HIV/Aids and the politics of the new South Africa

South Africa's Mbulelo Mzamane presented this paper at the HIV/Aids International Candlelight Memorial Gala Dinner held in Johannesburg in May 2003.

I have spent a lifetime trying to educate myself on all kinds of subjects and learning to stare facts in the face, however unpalatable, in order to make informed interventions. My circumstances as an activist in the struggle against colonialism, segregation, and Apartheid buttressed these tendencies towards intellectual independence. I like to locate myself within the tradition of the unfolding culture of liberation nationally and internationally. It is also the artistic temperament in me, perhaps, that values objectivity without eschewing passion. I would like in what follows to subject the HIV/AIDS debate to the same intellectual scrutiny with which I am accustomed to viewing most subjects. It is the least we can do as scholars and artists in struggle: to make informed interventions.

I would like to begin from the premise that what came to characterise the politics of the early years the Mbeki presidency, above every other contentious issue, was the HIV/Aids debate. No other issue sparked greater ‘controversy.’ But the controversy that continues to rage in some quarters obscures what should have been – and what I want to dwell on here as – the central issue in the debate: developing a comprehensive and integrated approach to providing health services in post-Apartheid South Africa.

I also want to suggest that part of the difference between the Mbeki government and its critics lies in the fact that government wants to pursue the ‘public health’ model of medicine and the opposition is assuming the ‘individualised curative care’ model that dominated the Apartheid state. Virtually every other industrialised country in the world utilises the former, which is why they have universal health insurance. If South Africa tried to make healthcare universal following the ‘individualised curative care’ model it would go broke lickety-split.

I would thus like to discuss the political issues and my take on the HIV/Aids debate – if we had time I would also have liked to dwell on the impact of the pandemic on society at large and on the economy in particular. In the final analysis, what my remarks should lead us to is a discussion of health reform that would address both the specifics of HIV/AIDS and the wider issues pertaining to public health, from the perspective of policy and implementation. In general, I favour a ‘public health’ model in place of the prevalent ‘individualised curative care’ model. These are all issues about which as concerned artists we should it make it our business to inform one another.

‘If you are tripped often enough, sooner or later you will stumble.’

The HIV/Aids debate was marked from the beginning by a great deal of hysteria that did little to advance the frontiers of knowledge, largely owing to the gross and willful misrepresentation of the facts. Mbeki was correct in, at least, one important respect: In his address to the conference on HIV/Aids, held in Durban July 2000, he stressed the fact that people had failed to ‘speak to one another honestly and frankly.’ He also noted that there had not been ‘sufficient tolerance’ for opposing views and that little allowance had been made for ‘all voices to be heard’ on the subject. There was a yawning gulf, indeed, between what Mbeki actually said (www.gov.za) and how the media that was mischievous, at times, and downright incompetent, on occasion, reported the matter. They showed little or no aptitude for either self-criticism or expository criticism and little knowledge of the issues.

The reason why some people are not convinced that the HIV virus is the sole cause of Aids is that medical science is pretty sure that it is not — there is a co-virus involved or a co-factor (Maugh II. 1996; Folkers. 1996). Moreover, the virus in South Africa is different from the one that appeared in and is prevalent in the West and it behaves differently. These issues, too, should have been at the heart of the debate, as a campaign to educate, but they were tragically absent.

We do not hold journalists in disdain, but they are not any more infallible than lesser mortals. We must not be understood to be taking a dig at the media. We are also nowhere saying ‘Stop the world while we investigate’. We want to emphasize the point, however, that orthodoxy turned to intolerance is bigotry. In the world of science the Galileo phenomenon can never be ruled out completely. Healthy skepticism creates the kind of scientific breakthrough that is celebrated annually by identifying Nobel laureates who stand outside the stream of orthodoxy that subsequently becomes discredited. Tarnishing scientists with whom received opinion is at odds with slurs like ‘dissidents’ can be the modern equivalent of the Inquisition, a role unreconstructed sections of the media often play. We are less concerned, however, with the philosophy of science than with the political economy of health as well as the broader issue of health reform in South Africa.

