BEHIND THE PRINCESS Marina Hospital, not far from the centre of Gaborone, are the two small buildings that house Botswana's largest anti-retroviral therapy clinic for people with HIV/AIDS. Alongside the red-brick blocks of the main hospital complex, these prefabricated buildings seem modest and temporary, but it was here that Botswana's ambitious HIV/AIDS treatment program – the first national scheme in Africa – was launched in early 2002. Over the past five years, the number of clinics across this sparsely populated country has grown exponentially, and there are now thirty-two sites, each with up to four satellite clinics, serving a national population of 1.8 million.
Botswana is one of the few African countries in which the urgency and scale of the government's response to HIV/AIDS match the size of the problem, according to Alex de Waal in his recent book, AIDS and Power (Zed Books, 2006). And the scale of the problem is enormous: an estimated quarter of the adult population live with HIV/AIDS, and life expectancy – which had been predicted to reach the age of seventy by the year 2010 – has fallen to below forty.
On this warm, still afternoon, the day's consultations are over and the clinic is beginning to wind down. The main corridor is lined with people waiting for their turn at the dispensary counter. It has been another long day: the clinic opens at 7.30am but people start queuing at dawn to see one of the six doctors who assess patients and monitor their treatment. Waiting for me near the end of the corridor is one of those doctors, Kenalemang Mmeko, who has worked at the clinic for a year after training in Grenada and placements in the United States and Britain. Of the two hundred patients who pass through each day, he usually sees about thirty. Nationally, with free treatment provided by a partnership between the government, the Gates Foundation and Merck pharmaceuticals, those figures translate into over seventy thousand recipients out of a potential group estimated at 110,000. Although that coverage is proportionally the highest in Africa, the aim is to get to everyone.
Cultural attitudes have stopped some people from using the program, or even from being tested. "Initially people preferred to try traditional medicine," says Mmeko, "but they saw that people kept on dying. They also saw that the people who were on anti-retrovirals were doing well." Numbers certainly rose enormously as the clinics spread across Botswana, but a range of factors – denial, lingering supernatural beliefs, the fear of stigma – meant that many people still weren't having a test. The government redoubled its efforts, introducing HIV tests as part of routine medical examinations and pregnancy tests. Activist groups mounted a concerted campaign to make sure that women were aware of the availability of tests and treatment.
Mmeko, who has been at work since early morning and was on call the previous night, is starting to look like he'd rather be home in bed. He quickly describes the standard routine – how people come in first for tests, then two weeks later to discuss the results and map out the treatment, then another week later to check on any side-effects and fine-tune the dose. This eventually settles down to three-monthly visits if all goes well, and monthly visits if the viral load hasn't fallen. With a shortage of medical staff still a problem for the program – around a fifth of Botswana's health-care professionals died of AIDS between 1999 and 2005 – long waiting times at the dispensary can make the treatment process difficult for people with jobs.
Mmeko says the latest figures show a fall in the rate of new HIV infections. This is consistent with the findings of the latest large-scale survey of HIV/AIDS prevalence in Botswana, supervised by the World Health Organisation, which found a fall of three percentage points among pregnant women, especially younger women, between 2003 and 2005. If this is accurate – and measuring the impact of HIV/AIDS in a country like Botswana is not straightforward – then it is welcome news, because previous data have suggested that the massive investment in Botswana was not translating into significant progress.
Botswana is one of a group of countries in southern and southeast Africa, from Namibia in the southwest to Mozambique in the east, with very high rates of HIV/AIDS infection. In each of these countries, the prevalence of HIV/AIDS in the fifteen to forty-nine age group is above 15 per cent, making this the hardest-hit region in the world. Botswana once had the highest recorded rate of all – 38 per cent – but last year UNAIDS used new data to revise that figure down to a quarter of the population.
The figures need to be treated with caution. Although prevalence data is used in all the standard international comparisons, it is not the ideal measure of the success of HIV/AIDS programs. The prevalence of the disease can grow even if the rate of new infections is falling, especially when treatment programs are prolonging lives. Meanwhile, data on the incidence of HIV infections is often patchy or not collected at all. These deficiencies in the data have made the job of assessing progress doubly difficult.
The task of preventing HIV/AIDS, rather than simply treating the disease, is also being undermined by social and cultural practices – some of which are longstanding and others a result of an accelerated process of modernisation in recent decades. As Karen Leiter, the co-author of a new report on Botswana and nearby Swaziland, Epidemic of Inequality (Physicians for Human Rights, 2007), writes: "If we are to reduce the continuing, extraordinary HIV prevalence in Botswana and Swaziland, particularly among women, the countries' leaders need to enforce women's legal rights, and offer them sufficient food and economic opportunities to gain agency in their own lives."
