIDS acted as a “trigger” for renewing the fight against malaria at the international level. It is possible to identify the moment of transition from AIDS as a priority to an approach that integrated it with the major international health problems in low-income countries. The transition embodied by Gro Harlem Brundtland This paradigm shift is embodied by Gro Harlem Brundtland, Director of the WHO from 1998 to 2003. Beginning with her inaugural speech, she launched an appeal for integrating downgraded and neglected diseases, especially tuberculosis and malaria, into international priorities. The Roll Back Malaria programme originated in this context, at least at the level of the WHO. UN Secretary-General Kofi Annan picked up the ball in 2000–2001, by including the diseases in the Millennium Development Goals (MDG). Few authors, however, highlight the role played by civil society’s transnational mobilisation against the pharmaceutical industry around the issue of ARV patents or the influence this had on pharmaceutical policies concerning malaria treatment. In fact, it is through the development of a response to the pressure of NGOs for access to AIDS drugs that pharmaceutical companies began to introduce new molecules against malaria. ACT (Artemisinin-based Combination Therapy) was introduced through a series of almost revolutionary bi-therapies, thanks to the “discovery” of artemisinin.6 This treatment represents the first time

144 A matrix of public action in Africa in the history of malaria that a drug produced no resistance. Given the breadth of the mobilisation against the pharmaceutical industry and the lawsuits filed against the latter in South Africa and Brazil, these pharmaceutical companies anticipated similar debates by negotiating fixed prices for malaria drugs, after agreements were signed with the WHO. ACTS using various combinations of artemisinin and other molecules was sold under numerous brand names. When they negotiated lower prices for ARVs with African States like Senegal, in 1999, and Cameroon, in 2001, the pharmaceutical companies acted as an oligopoly to tie price cuts to “secret” agreements for something in return. There is a strong probability that the agreements prohibited challenging the patents, even in the future. ACT prices ranged from US$1.2 to 2.4; that is, ten times the price of usual treatment.7 By assuring their monopoly on ACT and marketing it in most countries with high incidences of malaria, the pharmaceutical companies have been able to recuperate what they conceded in the case of ARVs. Taking the example of Senegal and Cameroon, where the malaria incidence is much higher than for AIDS, this represents an undeniable economic gain, yet some patients still do not have access to these costly treatments. The discovery of the efficacy (80%) of pesticide-treated mosquito nets also raised hopes for prevention, especially for vulnerable groups (pregnant women and children under five). Problems nevertheless remain at the level of the spread, use, and regulation of programmes for the distribution of treated mosquito nets, although there has been constant progress since the 2000s. In 2010, GlaxoSmithKline (GSK) decided to provide the scientific research community with a list, at no cost, of 13,500 active molecules against plasmodium falciparum. The profits gained by the pharmaceutical companies that hold patents for the commercialisation of ACT and the weak transnational mobilisation in this area attest to the presence of several epistemic communities within the international health “community” governed by WHO. The Organization has been increasingly side-lined in its co-actor role by large companies, foundations, and NGOs driving the initiatives that promote their interests. The fight against tuberculosis follows a similar logic. Fighting against tuberculosis neck-and-neck with HIV-BK co-infection While malaria represents a pathology strongly linked to the environment, especially hot and humid biotopes, tuberculosis is typically a social disease. Paradoxically, few authors in the social sciences have shown interest in this disease which, like AIDS, depends on networks of sociability linked to particular life conditions. Unlike HIV and malaria, a vaccine, the BCG, exists for TB.8 Even if its effectiveness is only partial, it does prevent severe episodes and death following contact with Koch’s bacillus, which is at the root of the infection. The anthropologist Laurent Vidal was a precursor in approaching tuberculosis through the dual viewpoint of the social sciences and its intersection with public health (Idrissou et al., 2010; Vidal et Kuaban, 2011). Hence a vivid

A matrix of public action in Africa 145 paradox, which tells us much about discourses on health in Africa in light of the globalisation of public policy, particularly in the plural domain of scientific research. The link with the crisis of health systems and, more generally, the economic crisis is even more striking than in the case of malaria and AIDS. The fact that 40% of tuberculosis patients are infected with HIV shows the link between the vulnerability of individuals, health facilities, and the environment. Although it is not a magic bullet, the TB vaccine does prevent the most severe cases of tuberculosis after contact with the Koch bacillus. The weakening of the immune system of people living with HIV exposes them to opportunistic infections, of which tuberculosis is the most frequent one in Africa, in a context of crisis in health systems that exceeds that of health facilities. The impact of AIDS programmes opened a paradoxical window of opportunity, an “absurd chance” constructed by the institutional apparatus and human resources affected to the care of people living with AIDS. Although the two programmes were distinct and parallel (except in a few cases, like in Côte d’Ivoire, which merged its two programmes in 1995), health personnel took advantage of the collaboration between hospitals to compensate from the ground up for the weakness of institutional partnerships between AIDS and tuberculosis programmes (Idrissou et al., op. cit.). The argument that formal awareness at the international level is low is not bolstered by facts, because the official policy of free anti-tuberculosis treatment existed long before AIDS treatment was free. The basic difference between response to the two diseases is explained by several factors: the poor circulation of information directed to tuberculosis patients; negligence of the rights of patients, faced with the health system breakdown; and finally, almost non-existent follow-up care for patients under treatment, which must last at least six months. Given that symptoms disappear during the first months of treatment, patients whose families hardly help them, if at all, with treatment compliance tend to stop taking the medication. The resulting resistant forms of the disease are the principle reason for the new “epidemic” of tuberculosis. Drug-resistant tuberculosis is a constant danger for public and individual health, a ticking time bomb of sorts. There can be as much as a decade between early treatment cessation and the return of symptoms. At this later stage, older medication is met with resistance. The transmission of a bacillus that is resistant to classic treatment further complicates the public health response, while signalling the obstacle course faced by the patient with acute pulmonary conditions that can indicate the beginning of the end. To date, several organisations, like Doctors without Borders (MSF) and the TB Alliance, along with Sanofi Aventis, have mobilised to find new treatments against multi-drug resistant and ultra-resistant tuberculosis, resulting in clinical trials. In other words, only 20% of patients afflicted with resistant TB and living in poor countries have access to effective treatment. The classic treatment consists of the administration of a quadritherapy (isoniazid, rifampicin, pyrazinamide, ethambutol) during two months, followed by a biotherapy (isoniazid and rifampicin) for four months.

146 A matrix of public action in Africa In 2013, two molecules, bedaquiline and delamanid,9 became available for compassionate use, thanks to the mobilisation of MSF and others. The absence of early diagnosis and rapid therapeutic protocols penalises the overall response.10 Evil is at the source When monitoring arrangements established for HIV-infected patients to lessen “loss to follow-up” are compared to those put in place for tuberculosis patients, a dramatic inequality treatment compliance becomes evident. In the first case, the patient’s therapeutic and social path is observed by a string of new workers (psychosocial counsellors, community outreach workers, social workers, psychologists, etc.), and a single absence from an appointment triggers an investigation. In the second case, compliance is rarely monitored. TB patients who stop treatment prematurely are therefore in need of a follow-up at least as intensive as that of HIV-infected patients. Once again, AIDS seems to receive more attention than other pathologies. It is worth recalling the nearly absurd context in which tuberculosis is treated. Close patient monitoring, including home visits, was actually invented as part of the response to tuberculosis, in the context of the WHO strategy known as “DOTS” (Directly Observed Treatment, Short-course). While this strategy has been taken up and reinforced in the context of monitoring patients on antiretroviral drugs, it has been flawed and largely abandoned in the context of monitoring patients on anti-tuberculosis drugs. The resurgence of tuberculosis in the time of AIDS has highlighted the urgent need to strengthen the response to tuberculosis control (the so-called “DOTS-plus” strategy) because of the multi- and ultra-resistant forms of BK and also HIV-TB co-infections. This is illustrated in Figure 6.2. The extent of the collapse of preventive measures through vaccinations put into place in the early 1980s in Africa is illustrated by Figure 6.2. This reckless public health failure is directly linked to the crisis of the State (Médard, 1992) and to the Structural Adjustment Programmes (SAPs) that were supposed to put an end to this “crisis”. Figure 6.2 shows the concatenation of vulnerabilities experienced by African populations faced with the “double penalty” (Vidal and Kuaban, 2011) of HIV and TB linked to the reduction of the reach of the State imposed by the

Population HIV-infected adults New tuberculosis cases HIV- infected new tuberculosis cases HIV/M tuberculosis coinfections

Figure 6.2 Disproportion of HIV-TB co-infection cases and TB cases among Africans populations in 2000. Source: Corbett et al., 2006

A matrix of public action in Africa 147 International Monetary Fund and the World Bank. Africans account for one tenth of the world’s population, seven tenths of people living with HIV, one tenth of new TB cases, more than eight tenths of new TB infections in HIV patients and, finally, eight tenths of cumulative HIV-TB co-infections worldwide. Defined as the social disease par excellence because of its mode of transmission (airborne contagion), which is a sign of the “mystique” of proximity or, worse, of close quarters, tuberculosis illustrates more than any other pathology the collapse of the mechanisms of prevention, care, and monitoring of people suffering from communicable diseases. The dynamic set in motion by the global programmes to fight AIDS – from the Global Programme on AIDS to UNAIDS – inspired a framework for the fight against tuberculosis with the “Stop TB” partnership founded in the early 2000s. A paradox among paradoxes, an aporia within international contradictions, tuberculosis is nevertheless at the origin of the internationalisation of policies to fight against communicable diseases and for the availability of free care, although the first patients to benefit were affected by the policy dysfunctions. The global response to AIDS provided an institutional example on which to base the response to the tuberculosis epidemic, by showing the contrast between a “pandemic” (AIDS) and an epidemic of the poor whose epistemic communities developed projects in the same space where others had invented one of the most ambitious mechanisms for international solidarity. It is in this context that the issue of access to health care and prevention for Africans underwent a major transformation, when the United Nations General Assembly adopted a resolution on Universal Health Coverage (UHC) in December 2012. This project is ambitious, and its implementation faces obstacles that make it important to carry out a political analysis of its construction, in conjunction with several other approaches (health economics, public health, socio-anthropology of health, development, etc.). The difficulties affecting health care access in sub-Saharan Africa are recognised and need to be overcome. The UN resolution is part of the dynamic in which the WHO Assembly had already taken a significant step forward, when it passed Resolution 58.33, in 2005. After an abundant literature attempted to show that direct payment for health services by users was a barrier to access to care, WHO recognised and encouraged its members to break with the ideology of direct costs borne by patients. The Resolution noted that “every individual should be able to access health services without facing financial difficulties”. In other words, the principle of exemption from direct payment was proclaimed for the most vulnerable and in situations where the price to be paid would represent a “catastrophic health expenditure” for the patient and/or their family. A major characteristic of universal health/health coverage is its objective of shedding light on the very different national trajectories of countries, including in sub-Saharan Africa, where a few countries have initiated this public action since the 2000s. Ghana (Agyepong et al., 2016), Rwanda (Chemouni, 2018), and Ethiopia (Lavers, 2019) are often cited as examples of very different modalities of universal access.

