A special report on the politics of AIDS and HIV in South Africa

A special report on the politics of AIDS and HIV
from epoliticsSA

POLICY BRIEFING: WHAT GOVERNMENT HAS DONE ABOUT AIDS IN SOUTH AFRICA

What follows is a brief overview of the South African Government’s response to the AIDS crisis since the disease made its presence felt in this country.

Prior to the 1990’s, little was done by the apartheid regime to combat AIDS besides the appointment of an AIDS Advisory Group in 1985. As the severity of the disease became known however, Government’s efforts became more serious. Meanwhile the ANC in exile had held a number of meetings on HIV and AIDS. In 1991, the South African government set up the first specific AIDS programme infrastructure in the form of a network of AIDS Training, Information and Counseling Centres.

By 1992, the National AIDS Co-ordinating Committee of South Africa (NACOSA) was established to develop a National AIDS strategy. This organisation comprised a diverse group of concerned individuals including Non-governmental Organisations, AIDS Service Organisations, Government representatives, the ANC’s Health Secretariat as well as representatives of business, trade unions and churches. After 2 years, this rather disparate coalition came up with a strategy, which they consolidated within a National AIDS plan. The new Government in July 1994 adopted this AIDS plan with much fanfare.

The plan envisaged the allocation of large amounts of money from the Government and donor organisations to AIDS-related projects. The bulk of the funds were to be spent on AIDS prevention and education programming, with a lesser amount being directed towards improving the primary health care system so as to provide counseling care and support to AIDS victims.

Top priorities were: to include the development of mandatory sexual education curricula in schools, mass information campaigns and better condom distribution schemes. Although, the plan originally had called for national and regional managers to effect implementation, then Minster of Health, Dr Nkosazana Zuma, decided instead to vest control in the Health Department’s newly created directorate on HIV/AIDS and Sexually Transmitted Diseases.

By 1996 however, severe problems had developed. Resource constraints had hampered implementation with much of the intended money never being allocated in the National Budget. Even money which had been allocated was left unspent, as the AIDS plan was submerged among competing priorities of the Department of Health which was undergoing major restructuring at the time. As a result, many of the policy targets were never reached.

Worst of all was the bad press the plan received as a result of the Sarafina II scandal. In early 1996, a large portion of the AIDS budget (R14,27 million) had been spent on a critically-panned musical play meant to spread awareness of the disease. Not only was the play considered ineffective in relaying its message but also proper tendering procedures had not been observed in acquiring the funding for it. Opposition parties, much of the news media and some NGO’s used this as an opportunity to attack Health Minister Zuma, who subsequently withdrew into a defensive shell.

On the eve of World AIDS day in 1996, AIDS educationists and health workers denounced the entire National Aids Plan as a shambles. Critics blamed a lack of commitment by Government at a senior level.

In 1997 however, Rosemary Smart was appointed as new AIDS directorate chief in the Health Department. She kick-started a number of new initiatives. An inter-ministerial cabinet committee on AIDS was set up, chaired by the Deputy President, Thabo Mbeki, to broaden the responsibility for the epidemic to include other Government departments.

While the core plan remained the same, certain additions were made such as the "Partnership Against AIDS" effort and the "Beyond Awareness" campaigns unveiled by the Government in 1998. Both of these projects were aimed at raising public awareness of the AIDS crisis and prompting companies, churches and civic organisations to tackle HIV/AIDS. Minister Zuma managed to push through a controversial law that allowed the South African government to bypass pharmaceutical patents and obtain essential medicines at much lower prices. While this move raised the ire of the large drug companies, it was lauded by international organisations that argue for the relaxation of patent and trade restrictions that keep essential AIDS drugs prohibitively expensive.

Despite these admirable efforts, the Government continued to embroil itself in AIDS-related scandals, which diverted attention and energy away from attempts to contain the pandemic. After the Sarafina scandal came the Virodene debacle. High profile members of Government including then deputy President Mbeki, championed a locally developed treatment against AIDS (Virodene) despite widespread criticism of the fact that the researchers behind the drug had circumvented usual testing procedures. Minister Zuma attempted to fast-track the drug, dismissing concerns raised by the medical community, suggesting they were in league with companies that did not want competition from Virodene. In fact, the drug was later revealed to contain an industrial solvent that was harmful to humans.