ADDRESSING THE UN General Assembly IN 2001, Botswana's president, Festus Mogae, described the AIDS epidemic as "a crisis of the first magnitude". Unlike neighbouring South Africa, where Thabo Mbeki's government has been agonisingly slow to recognise the need for action, or other neighbouring countries where corruption and poor government undermine all public health programs, the Botswanan government had both the means and the will to act. For Alex de Waal, the government's reaction to the epidemic echoes the way the governing Botswana Democratic Party has handled earlier crises. In his influential book, Famine Crimes (Indiana University Press) published a decade ago, de Waal described the unusually effective anti-famine policies adopted by the government in the early 1980s. He concluded: "Botswana is an anomaly in Sub-Saharan Africa ... a chronically food-deficit drought-stricken country that has consistently averted famine ... Botswana's enduring multi-party electoral system, the high levels of professionalism and accountability in its public service have been intimately linked ... It is made possible by wealth: Botswana is by far the richest of the countries considered in this book."
From the early 1960s to the late 1990s, annual economic growth in Botswana averaged 7.5 per cent – a rate unmatched in Africa and almost unique worldwide. The discovery of diamonds soon after independence certainly played an important role, but in other African countries a single, lucrative commodity – generally oil or diamonds – has had a devastating impact on democracy and the quality of government. As William Easterly shows in his recent book, The White Man's Burden (Penguin, 2006), the sudden increase in wealth raises the stakes in the struggle between the elites and the rest of the population, producing repression and corruption. Botswana largely avoided both, giving it the highest rating among African countries on Transparency International's corruption perceptions index. Botswana also has a lively, independent media, unafraid of challenging the government – especially, this year, over its controversial Intelligence and Security Services Bill. This is significant for the HIV/AIDS effort: research commissioned by de Waal found that "a free press is positively associated with energetic governmental AIDS policies" more than any other factor the study considered.
Botswana's first president, Seretse Khama, is usually credited with laying the foundations for Botswana's economic record and its political stability. Susan Williams' recent book Colour Bar: The Triumph of Seretse Khama and His Nation, (Penguin, 2006) depicts Khama as a calm, rational leader with a self-deprecating sense of humour. The fact that he had a legitimate claim to leadership of the largest ethnic group in Botswana before independence and was the democratically elected president for the first fifteen years afterwards gave his government two different sources of legitimacy. It also meant a greater degree of continuity between the pre– and post-independence periods than existed in many other African nations. The result was stability and a political style that could adapt to the institutions of representative democracy. Features of Botswana's traditional political culture – especially the fact that power was centralised in the chiefs – also helped to create favourable conditions for Botswana's positive economic development.
But, despite its remarkable record, the Botswana Democratic Party, which has been in office for over forty years, has been shedding electoral support. Although the opposition is fragmented, its share of the vote at the last national election – 48.3 per cent – was the highest since independence. The views of the government's critics seem to be gaining wider support.
Before I left Melbourne for Gaborone, I talked to Kenneth Good, an Australian academic who was deported from Botswana in 2005 after lecturing in politics for fifteen years. Good – a combative seventy-three-year-old who has repeatedly criticised the government's political and economic record and its treatment of minorities – would certainly be a nuisance to a government that seems acutely sensitive to bad publicity, but deportation was a massive overreaction. In Gaborone, Elmon Tafa from the radical wing of the main opposition party, the Botswana National Front, said that international agencies rate Botswana highly only because "they're comparing us with outright dictatorships". Closer to the middle of the political spectrum, many people expressed concern that some senior government figures – especially the vice-president, Ian Khama – are moving towards a more authoritarian style of administration. (Khama, a former army general, will become president next year when Festus Mogae's current term ends.) This shift, they say, is typified by the security legislation and the decision to require seventeen journalists and academics, previously free to visit Botswana at will, to apply for permission to enter the country.
Among the seventeen were David White and John Reed, journalists with the London-based Financial Times, who wrote a detailed survey of Botswana for the paper in June 2006. What probably got White and Reed into trouble was their frank account of the government's dispute with the San people, who have been vigorously encouraged, and sometimes forced, to leave their homes in the Central Kalahari Game Reserve. In a case that attracted international attention, the San took their fight to the High Court of Botswana in 2002. Survival International, the London-based organisation that campaigns for tribal groups, argued that the government's decision to remove the San from the reserve was destroying their culture; the government responded by accusing the organisation of treating the San as "anthropological relics". Three judges heard the case and two, including Justice Unity Dow, accepted the San's argument. In a remarkably blunt judgment, Dow criticised both parties to the action but concluded that the government's removal of the San from the reserve was "unlawful and unconstitutional".
