Continued Resistance: The Struggles of South Africa's HIV/AIDS
War
-- Samuel Choritz
The South African spirit is a hard nut to crack. Ten years after
the ending of Apartheid with non-racial democratic elections and
the election of the country's first black President, enormous
strides have been made in healing over past wounds inflicted on
a black majority by a white minority with outrageous policies
of racial separation, segregation, and discrimination. The much-touted
Truth and Reconciliation Commission, the forgiving personality
of Nelson Mandela and other resistance leaders, the drafting of
a deeply liberal constitution, Black Empowerment and affirmative
action, have all been some of the key weapons in an arsenal that
has facilitated a generally smooth transition towards a new and
democratic South Africa.
Of course, only a decade after Apartheid, serious problems persist.
Racial tensions still exist, from the rugby field (where, prior
to the recent Rugby World Cup, a white player in the national
side allegedly refused to share a room with a black team mate)
to the farm fields (white farmers insist they are being targeted
in an on-going spate of violent attacks and murders against them
in rural areas, while exploitation and horrific acts of abuse
committed against black farm labourers by white farmers still
persist). Social and economic disparities still straddle racial
lines to a large extent, with the white minority still controlling
a disproportionate percentage of the country's wealth. Unemployment
remains very high, exacerbated by strict labour laws and a brain
drain of skilled labour to foreign, mostly European, climes. And
the crime rate is intolerable, particularly when it comes to violent
crimes such as robbery, murder and rape.
These problems are severe, and in many cases mutually reinforcing.
For example, racially marked socio-economic differences and unemployment
fuel racial tension and crime, which in turn sparks an exodus
of skilled labour. But these problems are also surmountable, and
were these the only major tribulations confronting South Africa,
there would be reason to be optimistic about the country's future.
But such optimism is unjustifiable. The government has only recently
begun to tackle appropriately the biggest threat to the country's
existence, and the efforts being made may be too little too late.
Based on current trends, developments in meeting some of the South
Africa's other challenges risk being reversed. For while the South
African spirit may be tough to break, the South African body is
not.
An estimated five million South Africans are HIV positive, with
about 1600 new infections occurring daily. In absolute terms,
no country has more people living with HIV/AIDS. Out of a population
of more than 43 million, having 11 percent of the population HIV
positive is a staggering figure. Disaggregated, these data become
even more overwhelming. Since 1990, HIV prevalence in 15-49 year
olds, the most economically productive citizens, rose from less
than 1% to over 20%. 40% of all adult deaths aged 15-49 in 2000
were due to HIV/AIDS, as were about 25% of all deaths in the country
in that year. By 2010, the cumulative number of HIV/AIDS deaths
is expected to exceed 6 million.
The enormity of the implications of this epidemic on South Africa
are difficult to grasp and even more difficult to quantify. In
terms of human development, with its emphasis on expanding people's
choices and their quality of life, South Africa is doing worse
year by year, and the future is increasingly bleak. A 1998 Report
warned that, "The spread of HIV/AIDS represents a challenge
to all South Africans, threatening to offset recent gains in human
development." Unfortunately, this is exactly what has been
happening.
In 1995, a year after the end of Apartheid, the United Nations
Development Programme's Human Development Index, that ranks countries
according to their literacy levels, life expectancy any income
per capita, placed South Africa 89th out of 174 countries. In
2003, the same index saw South Africa slide to 111th place out
of 175 countries, ranking alongside Sri Lanka. Yet the per capita
gross domestic product of Sri Lanka is $800, compared to South
Africa's $3160. Based on income levels alone, South Africa would
have ranked 64 places higher. The major cause for this low standing
has been the heavy toll that HIV/AIDS has been exacting on life
expectancy.
Depending on the model used, it has variously been projected that
South Africa will experience a significant drop in life expectancy
of between five and 16 years over the next decade. Given the already
low life expectancy of 50.9 years , the average South African
will not have anything resembling an old age to look forward to.
If current rates continue, half of all South Africans below the
age of 15 could become infected over the next ten years.
The economic results of this devastation cannot be overestimated.
A 2003 report by the World Bank found that most studies of the
long term macroeconomic costs of HIV/AIDS, as measured by reduced
GDP growth rates, do not pay enough attention to the way in which
human knowledge and potential are created and can be lost. This
is one of the key channels influencing long-term growth. AIDS
destroys human capital- people's accumulated life experiences,
their human and job skills.
