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In the last decade, barrels of ink have been spilled on the failure of the South African state to address the growing HIV/AIDS epidemic among its people, writes Rebecca Hodes. In recent months, South Africa has undergone a number of seismic political changes. The controversial, populist Jacob Zuma, was elected the head of the ruling African National Congress to the dismay of many following his acquittal for a rape charge. In September 2008, President Mbeki was deposed by the ANC’s Zuma-dominated leadership, and the subsequent reshuffle saw the appointment of Barbara Hogan. The implications of these changes on health policy, as well as those associated with the potential outcome of next year's elections, are explored.

In the last decade, barrels of ink have been spilled on the failure of the South African state to address the growing HIV/AIDS epidemic among its people. In the opening years of the century, President Mbeki and his Health Minister, Manto Tshabalala-Msimang, became the focus of widespread derision due to their alliances with AIDS denialists and their obstruction of effective treatments for HIV/AIDS. During these years, the Treatment Access Campaign (TAC), founded by a small group of activists in 1998, led and ultimately won the struggle for public access to antiretroviral treatment in South Africa.

TAC has gained global recognition for its successes in securing cheaper access to generic medications in the public sector, lobbying for the introduction of a public programme of prevention-of-mother-to-child-transmission therapy in 2001, and for its continued contribution to ensuring the success of South Africa’s national programme of comprehensive HIV treatment. The last decade of South Africa’s HIV/AIDS response has therefore often been portrayed as a battle between activists committed to the health and human rights of people with HIV, and a recalcitrant political leadership refusing to accept the challenges posed by the epidemic. However, changes in the political landscape, detailed below, have heralded a new era. The state’s guiding policy on HIV/AIDS, known as the National Strategic Plan for 2007 – 2011, is South Africa’s most progressive policy on the epidemic to date. And with a new Minister at the helm of the Health Department, South Africa’s roll-out of antiretroviral treatment is continuing apace, albeit not without problems.

In recent months, South Africa has undergone a number of seismic political changes. The controversial, populist Jacob Zuma, was elected the head of the ruling African National Congress (ANC) at the party’s national conference in December 2007. Zuma’s appointment was met with dismay by HIV/AIDS activists, as well as many other South Africans, owing in large part to a rape charge brought by an HIV-positive woman in late 2005. Zuma was acquitted, but some disturbing revelations emerged at the trial.

Maintaining that the sex was consensual, Zuma admitted that he was aware that the complainant was HIV-positive, but that he had nonetheless failed to wear a condom. He also explained that he had taken a shower after having unprotected sex with the woman, in order to protect himself from HIV transmission. As the former head of the National AIDS Council as well as the so-called ‘Moral Regeneration Campaign’, Zuma’s admission that he had had unprotected, extra-marital sex with a woman whose HIV-positive status he knew, encouraged widespread public confusion about the risk of HIV-transmission via unprotected sex. HIV activists and other leaders of civil society responded with fury and frustration to Zuma’s assertion that he had showered in order to reduce the chances of being infected with HIV, arguing that his foolish remarks would encourage confusion around HIV infection and reverse hard-won gains in public awareness around the epidemic.

Moreover, many of the comments made by Zuma and his supporters during the case were overlaid with misogyny. Zuma’s supporters, who gathered daily outside the court, threatened the complainant and even threw stones at another woman mistaken for her. Zuma himself conveyed a bigoted and oppressive attitude towards women in his suggestions that women who dress in a particular way or have a certain sexual history are inviting sexual advances.