Log Raditlhokwa, a lecturer in social work at the University of Botswana, believes that the most worrying development in Botswana is what he calls "the decline of democratic ideals". We met at his office in the middle of the university's attractive, low-rise campus and walked across to the staff cafe. "The government used to consult on many issues," Raditlhokwa told me. "It didn't embark on major changes without giving people the opportunity for discussion."
This approach accorded with the long-standing practice in Botswana of holding large meetings, or kgotlas, of senior men to advise the chief. Trusting leaders to make the final decision rested on a belief that they would do the right thing – and Raditlhokwa argues that this trust has been undermined by falling confidence in the government and its leadership. But the government uses Botswana's excellent reputation among credit agencies and international institutions as ammunition against its critics. According to Raditlhokwa, "They say, 'The opposition is always complaining', but look at what Standard and Poor's says, look at what the World Bank says."
Contributing to the problem is the fact that civil society in Botswana is relatively under-developed, partly because the country's economic success meant that Western aid was withdrawn before non-government organisations had a chance to become financially stable. Young professionals were attracted to better-paid positions in government and the bureaucracy – although these, and the opportunities to teach at the university, are limited. As Jeff Ramsey, an adviser in the president's office, told me later in the week, one of Botswana's problems is that it can't make full use of a growing number of young graduates.
Despite his concerns about the direction of the governing party, Raditlhokwa obviously didn't want to leave me with the impression that Botswana's problems are insurmountable. As we walked back towards his office, he stopped to say: "Botswana is doing fine. But I'm worried that it doesn't have the institutional structure to sustain that."
UNDERLYING RADITLHOWKA'S COMMENTS, and those of other people to whom I spoke, was a sense that some of the tolerance and optimism associated with Botswana after independence from Britain in 1965 has been lost in recent years. Boarding the flight from Johannesburg to Gaborone a few days earlier, I had bumped into Neil Parsons, a historian from the University of Botswana. After we landed in Gaborone, we shared a taxi to the city. As we headed for the university, Parsons summarised his argument that the turning point for Botswana came in the early 1990s, when two things were happening simultaneously. Like many other countries, Botswana was moving away from overt government planning and control, which meant that its economy was increasingly exposed to international conditions. Meanwhile, conditions in neighbouring that country and Namibia were changing dramatically. Namibia had finally won independence from South Africa as that country was heading towards majority rule. Both countries began attracting international aid and expertise away from their relatively prosperous neighbour. "Circumstances meant that Botswana had promoted itself out of the ranks of the poorest countries," said Parsons. It lost the expertise that came with aid programs, especially from the Scandinavian countries, and it lost its special status as an island of democracy in Southern Africa.
As we left the airport, he pointed to a big, half-finished building on the right. This was a new diamond-sorting facility, the country's first, the physical manifestation of a new agreement between the multinational diamond company de Beers and the government of Botswana, and a sign, according to the Financial Times survey, of a shrewd move by the government to reduce its reliance on mining and tap into the benefits of processing diamonds.
I mentioned Parsons's analysis to Jeff Ramsey in his office on the second floor of the recently renovated presidential offices. Ramsey agreed that the fall of apartheid in South Africa was a turning point for Botswana. "It was certainly a good thing," he said, laughing, "but it means we're no longer very sexy in the wider world. In that respect we're no different from other countries in Africa." The transition to majority rule in South Africa had an enormous benefit: it allowed relations to normalise between the two countries. "Before Mandela was released, I was getting pretty worried about the way things were heading," said Ramsey. As one of the "frontline states" during apartheid, Botswana had been used as a base for anti-apartheid activity (often to the discomfort of the government in Gaborone), leading to cross-border strikes by South African forces in the mid-1980s.
Ramsey played down the threat of a more authoritarian presidency. He said that Botswana's strong traditions – "not democratic, per se, but tolerant" – and its record of transparency – "not that we're perfect, but we rate very well according to Transparency International" – would protect citizens from government. When I asked about the security legislation, he said these traditions could be relied on to ensure that the new laws weren't abused. "It's a small community," he added, "so everyone already knows what everyone else is doing."
OR DO THEY? After I talked to Jeff Ramsey I hired a car and set out for Lobatse, a large, sprawling town sixty kilometres south of Gaborone, where I was due to talk to Unity Dow, Botswana's best-known living novelist. One of the themes that runs through Dow's four novels is that the informal controls that existed in Botswanan villages, where relatives and neighbours watched over and to some extent protected girls and young women from certain forms of exploitation, had broken down. Multi-partner relationships, often coercive, were one of the results, with obvious implications for efforts to prevent the spread of HIV/AIDS.