In South Africa, this problem is especially severe. A capacity
gap is emerging as young adults- those most affected by the disease-
are dying before they are able to pass on their knowledge and
skills to younger generations. With such high numbers of adult
deaths, what is emerging is a society comprising older generations,
and very young generations, with increasingly thin threads connecting
the two. Even if adults do manage to live with HIV/AIDS for a
few years, people are often too sick to work or to provide for
their family. At the same time, the loss of income due to disability
and early death reduce lifetime resources available for the family,
even preventing children from attending school. By killing off
mainly young adults- economically active segments of society-
HIV/AIDS also seriously weakens the tax base, further inhibiting
the government's ability to meet the demands for public expenditure.
The social implications of this emerging generation gap are similarly
devastating. Parents, plucked from life in their prime, are leaving
orphans behind. It is now estimated that 13 percent of South African
children are orphans, and by 2008 it is estimated that 1.6 million
children would have been orphaned by HIV/AIDS. Three percent of
households in South Africa are now headed by children. This means
that a generation of children are growing up, or going to grow
up, without the indispensable parental guidance and affection.
According to Olive Shisana, executive director of social aspects
of HIV/AIDS and Public Health for the Human Sciences Research
Council, "The key to preventing new orphans is by extending
the lives of parents living with HIV/AIDS through the provision
of antiretroviral therapy and nutritional supplementations".
Besides all these negative consequences, the burden on the South
African health sector is enormous. One study found that, in the
absence of life-prolonging antiretroviral drug therapy, the country
can expect to lose at least 16 percent of its health workers to
AIDS in the future. This is especially worrying since it is the
younger health workers who have higher HIV prevalence rates. Furthermore,
the study found that of patients treated in public and private
medical facilities, 46% were treated for HIV/AIDS. These AIDS
patients stayed on average more than fifty percent longer in hospital
than non-AIDS patients.
Aside from these more obvious impacts, South Africa's security
is being increasingly compromised. The infection rate amongst
all soldiers is estimated at 23% of the total armed forces, although
others place the figure as high as 40%. According to the South
African National Defense Force, HIV/AIDS constitutes the biggest
single threat to the deployment of potential and operational effectiveness
of the military. Military analysts with South Africa's Institute
of Strategic Studies have warned that unless the spread of AIDS
among African armies is stopped soon, it is possible that many
countries, including South Africa, will soon be unable to participate
in peacekeeping operations.
Another particularly horrific side effect of this epidemic has
been a throwback to 19th Century Europe when it was thought that
syphilis and gonorrhea could be cured by having sex with a virgin.
In its South African incarnation, the myth of the "Virgin
Cure" is being peddled as a method of preventing/curing HIV/AIDS,
and it is being applied with spectacular brutality. Indeed, belief
in the "Virgin Cure" is one of the main reasons for
an epidemic of a different sort that is also plaguing South Africa:
child and infant rape. Nearly 60 children are raped every day
in South Africa.
While "child rape of children five years and over occurs
all over the world, the rape of infant girls occurs only [in South
Africa]". In one well-publicized and particularly horrific
case in November 2001, a nine month old baby girl was gang raped
by six men. Their motivation: to protect themselves against HIV.
With individual losses mounting daily, social fabric being ripped
apart, and the economy staring into an abyss, one would expect
a government, elected by and for the people, to respond swiftly.
Governmental action, after all, has been shown to be effective
in combating the disease. Senegal and Thailand have succeeded
in slowing and even reversing the rate of infection. In Uganda,
for instance, strong political commitment by President Museveni,
the promotion of public-private partnerships and community involvement
and education and awareness programmes have been effective in
bringing down infection rates, by as much as 25 percent. At one
time, Uganda had the highest rate of infection in the world. Currently,
about 6 percent of the population is estimated to be HIV positive,
the level which epidemiologists believe is a critical threshold
above which HIV infections are said to increase exponentially.
Yet, contrary to the country's remarkable history of resistance,
while South Africa is burning, President Thabo Mbeki spent too
long fiddling away. Indeed, Mbeki's only continuation of the country's
remarkable "struggle" past has been his resistance to
facing up to the emergency confronting South Africa. This is perhaps
the only fact more shocking than the impacts of the disease itself.
Mbeki's unwillingness to take anywhere near adequate measures
in combating HIV/AIDS is well known. Whether or not Mbeki explicitly
rejected the H.I.V. model, he has subjected it to relentless challenge,
famously pontificating that "A virus cannot cause a syndrome".
