For more than 30 years, the global HIV/AIDS epidemic has torn through countries with devastating consequences: 75 million people have been infected, 32 million people have died, and 37.9 million people are living with HIV. The majority of these people reside in the developing world, with Africa being ground zero for the epidemic. Despite this level of devastation, little systematic attention in the social sciences, with some exceptions, has been given to developing or using solid theoretical foundations to understand the complicated dynamics of the epidemic and the effectiveness of the responses to it.
Researchers, scholars, and practitioners should consider Kim Yi Dionne’s book, Doomed Interventions: The Failure of the Global Responses to AIDS in Africa, a major attempt to fill this void. Based on nearly a decade of research, the book is a comprehensive examination of Malawi’s struggle with HIV/AIDS that rests atop a theoretical puzzle that traverses political economy, liberalism, and public policy issues: Why is there a policy disconnect between the international donors supporting HIV/AIDS interventionism and the policies eventually implemented by local agents? Dionne’s book is the product of extensive field research conducted between 2006–10 that includes elite interviews, random sample surveys of rural Malawians, archival research, and ethnographic studies. She employs complementary secondary data analysis using Afrobarometer and Demographic and Health surveys across 30 African states, data from multiple international agencies, and government policy documents. This research is one of the most methodologically comprehensive approaches to understanding the global epidemic and its response produced in its more than 30-year history. Thus, the reader should have little doubt about the validity of the conclusions reached in the book. Dionne’s central argument is that the disconnect between donors and local agents results from the complex and ineffective nature of implementing interventions across multiple levels of governance and that the misaligned priorities between donors and targeted recipients are a result of leaders and citizens who do not give HIV/AIDS high priority in the context of the many substantial problems that Africans face on a daily basis.
After presenting an outline of her argument and methodology in the first chapter, the second chapter provides the reader an overview of the AIDS epidemic and the status of AIDS interventions in Africa. In chapter 3, Dionne establishes the central problems facing AIDS interventions on the continent: (1) the principal-agent problem that hinders intervention efforts and promotes problems such as corruption and (2) the misalignment of priorities within the interventions that can be traced to distinct differences between donor expectations and recipient priorities. This chapter is also the major theoretical contribution that Dionne makes to the literature and discussion of principal-agent problems. The principal-agent framework presented works exceedingly well as a theoretical starting point that challenges assumptions that interventions are linear or cookie-cutter policies in which all the actors are aligned with the same goals and objectives. Dionne presents the principal-agent issue in the context of a hierarchy of stakeholders (p. 46): international agents, national agents and principals, regional agents and principals, local agents, and ordinary citizens. International agents are, essentially, the funding mechanisms that lack the capacity for implementation, which must be done at the local level; national agents are domestic agents such as the Ministry of Health and others that implement interventions; regional agents implement national programs in their respective geographic areas; local agents are the significant link with those that may benefit from the intervention and may include village leaders, doctors, religious leaders, and community workers; ordinary citizens are the last people within the global chain—the intended recipients of the intervention.
This hierarchical portrayal of the global-to-local chain for intervention is important because it highlights the underlying problem at all links within it: the potential for people to exploit financial holes at every step, which leads to corruption or the misalignment of policies (intended and unintended; pp. 42–50). Dionne illustrates this problem with a detailed description of Kenya’s AIDS intervention corruption case that led to the investigation and dismissal of two successive directors of Kenya’s National AIDS Control Council. The Kenyan corruption case demonstrates the extent of the problem, involving implicated auditors and directors, senior managers, secretaries, government ministries, and NGOs accused of graft and corruption in the distribution of AIDS intervention funds. Although it may be easy to dismiss this corruption as motivated by personal enrichment, this case also demonstrates, certainly on a small scale, the nature of African patrimonialism and clientelism (such as that described by Nicolas Van de Walle and Joel Migdal in their research) where the accused had dispersed money to friends, subordinates, and others in their network of influence. Dionne makes this point, though subtly, leaving open the question of how much intervention money may be used as a method to buy or to consolidate political power versus its use for personal enrichment. This question is not easily answerable, but the role of patrimonial and clientelist politics cannot be disentangled from what Dionne accurately paints as a feeding frenzy for intervention money (p. 44).
In chapters 4–6, Dionne presents the detailed case study of Malawi and highlights the importance of donors in the country’s HIV/AIDS intervention. These chapters also present a detailed account of the local agents, village and local leaders, and the context of their decision making in rural areas that face significant problems that challenge AIDS intervention for priority. For instance, in a multitude of interviews with village leaders, she finds that their most pressing issue is their local water supply. But her research nicely contextualizes this as local leaders representing their entire population: everyone needs access to water (and food), even HIV-positive people. Hence, the picture she paints for the reader is one of practical governance and responsiveness to the needs of the local community.
Dionne concludes the book with a summary of her findings and concrete policy recommendations. The practical solutions that Dionne highlights include enhancing HIV/AIDS awareness and bundling HIV/AIDS intervention money with other development assistance to deter siphoning money to other pressing issues. The larger theoretical and normative question is within the context of developing democracies: Whose priorities matter—those of international donors or of local principals and agents? This question takes on even more importance given the colonial and postcolonial history of African states formerly subjected to the external influences of the major colonial powers and now to the major investment powers (such as Russia and China). Moreover, people living with HIV in other African states have faced a culture of discrimination, abuse, denunciation, demonization, sexual violence, and even death that is based on fear rooted in deeply traditional belief systems. Many of these abuses have been at the hands of the very local agents and fellow citizens among whom they live. If framed in this manner, then international donors may not be so easily swayed from what they see as a health problem with significant human rights currents running through it, an issue that has galvanized many HIV/AIDS activists.
If the late Speaker of the U.S. House of Representatives Thomas P. “Tip” O’Neill was correct, all politics is local. We should not be surprised that there exist corruption and a disconnect between donors and intended recipients, given the aid supply chain for interventions. Dionne’s research does an excellent job of bringing these issues to the fore in a sophisticated and comprehensive manner; her book is thus an important read for students of political economy, public policy, and global health governance.