Even more puzzling was the Health Ministry’s announcement in 1998 that the Government would no longer give the drug AZT to pregnant women. AZT was known to reduce the risk that babies would be born with the virus. The reasons Government gave for this decision ranged from the assertion that the treatment was unaffordable to that AZT, a widely used pharmaceutical, was dangerous. The Government, especially President Mbeki and new health Minister Manto Tshabalala-Msimang, has maintained the latter claim to date despite worldwide evidence to the contrary.

As pointed out in the POLITICAL BRIEFING, the new millennium has seen in both encouraging and disappointing signs in terms of the South African government’s AIDS policy. In early 2000, a National AIDS Council was appointed charged with the responsibility to widen the response against AIDS to sectors not yet engaged in AIDS work. The composition of the AIDS Council was, however, criticised. The Health Department also has developed a new policy document (not yet approved by Cabinet) designed to correct the shortcomings of the existing AIDS strategy.

With this positive news though has come reports that 40% of the Government’s 1999/2000 AIDS budget went unspent and that funding to AIDS Service Organisations in the current budget was cut by a further 43%. Also disturbing was the government’s defense of a decision to invite so-called AIDS dissidents to discuss AIDS in Africa in July. The dissidents claim, amongst other things, that HIV does not cause AIDS (see ISSUE BRIEFING).

While these debates rage on, people continue to be infected and people continue to die. It is becoming abundantly clear that Government has not been able to develop and implement an effective policy.

ISSUE BRIEFING: MBEKI AND THE DISSIDENTS

Over the last few months a controversy that took place a decade ago in developed countries and was resolved then, has been rehashed in South Africa.

The main protagonist of this controversy is Peter Duesberg, a California-based scientist, who raised his dissident views for the first time in 1987.

Duesberg had three main points of contention:

* AIDS is not caused by the HIV virus;

* drug cocktails used in rich countries to defer the onset of AIDS are toxic; and

* AIDS is a sociological and political phenomenon. They say poverty causes AIDS, rather than that poverty is a contributing factor to HIV. In essence, Duesberg argued that AIDS does not exist. That it is a term used to lump together all sorts of conditions that are actually separate and caused by a variety of things, such as poverty, use of hard drugs, etc.

The counter-arguments to this are:

A number of carefully conducted experiments and clinical case studies have shown HIV to be the cause of AIDS. HIV/AIDS has fulfilled all the four postulates of Koch raised by Duesberg in 1987. These are: the micro-organism causing the diseases must be found in all cases of the disease; must be isolated from the host and be grown in pure culture; must reproduce the original disease; and must be found in an experimental host so infected. These include case studies from accidental HIV exposure in laboratory workers, occupationally acquired HIV infection, hemophiliacs, mother-to-child transmission, and injection drug use. The chronological association between HIV infection and the development of AIDS has been demonstrated in all these cases.

HIV causes specific and observable damage to the immune system, which is not observed in the presence of poverty, malnutrition and many chronic infectious and noninfectious diseases without the presence of HIV. These other factors may be aggravating or contributing factors, but that none of these conditions, singly or in combination, causes result in AIDS. The dissidents’ arguments were dealt with in article by science journalist John Cohen in the journal Science (1994, 266) as well the US National Institutes of Allergy and Infectious Diseases.

Duesberg still has to provide experimental proof of his pronouncements in the late 1980s in relation to HIV and its relationship or lack thereof to AIDS, and his theories that illicit drugs or AZT or malnutrition are the causes of AIDS.

Why then does this debate come to South Africa?

Observers feel the debate started as a result of government’s problems in the 18-month standoff over AZT. The main argument within government of those opposed to AZT related to two things: Unhappiness over the monopoly of multinational pharmaceutical companies in the manufacturing of retroviral drugs and the cost issues relate to it; as well as the argument that AZT is toxic.

At this time, President Mbeki browsed on the Internet and came across the arguments of Duesberg. While Mbeki himself never said that HIV did not cause AIDS, influenced by the dissidents’ claims, he suggested that the theory that HIV causes AIDS needs to be revisited. In relation to AZT he stated in Parliament in November 1999 ‘… there exists a large volume of scientific literature alleging that the toxicity of this drug is such that it is a danger to health.’