Words aside, as damaging as those are, he has refused to take
action and to provide people living with HIV antiretrovirals -
the drugs, such as AZT, that combat, but do not cure, HIV and
can add years on to the life of a person living with HIV/AIDS.
Even though the U.S. Food and Drug Administration, the World
Health Organization, and South Africa's own Medicines Control
Council had all deemed AZT a safe, beneficial drug, Mbeki was
developing doubts about the safety of antiretroviral drugs.
In the case of the nine month old baby gang raped by six men,
the Health "Minister" for the province where the baby
was raped, Dipuo Peters, lambasted the hospital where the baby
was treated after media reports revealed that the child had been
given AZT. The hospital subsequently issued a circular reminding
doctors that they were barred from administering the drug to rape
patients. Yet, Post Exposure Prophylactics have been shown to
reduce the risk of HIV infection if administered shortly after
accidental exposure.
So, while millions were suffering, in May 2000 Mbeki launched
an AIDS panel to discuss the efficacy of accepted AIDS treatments
such as AZT, whether HIV causes AIDS, giving voice to widely discredited
AIDS dissidents who insist that HIV is harmless, that AIDS is
caused by poverty and "diseases of lifestyle".
In July 2000, Mbeki used the opportunity of his keynote address
at the 13th International AIDS Conference in Durban, South Africa,
attended by 12,000 activists and doctors from around the globe,
to highlight the dangers of poverty. Thumbing his nose in the
face of medical orthodoxy, Mbeki reiterated his controversial
view that HIV is not wholly responsible for AIDS, and stressed
that "The world's biggest killer and greatest cause of ill
health and suffering across the globe is extreme poverty".
He read for five minutes directly from a World Health Organization
report on poverty and disease, repeatedly blaming "extreme
poverty" for the "deeply disturbing phenomenon of the
collapse of the immune systems among millions of our people".
Certainly, poverty may increase people's vulnerability to AIDS.
But, " Mbeki's words implied that a variety of diseases that
had always afflicted the poor - like malaria and tuberculosis
- were suddenly being dressed up as AIDS". By attributing
the AIDS epidemic to mass poverty and malnutrition, Mbeki sidestepped
difficult questions about sex and responsibility. Mbkei came perilously
close to endorsing the dissident view that AIDS is not caused
by the HIV virus, but by environmental factors. Hundreds of delegates
walked out during his speech. Mbeki's stance also prompted an
unprecedented declaration signed by 5,000 scientists that said
that good scientific work, and not "myth", would resolve
the crisis.
Mbeki's obstinance reached new, and embarrassing, heights shortly
thereafter. Nkosi Johnson, then a frail 11 year old who was born
with HIV and who would die a few months later, made an impassioned
speech recounting the misery of losing his mother to AIDS and
attacked the government for failing to provide drugs to pregnant
HIV-positive women. Thabo Mbeki did not have the grace to sit
throughout the boy's plea- he walked out while Nkosi was still
offering his rebuke of the government's neglect of poor black
mothers and the president's politicking over Aids.
Taking her cue from above, and infused with her own disastrous
convictions, the Health Minister, Manto Tshabalala-Msimang, continues
to postulates equally damaging and deadly theories. As recently
as the 9th February 2004 she has also taken it upon herself to
prescribe palliatives for HIVAIDS: "I think garlic is absolutely
critical. Lemon is absolutely critical to boost the immune system.
Olive oil is absolutely critical ... just one teaspoon, it will
last the whole month".
Contrary to the supposed wonders of these ingredients, studies
by the University of Stellenbosch's food information centre, Nicus,
have found that consumption of the African potato suppresses the
immune system and damages bone narrow. Garlic powder, which has
anti-retroviral qualities, can cause serious damage to the stomach
lining. Garlic supplement can also counter the effects of other
HIV medicines.
But the effect of (literally) consuming these remedies has been
only part of the damage done. Of far more significance has been
the difficulty of AIDS-awareness programmes to get off the ground.
Educating people about the methods of transmitting HIV is a non-starter
when the President himself is spreading the message that a correct
diet is sufficient to combat HIV. And without a clear message
coming from the top, the environment is not enabling for effectively
preventing the spread of the disease. On the contrary, such a
programme of disinformation that is currently underway encourages
the dissemination of rumours about how the disease is spread,
and about how it is cured.
