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Understanding politics as part of doing impact studies





Overview

One of the problems with studies of the socio-economic impact of HIV/AIDS is that they have little impact. An explanation is that many are “stand-alone” studies that only look at one aspect of the impact and are not part of a strategy to respond. Using a crisis-management perspective that views disasters or crisis as politicised occurrences not to be managed only by technocrats, this article is meant to provoke a discussion on how to overcome the barriers that shelve so many impact studies. In contemporary politics, North and South, politicians are faced with an erosion in public trust in the capability of state institutions to perform their classic functions. Even though many politicians and bureaucrats may fully understand the implications of the AIDS-crises, they also have other matters desirous of attention on their agenda. Which matters are dealt with in what order, tends more to be taking advantage of »windows of opportunity« - situations in which there is both a possibility for and a need to act - than a rational process. Considering that such a »window« also provides a major potential for other players to advance alternative policies, this understanding of politics can form the basis for rethinking a better end-use of impact studies.

As a way of stimulating this discussion on how to seize the »windows«, the article gives examples of past windows and ends in questioning if impact studies not only should stipulate what to do, but also have approaches on how to overcome different kinds of barriers, and if a proper response against HIV/AIDS should focus solely on HIV/AIDS-related symptoms, or the same - and perhaps more - could be achieved by addressing country-specific, yet fundamental root-causes for poverty and disease.

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One of the major problems with many impact studies is that they are commisioned, carried out and then shelved«, Tony Barnett and Alan Whiteside write in their »Guidelines for Studies of the Social and Economic Impact of HIV/AIDS« (1)Tony Barnett & Alan Whiteside: Guidelines for Studies of the Social and Economic Impact of HIV/AIDS, UNAIDS Best Practice Collection, Geneva, UNAIDS, 2000. And continue: »This is partly because most are »stand-alone« studies - that is, they look at one aspect of the impact and are not part of a strategy to respond. Ideally studies should be part of, or feed into, such strategies.«

Any number of reasons can be offered as to why the recommendations of an impact study get nowhere near implementation; most of them have to do with the context of the study in question. However, there are some common denominators that play their part.

One is, as Alex de Waal (2)Alex de Waal: »AIDS: Africa’s Greatest Leadership Challenge Roles and Approaches for an Effective Response « notes in his essay on AIDS as Africa’s greatest leadership challenge, the quiet undermining from within: »Since colonial days, lack of voluntariness and insensitivity to local realities have routinely undermined trust in public policy. This has left a deep legacy of distrust in governmental interventions. Ordinary African citizens routinely suspect that any initiative from a government department or international agency may have a hidden agenda, or may be a passing fad that will soon be superseded. For many ordinary people and low-level bureaucrats alike, the established modus operandi is to try and survive despite public policy initiatives, paying lip service to them and going through the motions of implementing them, but in fact either ignoring them or subverting them.«

Even if that is overcome, there always is Friktion, as phrased by Prussian military philosopher Carl von Clausewitz (3)Carl von Clausewitz: Vom Kriege. Erstes Buch: Über die Natur des Krieges. Siebentes Kapitel: Friktion im Kriege »
Friktion ist der einzige Begriff, welcher dem ziemlich allgemein entspricht, was den wirklichen Krieg von dem auf dem Papier unterscheidet«
: »Friktion is the only conception which in a general way corresponds to that which distinguishes real War from War on paper.« No matter how meticulously planning is done, things seldom go as planned because of petty circumstances that cannot properly be described on paper and because the interconnectedness of matters just happens to be more complex, than can be envisaged.