The righteous tone in the South African media was disturbing and their fixations distracting. We recognise the critical role of the media in nurturing South Africa’s fledgling democracy, similar to its past role in the struggle against Apartheid. But it cannot do so by digging itself into some new Apartheid enclave of the mind. Both the left and the right in South Africa, quite frankly, have difficulties discarding tendentious politics of the past; realignment in politics when it occurs lands the individual in one camp or the other. Trench warfare thus continues unabated, with everyone weighed down by political baggage from the past. The media reflects these wider societal trends. The times demand that South Africans of European ancestry break out of their laager or outpost colonial mentality. They are the worst culprits in this respect, even if admittedly Africans are not always free of racist rancour either.

We were concerned, therefore, about what struck us at times as the media’s campaign of disinformation and vilification. The HIV/Aids issue should have been seen as too important to be used to score points against political opponents because the pandemic poses the single most potent threat to the country’s future. The South African media has not even elaborated this. Robert Shell and Rebecca Sheitlin (1996), then at Rhodes East London, published some of this, but it did not get wide play.

The problem with the media in this matter was its unwillingness or inability, even with the president’s text in front of them, to analyze and engage in expository criticism. Former leader of the opposition in the Apartheid parliament, Frederick van Zyl Slabbert (SAFM, Tim Modise Show, October 30 2000), half in jest and half in earnestness, describes South Africa as a ‘lazy journalist’s dream’. The problem goes deeper and calls into question basic journalistic skills and ethics and their basic knowledge of the issues in HIVAids. The HIV/Aids literature is rife with the co-virus theory, especially with respect to Africa. Recall that syphilis and gonorrhea were once thought to be one disease. The teacher in us wants, in all seriousness, to recommend remedial classes in note taking, precis, close reading, and practical criticism for journalists who are lacking in these skills – and they are in the majority. The rest of society largely took its cue from the media, which failed dismally to educate and inform the public on the issues. The ‘disinformation’ campaign may not have been intended in all cases – there are earnest and conscientious journalists who cover the subject – but it managed to sow considerable confusion. We know that is not the popular view, but that is just our point. The popular view on what the president and his ministers thought on HIV/Aids, even among congress alliance (SA Communist Party and Congress of SA Trade Unions) members, was based largely on fallacious reporting, with journalists and columnists quick to ‘ventriloquise’ government or score points for the opposition.

Opposition to the Mbeki government over the issue was widespread if not overwhelming and was by no means confined to European commentators in the media – Mbeki took too long and was too adamant to realise that his strategy had come up against a brick wall. Government only took a U-turn in its communication strategy following the case that was brought against it by the Treatment Action Campaign, making treatment of HIV/Aids cases a human rights issue. Government then declared unambiguously for the first time, something they could have stated earlier and thus put the matter to rest sooner, in a Cabinet Statement of April 17 2002 issued by the Government Communication and Information Services:

"Government will intensify the awareness campaign, as part of its comprehensive strategy against HIV/Aids. The challenge is to ensure that awareness continues to translate into a change in behaviour. In conducting this campaign, government starting point is based on the premise that HIV causes Aids. It is also critical for us, as a nation, to note that there is no cure for Aids. In this regard, promoting awareness and life skills and HIV/Aids education forms the core of our approach.
Tracking Progress on the HIV/Aids and STI Strategic Plan for South Africa, June 2000 – March 2003 goes even further and provides government’s ‘multisectoral response to HIV/Aids, at all levels of society’. This comprehensive plan deals with
- Prevention
- Treatment, care and support
- Human and legal rights, and
- Monitoring, research and surveillance."

Given the fact that this was government position all along, it is inexplicable how the issue became political football in the way it did. Sipho Seepe, who emerged as Mbeki’s most vocal African critic in the media on just about every conceivable issue – and consequently earned himself a regular column in the Mail & Guardian – wrote the following in an op-ed published in the Sowetan Sunday World (5 November 2000):

"We have also seen the suppression of public dissent within the ruling party. The most glaring example was Mbeki’s obsession with championing the cause of discredited scientists who hold that HIV does not cause AIDS.

"It took months before alliance partners – ANC, COSATU, and SACP – expressed their dissatisfaction with his stance. By that time the president had already disgraced himself locally and internationally.

"When faced with such intellectual paucity, the role of intellectuals in society becomes critical.

"Fundamental to intellectual work is a spirit of enquiry that is critical and, if need be, oppositional.

"Intellectuals should not compromise on intellectual independence. Intellectuals must understand their role is to raise embarrassing questions publicly and they must be prepared to confront orthodoxy and dogma.