While Mbeki's obsession with finding African solutions to all
African problems can be blamed for a failure of the government
to respond responsibly, a lack of money cannot be used as a justification
for the government's refusal, until recently, to provide affordable
anti-retrovirals.
Indeed, when the Global Fund for AIDS donated $60 million directly
to Kwazulu-Natal, one of South Africa's poorest provinces, the
government intervened to stop the transfer of funds on the grounds
that the grant application had been improperly filed. While thousands
of lives could have been saved, the Health Minister nitpicked
that "the Global Fund was trying to bypass the democratically
elected government and put it (the money) in the hands of civil
authorities…Perhaps this is because the Fund does not trust governments
elected by the people." Even if a lack of trust was not the
Global Fund's motivation, it would have been understandable. Indeed,
bypassing the democratic central government may, in fact, have
been responding to what the people wanted. One study has found
massive public support, between 96.5% and 95% respectively, for
the provision of antiretrovirals to prevent mother-to child transmission
and for the treatment of people living with HIV/AIDS.
In addition, in similar display of disregard for the priorities
facing the country, and setting aside socio-economic concerns,
the government recently entered into a $6 billion arms deal that
is difficult to justify. (In fact, the arms deal has been corruption-tainted
and resulted in the ANC's Chief Whip, Tony Yengeni, being sentenced
to four years in prison.)
The bitter irony in all this is that South Africa led the battle
against international pharmaceutical companies for the right to
circumvent patent laws to produce generic antiretrovirals and
make them affordable to the masses. In April 2001, thirty-nine
leading pharmaceutical companies dropped their court challenge
to prevent the South African government from importing, manufacturing
or licensing cheap copies of their patented medicines - including
AIDS drugs. Even before the court victory, the government could
likely have reduced the price of antiretrovirals by purchasing
generic antiretrovirals from India. Yet, despite the drug prices
coming down, and despite having won this momentous battle, the
South African government still refused to start a roll out plan
for distributing the needed drugs en masse.
In fact, having won this battle, the government found it difficult
to cite drug prices as a main stumbling block to delivering antiretrovirals.
So it simply shifted the goalposts, declaring that antiretrovirals
are toxic and unsafe for human consumption. This toxic argument
has been applied most famously to a drug called Nevirapine. The
provision of this antiretroviral therapy to women at the onset
of labour and for a short period postnatally to the infant has
been shown to reduce greatly the likelihood of a mother transmitting
HIV to her unborn baby. In one study in Thailand, Nevirapine had
prevented transmissions form mother to child in 98% of cases.
While the German-based pharmaceutical company Boehringer Ingelheim
that manufactures the drug offered to distribute the drug for
free, the government rejected this hand out, stating that its
safety had yet to be proven, limited the drug's distribution to
a handful of pilot sites.
Certainly, antiretrovirals are toxic. A powerful drug is needed
to fight a powerful disease. But the toxicity of the drugs is
not more harmful to the patient than the impact of the disease
itself, and the benefits that antiretrovirals bring in most cases
in terms of improved quality of life and enhanced longevity certainly
outweigh the costs of any side-effects. The toxicity argument
is a particularly hard one to swallow given that HIV positive
members of parliament were being covered by health plans that
included medicines the government was deeming to toxic for the
poor to take.
With all this feet dragging, the ruling clique has not remained
unscathed by the devastation of this disease, even though Mbeki
very recently claimed he knew no one with AIDS. A rather peculiar
statement since Mbeki's spokesman, Parks Mankahlana died of an
AIDS related illness in 2000 at the ripe old age of 36. Peter
Mokaba, the former Chairman of the ANC Youth League, who in 2000
wisely proclaimed that HIV does not exists and that AIDS drugs
are poisonous, earning the epithet "the champion of the dissident
viewpoint", sadly proved himself wrong by himself dying from
AIDS related diseases in June 2002.
Yet the government's position has only recently begun to shift,
thanks in part to stiff resistance to its policies all along the
way. This resistance has broadly taken two forms: acting where
government refuses, or is unable, to act; and changing the way
the government acts in the first place.
In the first instance, concerned individuals, civil society and
the private sector have developed their own responses to the HIV/AIDS
epidemic while the government debates causes and toxicity levels.
This has ranged from volunteers visiting and taking care of patients
where there is a lack of nurses and doctors, to renegade members
of the African National Congress, the ruling party, administering
antiretrovirals to pregnant women.
