http://www.pambazuka.org/images/articles/364/47421mbeki.jpgIn this Pambazuka exclusive look at William Gumede's "Thabo Mbeki and the Battle for the Soul of the ANC", we serialize in five parts Gumede's chapter on Mbeki and the controversies surrounding his AIDS policies. Be sure to look for parts two through five in the upcoming Pambazuka issues.
For too long we have closed our eyes as a nation, hoping the truth was not so real. For many years, we have allowed the HI virus to spread, and at a rate in our country which is one of the fastest in the world. – Thabo Mbeki, 9 October 1998
Now ... the poor on our continent will again carry a disproportionate burden of this scourge – would if anyone cared to ask their opinions, wish that the dispute about the primacy of politics or science be put on the backburner and that we proceed to address the needs and concerns of those suffering and dying. – Nelson Mandela, 13 July 2000
It is important that we recognise that we are facing a major crisis and that we want to invest as many resources as we did when we fought against apartheid. This is not a state of emergency but it is a national emergency. – Archbishop Desmond Tutu, 30 November 2001
As his international AIDS Advisory Council met for the first time, Thabo Mbeki mulled over the words of Irish poet Patrick Henry Pearse: ‘Is it folly or grace?’
Notwithstanding the conclusions of mainstream scientists almost a decade before, Mbeki set up the council to examine both the cause and most effective way of treating acquired immune deficiency syndrome (AIDS) in developing countries. His ‘folly’ in reopening the debate on what causes AIDS rather than focusing on practical ways to curb the pandemic sweeping Africa was roundly condemned. ‘Stop fiddling while Rome burns,’ chided Desmond Tutu, former Archbishop of Cape Town. But AIDS denial is not the exclusive province of presidents. Mbeki’s controversial health minister, Manto Tshabalala-Msimang, enthusiastically prescribed an alternative therapy that sounded more like a salad dressing than treatment for a sexually transmitted disease that kills around 600 South Africans a day.
After years of foot-dragging and obfuscation, the South African government finally rolled out antiretroviral drugs that could save the lives of millions at state hospitals two weeks before voters went to the polls in April 2004.The long-awaited plan to distribute ARVs to an estimated 5 million people had been approved in November 2003, but due to what officials claimed were ‘capacity constraints’, patients had to wait another five months for the first drugs to reach them.
Few were surprised when AIDS activists questioned the government’s timing and motives. ‘Even though we welcome the roll-out plan, we have mixed feelings about whether the government reached a turning point because of elections, ’said Tembeka Majali of the Treatment Action Campaign (TAC), the country’s most vocal and visible AIDS activist group.
Before the limited public roll-out, fewer than 20000 South Africans were taking ARVs, as only those with expensive private medical insurance could afford them. Zackie Achmat, head of the TAC and the country’s best-known AIDS activist, only started taking ARVs towards the end of 2003 after refusing for years to avail himself of the life-giving drugs until the government agreed to offer treatment through the public health system.
Leading black gay activist Simon Nkoli,a close friend of Achmat, died in 1998 after contracting AIDS-related thrush. He was among the millions who could not afford the drugs, and at his funeral Achmat announced that he was launching a campaign to make ARVs available to poor South Africans. He had learnt that a single dose of the generic version of fluconazole, used to treat thrush but not sold in South Africa because of international patent laws, cost just eighty cents.
Government blamed lack of efficacy, potential toxicity and high costs for ARVs not being made available at state expense, but scientific evidence indicates that the drugs are highly effective against mother-to-child transmission of HIV and, at least in the short term, the benefits appear to outweigh the risks.
In Europe, North America and Brazil, ARVs have reduced mortality due to HIV/AIDS-related illnesses by between 50 and 80 per cent. In South Africa, two critical barriers remain to the widespread availability of these life-saving medicines and a possible nett saving on the health budget in the long run: lack of political will, and resistance on the part of patent holders to generic competition.
Pharmaceutical companies are protected by intellectual property rights policed by the World Trade Organisation from the manufacture or import of cheaper versions of their drugs. The corporate view is that high prices are necessary to recoup research and development costs.
However, generic anti-AIDS drugs are sold in India for a quarter of the price charged by the big pharmaceutical companies, and have the added advantage of Thabo Mbeki and the battle for the soul of the ANC combining three drugs in a single pill that has to be taken twice a day. The Western ARV protocol requires patients to take up to twelve pills – all produced by different companies – a day, at different times, some with water, some without. Despite the obvious advantages of a simplified regimen, South Africa succumbed to pressure from the West and opted for the more expensive and complex therapy in its limited ARV roll-out.
Private health care in South Africa makes up around 70 per cent of the total national budget, yet only about 7 million of the country’s 44 million citizens can afford private health insurance. The rest depend on government services. Until 1999, medical aid funds were allowed to cherry-pick their paying members, and typically accepted young, healthy, low-risk candidates.
The poor and unemployed were generally excluded due to the high premiums, and relied on the state for health care. An Act of Parliament put a stop to the rejection of certain candidates by insurance carriers, but most South Africans still cannot afford the astronomical costs of private care.
Drug costs are a significant factor in the national health budget. Only medication that is included on a list of essential drugs is available within the state system, and generics are encouraged where possible. When no generics exist, the health department buys in bulk from the pharmaceutical industry via a tender system. Drug companies have fiercely resisted parallel imports of cheaper generics, insisting that their patents be respected.