A third factor - and the theme to be developed in this paper - is that one should not be naive about the making of politics: Policy-making is not alway the rational process, in which the better arguments prevails, text-books could lead to believe. As Otto von Bismarck summed up his experiences as Prussian chancellor: »Politics in itself is not a logic and exact science, it is more the ability of choosing what is least damaging or most proper in the given circumstances«(4)»Politik ist eben an sich keine logische und exakte Wissenschaft, sondern sie ist die Fähigkeit, in jedem wechselnden Moment der Situation das am wenigsten Schädliche oder das Zweckmäßigste zu wählen«. To this could be added that perceptions of something as being of sufficient importance to require action, or of the least damaging, is indeed relative, depending both on who has the attention of which ears at what time, and on the ability to comprehend what is being conveyed. To complicate matters even further, it should be taken into consideration that deciding to do nothing, sometimes constitutes an action equal in consequences - though it may differ in outcome - as deciding to do something.

When society moves in the direction we term as progress, we like to understand it as the result of things brought about, preferably by political leadership. And it can be done, as illustrated by historian Simon Szreter in an essay (5)Simon Szreter: Economic Growth, Disruption, Deprivation, Disease and Death: On the Importance of the Politics of Public Health for Development, pp. 76-116
In Plagues and Politics: Infectious Diease and International Policy, edited by Andrew T. Price-Smith, Basingstoke & New York, Palgrave, 2001
, where he questions the notion that economic growth is correlated with general improvements in the prosperity and health of a society. Comparing economic growth rates in England from 1800 to1870 with life expectancy at birth, Szreter finds little if any health improvements for the nation as a whole over the period. Despite economic growth the national average for life expectancy at birth remained at 40-41 years until the 1870’s. When it did happen it was, he demonstrates, the result of political action.

The operational word is his argument is »average«, because many examples can be found of increases in real wages leading to prosperity and better health. However, on average these examples were outweighed by a combination of an increasing demand for labour and rural depressions with the result that the industrial towns continually received rural immigrants, who tended to fill the least secure and lowest paid jobs and could therefore only afford the poorest housing.

A turning point came when municipalities in the manufacturing centres began investing in sanitation with a separation of the supply of drinking water from the sewer. The reason it had not happened before was not lack of knowledge nor lack of ability to think big. When it came to rail communication town councils proved quite capable in that respect, especially since no one questioned the commercial benefits of having a railway going right through city centres that in the 1840’s and 1850’s were refashioned accordingly. Even when it came to the water supply town councils could take the initiative. At least as long as water was seen as an industrial raw material.

The political will stopped short of sanitation. The majority of the electorate - the petty bourgeois ratepayers - could not be induced to vote for, still less campaign for, such an expensive municipal measure, even though it may have given them longer, healthier and more prosperous lives. The benefits to be gained were too abstract, remote and speculative to carry conviction for these practical men, who had more than enough to do just surviving on a week-to-week basis in trade, while at the same time trying to avoid bankruptcy. A prospect drawing only closer since the increased demand for local rates would have to come out of their limited balances.

When change did come about in the late 1860’s, it was result of a new political tide combined with voting reforms. The new political will could be found in the preachings of a number of charismatic Nonconformist minister in Birmingham, who advocated a religiously inflected call to civic consciousness and pride and the undertaking of public goods works that soon spread to Britain’s other ‘city states’. Changes in the formal municipal voting qualifications in the late 1860’s quadrupled the electorate with an influx of working men. These urban consumers and the new breed of politicians, who wooed them instead of the traditional producer and retailer interests, formed an alliance that brought about change. It should be noted, though, that the tax system made things easier for the reform politicians. The new majority was formed of voters, who were not faced with direct bills for the improvements in living conditions and amenities. As tenants rather than homeowners they did not pay local rates directly; instead they paid indirectly into the rents to their landlords.

Change takes political will, as can be learned from this very compressed rendition of the interactions of economic growth, public health and political leadership during the English Industrial Revolution. But this example should not lead to believe that change always takes formidable Birmingham-ministers to be brought about. On a smaller scale political entrepreneurism - understood as being more than familiar at playing the political game of policymaking - can get you a long way. It may not be the direct route and not all ends are necessarily met, still you may achieve a lot.