It is difficult to understand the logic behind Mbeki’s actions. Is it because he does not trust scientists? Are his pronouncements meant to cast doubt on and undermine scientists and the scientific method in South Africa? It is telling that the country’s leading scientists, including Dr William Makgoba, president of the statutory Medical Research Council, condemned Mbeki's statements.

What appears to have intrigued President Mbeki is that most of the work is done on Europe. There has been no proper study of the link between poverty and AIDS.

The dissidents have obviously exploited this opportunity to spread their propaganda. In some ways they have a hand in the way the issue has blown up in the South African media. In fact some dissidents were quick to respond to a request by Mbeki to come to South Africa and circulated details of their private conversations through e-mail.

The dissident issue is also a useful argument for caution or a way to deflect attention from government’s stalling on a commitment to a programme involving drugs, like AZT, that slows down the disease. Government claims it does not have the money; and secondly it has been in a long fight with pharmaceutical companies.

The controversy around the dissidents and Thabo Mbeki is not just limited to science. It undermines some of the strategies government has put in place; has a negative impact on people with HIV and AIDS and their families; is demoralising to those closely involved in the quest to alleviate and eradicate HIV/AIDS (both in government and NGOs); undermines the South African scientific community; and does not bode well for South Africa’s image internationally.

WHO’S WHO

Manto Tshabalala-Msimang. Appointed Minister of Health in the Mbeki administration (since 17 June 1999). Tshabalala-Msimang (b.1950) was first elected a Member of Parliament in 1994. She served as chairperson of the portfolio committee on Health in the National Assembly (since 1994), and from 1 July 1996 served as Deputy Minister of Justice. She spent 28 years in exile and worked in health services in Tanzania and Botswana, the United Nations Development Programme and the ANC department of health. She returned to South Africa in 1990. She has an extensive background in child health and worked in community health organisations in Kwazulu-Natal upon her return to South Africa. Born on 9 October 1940 in Durban, Kwazulu-Natal, Tshabalala-Msimang studied at the University of Fort Hare (South Africa), the First Leningrad Medical Institute (USSR), University of Dar es Salaam Medical School (Tanzania), and has a Master’s degree in Public Health from the University of Antwerp (Belgium). She is married to ANC veteran and former South African High Commissioner to the United Kingdom, Mendi Msimang.

Mirryena Deeb. Chief Executive Officer of the Pharmaceutical Manufacturers Association of South Africa (PMA) since 1995. PMA represents local and multinational research-based pharmaceutical companies in South Africa. Deeb (b.1962) is a former associate business editor of the South African financial magazine Financial Mail (1988-95). In 1996 she received the Kaiser Foundation Award for ‘excellence in journalism that advances the health status of the poor’. Deeb studied at the universities of Witswatersrand (BA, International Relations, Politics and Law, 1984) and Natal, Pietermaritzburg (Law degree, 1996). She also serves as council member of the Geneva-based International Federation of Pharmaceutical Manufacturers Associations (IFPMA), the representative of the global industry. She is presently a director of the IFPMA.

Ian Roberts, Special Adviser to the Minister of Health (appointed at the level of deputy director-general of department of Health in terms of civil service codes) since 1996. He had spent his previous career working as a medical doctor (1979-85) and research director in the UK and Spain. Roberts (b.1953 in South Africa) studied medicine in the United Kingdom at Surrey University and business management at the London Business School (1993). Before joining the ministry of Health, he worked as a senior management consultant for the Monitor Company in South Africa (1995-96). Prior to coming to South Africa he had worked for a range of medical research laboratories: Laboratorios Almirall (Barcelona Spain); Clinical Research Foundation (London) as part of the Boehringer Ingelheim Group of Companies; and Roussel Laboratories (London and Paris).

Bongani Khumalo. Head of government’s HIV/AIDS programme and rural development. His appointment is effective from May 1. Khumalo (b.1953) is currently deputy chief executive of the state electricity utility company, ESKOM. He is described as a ‘technocrat’. As head of human resources and transformation at ESKOM, Khumalo was in charge of ESKOM’s AIDS strategy, internal transformation and restructuring and instrumental in its rural development programmes. He has worked for ESKOM since 1992. Previously he had worked for the South African Red Cross Society as a regional manager in Gauteng, where he had clashed with management over alleged racism and failure to transform its operations. He has subsequently been vindicated. Khumalo was elected president of the South African Men’s Forum three years ago.

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