The social, economic and health consequences of AIDS for South Africa are devastating. Particularly harrowing has been the rise in the number of orphans and the emotional impact on millions of children who will grow up without parents. Not only are crime and social instability destined to follow in the wake of the pandemic, but current and future demands on the state coffers are astronomical. In alliance with COSATU, the SACP, churches and social organisations, the TAC has been at the forefront of attempts to shift government’s head-in-the-sand AIDS policies. The cabinet plan released in November 2003 promised that government would establish a network of centres for distribution of ARVs, beef up efforts to prevent transmission of the virus and increase support for families affected by HIV/AIDS.
The cost of offering treatment to all South Africans with AIDS by 2010 was estimated at between $2.4 billion and $3 billion a year. The cabinet cited the lower costs of ARVs as a major factor in the decision to go ahead with the roll-out, noting: ‘New developments pertaining to prices of drugs, the growing body of knowledge on this issue, wide appreciation of the role of nutrition and availability of budgetary resources [had] allowed government to make an enhanced response to AIDS.’
But why had it taken so long to reach this point?
In the heady days following the unbanning of the ANC, little attention was given to AIDS. Although alarm bells were ringing, South Africa’s collective political focus was on the delicate and engrossing negotiations for a democratic dispen- sation. The apartheid regime had been deaf to calls for action, seeing AIDS largely as a disease that affected gays and blacks, constituencies the previous government was not particularly interested in, and was most prevalent among migrant workers from the southern African region.
AIDS was not high on the first democratic government’s ‘to-do’list either. The ANC alliance’s priority was trying to hold the fractured country together while getting to grips with governance, delivery and the economy. AIDS was one among many seemingly less urgent problems.
Given South Africa’s combustible social mix – a large migrant population, people displaced because of apartheid, the breakdown of traditional family bonds, a labour system that keeps men away from home for most of the year – it is hardly surprising that AIDS struck with such devastation. But when the full realisation sank in, there was first denial, then perplexity, and finally escapism, as confronting the situation became mired in foolish debate over what had caused the pandemic in the first place.
During his term of office, Nelson Mandela effectively ignored AIDS, avoiding the subject on the grounds that, in his culture, an elder did not publicly discuss sexual issues. Since then, he has recognised the severity of the problem and become deeply involved in efforts to stop the spread of AIDS.
When Mandela assumed the presidency of the ANC in 1991, SACP general secretary Chris Hani and future health minister Nkosazana Dlamini-Zuma were the ANC’s most vocal harbingers of a looming crisis.As deputy president, Mbeki barely mentioned AIDS, except for allusions in a couple of speeches to the disease being as great a threat as poverty in the new South Africa.
In fact, the AIDS time bomb threatened to decimate the world’s youngest democracy unless vast resources were made available to defuse it, but the initial response of the ruling elite was ‘this isn’t happening to us ... it cannot be as bad as people say’.
But it was.
The ANC in exile had held a number of meetings on HIV/AIDS, and the first paper on the disease published in South Africa in 1985 forecast that it would remain largely confined to male homosexuals, as had been the case in America and Europe up to that time. In the same year, the government appointed an AIDS advisory group, followed six years later by a network of training, information and counselling centres.
In 1992, the ANC’s health secretariat, the government, non-governmental organisations, AIDS service organisations, representatives from business, trade unions and churches, and a diverse group of concerned individuals set up the National AIDS Coordinating Committee of South Africa (NACOSA). In the spirit of the CODESA talks, it was instructed to reach consensus on a national AIDS strategy for the new South Africa.
Their plan, adopted in July 1994,recommended the pooling of large amounts of money from government and donor organisations for expenditure on countrywide education and prevention programmes.
First, however, an AIDS infrastructure had to be established. The centrepiece was a special directorate in the department of health, and the government also appointed a ministerial AIDS task team, headed by Mbeki. Awareness campaigns and support for an HIV vaccine initiative followed.
By early 1996,it became apparent that the plan was full of holes. Much of the intended funding was diverted by the Treasury to more pressing needs, while money that was allocated to the health department remained unspent as the AIDS plan was buried by competing priorities in a health system in transition. Many of the AIDS policy targets were never attained.
Public controversy followed revelations that a hefty chunk of the AIDS budget – R14.27 million – had been spent on Sarafina II.The musical production by acclaimed playwright Mbongeni Ngema was designed to raise AIDS awareness among African youth,but the critics panned it as an ineffective and costly failure in terms of relaying the anti-AIDS message. Worse, it emerged that normal tendering procedures had been bypassed in awarding Ngema the funds, and the production was scrapped in midstream.
The resulting scandal strained the bond between government and AIDS activists. Opposition parties, the media and many NGOs unleashed a barrage of attacks on the health minister, who withdrew into a defensive shell. Government and Ngema claimed the criticisms were anti-government, anti-black and racially inspired,and on the eve ofWorld AIDS Day in 1996,activists and health workers denounced the entire National AIDS Plan as a shambles, greatly angering both Dlamini-Zuma and Mbeki.
The furore erupted just as the gloss of freedom was starting to give way to grassroots anger over non-delivery and thwarted expectations. Acutely sensitive to criticism, especially when it emanated from the ANC camp, political home to most of the AIDS activists, the government lashed out in anger. At the party’s national conference that year, President Mandela railed against NGOs that stood in judgement of government.
The dust had hardly settled when a new AIDS scandal broke out.
*William Gumede is the author of Thabo Mbeki and the Battle for the Soul of the ANC - Published by Zed Books (http://zedbooks.co.uk).
* This article is the first part of a chapter in the second edition and is published with the kind permission of the author. His latest book, "The Democracy Gap - Africa's Wasted Years", will be published later this year.
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