The acquittal was greeted with dismay by women’s rights groups and other civil society leaders across South Africa. Meanwhile, Zuma’s political ambitions were temporarily frustrated, not so much by the rape charges as by corruption charges relating to South Africa's 1999 arms deal, and to his relationship with his previous financial advisor, who was imprisoned for fraud and corruption in July 2005. Zuma’s corruption case is pending, as a procedural point will soon be argued in the Supreme Court of Appeal. However, as the current President of the ANC, if Zuma is cleared or pardoned of corruption charges it is likely that he will be the next President of South Africa. There is much speculation about Zuma’s possible HIV policies should he become the next President. It is possible that Zuma’s dogged traditionalism will find expression in HIV policies. He may support ‘virginity testing’ of young women, and impose other culturalist proscriptions pertaining to sexual behaviour. It is also possible that Zuma may try to make amends for the damaging remarks made during his rape trial, and to distance himself from Mbeki’s discredited stance on HIV, by promoting more progressive policies on comprehensive HIV care and particularly ART as South Africa scales-up its public ART programmes.

In September 2008, President Mbeki was deposed by the ANC’s Zuma-dominated leadership. This was subsequent to allegations that Zuma’s prosecution was animated by Mbeki’s desire to sideline Zuma. Kgalema Motlanthe, an ANC stalwart with strong ties to the Unions, was made interim President pending next year’s elections - after which is its widely expected that Zuma will assume the presidency.

One of the side-effects of Mbeki’s ousting was a Cabinet re-shuffle. Some ministers resigned in solidarity with the ousted President. Among those who remained were the Health Minister Tshabalala-Msimang. Derisively labelled ‘Dr. Beetroot’ owing to her to long-standing insistence that healthy diets and traditional medicines were appropriate treatments for HIV, Tshabalala-Msimang was reassigned by President Motlanthe to the office of the Presidency. In her stead, Barbara Hogan was named the new Health Minister - a step that was met with rejoicing by the TAC and other leading civil society organisations.

Hogan has a long history with the ANC, and spent almost a decade in prison due to her anti-Apartheid activism. She became a member of parliament subsequent to South Africa’s first democratic election in 1994, and joined the Finance Portfolio Committee. She chaired the Portfolio for five years until President Mbeki removed her from the position, allegedly due to her explicit opposition to the President’s stance on HIV/AIDS. Hogan was one of the few members of parliament to openly oppose President Mbeki’s AIDS denialism and the failure of Health Minister Tshabalala-Msimang to support the public roll-out of ART. Hogan is known for her pursuit of financial transparency and accountability within political structures. These qualities will be of particular value in the Department of Health, renowned for its lack of financial accountability as reflected in the Department’s overspend of R450 million in the last fiscal year.2 The details of the overspend remain uncertain due to the lack of public accountability that previously characterized the Department’s functioning.

The lack of openness surrounding the Department of Health’s expenditure is largely attributable to Tshabalala-Msimang’s gross mismanagement of the Department. But perhaps even more serious than this lack of fiscal oversight are the structural weaknesses within the health sector, which were neglected by Tshabalala-Msimang during her disastrous nine year tenure.

The health care system in South Africa, as in much of the rest of the continent, is hobbled by a shortage of doctors and nurses. In 2006, the African Union estimated that low-income countries subsidized high-income countries to the tune of R500 million per year, through the loss of their healthcare workers.3 In 2007, the World Health Organisation estimated that Southern Africa accounted for 25% of the global disease burden, yet had only 2% of the world’s healthcare workers. The South African Medical Association, Médecins Sans Frontières (MSF) and the Democratic Nurses Organisation of South Africa (Denosa) have long pointed to the critical lack of healthcare workers in South Africa.