"An intellectual cannot easily be co-opted by governments and corporations. Their raison d’etre is to represent all those people and issues that are routinely forgotten or swept under the carpet."

Few would disagree with some of the points Seepe makes on the role of the intellectual. To point out fallacies in his arguments or double standards in his views is not to deny him the right to express his opinions either – his articles are actually lively, combative, and certainly reflective of dissenting views seldom expressed by Africans in the press. There is an underlying context and a contest that we wish to bring out, however, which give an altogether different spin and an added edge to his words. In this fashion, he typifies mainstream media responses to the Mbeki government in general, and the HIV/Aids debate in particular. The point scoring, for example, that is the intended objective of his exercise becomes manifest when he trips up himself in inconsistencies in what is a double game that he does not quite succeed, however, in pulling off. Quite apart from the fact that what he says about Mbeki ‘championing’ the cause of some discredited group of scientists is not altogether true – Mbeki sought both orthodox and dissident views on the subject, in just the way Seepe recommends intellectuals should conduct themselves – he would deny Mbeki precisely the role he ascribes to intellectuals: ‘a spirit of enquiry that is critical and, if need be, oppositional’ and fearlessness to ‘confront orthodoxy and dogma’. But presumably, in Seepe’s mind, one cannot be both a president and an intellectual. Conversely, Seepe is mapping out some exclusive province for himself. His self-regard is, in fact, remarkable. He writes in handbook fashion in a style that employs the imperative case all the time, even as he warns others to eschew dogmatism – ‘intellectuals should…’; ‘intellectuals must …’; ‘an intellectual cannot…’ He passes himself in this way as the intellectual par excellence. All this verges on narcissism.

There are, in fact, two points of view: Seepe’s and all the wrong points of view. His exaltation of intellectual independence in this way is questionable and more like a call-to-arms. Intellectual independence is an intellectual’s most formidable asset – and that is nearly tautological – but except to the omniscient, it is not an end in itself. Never to ‘compromise’ regardless is pigheadedness – precisely what he finds fault with in Mbeki’s stance on HIV/Aids. Mbeki’s own undoing in the matter, it can be argued, was his uncompromising intellectual independence that blinded him for a while to a cardinal rule in politics, namely, that politics is the art of the possible. Intellectuals of the highest calibre are humble people as well who concede their mistakes in light of incontrovertible evidence – qualities that were in short supply between the president and his equally implacable opponents. Pots calling kettles black – and vice versa. Thus, in the end, issues took on added significance in pursuit of agendas that Mbeki’s opponents would not own up to in public, in the way in which they demanded complete openness from him. Finally, truth became the casualty of the bickering and the nation plodded on its weary way not in any respect the wiser for it. The strategy of the media and the opposition throughout this saga had been to try repeatedly to trip up Mbeki for motives that went beyond the HIV/Aids question. If you are tripped often enough, sooner or later you will stumble.

Society thus remained baffled or transfixed – not by Mbeki’s obsession with championing the cause of discredited scientists who hold that HIV does not cause Aids but – by the media’s obsession with extracting a simple ‘Yes’ or ‘No’ answer to a question on a complex subject. We know, for instance, that a correlation exists between smoking and cancer. If a question is posed, however, about whether smoking causes cancer, one’s answer has to be qualified somewhat. Some people smoke all their lives and never die of cancer. The HIV/Aids pandemic is even more complex than that. The problem does not lend itself to a multiple-choice examination. If the President; or his Health Minister, Dr Manto Tshabalala-Msimang (from the ANC); or his Minister of Arts, Culture, Science, and Technology, Dr Ben Ngubane (from the IFP) say they cannot answer ‘Yes’ or ‘No’, what is confusing about so simple a statement?

Without doubt, there were blunders from the start in the way government launched its HIV/Aids campaign. The R14 million Sarafina II debacle stands out, as does the virodene fiasco. In fact, Health Minister Manto Tshabalala-Msimang, when she was still chairperson of the parliamentary portfolio committee on health, was most critical of the R14 million government wasted to fund a single theatrical production in its ill-advised HIV/Aids educational campaign. Then there was the long drawn out battle between government and the Treatment Action Campaign (TAC), who should have been allies over the matter, arising from government reluctance that, in fact, verged on folly to roll out cost effective treatment for the purpose of reducing mother-to-child transmission. The courts eventually ruled in favor of TAC and government subsequently reversed its policy that it should not have adhered to so adamantly in the first place. While it is true we still do not know enough about the side effects that result from administering anti-retroviral drugs to curb mother-to-child infection, there is nonetheless enough evidence to suggest usefulness. Government shot itself in the foot by dithering too long. It wanted to settle constitutional questions over the competence of the judiciary to over-rule the legislature over policy formulation but chose the wrong issue to make the determination.