148 A matrix of public action in Africa One hundred million people fall into poverty because they have to pay for the services they receive. The objective of UHC is to meet the challenge of ensuring that as many people as possible have access to health services. In this context, the historicity of public action in health in African countries must inform us of the political, and not only financial, capacities that govern the gradual implementation of universal health coverage. The need for the State and the bipolar process of public action The diachronic process that divides public action in health between a “statist” period (1960–1980) and a period of post-governmental public action, in which the “strategic” State gives way to a “regulatory” State accompanied by a slew of new actors (1980s–present), can be easily extended to other sectors. In the following section, two sectors are examined to illustrate in a different but highly relevant manner the reconfiguration of the African State within an international multi-localised matrix. Like public health, the educational sector shows how the African State pulled back to the advantage of the international sphere (international organisations and NGOS) and national and infra-national organisations. The environmental sector illustrates the integration of Africa into global debates that translated into public action. Their integration is rooted in Western concerns that began at least three centuries ago and have more involved emerging countries. It is now possible to imagine another phase, after the 1980s, of the process that this book describes as the articulation between “de-statisation” of Africa (Médart, 1992) and what have been described as normalisation policies stemming from “mobile actor networks having different institutional affiliations, capable of producing and disseminating norms and of involving public authorities as one resource for arbitration and sanction among other resources”. (Dudouet, Mercier and Vion, 2006, p. 369) Maurice Enguéléguélé makes more-or-less the same observation about public action in Africa. The few differences between his description in that cited above concerns the limited decision-making autonomy of African States (Enguéléguélé, 2008, pp. 12ff.) It is nevertheless important to avoid falling into the facile binary reading of exogenous versus endogenous. This happens when processes and forums lead to the analysis of the State by public action “forcing, in fact, a questioning of the deeply intertwined pathways and interactions between top and bottom” (Enguéléguélé, 2008, p. 10). Within this logic, public action in Africa should not be considered the receptacle of internationally and/or supra-nationally imposed constraints. Rather, it should be characterised by what anthropologists would call syncretism; that is, “a combination from which it is impossible to separate out the parts” (Amselle, 1990, p. 248). In the sub-Saharan context, as I demonstrated in the chapter on the African State, supra-national actors are also the sources of arbitrage and sanction for

A matrix of public action in Africa 149 national public authorities. The examples of coordination and international regulation of public action at the national level (the Global Fund’s Country Coordinating Mechanism, or CCM; the International Conference on the Environment, Education, AIDS, etc.) embody this dual strategy of constraints and resources.

Education and the environment: contrasting illustrations of the production of standards for transnational public action? Education: selling schools at a discount after the Africanisation of managers? Public action in the education area follows the same timeline as the matrix of action in Africa described above. Marie-France Lange, an expert in educational policy in sub-Saharan Africa, has confirmed what has been shown for health: From the 1960s to the 1980s, the African State was significantly involved in developing school systems. Some countries nationalised all of the private schools; others experienced a growth in public schools. The State was everywhere present, leaving few initiatives to other actors. Associations played an insignificant role, NGOs rarely intervened in the school system and the funders had only a moderate influence on educational policy and the financing of reforms (Lange, 2002, p. 37). Ever since the Independence era, African governments had perceived schools as the centre of nation-building and the foundation of all economic development (Bierschenk, 2006, p. 268). It is the UNESCO-sponsored 1961 Conference of Addis Ababa on extending education in Africa – later called Education for All (EFA) – that enacted education as a political object. “The discourse on schools was mainly political, harkening back to the State and the nation and attributing to teachers a central role as change agents” (Bierschenk, 2006, p. 269). The changes that began in the 1980s were followed by the collapse of education budgets without a corresponding fall in demand. The rise of mass education,11 which began after independence, was replaced by the school crisis. In the case of health, as in education, there was what Dominique Darbon calls “an under-managed Africa” (Darbon, 2001). The SAPs only amplified the process. Education in Africa today is subject to a global structural policy led by the World Bank. Reaffirmed at the Jomtien Conference in 1990, Education for All is defined as a global objective, whose justification is both moral and economic. According to education economists (Mingat, 2003), equity and efficiency in education are complementary, not mutually exclusive. The World Bank and NGOs entered the fray with a standardisation of education policy in the most poor and vulnerable countries. Although the 1960s witnessed the dual movement of respect for historical specificity12 and conformity to education models from the respective colonial

150 A matrix of public action in Africa administration, with emphasis on training managers, the standard proposed by funders responded to other necessities. For example, the previous 1960–1980) scholarship system for higher education at national universities and abroad was replaced by a policy constructed by international organisations that privileged secondary education (Lange, 2002, 2003). “Replacement” here actually refers to the shift from bilateral development to financial supervision by the Bretton Woods institutions of countries supposedly being “re-adjusted”. For the funders, the goal was to try to reduce the social impact on education and health from the drastic economic policies imposed on African States. In the case of education, it was a question of softening the phenomenon of de-schooling that hit African societies in the late 1980s, especially in the most disadvantaged context, namely that of rural areas and of girls who in certain social groups were subjected to the choice of parents who could not send all of their children to school: The period of de-schooling was followed by a period of re-schooling in most African countries. This quantitative evolution took place concomitantly with the implementation of liberal policies […] that triggered a diversification in the education field […]. Educational issues diversified and complexified because of the intensification of family competition to control the education of their children, and of the appearance of new actors. (Lange, 2002, p. 38) The Education for All initiative that set the goal of universal schooling by 2000, was affected by structural adjustment. The education policy driven by the World Bank and the IMF made allowances for an “adjustment with a human face”, conditioned by the lowering of costs for African States (Samuel, 2013). Bilateral development agencies, private educational enterprises, NGOs, funders, and States put together forums equivalent to those known in other sectors. This ensemble was represented in the establishment of “global conferences”, with the one on education taking place in 1990, at Jomtien (Thailand) and followed up by the one in Dakar, in the same way as the better-known conferences on the environment and AIDS: The international consensus on the priority of education also legitimises an increasing interventionism in the countries of the South by funders in this sector, which in turn generates strong tendencies towards homogeneity and uniformity, but also towards the diversification of actors and institutions. (Bierschenk, 2006, p. 271). Since the Sixties, the perspective on school and education on the African continent shifted from an elitist, political paradigm (the UN project and the training of elites) to a global, hegemonic discourse produced by funders (the World Bank and the IMF), that positioned the African States as recipients of norms produced at the international level (see Table 6.3).

A matrix of public action in Africa 151 Table 6.3 Major education sector conferences in Africa. Themes

International conferences

•• Access to •• Addis Ababa (1961) education •• Jomtien (1990) •• Quality of •• Declaration of Dakar education •• Governance

National programmes

Major funders

•• 1996: Ten- Year Programme for Education and Training (PDEF, Senegal) •• 1999: Ten-Year Programme for Basic Education (PDDEB, Burkina Faso) •• 1998: Ten-Year Programme for Education (PRODEC, Mali)

•• •• •• •• •• •• •• •• •• ••

The World Bank UNESCO UNICEF AFD/ French Development Agency USAID JICA ACDI USAID BAD BID

Source: Hugon, C., unpublished manuscript, 2014

The victory of a two-pronged cognitive approach: desolation and pragmatism for education in Africa? The big problem posed by restructuring and standardising education policies goes hand-in-hand with the very definition of education. In fact, as the authors of Savoirs et politiques du développement (Knowledge and Development Policy) note: Educational systems vary as a function of a country’s structures of production because there are no universal processes for education. Therefore, there is a risk to privileging only primary education in a global economy founded on knowledge which forces countries, even the poorest ones, to acquire technical training of the highest quality. (Géronimi et al., 2008, p. 19) It’s euphemistic to speak of “risk” when trying to account for the choice of privileging primary school to the detriment of an entire educational trajectory that culminates in reinforcing universities and other institutions of higher learning to train African executives and managers. Sophie Lewandoski’s critical analysis perfectly sums up the process of cutting off African actors from the educational policies that concerned them: In the specific context of the internationalisation of education policies in subSaharan Africa, the monopoly of the definition of notions about knowledge, education and social change comes back into play. The distance between the entity of the State and the weakest social groups has increased, especially

152 A matrix of public action in Africa because of funders and certain individuals situated at the interface of norms. Multilateral organisations in particular have an important capacity for producing knowledge and discourses that are negotiated and revisited at the interface with certain actors (marabouts, State agents, NGO directors, and experts), but not with grassroots actors who often are not even aware of them. For example, many teachers have never heard of Education for All policies and are totally ignorant of the official justification for using volunteers in education, which they condemn. Social inequality between groups in the construction, access to and negotiation of international norms for education reinforces and restructures pre-existing inequalities. (Lewandowski, 2011, pp. 42–43) Liberalism-inspired school policies aim to produce social and economic agents equipped with the minimal proficiencies needed for the functioning of a market economy: basic reading, writing, and numeracy. Beyond this deliberate caricature, the return of the State, this new State embedded in multi-actor configurations, can, in certain situations, trigger new dynamics closer to internal issues (adaptation or creation of curriculums as a function of specific demands and needs) and global dynamics. An example is the establishing of private and public institutes of management in higher education, in most African countries. These new structures signal a paradigm shift in the training of African elites that Boubacar Niane brilliantly sums up, by presenting a system that went from “énarques13 [administrative élites] to managers” (Niane, 1991). After the administrative elites in most Francophone African countries were educated in the National Schools of Administration and Magistracy, a new group came on board in the mid-eighties: “managers, engineers, ‘captains of industry’ who never stopped believing in the ruling institutions comprised of governments, National Assemblies, parastatal agencies” (Niane, 1991, p. 46). This observation, based on Senegal, holds for most Francophone countries. It reveals a cognitive change through which neoliberal thought wins. This explains the growing dominance of the training for administrative managers whose higher education is costly and oriented towards a utilitarian and/or Anglo-Saxon pragmatic model. It has replaced an education that the best African students were able to pursue, with the benefit of scholarships, in their own country or abroad. In another remarkable book, Boubacar Niane denounces “proxy elites” (élites par procuration) (2011), who are trained according to a model that depoliticises public action and conforms to the doxa of international organisations, via the “adjustment agencies” of bilateral development.14 In short, the priority given by the World Bank and other funders working according to the logic of “normalisation and standardisation agencies”,15 which involves accepting the social inequalities that determine the access to resources (higher learning), according to a pragmatic logic. The issue of environmental protection, to which I now turn, also provides the outlines of the matrix of public action in Africa in a globalised world.