When looking at HIV/AIDS from the political entrepreneur point of view, there are some factors to be reckoned with from the onset:

One is the invisibility. Barnett and Whiteside (6)Tony Barnett and Alan Whiteside: »Guidelines for Studies of the Social and Economic Impact of HIV/AIDS«. point out that in order »to see the socioeconomic impact af HIV/AIDS, you have to look for it.« The true impact of the pandemic is yet to be seen, even in the worst afflicted countries.

Another is the tendency to fight the next war using the tactics of the previous. Tempting as it may be to draw a parallel between development - or lack thereof - and HIV/AIDS, it would be an underestimation of the opposition, because HIV/AIDS is a less generous adversary than lack of development.

Another again is the conservatism of thinking. de Waal notes (7)Alex de Waal: »AIDS: Africa’s Greatest Leadership Challenge Roles and Approaches for an Effective Response « that »the leadership skills and approaches required are very different from those demanded for conventional political struggles«. Fighting AIDS is nothing like fighting for the liberation of a country or staying in power, and what you used to do in order to mobilise hardly works here; instead it takes promises of openness, tolerance and a readiness to change.

Yet another is the box-thinking. de Waal also sees it as a particular problem with HIV/AIDS that it is often labelled as a health policy issue, making those who are not health professionals reluctant to speak on the issue on one hand, and on the other confining it to be owned solely by ministries of health. They may have the experts, but if they have shortcomings in that ministry, these could impede implementation of policy.

Political entrepreneurism builds on the assumption that despite these factors (and probably several more) there is still room for manoeuvre. Politicians no matter if they are democratic or dictatorial do not function in vacuum. Governments are repeatedly faced with external as well as internal influences that on way or the other has to be dealt with. Among external influences may be natural disasters, technological mishaps, tensions in relations with neighbouring states or more recently the influence of the globalized economy. Traditionally, a major internal concern has been intra-elital positioning; more recently the dissatisfaction the relative deprived has been added as a contingency. Whereas the poor and the insecure do not tend to identify with one another and mobilise around generic issues like food or AIDS, the relative deprived, those who perceive a widening gap between the level of satisfaction they have achieved and the level they feel they deserve, find it easier to join forces. In the right context this can cause political unrest and undermine the legitimacy of the system.

Governments are assumed to be well prepared for any crisis that may occur and to take effective measures to protect the public, limit harm and compensate damage. Failing to live up to expectations may make them look weak and inept in the public eye, and this in itself could make matters worse. The role of a political entrepreneur working for the leadership is to find the room for manoeuvre needed to counter predicaments.

To better appreciate this room, some words on the concept of »crisis«. According to Dutch political scientist Paul t’Hart (8)Paul t’Hart: Political leadership in crisis management: An impossible Job?
Key Note Address, Research Meeting “The Future of European Crisis Management” Uppsala University, 21 March 2001.
crisis are events that are not clearly marked in time and space. Crisis are to be viewed as critical epochs of high stress, high politics and high activity that expose and disrupt ongoing social, political and organisational processes. Crisis do not stop at borders, as we have seen with refugees, food scares, epidemics. Crisis are not discrete events sequenced neatly on a linear time scale, but are processes set in social time. Furthermore they are inter-linked, as we have seen in the Third World where political violence, economic crisis and natural disaster combine to produce catastrophes And crisis are relative, because a crisis is not perceived the same way by all actors.

Coping with unwanted, unexpected contingencies is, however, only one side to crisis. The relativity of crisis indicates a degree of construction and interpretation behind each crisis, that have various parties try to argue for or against the notion that some event, condition or contingency constitutes a salient, credible threat to essential public values and interests. The seemingly resent epidemic of crisis leads to question, if the increase in crisis is really due to heightened objective risks? Or is it because something can be gained from the handling of a crisis that goes beyond the mere coping with contingencies?

