In addition to the methodological limitations to illustrating quantitatively the relationship between governance and infectious disease control, there are several examples that can be cited to suggest that more authoritarian responses lead to more effective disease control, or that governance has little ultimate impact on infectious disease rates. Certainly it is true that, despite the best (or worst) intentions of individuals and governments, infectious pathogens can be stubbornly indifferent or even contrary to theories of health and human rights. HIV transmission can be limited in civil war settings, for example, even when human rights abuses are widespread and governments have collapsed. In Angola, a protracted civil war which reduced cross-border travel and trade is thought to have left the country somewhat protected from the early introduction and spread of disease compared to many of its neighbors; however, the war also impeded the ability of the government to conduct surveillance and education around the disease, and destroyed the health services needed to respond to AIDS. The war also curtailed the formation of a vibrant civil society, such as the development of NGOs and AIDS service organizations, which have been highly effective in both prevention and care elsewhere.

Post-conflict countries often see a sharp increase in HIV prevalence, presumably as measures of governance are improving, indicating that the relationship between HIV and governance may involve a similar time-lag to the relationship between widespread transmission of HIV and the onset and recognition of AIDS. In Mozambique, for example, the HIV rate soared shortly after the cessation of civil conflict in 1992. Another example of the difficulty with the temporal relationship between governance and HIV prevalence comes from the Kingdom of Swaziland, referred to above. The rapid rise in HIV prevalence, from 4 percent in 1992 to 26 percent in 1996, did not occur with a simultaneous deterioration of governance; rather, the precondition and weaknesses in Swaziland allowed for the rapid spread of HIV once it was fully introduced into the country. Conversely, the apparent improvement in the HIV epidemic in Zimbabwe, with HIV prevalence decreasing from 25 percent to 20 percent between 2001 and 2005 despite a worsening human rights and governance environment, may be reflective of earlier actions by the government and, importantly, by international donors, while the impact of current government actions will only be reflected in the years to come (Human Rights Watch, 2006a). Vaccine-preventable diseases may similarly reflect a time-lag between the breakdown of governance (and hence vaccination campaigns) and the accumulation of a large enough susceptible cohort of individuals to sustain disease transmission.

Affluent societies with representative governments are also not immune to leadership failure. For example, during the early years of the AIDS epidemic there was cover-up and scandal over the failure of regulators in Canada, Japan, Ireland, France, and elsewhere to stop promptly the use of tainted blood products that were infecting hemophiliacs with HIV. While broad measures of governance may relate generally to the willingness of governments to adopt effective disease control policies, government policies to control diseases that affect specific (favored or non-favored) populations, or are related to culturally sensitive transmission modalities, may be poorly correlated with overall measures of governance.

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