A matrix of public action in Africa 153 Environmental preservation: from the conservation paradigm to the dynamics of sustainable development Two themes emerge in the global history of public action for environmental protection: the conservation/preservation paradigm and the sustainable development model that challenged it. Environmental issues and transnational aspects relative to the protection of biodiversity are well-documented in the social sciences. The relevant studies continuously articulate what is at stake internationally, nationally, and locally, according to specific focal points: NGOs, the so-called question of governance, contradictions between different paradigms, the contrast in the evolution of priorities, placement on different international agendas of certain subsectors at the expense of others (Aubertin, 2005; Dumoulin and Rodary, 2005; Compagnon, 2005; Cormier-Salem 2006). A synoptic and necessarily partial reading of this literature reinforces the guiding hypothesis of inter-sectoral comparison focussed on the central role played by actor coalitions. The hypothesis can be expressed as follows: transnational public action in contemporary Africa is a function of the interests and the power of transnational epistemic communities and the coalitions between these communities and transnational networks that traverse (or not) African States. What follows takes up the evolution of public action that, as I mentioned earlier, is anchored in much older concerns, but is a function of the modification of paradigms at the international level and of the new ecological, social, and political stakes concerning biodiversity in contemporary Africa. The conservation paradigm: the trans-nationalisation of an old public action In Europe, environmental movements for the conservation of flora and fauna have existed since the seventeenth century. Colonial penetration, especially British, built the bridge that allowed the conservation paradigm to move from Europe to Africa. In the United States, a second conservation paradigm originated independent of the first. Its theme crystallised in debates between “conservationists” and “preservationists” in the second half of the nineteenth century (Dumoulin and Rodary, 2005, p. 61). This double dynamic of the British colonial Empire and American lobbyists gave birth, at the end of the nineteenth century, to the first protected areas in sub-Saharan Africa. The main actors of this trans-nationalisation of nature conservation were British and American NGOs founded simultaneously in the last two decades of the nineteenth century. In the United States, the Audubon Society was founded in 1886, the Sierra Club in 1892, and the New York Zoological Society (known today as the Wildlife Conservation Society, or WCS) in 1895. This last NGO is “one of the most active in the conservationist movement” (Dumoulin and Rodary, 2005, p. 61). Conservationist activities were extended to natural parks and protected areas. In doing so, the associations integrated the interests of certain stakeholders – aficionados of safaris and hunting on the African continent – and who were very

154 A matrix of public action in Africa present among Europe’s political classes. Only recently, with the increase in poaching and the recognition of the endangerment of protected species, and more broadly, the theme of preservation and biodiversity, has this activity been subject to the critical gaze of “international civil society.16 The first game reserves, forest reserves and national parks appear and are disseminated as tools for sectoral action during this period, especially in North America and Anglophone Africa. The reserve was thus a dominant form of utilisation of space that was to be protected. It authorized the exploitation of some natural resources, like game and wood, and prohibited extracting others. The first phase was thus not “preservationist”, in the modern meaning of the word, because use of certain resources was authorised in the reserves. Only with the spread of national parks did total prohibition of resource extraction begin. (Dumoulin and Rodary, 2005, p. 62) Outline for an international organisation at the beginning of the twentieth century The internationalisation of environmental public action has its roots in the period between 1900 and 1945, with the amplification of the ties constructed by the conservationist movement and repeated efforts to found an international movement. These culminated in 1947 with the creation of the International Union for the Protection of Nature (IUPN). In 1956, the organisation was given its current name, the International Union for the Conservation of Nature (IUCN). Several organisations participated in its creation, including twenty-four national delegations, the International Council for Bird Preservation – United Kingdom (ICBP), UNESCO and the UN Food and Agriculture Organization (FAO). Up until the end of decolonisation in the 1960s, the IUCN was the tutelary authority for nature protection. The arrival of a new generation at the UN in the 1960s presented an alternative. Thus, in 1961, the World Wildlife Fund (WWF) was founded for flora and fauna, with the goal of collecting funds and creating partnerships ties between decisionmaking organs in the global North, particularly in Europe. Today, this NGO is considered “the most important symbol of this globalised sector” (Dumoulin and Rodary, 2005, p. 64). Vacillations between “scientific communities” and “epistemic communities” As in the case of AIDS, the US Agency for International Development (USAID) is the most powerful of tools for bilateral development in this environmental area, because it is the major funder of “conservation”. USAID rests on an oligopoly of mostly American NGOs that it favours through its grants. Although marginalised by the rise of the “development” paradigm, compared to which they seemed figuratively landlocked, conservation proponents returned with a vengeance, thanks to a 1980 report, the World Conservation Strategy (Dumoulin & Rodary, 2005,

A matrix of public action in Africa 155 p. 83). The publication was part of the more general development framework for natural resource management. Within this configuration, the IUCN participated in the creation and reinforcement of an epistemic community, thus adhering to international influence in transnational public action: These cross-collaborations favor the development of expertise and the multiplication of specialised agencies in the construction of global knowledge of biodiversity. This is the case of the expertise of the World Resources Institute (WRI) and the World Conservation Monitoring Center (WCMC) created by the IUCN, UNDP and the WWF. The placement of the biodiversity issue on the global agenda was accompanied by larger numbers and by the displacement of the former epistemic community [already affected by obsolescence]. (Dumoulin and Rodary, 2005, p. 77) The 1970s, it should be recalled, corresponded to the period in which the “planning State” possessed relative autonomy in the conception and implementation of public works. This was also the period when larger movements for environmental protection emerged, beyond conservationist lobbies. More oriented towards the issues of “development” and “humanitarian aid”, these dynamics produced a political critique of conservation, which was accused of not taking into account the well-being of populations in the global South. In this spirit, NGOs played an important activist role to assure that biodiversity would be placed on the international agenda and that NGOs themselves would be in charge of implementing international environmental public policy (Chartier and Ollitraut, 2005, p. 39). The roles taken by these NGOs overlapped with a variety of forums, arenas, and networks within the biodiversity field: NGO members of State delegations during international negotiations, NGO protestors in counter-forums, local NGOs surviving with just a few volunteer members, NGOs with offices sprawled all over the planet and a business management style, NGOs for the environment, development or human rights. (Chartier and Ollitraut, 2005, p. 41) The NGOs of the 1980s more-or-less fit the definition of “epistemic communities” when they adopted the position of “scholar-activists” (Pouligny, 2001; Chartier and Ollitraut, 2005) and through coalitions that brought together activists and academics. The fall of the Berlin Wall led to the rise of NGO “eco-power” (Lascoumes, 1994) in the configuration of the New World Order. This was also a period when epistemic communities and stakeholders were polarised over the issue of “sustainable development”, without there being either a completely shared set of priorities or a coherence in international agendas, given the diversity of actors and interests. According to Chartier and Ollitrault (2005, p. 27), “these rifts evidence the struggles these organisations went through before the funding agencies to justify their identity and build what public and private international donors would view as trustworthy social capital”.

156 A matrix of public action in Africa The South and the danger of global warming: a “double penalty” for Africa? The question of global warming provides a masterful symbol for illustrating the ambivalent position of the so-called “countries of the South” within the world order. Contrary to the institutional responses for fighting communicable diseases, developing countries have not been at the centre of the concrete concerns of international actors. The consequences of global warming, notably due to greenhouse gas emissions, affect primarily the countries emitting industrial pollution. Yet they could not reach a consensus, and two of the main industrial nations, the U.S. and China, never signed the Kyoto protocol for reducing greenhouse gas emissions. The “Earth Summits” held since 1972 illustrate the disagreements which countries in the South are in some way the collateral victims of. The “Earth summits”, at the height of confusion During the Rio+20 summit in 2012, no consensus was reached on the connection between “sustainable development” and “ecological constraints”. This situation created the risk of a status quo that would neutralise change efforts against the consequences of global climate change. In the end, no “Earth Summit” escaped the fact that a configuration of actors representing industry, economic and political interests displaced risks that were known and documented. Countries situated in or below the tropics had been subjected to ecological constraints for decades, without adequate measures ever being taken. In this context, the Rio Earth Summit of 1992 was already poised to alert and act to reduce desertification, deforestation, drought, and flooding. Like in other “social sectors” of international public action, French political science (like its African counterpart) did not enter this field with much enthusiasm, including with regards to the emblematic environmental issue, global warming: Because the US gives millions of research dollars, because an international panel (the IPCC) of several thousand scientists produces regular reports, because most scientific disciplines have mobilised around this issue (with the notable exception of French political science), because the increased frequency of meteorological catastrophes (floods, drought, tornados) has led us to establish a relationship of cause and effect, […] because the issues of energy and gas are a major stake in international negotiations on the climate and because the American president masterfully plays the role of villain – for all these reasons, the greenhouse effect interests the media. (Smouts, 2003, p. 191) But the fact remains that coalitions built around a cause are much more disparate in the field (understood in the Bourdieusian sense) of environmental protection than, for example, in the international response to the AIDS pandemic. Environmental risks (such as those linked to the shortage of water) in poor countries and therefore

A matrix of public action in Africa 157 in African ones remain, having never been taken up by an issue-based coalition ready to compel politicians to rally to their cause: Curiously, the decrease in arable land and the change in essential soil functioning are rarely brought up. Is this because the commitments made in Rio expressed in the United Nations Convention on the fight against desertification have not been honoured? Or is it because the earth is a sensitive issue and States do not wish to see their cultural practices discussed? (Smouts, 2003, p. 192) In this case and in others, one should accept the hypothesis that, whatever the sector, priorities are set according to the interests of the most powerful (unless power is challenged by a counter-power) to assert or justify ideas that are principally (non-)decisions on the part of institutions that preside over international bio-politics. Marie-Christine Cormier-Salem’s example of the protection of coastal areas is characteristic of this hypothesis and can be extended to all of the sectors discussed in these pages, following what Sophie Lewandowski has shown for education. Biodiversity as a whole cannot be preserved. So, choices must be made, and their criteria are subject to debate, even for naturalists (Cormier-Salem and Roussel, 2000). To go back to the example for the West-African coastlines, what is the legitimacy of actions made in favor of sea turtles, swordfish and mullets? Why not privilege sardinella, tassergals and octopuses? Not only is this choice socially questionable, but is also quite irrelevant ecologically. It is based on the hierarchisation of between elements of biodiversity, those considered worthy of interest and of being an object of protective measures, and then the rest, ordinary, diminished in value, or simply forgotten. (Cormier-Salem, 2006, p. 18) Cormier-Salem’s conclusion converges with Smouts’s. It is according to this logic that the hypothesis formulated can be confirmed. Such a proposition allows us to propose a central element of cognitive, normative, structural, and even ideological (in the true sense) determinants of public action in Africa in general, but more specifically in low-income countries in a feudal relationship to international financing and to the cognitions, will, and instruments of public action that accompany such resources and their conditions. “Getting on the diplomatic agenda is somewhat random, a function of the influence of such and such NGO, of political games” (Smouts, 2003, p. 193). It’s also within this framework that Rozenn Diallo’s demonstration of “conservation in Mozambique” captures the double allegiance facing “bureaucratic enclaves”, between the State and the funders (Diallo, 2012). Natural catastrophes, from desertification to floods, are increasing in Africa. They are also accompanied by the process of ecosystem destruction through the exploitation of forests for industrial and commercial purposes. Multinational companies depend on African public authorities, through patron–client relationships

158 A matrix of public action in Africa that say much about States whose agents use their positions for a personal gain that eventually becomes a political resource (Bayart, 1989). This is the dramatic case of the African equatorial forest (Bigombe-Logo, 2004). Certain countries, like Cameroon, have organised a “governance by default”, a laissez-faire attitude vis-à-vis companies and multinationals susceptible of circulating what they earn from exploiting land, in ways that make and unmake the networks of political reproduction. In so doing they barely pretend to respect the very same international priorities which they broadcast (Pigeaud, 2011). Each sector has its own specificity. By choosing three different domains, I have tried to show that there exists a matrix of public action in Africa, from which can escape only those countries that benefit from a relative economic prosperity or a certain economic and political capacity to impose national priorities on international development. This can happen without dissenting voices, as in Botswana (Médard, 1999; Chabrol, 2012) or with ideological friction, as in South Africa (Fassin, 2002a, 2002b), to cite but two major exceptions that confirm the configuration of the matrix that I am offering for discussion and scientific critique.

