-- 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%.[1] 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.[2] By 2010, the cumulative number of HIV/AIDS deaths is expected to exceed 6 million.[3]
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.”[4] 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.[5] 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.[6] Given the already low life expectancy of 50.9 years[7], 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.[8]
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.[9] 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”.[10]
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.[11]
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.[12] 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. [13]
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]”.[14] 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”.[15] 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.[16] 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.[17]
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”.[18]
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.[19]
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.[20]
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.[21]
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.[22] Achmat’s vast self-sacrifice won him international and domestic recognition. He has been labeled most important dissident in South Africa since Mandela,[23] 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."[24]
. 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.
[1] www.unaids.org
[2] Medical Research Council of South Africa, “The Impact of HIV/AIDS on Adult Mortality in South Africa”, September 2001
[3] Medical Research Council of South Africa, “The Impact of HIV/AIDS on Adult Mortality in South Africa”, September 2001
[4] UNDP, HIV/AIDS and Human Development in South Africa, 1998
[5] Business Report, August 4 2003, www.busrep.co.za/index.php?fArticleID=201015
[6] Medical Research Council of South Africa, “The Impact of HIV/AIDS on Adult Mortality in South Africa”, September 2001
[7] UNDP, Human Development Report 2003.
[8] Guardian, “South Africa pins hope on hip safe sex campaign”, May 22, 2003
[9] www.cdc.gov/nchstp/od/gap/countries/south_africa.htm
[10] Report, August 4 2003, www.busrep.co.za/index.php?fArticleID=201015
[11] Human Sciences Research Council, “The Impact of HIV/AIDS on the Health Sector”, 2002
[12] www.global-defence.com/2003/sandef_03.htm
[13] http://crisisweb.org/home/index.cfm?id=1831&l=1
[14] www.scienceinafrica.co.za/2002/april/virgin.htm
[15] Samantha Powers “The AIDS Rebel”, the New Yorker, May 2003
[16] Sunday Times, 16 July 2000
[17] bbc.news.co.uk/1/hi/world/Africa/826742.stm
[18] http://www.mg.co.za/Content/l3.asp?ao=30905&t=1
[19] http://www.suntimes.co.za/2003/03/30/news/news27.asp
[20] Nelson Mandela/Human Sciences Research Council study on HIV/AIDS in South Africa, 2002
[21] http://www.news24.com/News24/South_Africa/Aids_Focus/0,,2-7-659_1481414,00.html
[22] Achmat only started taking antiretrovirals in August 2003 after suffering severe health problems.
[23] Samantha Powers “The AIDS Rebel”, the New Yorker, May 2003
[24] Cabinet Statement, 19 November 2003