In policy analysis the term »Window of opportunity« is used to understand what happens when a decision is taken that deviates from the expected (9)See John Kingdon: Agendas Alternatives And Public Policy, New York, HarperCollins College Publishers, 1995, and
Michael D. Cohen, James G. March & Johan P. Olsen: »A Garbage Can Model of Organizational Choice«, Administrative Science Quarterly, 17/1972, pp. 1-25
. Most of the time the self-evidence of the existing policy settings guarantees governance to be business as usual. But sometimes situations, often constructed as crisis, present themselves and opens up a window that allows for a kind of decision-making only possible in the window. Up until the Summer of 1985 the Danish government had been against the added expense of screening donor blood for HIV/AIDS, but when the News on TV could tell of an infected donor, who had donated several portions of blood, the minister found the money overnight (10)For a full account of the Danish Blood Scandal see Anne Brockenhuus-Schack & Poul Birch Eriksen: AIDS - mellem linjerne, Copenhagen, Sommer & Sørensen, 1988.
For readers unfamiliar with Danish, see:
Erik Albæk: »Denmark: AIDS and the Political ‘Pink Triangle’,« pp.281-316 in David L. Kirp & Ronald Bayer, eds., AIDS in the Industrialized Democracies: Passions, Politics, and Policies, New Brunswick, New Jersey: Rutgers University Press, 1992.
Erik Albæk: »The Never Ending Story? HIV and the Blood Supply in Denmark,« pp.161-189 in Eric A. Feldman & Ronald Bayer, eds., Blood Feuds: AIDS, Blood, and the Politics of Medical Disaster, New York & Oxford: Oxford University Press, 1999.
. The Danish case is illustrative in another respect, because it also shows how other parties can use the window of opportunity for their own purpose. When the story of the infected donor broke, the chairman of the Danish Association of Haemophiliacs personally delivered a press release to the major media organisations in Copenhagen. The press release told of how the haemophiliacs in vain had tried to persuade the Minister of the Interior (and Health) to introduce requirements of subjecting blood products to heat treatment. The chairman was invited to be on the News on TV, and under the impression of the story of the contaminated donor blood, the minister requested the heat treatment. Examples are not that hard to find, once you get the idea of what to look for. Some recent examples can be found in the way Germany, the Netherlands, Denmark and other countries handled the BSE-crisis, using it to change the makeup of the meat-producing sector, or in the multinational pharmaceutical companies’ patent case against South Africa and the subsequent discussion about the price of medicine.

The dualism of crisis management - coping with the unwanted and gaining advantages at the same time - can be viewed by politicians who sees reform as needed - and possible - as a way of overcoming political deadlock. »Framing critical contingencies and policy predicaments as crisis provides potential momentum for policy reforms, since it helps to delegitimise and thus deinstitutionalize existing policies and structures« (11)Paul t’Hart: Political leadership in crisis management: An impossible Job?. This construction can create the platform needed for to reformist leader to demonstrate resolve to pursue major policy and institutional change as a way out of the crisis. t’Hart points out that it demands a lot of political craftsmanship, since reformist leadership not only needs to embrace novel policy ideas; it also requires the skills to ‘sell’ them to diverse audiences, and the wielding of power to see them enacted. All this is to be done in an environment of inherent uncertainty about their outcomes and most likely considerable resistance in societal, political and bureaucratic arenas. However, this is what political craft is all about and what politicians do for a living.

Their difficulty lies much more in getting new ideas. This is where writers of impact-studies and the like come in as introducers of the stuff novel policy is made of. Their chance is to give politicians the arguments for a cause politicians did not even know they were for. To do so takes a clear understanding of how far politicians dare to commit themselves during certain points of a process, an acceptance of the needs of politicians to appear constructive and deconstructive at the same time, since they - and not the writers of impact-studies - walk the tight rope between tradition and change, a constant flow of suggestions on how to solve the problem at hand, and a lot of flexibility and ingenuity in case/when the politicians have to make compromises involving the least damaging and probably not the most optimal.