The construction of a new social tie: transnational, differentiated, and flawed Each of the sector-specific illustrations in this chapter show a reduction in the perimeter of the African State, followed by its “return” in the international sphere. It is possible to argue that this reconfiguration of the State through the supranational is not specific to Africa, as certain works on public action in Europe and elsewhere have shown (Petiteville, 2005; Petiteville and Smith, 2006; Hassenteufel, 2011). However, this argument cannot avoid taking into account certain phenomena, which I will now attempt to describe. The return of the State The major actor constituted by the State in Africa is often and unfortunately relegated to a minor key by research on international governance. In the international regulation of access to pharmaceuticals and treatment in Africa, as in other domains of public action, the analysis of the role played by the State helps us understand the type to which it corresponds within the “matrix” of public action. This role depends on whether it can be shown to be proactive, passive, “activist”, or almost absent (Eboko, 2013). To this, it should be added that since the 2000s, the role of the State has been more and more present in the discourse and strategies of international organisations. From this viewpoint, if the 2000s validated in some way the shrinking perimeter of the State, it also showed the inverse: the State’s return within the matrix of public action in Africa. International organisations tended to conceive of a world in which the State, not being trustworthy, would be reduced to a sort of “minimum

A matrix of public action in Africa 159 service” in the politics of development (Nay, 2010). The idiom that emerged at the end of the Structural Adjustment Policies (the late 1990s) demonstrates the vision of Africa held by international organisations and development partners, but undoubtedly also the reality of African States post-SAPs: “policies for the alleviation of poverty”. This label sums up how international organisations name public policy in Africa, regardless of the sector. The return of economic growth in most African countries is supposed to be used in the “fight against poverty” by way of the implementation of a roadmap christened the “strategic document for reducing poverty” (SDRP). In the perspective of the return of the State, or rather of a new post-adjustment African State, international development partners17 launched the “Paris Declaration” (PD) on “aid effectiveness” in 2005. This was an international agreement which about one hundred ministers and high-level officials signed, thereby committing their countries and organisations to reinforce efforts for alignment, harmonisation, and management based on the aid outcomes thanks to actions that can be monitored and evaluated with a series of indicators.18 The major concern with this new relationship between the “regulated State” and its partners has to do with what is known as “mutual accountability”. The only definition of this accountability illustrates the dissymmetry of political responsibility between State actors and their partners. In fact, citizens have demanded more and more accountability from political authorities. Yet these same potential beneficiaries of public action barely know the civil servants and international experts who should be liable vis-à-vis citizens whose lives and survival they engage, in a remarkable democratic void. The Paris Declaration lent support to the Accra Agenda for Action (AAA), adopted in 2008 with the same partners. A parallel argument can be made for the Busan Conference (2011)19 on development effectiveness. These States surveyed and reoriented the international modalities of public action, according to their capacity to assert their priorities or not, and above all to their enrolment in international, institutional, and relational networks which fan out from the matrix. The difference between countries is found not only at the level of global power, but also in the circulation of power, within a multilevel governance in which the African State does not always play a role. It redeploys its priorities, not the way it did in the 1960s and 1970s, but as a function of the new cluster of partnerships that merges its new strategic orientations with its “power” or “powerlessness”. Botswana is not the DRC. Beyond all evidence, African organisations (the African Union, the UN Economic Commission for Africa, the African Development Bank (ADB), and international experts working in networks of African international relations (Sindjoun, 2002) assert themselves in a new epistemic community. They are redefining the African State as a developmental State, defined as “a state that makes economic development the top priority of government policy, and that is able to design effective instruments to promote such a goal” (Economic Commission for Africa, 2011, p. 95).

160 A matrix of public action in Africa The trajectories of African States are plural and subject to dynamics in which they tend to have similarities with and differences from one another. In States in permanent economic and political reconstruction, the blend of democracy and political action is as fragile as it is precious. Within this perspective of hybridisation, simulation and recomposition of models of public action designed at the international level (Darbon, 2009) are central to understanding the different ways in which African States confront the world order. The compression of the African State from the pressure imposed by Bretton Woods institutions is intrinsically linked to its social and economic crisis and to the crisis the World Bank termed, without concern for its own responsibility, the crisis of governance in Africa (World Bank, 1989). In fact, the transfer of expertise in public policy from the African State towards international organisations and transnational actors bluntly demonstrates the victory of a Real Politic and New Public Management founded on performance-based financing. This is what guides the differential dynamic of the matrix of public action in Africa. The international financial crisis has generated incentives and discourse that promote the search for domestic financing of African States. At the same time, non-negligible progress has been made at the level of public action in health, in which the fight against AIDS has been the leading figure. Between international concerns and Africa’s new economic hope, the continent faces prospects and perhaps the possibility of choosing its own destiny. The context is difficult, yet it is illuminated by the freedom offered by the shortcomings of Africa’s former guardianship. This is the context in which the goal of Universal Health Coverage (UHC) has emerged at the international level. The Covid-19 pandemic paradoxically demonstrates how African States are regulated by their international partners. By showing how, even before their first Covid-19 related deaths, African states took the lead in matters of prevention (closing borders, epidemiological surveillance, protective measures, etc.), we suggest what almost amounts to paradigm reversal. Covid-19 illustrates how the norms and procedures that undergird the accompaniment of African States by technical development partners are as much ideological as financial. Like the AIDS pandemic, in which Sub-Saharan Africa was the most affected region in the world, Covid-19 reveals a diversity of epidemiological situations on the continent that current discourse erases with facile labels. For example, South Africa accounts for 40% of Covid-19 cases in Africa (215,855 cases out of 500,000 cases in July 2020). Similarly, the geographic mobility that characterizes that country partly explains why it also accounted for the highest number of HIV cases in Africa and the world. This characteristic logic of the Republic of South Africa both follows and is different from the epidemiological problem of communicable diseases where SARS Cov-2 is involved. To date, all 45 sub-Saharan Africa countries have been affected by the pandemic. Though this region represents 17% of the world population, it represents only 3.3% of the cases in the world. Hence, the “true false” conundrum of Sub-Saharan Africa when examined through the lens of alarmist discourses at the WHO and in Western media at the beginning of this pandemic.

A matrix of public action in Africa 161

A political anticipation: the Covid-19 reference laboratories in Africa and epidemiological surveillance Even before the first case of Covid-19 had been formally diagnosed on the African continent, the African Union and the African Center for Diseases Control (CDC Africa) designated the Pasteur Institute of Senegal as the reference centre for diagnosing Covid-19 in Africa. A first seminar, which brought together representatives of several African countries, was held February 6 to 8, 2020, in Dakar, under the aegis of the African Union and the CDCs, in collaboration with the WHO, ECOWAS (the Economic Community of West African States) and the German firm, TIB Molbiol. Before the pandemic, Africa had only two reference centres of this type. By March 2020, according to the WHO, the continent housed a good forty such centres. Even before the first cases of Covid-19 infection had been identified, most countries had established prevention measures and border controls, especially in international airports. The first countries to have diagnostic tests were the ones that had experienced the Ebola epidemic in West Africa in 2014. Senegal’s first case of infection with SARS Cov-2 was the first to be identified in Sub-Saharan Africa, after Algeria’s and before Nigeria’s. By July 8, 2020, the Regional Bureau for Africa of the WHO announced that Covid-19 infections in Africa had passed the 500,000 mark, and there was reason for concern because an increasing number of countries have experienced an important increase in the number of cases. WHO further claimed that “Until now, in less than five months the virus has killed 11,969 victims, more than the 11,308 lives lost during the worst Ebola epidemic in the world, which affected West Africa between 2014 and 2016” (OMS). Furthermore, only Egypt and South Africa have had more than 1,000 deaths thus far. South Africa also accounts for the largest number of cases on the continent, with 215,855 cases and 3,502 deaths, followed by Egypt (77,279 cases and 3,489 deaths), Nigeria (77,279 cases and 669 deaths), Ghana (29,789 cases and 129 deaths) and Algeria (16,879 cases and 968 deaths). Algeria, Egypt, Ghana, Nigeria and South Africa represent about 42% of Covid-19 cases, according to a bulletin from the African branch of the WHO, which adds that South Africa by itself accounts for 29% of the total number of cases on the continent.20 African responses to Covid-19 are partly based on the “memory of pandemics”, in which Africa was, if not the epicentre, a particularly vulnerable terrain. Such pandemics involved the Ebola virus disease (EVD) and the three diseases targeted by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Eboko, 2019). One of the reasons for the difference between the impact of the Covid-19 pandemic on Africa as opposed to the rest of the world may be explained by the young age distribution of the African population. This demographic fact differentiates the African continent from Europe and the United States, for example, where the majority of Covid-19 deaths involve people over 65. This older age

162 A matrix of public action in Africa group is proportionately far smaller on the African continent, given its high birth rates and high (but falling) mortality, compared to the other continents. Generally, an inversion of the policy paradigm can be observed in the Covid19 response underway in African countries, which follows the logic of earlier political and economic responses by African authorities.21 The bilateral development agencies and international financial institutions that constitute their usual partners intervene according to the somewhat variable policy logic and economic predictions of the African States. The following remarks draw on the epistemic project of Policy Transfer (Dolowitz and March, 2000; Stone, 2012). In fact, from one State to another, broadly disseminated global knowledge, whether about the physiopathology of the coronavirus or its epidemiological patterning in Asia and Europe, informs African responses. These have been adapted to national social and political contexts. The resulting overview of these public actions calls for an ongoing, in-depth analysis of the research concerning “the rehabilitated State in Africa” (Grégoire et al., 2018) and for “reflecting about public action in African contexts” (Darbon and Provini, 2018). From multilateral organisations and bilateral development agencies to international non-governmental organisations (INGOs) and public-private partnerships (PPPs), the partners of public authorities in African States are back, providing the financial and economic support which these states need to buffer the social and economic shock of the Covid-19 pandemic. This “matrix of public action in Africa” – the focus of Chapter 6 – re-emerges with the proactive attitudes observed when the pandemic arrived on the African continent. The problem of debt and moratoriums on new loans highlight the uncertainties and vicissitudes of the unequal and highly differentiated integration of African economies into the “World Economy”.