The skills shortages, quality disparities between urban and rural healthcare centres, and the ubiquitous lack of resources in the public health system are partly the legacy of Apartheid-era public health policies, which concentrated resources in the richest provinces and urban areas in particular.4 But the skills shortage was exacerbated by Tshabalala-Msimang’s failure to enact measures to ameliorate the crisis. This skills shortage was identified as far back as 2001 as the health sector’s ‘key constraint’.5 In 2003, the National Health Act called for the Minister to develop a strategic plan to address the flight of doctors, nurses and pharmacists to rich world countries, where salaries were higher and jobs less demanding. Between 1989 and 1997, 80 000 health workers emigrated, and by 2003 there were roughly 30 000 unfilled positions in the public health sector.6

By 2005, the health sector was facing a critical shortage of doctors and nurses, with staggering vacancy rates at hospitals and clinics.7 But despite promises by the Health Minister of a national human resources plan to address shortages in health personnel, the plan was delayed, leading the general secretary of the Denosa to remark that, ‘By the time they [the government] are willing to negotiate with us, there may not be any nurses left in the public sector’.8 Shortly after her assumption of the position as Minister of Health in September 2008, Hogan explained that her first priority was to boost the morale of healthcare workers, encouraging doctors and nurses to remain within the health sector to ameliorate the critical shortage in skills. In her landmark speech at the HIV Vaccine Research Conference in Cape Town on 13 October 2008, Hogan stated: ‘We know that HIV causes AIDS. The science of HIV and AIDS is one of one of the most researched subject in the medical field’.9 This statement garnered wide attention in the local and international press, because of the change it conveyed to years of prevarication by Mbeki and Tshabalala-Msimang over the causes of HIV and the optimal forms of treatment.

Over two million South Africans died of AIDS during the presidency of Thabo Mbeki. A study recently published by the School of Public Health at Harvard claims that 330,000 lives could have been saved had Mbeki and Tshabalala-Msimang implemented the necessary treatments for HIV, including ARVs and the prevention-of-mother-to-child-transmission programmes. Instead, Mbeki and his health minister engaged in AIDS denialism and undermined the scientific governance of medicine. Many more people would have died had it not been for TAC’s activism, which led to Constitutional Court orders compelling Mbeki and Tshabalala-Msimang to implement an HIV treatment plan which included the provision of PMTCT and ARV’s.

The redeployment and essential political declawing of Tshabalala-Msimang, and the institution of Minister Hogan were evidence of further shifts in the state’s policies on HIV/AIDS. Growing opposition to high-ranking political obstruction of antiretroviral treatment and the championing of traditional remedies and nutritional supplements came to the fore in mid-2007, when Deputy President Phumzile Mlambo-Ngcuka and Deputy Health Minister Nozizwe Madlala-Routledge spearheaded the development of the National Strategic Plan on HIV/AIDS and Sexually Transmitted Infections, 2007 – 2011. The plan drastically overhauled the state’s commitments to addressing HIV and other sexually transmitted diseases, and brought together civil society, healthcare workers and other interested parties. For the first time in years, government and activists mutually accepted new policy positions on HIV, and began to collaborate on the expansion of key health programmes concerning the education, prevention and treatment of HIV and other sexually transmitted infections.

While these shifts are welcome, celebrations may be premature. Minister Hogan’s position is only guaranteed until the election which is set to take place early next year. While the Zuma prosecution plays out in the courts, analysts can only speculate whether or not Hogan will remain in her post once, as expected, Zuma takes the reins following the election.

The ruling ANC has split, and a new party has emerged under the direction of previous ANC and Union leaders who are disaffected by Mbeki’s abrupt ousting and the prospects of being governed by Zuma. Named COPE (the Congress of the People), the very title of the party is disputed by the ANC, which claims ownership over the anti-Apartheid activities of the 1950s to which the name refers.

Hogan's biggest challenges will be to meet the treatment and prevention targets of the HIV/AIDS National Strategic Plan, integrate TB and HIV treatment, develop a feasible human resources plan for health workers and undo the considerable legacy of AIDS denialism left by her predecessor. TAC will do all that it can to assist her and the Department of Health to meet these challenges.

* Rebecca Hodes is Director of Policy, Communication and Research, Treatment Action Campaign (TAC). (Thanks to Nathan Geffen, whose previous research on HIV in South Africa forms the bedrock of this article. Thanks also to Adv. Michael Obsborne for his valuable comments.)

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