In the mid-1990s, Unity Dow appeared before the High Court – which is based in Lobatse – to challenge the constitutionality of the 1984 Citizenship Act, which granted automatic citizenship to children whose father was Botswanan, regardless of the mother's nationality, but not to the children of women who were married to foreigners. At the time, Dow – who worked as a lawyer with activist organisations – was married to an American, so her children were not citizens by right. The government opposed the case, but the judgment went in Dow's favour, significantly improving the legal status of women but not necessarily endearing Dow to the government.
Yet, just a few years later, Dow was appointed the first woman judge of the High Court of Botswana. In the large, sparsely furnished lounge room of her home behind the High Court building, I asked Dow whether she was surprised when, in her late thirties and having defeated the government in a case watched around the world, she was invited to become a justice of the court.
"Yes, I was surprised, because of my age, my work, my gender ..." she said. "So why was I appointed?" She smiled, "Because of my work, my gender ..."
The court's decision in the citizenship case had an enormous impact in Botswana, helping to create a movement to change a whole range of Botswanan legislation – relating to marriage and property rights, for example – that discriminates against women.
Since she was appointed to the High Court, Dow has written four novels, the first three of which were published by Melbourne-based Spinifex Press. Her first novel, Far and Beyon' (2001), deals with the devastating impact of HIV/AIDS on a family in the 1990s. The novel captures the mood that Festus Mogae was trying to convey when he told the UN General Assembly that people were dying "in chillingly large numbers" in Botswana. Although the main characters, Mosa and her brother Stan, are bright and ambitious,Far and Beyon' conveys a strong impression of a society that has lost a great deal, without yet gaining very much, in the process of modernisation. In a matter of two or three generations, households have moved from a pastoral lifestyle to a relatively urbanised existence, accompanied by shifts in relations within families and between the sexes.
The Screaming of the Innocent (2002), Dow's second novel, is based on a real case of a ritual killing of a child, a practice that has its roots in traditional initiation ceremonies. It is a compelling account not just of how a belief in the supernatural still exists in a society that has adopted many Western beliefs and practices, but also of how powerful figures in a small town – the village head, a school principal and a successful businessmen – can force their will on ordinary people and manipulate the local representatives of government. The novel vividly portrays multi-partner relationships, which have their roots in traditional attitudes to male-female relations and sexuality. The supernatural world again plays an ambiguous role, at worst allowing individuals to escape responsibility for their own actions. "Someone else is doing things to you," said Dow. "You might drink too much, have a car crash, and then blame witchcraft. This really becomes a problem when it's applied to AIDS."
Dow's third novel, Juggling Truths (2003), returns to the kind of village that featured in Far and Beyon', but is set thirty years earlier, when the traditional codes of behaviour were stronger. This is the most successful of the four novels, written with a freshness and subtlety that matches the optimism and courage of the main character. Dow's latest novel, The Heavens May Fall (Double Storey, 2006), also portrays a more nuanced reality than the early novels, featuring a main character who shares the resolve of all Dow's heroines but finds that people's motivations are more complex than she imagined.
Again and again, especially in the novels set in the present and the recent past, men in positions of authority – teachers, police, village leaders – force themselves on young women and girls. Dow believes that this reflects changes in housing and lifestyles. "There are now a lot of private spaces that didn't exist before," she told me. "When I was growing up, houses were for sleeping in, and most of life was spent outside. It was hard for men to find the right place to commit these acts. When I was growing up there were also lots of eyes watching out. If I got home late from school and my mother wasn't home, a neighbour would ask where I'd been since school finished – and I wouldn't be surprised to be asked." Now, she says, children still obey adults outside their family, but the controls on adult behaviour have broken down.
Does this mean the problem is getting worse? "I want to be an optimist and say no," Dow said. "Working in this job you get a sense that women and children won't stand for things as much – that they won't just do what an adult says they should do. If an adult invites a child into their bedroom they know something is wrong, but they're torn between the old idea that 'every adult is your mother or father' and their awareness of danger. Certainly the average child in Gaborone would realise that something wasn't right."
WITH A LIVELY local media, long-term political stability, a growing number of graduates and a diversifying economy, Botswana is almost unique among African countries. Yet Gaborone still has an air of improvisation – typified by the prefabricated clinic behind the Princess Marina Hospital – as if there's a feeling that the wealth might run out and leave nothing behind. Unemployment is high and Botswana continues to do badly in international comparisons of income inequality. But many African countries would no doubt be happy to have Botswana's problems as long as they also had the country's wealth and its tradition of political stability.
The stability has at least one price. It's summed up in a comment about the government's program of free anti-retroviral treatment, made by Alice Mogwe, director of the Botswanan human rights organisation Ditshwanelo. "The government gives but does not empower," she says. "Its progress is based on dependency." The risk is that the government will push this paternalism in a more authoritarian direction, which could undermine the open discussion and local activism that is essential in fighting HIV/AIDS.