Notes 1 2 3 4 5 6 7 8

9

10

Ensemble pour la Solidarité thérapeutique en réseau. See: www.esther.org Le Monde, June 27, 2001. The English translation is Paxton’s, citing Eboko (Paxton, 2012, p. 143). See www.theglobalfund.org/fr/news/2017-11-14-global-fund-appoints-peter-sands-as -executive-director/ Source: Programme “Roll Back Malaria”: www.rbm.who.int/fr/keyfacts.php Artemisinin is naturally produced by a plant and has been known for centuries. Research began to study its virtues against malaria beginning in the late 1990s. Treatment lasts 72 hours, with eight doses a day. In almost all typical forms of malaria diagnosed after the first signs of symptoms, the symptoms clear and the disease is cured, without side effects or chemical resistance. The BCG vaccine (Calmette Guerin Bacillus), discovered in 1921 by Albert Calmette and Camille Guérin, is more effective for new-borns, whom it protects against 75 to 85% of the severe forms of tuberculosis, than for adults, for whom the protection is only 50 to 75%. Bedaquiline is marketed by Jansen-Cilag and delamanid by the Japanese firm, Otsuka. These molecules are used in association with other anti-tuberculosis drugs. A treatment against drug resistant TB usually lasts two years. These new p-molecules could reduce the treatment to six months. Drug-resistant tuberculosis (TB-R and DR) includes forms of tuberculosis that present resistance to one or more first-line treatments. There are two sub-types. Multi-drug resistant tuberculosis (TB-MR or MDR) is the form resistant to the two most powerful

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11 12

13

14

15

16

17 18 19 20 21

first-line anti-tuberculosis drugs. Extensively-drug resistant tuberculosis (TB-UR and XDR) is the form caused by TB-MR resistant to several second-line treatments. https:// msfaccess.org/TBmanifesto/ The number of students in sub-Saharan Africa rose from +27 million in 1970 to 80 million in 1990. In the 1960s and 1970s, several so-called socialist experiments extolled a “decolonised” school for the African continent. See, for example, Education for Self-Reliance, the philosophy of the Tanzanian, Julius Kambarage Nyerere (Bonini, 2003) and the Ecole Nouvelle (new school) in Benin. Translator’s note: Enarques are graduates of France’s elite Ecole National d’Administration (ENA), established by President Charles de Gaulle to train leaders and administrators for the reconstruction of the post-war nation. It counts among its graduates numerous presidents (French and foreign), ministers, high-level civil servants, and CEOs. Senegal and Cameroon provide two examples of parallel structures, the Centre Africain d’Etudes Supérieures en Gestion (CESAG, or Center for Graduate Education in Management) in Senegal, and the Institut Supérieur de Management Public (ISMP, or Graduate Institute for Public Management). The CESAG replaced the Ecole Supérieure de Gestion des Entreprises (ESEG, or Graduate School for Business Administration) in 1986. Graduates of the ENAM in particular “take seminars […] taught to a great extent by civil servants who trained in the US in management and engineering” (Niane, 1991, p. 46). Created with similar goals, Cameroon’s ISMP was founded in 1985 with the technical and financial support from Canada’s development agency. At first, the institute was co-directed by a Canadian manager and a Cameroonian civil servant who had just received a Masters and a PhD in management in Canada, at the University of Laval (Quebec). The first director of the CESAG held an MBA and a PhD from the University of Montreal. These are not mere coincidences. François Quesnay (1694–1774) was an economist and physician in the court of King Louis XV, for whom he was also a counselor. The ideology of “laissez-faire, laissezpasser” (“leave things alone, let them pass”) was the basis of the Physiocrats School of economic thinking, which Quesnay founded. See, for example, Poulon (2005). To illustrate, when the King of Spain, Juan Carlos, fractured a leg in Botswana during an elephant hunt in 2012, it made headlines. In France, a major aficionado of hunting in Africa’s natural parks is former president Valéry Giscard D’Estaing. Another example is the high-ranking official, Michel Baroin, who was the former cabinet head for Edgar Faure, who presided over the French National Assembly from 1971 to 1974. A French businessman and the father of another high-ranking official under President Jacques Chirac, he died in 1987 in an airplane crash in Cameroon, where he hunted regularly. See the UNDP Strategic Plan for 2008–2011: www.pnud.org.ma/pdf/plan_strategique _2008-2011.pdf www.oecd.org/dac/effectiveness/parisdeclarationandaccraagendaforaction.htm Fourth High Level Forum on Aid Effectiveness, Busan (South Korea), held November 29 to December 1, 2011. www.climatefinance-developmenteffectiveness.org/ https://news.un.org/fr/story/2020/07/1072561 Sabine Cessou, “La riposte des institutions africaines”, Radio France International, le 18/05:2020: https://www.rfi.fr/fr/afrique/20200518-covid-19-la-riposte-institutions-afr icaines-coronavirus

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Conclusion The return of the African State?

Kofi Annan’s idea for a Global Fund emerged on the international scene in 2001. This innovative financial instrument, established within the year, contributed to nothing less than a global paradigm shift (Bradol, 2005; Moatti, 2011; Annan, 2012). This change brought about a symbolic rift, undermining arguments, both serious and trivial, against access to AIDS medications in Africa. The transnational mobilisation of actors and the involvement of international organisations brought about an exceptional response in the health field. Might it offer a model?

Resisting the end of AIDS: from daydream to reality By the end of the first decade of the 2000s, UNAIDS and its partners had been moving towards a new horizon, the “90-90-90” paradigm, which heralded the end of AIDS. In fact, new scientific discoveries allowed them to posit the following: if 90% of everyone is screened for HIV, if 90% of those who screen positive are immediately put under treatment, if 90% of those under treatment are compliant as indicated by an undetectable viral load, then the transmission of the virus will have ended. Two major scientific discoveries are at the origin of this paradigm shift: the “Swiss Statement” and “Test and Treat”. The “Swiss Statement” of 2008”: the beginning of the dream The dream began with the publication of a Swiss protocol showing that the transmission of the virus in a sero-discordant couple (a sero-positive person and a sero-negative person) decreases significantly once the viral load of the infected person has dropped in connection with early initiation of antiretroviral (ARV) therapy. Following almost a decade of research on this issue (Quinn et al., 2000; Castilla et al., 2005; Vernazza et al., 2008), the Swiss Federal Commission not only prompted an international debate, but also validated, at the institutional level, medical evidence that goes against the dogmas, logic, and idioms of HIV prevention. Subsequently, no scientific study was produced to challenge the “Swiss Statement”, even if the political and practical application of the new medical knowledge were subject to caution. At issue was the translation of scientific evidence into effective interventions at the international level.1 The effects of these

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discoveries were nevertheless felt in Africa, especially because they spurred a gradual reinforcement of the idea of early treatment. This is the case of “Test and Treat”. “Test and Treat” in 2010: a mathematical model for a political ambition In 2010, an article was published on the mathematical modelling of data from a cohort of homosexual men in New York (Stephen et al., 2012). This mathematical extrapolation validated the idea that, regardless of the state of their immune system, patients who initiate treatment as soon as their sero-positivity is confirmed have better life expectancy with better health and a weak likelihood of transmitting HIV in the long run. When the WHO then raised the thresholds concerning immunity, various institutions and even strategic plans to fight AIDS integrated the principle of early treatment. Within this configuration, the Kwa-Zulu Natal region in South Africa comprised a living laboratory for protocols for stopping the progression of AIDS and, on the basis of what then was theoretical, eradicating AIDS altogether. In the country most afflicted by the HIV epidemic, the hint of dawn tinted the horizon. The euphoria resulting from treatment protocols that reduce HIV transmission must nevertheless be relativised, particularly in relation to sub-Saharan Africa, because of the lack of attention health policies have paid to resistance that recent research suggests could set off a “fourth epidemic” (Laborde-Balen et al., 2018). In fact, the “90-90-90” ambition stems from the widespread belief among global health actors in technical, measurable solutions, whose numbers, generated by computers, incarnate reality. The idiom of the magic bullet permeates the neoliberal logic in which African States are embedded. When the field of health is compared to other sectors, the distortions of each sector become apparent. They lie in the quantified objectives assumed to measure the sector’s success and in the inward gaze that process entails. The Abuja Declaration offers a felicitous example. In 2001, the African heads of States gathered in Abuja (Nigeria) committed themselves to increasing to 15% the proportion of their respective budgets allocated to health. By 2019, only seven States had met their commitment: Rwanda (18.8%), Botswana (17.8%), Niger (17.8%), Malawi (17.1%), Zambia (16.4%), Burkina Faso (15.8%), and South Africa (15%). This raises two political questions. Given the economic and demographic disparities between countries and within countries (for example, Nigeria), what does 15% represent for the most destitute? In Burkina Faso, for example, an observer playfully but lucidly insisted that “15% of nothing is nothing”.2 This pithy yet meaningful statement was at once a response to the imaginary that generates the criteria and ideology of neoliberal economics and an avowal of the distance needed to be able to make a political analysis of the indicators in question. The second question follows on the logic of the first. At the same time the heads of State were pronouncing their famous Abuja Declaration in 2001, they were just coming out of a drastic, historical “cure” that had weakened all of the social subsectors (health and education, in particular). They now faced

170 Conclusion multiple political and economic stakes. On April 27, 2001, the very day of their Declaration, the UN Secretary General, who was at the meeting, launched the idea of the Global Fund, which would come to life a year later (Eboko et al., 2015). In other words, when the heads of government were signing their commitment, they were already aware that they would be benefiting from grants with no strings attached (yet) to target the three pathologies that were undermining the health of the population in their respective countries. The Fund and the promises it generates have no equivalent in education, agriculture, security, infrastructure, or any other sector. Why would the heads of government respect their commitment? It is quite possible that, given what Kofi Annan promised at that same meeting, the African leaders translated the contradictory injunction into a manifestation of good will that was in part strategic. When global health actors began launching petitions and calls for respecting the Abuja Declaration, they were illustrating a closed world in which priorities, however legitimate, mask the plurality of causes an African leader must confront. The trajectory of the political in the context of highly technicised public policy allows one to discern, at the summit of the State, political sentiments concerning a concrete public action carried out by legitimate bodies and translational networks. By applying the perspective of comparative political sociology to public action on AIDS, this book has been able to develop an analysis of two additional health subsectors, malaria and tuberculosis, and two national sectors, education and the environment. This trans-sectoral comparison, accompanied by a socio-historical approach to public policy in Africa, is synthesised and justified using a matrix of public policy in contemporary Africa. As a framework, the matrix allows us to identify within each sector the same types of actors, be they international (multilateral and bilateral organisations, foundations, NGOS, etc.), national (institutions, voluntary groups, the private sector, etc.), or transnational (epistemic networks and communities). The recurrence of the same typological elements across different sectors since the mid-1980s allows the matrix to be used as a basis for analysing public policy in Africa. Differences between the subsectors of health and between the health sector and other national sectors can be linked to the different levels of political awareness and to the position of epistemic communities (Haas, 1992) within each. From this vantage point, the struggle against AIDS constitutes an exception that reveals both the possibilities for public action in some sectors in Africa and historical aporias in other sectors. The threat of cutbacks in international funding, notably by the Global Fund Against AIDS, Tuberculosis and Malaria, heightens the risk that “normalisation” of public action around AIDS might come to resemble the dynamics in other sectors which, as I have shown, are governed by the rules and norms of laissezfaire, itself a deliberate distortion of neoclassical and neoliberal economies. In this context, François Quesnay, the founder of the eighteenth-century economic school of Physiocracy, prevails over John Maynard Keynes and the regulation of the economy through central State intervention, a turning-point which is not necessarily progress.