Which once again brings us back to the relativity of concepts and contexts. Perhaps a way forward would be trying to answer questions like: Is the fight against AIDS best served by focussing solely on AIDS-related determinants? Is the fight against AIDS best served by addressing the symptoms of the disease or the underlying root causes, like poverty, other infectious diseases, lack of infra-structure etc? And what is in the best interest of the politicians?

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Notes

1. Tony Barnett & Alan Whiteside:Guidelines for Studies of the Social and Economic Impact of HIV/AIDS, UNAIDS Best Practice Collection, Geneva, UNAIDS, 2000

2. Alex de Waal: »AIDS: Africa’s Greatest Leadership Challenge Roles and Approaches for an Effective Response «

http://www.justiceafrica.org/aidspaper.html (Seen June 18, 2002)

3. Carl von Clausewitz: Vom Kriege. Erstes Buch: Über die Natur des Krieges. Siebentes Kapitel: Friktion im Kriege

»Friktion ist der einzige Begriff, welcher dem ziemlich allgemein entspricht, was den wirklichen Krieg von dem auf dem Papier unterscheidet«

www.clausewitz.com/CWZHOME/VomKriege/VKTOC.htm (Seen June 18, 2002)

English translation of On War to be found at

www.clausewitz.com/CWZHOME/On_War/ONWARTOC.html (Seen June 18, 2002)

4. »Politik ist eben an sich keine logische und exakte Wissenschaft, sondern sie ist die Fähigkeit, in jedem wechselnden Moment der Situation das am wenigsten Schädliche oder das Zweckmäßigste zu wählen«

Otto von Bicmarck in speech to Reichstag, 15th of March 1884

5. Simon Szreter: Economic Growth, Disruption, Deprivation, Disease and Death: On the Importance of the Politics of Public Health for Development, pp. 76-116, In Plagues and Politics: Infectious Diease and International Policy, edited by Andrew T. Price-Smith, Basingstoke & New York, Palgrave, 2001

6. Tony Barnett and Alan Whiteside: »Guidelines for Studies of the Social and Economic Impact of HIV/AIDS«.

7. Alex de Waal: »AIDS: Africa’s Greatest Leadership Challenge Roles and Approaches for an Effective Response «

8. Paul t’Hart: Political leadership in crisis management: An impossible Job?

Key Note Address, Research Meeting “The Future of European Crisis Management” Uppsala University, 21 March 2001.

http://www.ocb.se/dokument/filer/plenary3_t_hart.pdf (Seen June 18, 2002)

9. See John Kingdon: Agendas Alternatives And Public Policy, New York, HarperCollins College Publishers, 1995, and

Michael D. Cohen, James G. March & Johan P. Olsen: »A Garbage Can Model of Organizational Choice«, Administrative Science Quarterly, 17/1972, pp. 1-25

10. For a full account of the Danish Blood Scandal see Anne Brockenhuus-Schack & Poul Birch Eriksen: AIDS - mellem linjerne, Copenhagen, Sommer & Sørensen, 1988.

For readers unfamiliar with Danish, see:

Erik Albæk: »Denmark: AIDS and the Political ‘Pink Triangle’,« pp.281-316 in David L. Kirp & Ronald Bayer, eds., AIDS in the Industrialized Democracies: Passions, Politics, and Policies, New Brunswick, New Jersey: Rutgers University Press, 1992.

Erik Albæk: »The Never Ending Story? HIV and the Blood Supply in Denmark,« pp.161-189 in Eric A. Feldman & Ronald Bayer, eds., Blood Feuds: AIDS, Blood, and the Politics of Medical Disaster, New York & Oxford: Oxford University Press, 1999.

11. Paul t’Hart: Political leadership in crisis management: An impossible Job?


© Poul Birch Eriksen