The private sector, for reasons of its own, has launched a strong
response. With HIV positive workers having high absentee and death
rates and low levels of productivity, the bottom lines of many
companies in South Africa, such as the mining giant Anglo-American,
have been taking a hit. In response, these companies have found
it cheaper to provide antiretrovirals to all HIV positive workers
than to retrain frequently new ones.
Such efforts are commendable, but without government assistance,
they can only be of limited value. And this is why the second
form of resistance is so crucial: getting the government to take
the necessary action where it is needed most. To this end, civil
society has again been playing a major role.
To their credit, the powerful Congress of South African Trade
Unions (COSATU), a close ally usually in bed with the government,
broke ranks with the ANC with regard to its anti-retroviral policy,
making bold declarations on the need to fight HIV/AIDS and for
an immediate action plan to provide antiretrovirals to HIV positive
workers. There has also been serious in-fighting in the ANC ranks.
But the most notable, successful and well-publicized campaign
in this post-Apartheid struggle has been the work of the Treatment
Action Campaign (TAC), a grassroots movement that works to secure
life-saving AIDS medicines for poor South Africans. Headed by
Zackie Achmat, an outspoken activist living with HIV, TAC has
led the challenge against the government's refusal to provide
affordable antiretrovirals.
Achmat is probably most famous for the fact that he launched
the world's first ever drug strike, refusing to take his medication
until antiretrovirals were made affordable for all South Africans.
Achmat's vast self-sacrifice won him international and domestic
recognition. He has been labeled most important dissident in South
Africa since Mandela, and was named by Time magazine as one of
the 35 Heroes of 2003. Mandela himself has adopted his cause,
wearing the "HIV Positive" T-shirts TAC distributes,
calling for HIV positive mothers to be given AZT, and explicitly
stating the existence of a link between HIV and AIDS. Mandela
has also acknowledged that members of his immediate family had
been lost to AIDS.
TAC has been particularly successful in stimulating public interest
in the HIV/AIDS debate. In March 2003 TAC embarked on a civil
disobedience campaign that aimed to have 600 people arrested daily,
representing the number of people dying each day in South Africa
from HIV/AIDS. In the same month TAC also laid culpable homicide
charges against the Health Minister and her trade and industry
colleague.
Thanks in part to these high profile campaigns, there has recently
been a gradual reversal in government policies on HIV/AIDS. For
example, in August 2001, a coalition that included TAC sued the
government for failing to provide Nevirapine to HIV positive mothers.
A lengthy legal battle followed, in which the government appealed
an initial ruling forcing it provide Nevirapine, claiming that
its own modest program at a few test sites was sufficient. Finally,
in a blow to Mbeki and his Health Minister, the Constitutional
Court, South Africa's highest judicial authority, ruled in July
2002 that the government was violating the constitution by not
providing Nevirapine. The government has only begrudgingly complied.
After stops and starts, countless delays, and thousands more deaths,
on 19 November 2003 the Mbeki government finally launched its
plan for rolling out free antiretrovirals. The plan envisages
that "within a year, there will be at least one [antiretroviral]
service point in every health district across the country, and
within five years, one service point in every local municipality."
. The plan also commits government to investing substantial finance
into "upgrading our national healthcare system" via
"recruitment of thousands of professionals and a very large
training programme to ensure nurses, doctors, laboratory technicians,
counselors and other health workers have the knowledge and the
skills to ensure safe, ethical and effective use of medicines."
Government has also committed to a massive public education campaign,
improved prevention efforts and improved treatment of opportunistic
infections.
In spite of this recent about-face, the battle remains far from
over. The roll-out plan lacks a sense of urgency- it only seeks
to supply antiretrovials to about 53,000 people by the end of
2004 and about 1 million people by 2008. That is too late for
too many people. In addition, prevention is the best cure for
HIV/AIDS. But prevention requires mass education and awareness
campaigns. And this in turn requires a strong, clear, and loud
message to come from Mbeki that dispels any remaining myths about
how HIV is transmitted and about how it is cured. With the issue
of HIV/AIDS almost entirely absent from Mbeki's annual State of
the Nation address on 5 February 2004, it appears that the government
is continuing to resist adopting an appropriate response to the
HIV/AIDS problem. And as long as the government continues to drag
its feet, South Africa's history of struggle is likely to manifest
itself in continued resistance to these policies.
Samul Choritz is a Freelance writer from South Africa.
HOME