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Public action against AIDS in Africa: a distorted mirror image of the world order The establishment of the Global Fund in 2002 also coincided with the creation of an instrument for transnational public action that mobilised a network of actors and a series of advocacy coalitions from the global North and South. It engendered a dynamic which in turn stimulated other sources of funding at the international level. The Fund’s development revealed international practices and their contradictions, as these were caught up in multilateral dynamics and bilateral relationships between countries of the North and the South. Through this instrument, the whole problem of transnational public action comes to light, as if refracted through a prism of the world order. Currently, this instrument and the international financial difficulties stemming from its bureaucratisation provide a reading of the highly contrasting circumstances of African countries in international relations. Since its launching in 2002 at the G8 summit in Okinawa (Coriat, 2008), the Global Fund has allowed more than 17.5 million people to receive combination antiretroviral therapy (cART) through hundreds of programmes, to the tune of US$4 billion per year.3 Thanks to The Fund, 800 people initiate treatment every day. These results are likely to dwindle, not only because of a decline in resources but also from the bureaucratisation of the funding received (Tchiombiano et al., 2018). Initially, the Global Fund’s rejection of funding requests from resource-poor countries, despite its awareness of patient needs and expectations, symbolically reversed the “right to intervene” (droit d’ingérence) established during the Biafra War. The world, and Africa in particular, faced a de facto “refusal to intervene”, because applications for aid now had to be structured according to ever more restrictive accounting and administrative standards. Not only did the lack of expertise come into play, but also a collusion between policy-making and the national political arenas through which national experts are appointed and terminated. Specifically, this happened through the politically motivated replacement of experts charged with preparing the proposals for the national group as well as because of unbalanced or poorly written applications, corruption, and other circumstances that led to the rejection of applications. In other words, bureaucratic shortcomings exist at the level of both African States and the Global Fund. Although mechanisms existed for some funding and for emergency responses between two application rounds, when countries (and patients) received the message, “Application Rejected”, they experienced a sort of bureaucratic coup d’état. Negative decisions threatened to sentence patients to a state of moral and physical insecurity. A useful metaphor would be the situation of a destitute family that has been denied access to care on the pretext that the forms required for hospital admission have not been filled out properly or have been deliberately falsified by the head of family. In other words, the Global Fund “sanctioned” patients with irrefutable needs, because of the presumed incompetence or fraudulent acts of certain authorities (government Ministers, program directors, etc.).

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Thus, from roughly 2002 to 2012, in certain African countries with authoritarian or quasi-authoritarian regimes, patients were caught between the hammer of the Global Fund’s bureaucratisation and the chisel of certain African officials whom autocrats appointed for political reasons, without giving citizens the possibility of holding them accountable.4 At no time in its history had the Global Fund seemed so close to undermining its initial mission as when these bureaucratised and politicised procedures were simultaneously imposed on recipient countries. Although it does not refer to the Global Fund, Vinh-Kim Nguyen’s denunciation of the “republic of therapy” for treating consequences rather than causes of problems and his critique of the dual biomedical and bureaucratic domination of the AIDS question in Africa, have never been more relevant: “the power to save lives is as important as the power to inflict bodies with deadly blows (Nguyen, 2010, p. 6). This potential undermining is in keeping with the reversal of the paradigm of humanitarian solidarity that marks the other side of philanthropy: a biopolitics constituted, more than ever, by what Foucault called “the right to ‘make live’ or to ‘let die’” (Foucault, 1976/1997, p. 256). The current situation, in which uncertainty and the power of international instruments are reinforced and linked to the international financial crisis, reaffirms Foucault’s formulation and validates Nguyen’s analysis at a level of generality beyond the case of AIDS. Several days before the nineteenth International AIDS Conference (AIDS 2012) in Washington D.C., the eminent virologist Anthony Fauci declared that “we are beginning to see that it is really possible to affect the infection and turn around the trajectory of the pandemic”.5 In times of crisis, such a declaration is far from meaningless and open to different interpretations. First, it illustrates the self-confidence of an epistemic community certain of its historical triumphs and anticipating unprecedented successes in the future. At the same time, this optimism highlights a divide within the so-called community and embodies the hegemonic pattern of biomedicine, in a field that draws its strength not only from advances in medicine but also from the mobilisation of international social movements, without which the “victories” would be few. Before generalised access to combination antiretrovirals in Africa, and in the developing world more generally, researchers writing in the Lancet likened “international apathy” to a “crime against humanity” (Hogg et al., 2002; Ford et al., 2011). Following Nguyen, this is another way of saying that when a tragedy in Africa affects the world, the lack of action can be equated to a crime against “humanity”. Tuberculosis and malaria, whose current mortality rates, as I have shown, more or less equal those of AIDS, did not provoke the same sort of indignation. On a broader level, Jean-François Bayart’s problematising of “global governance” captures the split engendered by the differentiated integration of global subjects: One of the main lessons of postmodern anthropology will have been to demonstrate how globalisation is not tolling for the “death of territories” so much as reinventing them through the effects of “glocalization”; i.e. the compacting

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of global and local dimensions, sometimes (but not necessarily) to the detriment of national intermediation. (Bayart, 2004/2007, p. 121) This situation also allows us to pose the question of the place of the African State “in action”, or more precisely “in co-action”, to which I now turn.

The return of the State Studies of international governance too often minimise the African State’s position as a major actor. Yet the analysis of the role of the State in the international regulation of access to drugs and health care and in other policy domains in Africa teaches much that is relevant to understanding the category it falls into – proactive, passive, activist, or quasi-absent – within the matrix of policy (Eboko, 2013). Since the early 2000s, however, the position of the State has become ever more present in the discourse and strategies of international organisations. What happened during the 2000s, in fact, both confirms the narrowing of the State’s scope and admits its reverse: the return of the State. Beyond surviving, the State made a come-back within the matrix of public policy in Africa. International organisations had previously conceived of a world in which the State, being untrustworthy, would be reduced to a sort of minimum service role in development policy (Nay, 2010). The “anti-poverty policies” label that emerged towards the end of the structural adjustment policies (SAP) era, in the late 1990s, captures how international organisations and “development partners” saw Africa, but it undoubtedly applies to the post-SAP reality of African States. It sums up nicely how international organisations depicted African public policy, regardless of the sector. It was assumed that the return of economic growth in the majority of African countries would alleviate poverty, thanks to the implementation of a World Bank/International Monetary Fund roadmap known as the “Poverty Reduction Strategy Papers”. Shortly after his election in November 2010, Guinean President Alpha Condé warned that such language could not be substituted for ambition and actual political projects, as if to emphasise that international organisations envisioned only the absolute minimum as far as African public policy was concerned. “Africa is rich”, Condé stated. “Many high-level Africans are part of the diaspora in Africa, Europe and the United States. They are the ones who can help us. Were they to return, they would be like the foreigners who help us restart the country. Here, everything needs doing.”6 In 2005, anticipating the return of the State, or more precisely, of a new, post-Structural Adjustment African State, international development partners launched the Paris Declaration on Aid Effectiveness.7 One hundred or so ministers, high-level officials and other decision-makers signed on, engaging countries and organisations to make efforts at alignment, harmonisation, and management based on concrete efforts for aid, as indicated through monitoring and systems of indicators.8 The chief concern of this new relationship between “the regulated State” and its partners is best summarised in the term, “mutual accountability”.

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The definition of accountability itself reveals the asymmetry between State actors and their partners as far as public responsibility is concerned. Citizens increasingly demand accountability from political authorities from whose programs they stand to benefit. Yet these international experts and high officials remain unknown to the public and hence scarcely accountable to the very citizens whose lives and survival depend on them. The result is a rather striking vacuum in democracy. The Paris Declaration also provided the backing for the Accra Agenda for Action, adopted by the same partners in 2008. Finally, along the same lines, the Busan Forum 2011 involved “aid effectiveness”.9 Here again, it is worth noting the absence of any clear, agreed-upon definition of “development” (Baré, 2006). In other words, theoretically, each State could define its priorities for public action and agree to submit them to an objective evaluation within the context they chose. Thus, the lack of focus on the State in so-called development studies of Africa, which this book has hoped to counterbalance, is significant for two reasons. The first is fairly straightforward. In the process of glocalisation evoked earlier, it is the national dimension that withers away with the individualisation of pathways and growing domination of actors and institutions from the North. The second reason poses more of a problem, because of the pivotal position of States in the transmission, hybridisation, simulation, and reconfiguration of models for public action prescribed at the international level (Darbon, 2009). Minimising the State dimension of transnational contexts does have some effect on the elimination of State-level action and formal responsibilities regarding the world order. France’s military interventions in Ivory Coast (2012) and Mali (2013) illustrate how the agencies responsible for standardisation in particular domains, such as security and the territorial integrity of States, prescribe normative frameworks that allow or facilitate action as a function of direct linkages and agreements between the African States and their traditional partners, especially in situations in which the UN and its sub-regional military forces are unlikely to intervene militarily (Nivet, 2002). These States count. They reorient the international modalities of public action according to their capacity to make their priorities count, which in turn depends on their enrolment in international, institutional, and more personal networks according to the matrix I have presented. As such, the difference between countries should not be sought only at the level of “global power” but in the circulation of power within multiple levels of governance in which the African State is not always a player. Contrary to how it deployed its priorities in the 1960s–1970s, the State now acts in accordance with a new cluster of partnerships, strategic orientations, and its degree of strength or powerlessness. In other words, Botswana is not the Democratic Republic of Congo (DRC). Beyond this obvious fact, African organisations – the African Union, the Economic Commission for Africa (ECA), the African Development Bank – and international experts working within the networks of African international relations (Sindjoun, 2002) have become new epistemic communities. They are redefining the contemporary African State as a developmental State, understood to

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be “a state that puts economic development as the top priority of government policy, and is able to design effective instruments to promote such a goal” (CEA, Economic Report on Africa 2011, p. 95). African States follow diverse trajectories, their similarities and dissimilarities engendered by contrasting dynamics. For example, the less democratic States, in the institutional and political meaning of that term, are those which distribute State resources according to an entrenched system of clientelism which ensures their survival. These States (the DRC, Congo, Gabon, Cameroon, Togo, Equatorial Guinea, Guinea-Bissau, etc.) more-or-less delegate public policy to international organisations and NGOs. A notable exception is Mali, whose democratically elected president, Amadou Amani Touré, was ousted by military forces in the face of lawlessness at a time when rebels and extremists threatened to annex the country’s north. Democracy and public action constitute a fragile yet precious bond in States undergoing permanent economic and political reconstruction. With her literary gifts, the Cameroonian writer, Leonora Miano, deplores this image of Africa: You are the myth of conquest and discovery. You are the hope of salvation for those who have no idea what to do with their good intentions. A little story they tell themselves […]. Let it be known: all the lepers live where you are. All the children without love, the villages without water. They miss you. They are nowhere else. You are there, the symbol of suffering. […] You are the only territory incapable of giving birth to the Universal. (Miano 2008, pp. 14–15)

Political science at an epistemic crossroads Although this book adopts a socio-political framework, I have written it with the intention of engaging the different social sciences, without pretending to reconcile disciplines and geographic areas that remain ignorant of one another, and hence not susceptible to debate. It is worth recalling that development policy research covers the same territory explored in this book: public action, nothing more nor less. Yet the polysemy of definitions used in development policy reflects not so much the perspective of certain disciplines and paradigms as different approaches to Africa and development. Whether articulated by political scientists in France, professionals of development policy, or researchers in the so-called anthropology of development, the terms used can be misleading. When the French political scientist, Olivier Nay (2010), speaks of development policies, he means international development aid policy. African States are very marginal to his sphere of interest. When the anthropologist Jean-François Baré evokes development policy, he is referring to multilevel public actions concerning States in the global South. Similarly, the Africanist anthropologist Jean-Pierre Oliver de Sardan and his colleagues place the State at the centre of their work.

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These conceptual differences are understandable, given the separation between academic fields, theoretical perspectives, and specific bodies of literature. This sort of distance, however, diminishes the potential for valuable collaboration among those interested in public action (Hassenteufel, 2011), whether in international relations generally (Smith, 2013), in Africa specifically, or in other areas. François Baré summarised the continental drift between bodies of knowledge with unusual candour, when he lamented that the co-editors of a special issue of the Revue Française de Science Politique (French Journal of Political Science) had reduced the field of public action to cognitive analysis approaches. According to Baré, the distinguished political scientist Pierre Muller, one of the issue’s coeditors, had gone so far as to assert that “the object of public policy is not only to resolve problems but to construct interpretative frames for [understanding] the world” (Baré, 2006, p.19). That claim can be reversed for, other than research by Africanists, only two publications in the French political science literature on public policy mention Africa: The State in Africa by Jean-François Bayart (1989/1993) and the chapter on public policy in the Traité de science politique (Manual of Political Science) as well as related publications by Georges Balandier (Grawitz and Leca, 1985). This seemingly mutual indifference of scholars to the work of others may simply reflect their collective ignorance of what exists outside their own spheres of research. The infrequency of exchanges between these networks protects them from harsh criticism directed at their shortcomings. Christian Coulon and Denis-Constant Martin nevertheless provided an early corrective in their 1991 edited volume on African politics. More recently, Mamoudou Gazibo and Céline Thiriot (2009, p. 15) have expressed a similar line of thinking. “A back-and-forth movement between general frameworks and local contexts is necessary”, they write, “especially as Africanists, despite what one assumes, have often contributed to theoretical advancements in political science, thanks to the results of fieldwork in Africa”. One of my goals, in keeping with the ambition of these researchers who have preceded me, is to contribute to strengthening these links, in which strength is in unity. Unless disciplinary differences are bridged and research is shared within an international configuration, even the most brilliant work will be confined to only the most marginal if not subaltern audiences and forms of knowledge. In one of his most beautiful texts, Albert Camus wrote: In psychology as in logic, there are truths but no truth. Socrates’ “Know thyself” has as much value as the “Be virtuous” of our confessionals. They reveal a nostalgia at the same time as an ignorance. They are sterile exercises on great subjects. They are legitimate only in precisely so far as they are approximate. (Camus, 1942/2018, p. 19) In keeping with Camus’s perspective, the possibility of renewing the social sciences will come from those who choose uncertainty and new challenges over

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the certainty of the geographic areas and themes they have already encountered in their own training, in teaching others, and through professional meetings and international networks. I have offered this book as a tribute to the networks of researchers who know how to create new collaborations. This is how my research has been constructed, between North and South, through a kinship that, I have finally acknowledged, owes more to the ongoing process of learning than to chance (Eboko-Ekoka, 1985). The Covid-19 moment here provides a radical illustration of the constraints inherent to the norms of neoliberal globalisation, whose naturalising effects have been questioned by the abundant critical literature that emerged from the political economy of the African continent (Hibou, 1998). Although Africa has been relatively unscathed by a pandemic that the West imagined would devastate the continent, the rules of economics and neoliberal indebtedness threaten the continent from a financial point of view. It is as if Africa never escapes from the constraint of counting what she owes the world, in a world that refuses to take account of what it owes Africa or of the political lessons that it can learn from Africa. In his inaugural lecture to the Collège de France in December 2018, the anthropologist Didier Fassin certainly never doubted that his remarks were at once a magisterial synthesis of the “inequality of lives” anchored in thirty years of research and a premonition of what the world would become several weeks later, with the outbreak of Covid-19. In his most recent book, Life: A Critical User’s Manual before this lecture, he writes: Far from being an unpredictable event, and the product of coincidences and contingencies, death is thus the translation into bodies of unequal social relations in which history left its mark. What we call life expectancy is its double […]. [This phrase] should also be apprehended in a philosophical sense, suggesting expectation, in other words, the inscription of the future in the lived. Thus, the inequalities in life expectancy do not simply call for the measure of quantities of life […], but just as much for the recognition of qualities of life (the self-realization in the relations with others). (Fassin, 2019, p. 118) Africa calls on us to evaluate, the effects of the dark fault-lines of inequality and the past on the lives of its inhabitants here and now, so that we can imagine together how social bodies, cut off from the wisdom of elders and targeted by the macabre particularity of Covid-19, might resist. Africa in the plural – young, full of hope and uncertainty – projects a vitality that should inspire the rest of the world to see differently.

Notes 1 This topic was addressed publicly for the first time in 2008, by a panel of political scientists, public health specialists, and researchers, including the Swiss authors of the article in question. The panel was co-organised by Marc Dixneuf, a political sci-

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5 6 7 8 9

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entist working with the French AIDS association, Sidaction, and myself, for the session, “Political Science: From Evidence to Implementation”, of the 17th World AIDS Congress in Mexico. I heard this comment at the headquarters of an international organisation in Ouagadougou in April 2014. www.theglobalfund.org/media/7744/corporate_2018resultsreport_summary_en.pdf. Consulted March 4, 2019. In 2011, Cameroonian activists organised a march on their country’s National Assembly to demand that the authorities implement a decision they had signed in Abuja (Nigeria) in 2001 to increase the health budget by 10%. These grass-roots activists have been prosecuted for “demonstrating illegally”, and this in a country that considers itself a democracy. www.lorientlejour.com/category/%C+La+Une/article/768735/Sida+%3A_la_fin_de_ la_pandemie_est_en_vue%2C_juge_un_eminent_virologue_americain.html www.refi.fr/emission/20101117-une-election-annoncee-alpha-conde-guinee. President Alpha Condé made a similar statement at Paris’s Institute of Political Sciences (Sciences Po) in 2011. See the UNDP strategic plan for 2008–2011: http://web.undp.org/execbrd/pdf/dp07-4 3Rev1.pdf www.oecd.org/dac/effectiveness/parisdeclarationandaccraagendaforaction.htm Fourth High Level Forum on Aid Effectiveness, Busan (South Korea), November 29– December 1, 2011. www.oecd.org/dac/effectiveness/fourthhighlevelforumonaideffe ctiveness.htm

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Index

Abé 4, 26, 71, 113 Africa 1–42, 48–54, 61–63, 66, 68, 70, 72, 75, 77, 80, 83–84, 86, 89–92, 95, 97–110, 116, 118–119, 122, 124, 126–127, 129, 131–134, 136–138, 140, 142–146, 148–149, 151–154, 157–165, 168–169, 177 Agier 92 AIDs 2–11, 15–43, 49–57, 59–62, 65, 68–75, 77, 80–89, 91–92, 95, 99–110, 113–122, 124–127, 132–134, 136–138, 140–147, 149–150, 154, 156, 160–161, 168–170, 172 Altman 27, 50, 124, 137 Amselle 29, 148 Annan, Kofi 42, 53–54, 137, 143, 168, 170 ANRS 23–24, 67–70, 72, 77, 100, 103, 106–107, 110, 113, 125 Asia 24, 49, 61, 117, 119, 143, 162 Atlani-Duault 92 Aubertin 9, 127, 153 Awondo 126 Bado 142 Balandier 29, 176 Baré 174–176 Barnett 9 Batsell 9, 27, 110 Bayart 6–8, 12, 37, 98, 110, 115, 158, 172–173, 176 Belgiu 105–106 Benin 8, 52, 55–56, 68–70, 73–74, 77, 96, 110, 127, 163 Benkimoun 6 Biehl 9 Bierschenk 25, 149–150 Bigombe Logo 9, 121, 158 biodiversity 3, 144, 153–155, 157 biopolitics 157, 172

Blaikie 9 Boniface 127 Boone 9, 27, 110 Bossy 133 Botswana 6, 16, 81, 83–85, 91–92, 113, 158–159, 163, 169, 174 Bourdier 33, 35, 114, 140 Boussaguet 50, 102 Boyer 4, 25, 90 Bradol 168 Bratton 48–49 Brewer 16–17 Broqua 33, 114, 122, 124, 140 Brugha 57 Burkina Faso 8, 24, 51–52, 54–55, 70–71, 74–77, 85–86, 93, 110, 151, 161, 167, 169 Burundi 24, 83, 92 Buse 27, 137 Bush, George W. 42, 53, 61 Busino 120 Calas 92 Cameroun 50, 77, 88, 106, 113, 142 Camus 176 Castilla 168 Cefaï 17 Central African Republic 92, 109 Chabrol 61, 81, 84, 85, 91, 158 Chartier 155 Chevalier 85 Chirac, Jacques 41, 54 Clinton, Bill 38, 54, 61, 72, 74, 132 Coenen-Huther 120 Commeyras 89 Compagnon 9, 127, 153 Comparison 2, 3, 7–8, 15, 22–23, 36, 42, 80, 138, 144, 153, 170 Congo 24, 31, 92, 96, 108, 109, 174, 175

186

Index

Coquery-Vidrovitch 96 Coriat 60, 171 Cormier-Salem 153, 157 Cornu 87, 119 Côte d’Ivoire 8, 17, 21, 26, 31, 40, 41, 49, 52, 64, 68–73, 77, 85, 87, 92, 110, 113, 122, 138, 145, 149 Coulon 176 Covid-19 160–162, 177 crisis 1–5, 30–32, 37, 52, 54, 66, 68–69, 71–73, 75, 83, 92, 99, 103–104, 137, 140–141, 145–146, 149, 160, 172 Cros 4 Crouzel 98, 99

Fassin 11–12, 18, 20, 27–31, 34, 37, 92, 110, 138–139, 158, 177 Fillieule 140 Ford 144, 172 Fote-Harris 96 Foucault 34, 39, 172 France 7, 9, 18, 23–25, 27–28, 38, 41, 50, 54, 61, 63–65, 69–70, 73–74, 76, 105–106, 108, 110, 115–116, 124–126, 131, 133, 141, 142, 144–145, 149, 163, 174–175, 177

Darbon 5, 19, 27, 36, 38, 48, 70, 98–99, 113, 131, 149, 160, 162, 174 David 109 Delaunay 103 Delor 115 Demange 23, 39, 42, 62–63, 66–69, 72, 75, 77, 82–83, 119 Desclaux 49, 70, 86, 103, 119, 122 Desgrees du Lou 122 Diallo 157 disease 6, 15, 20, 25, 28, 31, 33, 41, 49, 51, 54–56, 70, 82, 84, 88, 105, 107–108, 114–117, 122, 136, 138, 140, 142–145, 147, 149, 156, 160–162 Dixneuf 50, 177 Dolowitz 157, 162 Dozon 3–4, 18, 20, 27, 28, 30, 138 Democratic Republic of Congo 109, 159, 174–175 Dumoulin 153–155 Duran 9, 39, 99 Durkeim 33, 40, 97–98, 114–115

Gabas 61 Garbus 60 Garmaise 55 Gates Foundation 34, 38, 54, 58–59, 63, 68, 84, 144 Gaxie 2–23 Gazibo 176 Geronimi 151 Gentilini 108–109 Germany 69, 105–106, 119, 144 Ghana 69, 106, 110, 147, 161 Gilks 71 Global Fund 5–7, 25, 36, 38–39, 42, 52–57, 59, 60–62, 64–66, 68–77, 83, 90–102, 113–114, 134, 136–137, 139–141, 144, 149, 161, 168, 170–172 Gobatto 30, 116 governance 5–6, 8, 36, 40, 48–77, 95, 114, 138, 140–141, 151, 153, 158–161, 172–174 Grawitz 17, 176 Gruenais 3, 31 Guebogou 22 Guinea 96, 173, 175 Guinea-Bissau 175

Eboko 3–7, 16–18, 21–24, 26, 32–33, 35, 37, 40, 42, 49–50, 54, 62–63, 70–71, 76, 81, 84–87, 91, 97, 100, 104–105, 107, 113–114, 137–138, 140, 142–143, 157–158, 161, 170, 173, 177 Eboko-Ekoka 177 education 3, 9, 95–96, 120, 122, 127, 131–133, 136–137, 148–152, 157, 163, 169–170 Elias 5, 131 Engueleguele 3, 13, 28, 35, 44, 95, 158 Ethiopia 110, 147 Europe 1–3, 9, 18, 26, 63, 69, 76, 108– 109, 116, 142, 153–154, 161–162, 173 Evrard 133

Haas 3, 133, 170 Hassenteufel 5, 7, 9, 15–17, 22–23, 26, 42–43, 48, 52, 97, 138, 158, 176 health 2, 4, 6, 8–10, 15, 17, 22–33, 35–41, 43, 51, 53, 59–61, 63–65, 69, 71, 73–75, 80–81, 84–86, 88–91, 93, 95, 97, 99–104, 107–108, 113, 118, 124–127, 131–138, 142–150, 160, 168–170, 173, 177–178 Hibou 98, 137, 177 Highley 121 HIV 6, 10–12, 15–16, 19–20, 23–24, 28, 30–41, 43, 47, 50, 52, 58, 63, 67, 70–75, 80–85, 87–92, 94, 99–100, 102–109, 117–122, 125, 127–128, 133, 136, 138, 139–141, 143–147, 160, 168–169

Index Hogg 172 Hugon 61, 151, 157, 161 Hyden 48 ideology 31, 96, 137, 147, 163, 169 Idrissou 144–145 illness 29, 108, 143 Italy 69 Jacquot 36, 102 Jobert 17, 32–34, 36, 99 Jones 15, 16 Kaptué 106–107 Kazatchkine 65, 68–69, 141 Kenya 16–17, 21, 83, 124 Kerouedan 3, 55, 71, 100 Kouchner 41 Koulla-Shiro 107 Kuaban 144, 146 Laborier 22, 36 Lachenal 9, 105–106, 109 Lafaye de Micheaux 49 Lange 9, 127, 149, 150, 180 Laroche 48 Lascoumes 38–40, 56, 155 Laurent 4, 18, 26, 28, 71, 113, 144 Lavisse 115 Le Galès 38–40, 56 leadership 24, 60, 70, 75, 80–83, 85–86, 88, 91, 97, 99, 106, 110, 113, 119–121, 136 Leca 17, 176 Lert 104, 124, 156 Liberia 24, 106 M’bokolo 29 M’Boup, Souleymane 83 M’Pelé, Pierre 103, 108–110 Malawi 16, 124, 169 Mali 24, 54, 63, 75, 92, 98, 115–117, 121, 132, 134, 148, 151–152, 170, 174–175 Man, Jonathan 20 Mandjem 35, 87, 119 Mann 3, 5, 7–9, 11, 20, 23, 26, 38–39, 51, 84, 109, 140, 148 Marks 15, 88, 162, 172, 177 Marsh 142 Martin 106, 176 Mauritania 16, 66, 68, 140 Mbali 118

187

Mbembe 7, 9–10, 96 McCoy 59 Médard 5, 7, 23, 84, 98, 110, 146, 158 Meimon 25 Miano 175 Mingat 149 Moatti 4–5, 26, 40, 50, 54, 70–71, 90, 138, 168 Monnier 99 Mozambique 16, 84, 126, 157 Mselatti 50 Muhongayire 4, 25, 30 Mullee 17, 32, 34–36, 43, 70, 100, 176 Namibia 16, 84 Nantulya 55 Nay 20, 60, 65, 159, 173, 175 Ndoye, Ibra 103 Nemeckova 81, 84 Nguyen 11, 39, 70, 172 Niane 152, 163 Niang 124 Niger 8, 16, 24, 52, 55–59, 67, 71–72, 169 Nigeria 54, 110, 124, 161, 169, 178 Njiengwe 125 Nkoa 53 Olivier de Sardan 175 Ollitrault 155 Orsi 142 Otayek 74 Ould-Ahmed 49 Owona Nguini 3, 85, 114 Palier 17, 42 Paluski 121 pandemic 5–6, 9, 15, 19–20, 30, 32, 37, 42, 54, 64, 75, 80, 114, 136–138, 141, 143, 147, 156, 160–162, 172, 177 patent 49–52, 89, 117, 136, 143–144 Patterson 32, 37, 60, 118, 140 Paxton 162 Pechu 140 PEPFAR 38–39, 42, 53–55, 58, 61–62, 70–73, 75, 83, 90, 101–102, 139 Petiteville 158 Petryna 9 Pigeaud 114, 158 Pinell 7, 117, 124, 140 PNLS/National AIDS Committee 19–24, 41, 43, 72, 74, 81, 86, 88, 100, 102–105, 107, 109, 134, 139

188

Index

Poku 37, 116 public policy 1–5, 7–8, 15–20, 23–27, 32–37, 39–40, 42–43, 50, 66, 80, 86, 91, 95–97, 99–102, 113–114, 116, 122, 126–127, 132, 137, 145, 155, 159–160, 170, 173, 175–176; design, 2, 4, 23, 25, 56, 76, 95, 159–161, 175; implementation 2, 5, 15, 17, 17–19, 21– 22, 42, 50, 52–53, 56, 57, 60, 70, 73, 75, 99, 102, 127, 132–133, 139, 147–148, 150, 155, 159, 163, 173, 178; instrument 2, 9, 33–34, 36, 38–40, 48–49, 55–57, 60, 157, 159, 168, 171, 174–175; matrix 2, 9, 48, 95, 102, 113, 127, 131–162, 170, 173–174 politics 1, 6, 10–11, 18, 26–27, 30, 36, 38, 48, 85, 101, 113, 126, 132, 137, 159, 176 Pollak 124 Pouligny 155 Prolongeau 87 Provini 162 Prunier 92 Pulon 163 Putzel 83 Pizarro 140 Quinn 168 Ravinet 36, 102 Raynaut 4, 27, 30, 32, 99–100 Rodary 153–155 Rothchild 49 Rwanda 4, 20, 24, 30, 83, 92, 147, 169 Sabatier 43 Samb 70 Same-Ekobo 143 Samuel 150 SARS Cov-2 160–161 Schneider 31, 34 Schoepf 110, 137 Senegal 8, 16–17, 21, 31, 40–41, 49–50, 52, 55–59, 67, 70–72, 80–83, 86, 91, 102–103, 110, 113, 122, 124, 134, 138–139, 144, 151–152, 161, 163 sexuality 20, 34, 81–83, 122, 124–125, 140 Seytre 83 Sierra Leone 24, 92, 106 Sindjoun 12, 31, 92, 98, 159, 174 Smith 2, 8, 9, 16, 43, 158, 176 Smouts 9, 50, 127, 156–157 Somalia 92 Souteyrand 71, 124

South Africa 6, 10–12, 16, 30–32, 35, 37, 40, 42, 50–51, 84, 87, 117–119, 122, 124, 138, 144, 158, 160–161 Spain 163 state 1–3, 5, 7–10, 12, 15–16, 19–21, 23–26, 30, 32–43, 49, 51–53, 60, 63–64, 66–67, 74–75, 80–87, 91–92, 95–101, 110, 113, 119–120, 123–125, 127, 132–134, 136–137, 140–141, 144, 146, 148–153, 157–162, 168–171, 173–176 Stephen 169 Stephens 140 stone 162 Sub-Saharan Africa 4, 6, 8–9, 15, 18, 20, 27, 37, 54, 80, 84–86, 90, 116, 118, 122, 136, 138–140, 143, 147–149, 151, 153, 160–161, 163, 169 Sudan 124 Surel 17, 42 Swaziland 16, 84 Switzerland 38 Tanzania 124, 163 Taverne 30 Tchiombiano 141, 171 Thatcher 39 Thiriot 176 Tilly 126 Togo 175 Toulabor 7 TouraineV26 115, 140 tuberculosis 3, 6, 9, 15, 28, 36, 51, 53, 101, 108–109, 133–134, 136–139, 141, 143–147, 161–163, 170, 172 Uganda 32, 40–41, 49–50, 75, 81–83, 85, 87, 91–92, 113, 118–119, 138–139 UNAIDS 6, 15, 19–20, 25, 31–32, 36, 38, 41, 49, 54, 60, 72, 82–83, 87–90, 101, 106–107, 109–110, 116, 134, 139, 147, 168 UNDP 87, 98, 101, 139, 155 UNESCO 134–135, 149, 151, 154 UNGASS 73, 134, 137 UNITAID 54, 74, 90 United Kingdom 83, 96, 101, 134, 105, 153–154 United States 1, 18, 59, 61–62, 65, 73, 101, 105, 107, 117, 131, 133–134, 141, 153, 161, 173 Vasseur 114 Vennesson 31

Index Vernazza 168 Vidal 3–4, 18, 28–32, 50, 92, 144–146 Weber 97 Whiteside 37, 116 World Health Organization 15, 71, 100, 137

189

Wieviorka 115 World Bank 1, 23, 25, 38, 39, 48, 53, 60, 68, 69, 71, 74, 89, 95, 98, 101, 134, 139, 147–154, 160, 173 Zambia 16, 87, 119, 124, 169