We cannot agree, however, that the government did nothing useful about the problem or that everything they did was wrong. For one thing, the government learnt, as the taxpayers wanted, not to throw money at the problem and to act with greater circumspection – perhaps with too much circumspection. Health Minister Tshabalala-Msimang knew better than to become embroiled in ill advised spending, without taking all the facts into account. Still, there were some positive results realised. For example, owing largely to government awareness campaigns, HIV infections among pregnant teenage girls fell by 25% between 1998 and 2001. These are spectacular results that go against the trend in sub-Saharan Africa, where Aids among women has been spreading, with about twice as many young women as men infected (Ross: 2002).

President Mbeki and his former Minister of Health, who later became Minister of Foreign Affairs, Dr Nkosazana Dlamini-Zuma, have not been given enough credit for standing up to the multinational pharmaceutical companies and compelling them to drastically reduce the price of drugs worldwide. The case that was brought by 39 major international pharmaceutical companies against the South African government, for violating international patent laws that outlaw the importation of much cheaper generic drugs to fight the pandemic, would not have come before the courts. That it did is on account of the tough stance the South African government took on the matter. The health of a nation is too important a matter to be left to media moguls, multinational pharmaceutical companies and profiteers of every description. Nor should it become the exclusive preserve of an influential and vocal clique with a political agenda. It cannot be left completely to scientists either, as if there are no social, political and economic implications underlying supposedly ‘pure’ scientific issues. The notion of scientific ‘neutrality’ is a fallacy. The South African government had every right to intervene and take a lead in a matter that, by its very nature, required a multi-faceted approach. Admittedly, the government needed to take its cue from those who knew best, after taking all the facts into consideration; that was precisely the point behind the government exercise that unfortunately went sour in consulting all shades of opinion on the matter.

‘A true measure of a society’s strength is the health of its citizens.’

President Mbeki’s cardinal sin was to interrogate orthodox wisdom on the subject and to link HIV/Aids – not de-link HIV and Aids – to poverty, both in terms of causality and the quest for effective remedies. It is a link with which the poor are all too familiar, even in affluent societies such as the US. Poverty is the major reason life expectancy is lowest in economically depressed communities. Life expectancy among Europeans is higher than among Africans in South Africa and is indubitably a function of affluence, where it is high, and poverty, where it is low. It is not unconnected to poverty that 1 in 50 African-American males test HIV positive compared with 1 in 2000 among European-American males; that 1 in 160 African-American females test HIV positive compared with 1 in 3000 European-American females. It is not unrelated to poverty that of an estimated 36 million people with HIV/Aids worldwide, 25 million live in sub-Saharan Africa or that the overwhelming majority of the 21 million people worldwide killed by the pandemic up to the year 2000 are Africans. The analysis of the HIV/Aids situation in South Africa should not be any different, with poverty the common factor. It cannot be coincidence that 11.5 per cent of the world’s HIV/Aids cases were found in a country that has the widest disparity in the world between wealthy Europeans and impoverished Africans.

That is not to rule out other factors that cause or compound the problem. There are complicating factors, in fact, especially among African males. Their macho culture causes some to view the use of condoms as unmanly. Patriarchy leads males generally and not just Africans to demand ‘conjugal rights’ from their wives, who are helpless to insist on safe sex. Ignorance and superstition lead some desperate infected males to rape virgins for a cure; cultural taboos inhibit open discussion of sexuality, etc. That is where the government rightly laid the emphasis in schools and communities to combat the spread of the disease. The most invaluable service concerned artists have rendered the cause has been to raise social awareness even higher. Names that immediately spring to mind include Hugh Masekela, Gibson Kente, and the late Anneline Malebo.

There was nothing confusing, therefore, about pointing out the obvious correlation between good health and wealth, on the one hand, and poor health and poverty, on the other hand. There was nothing confusing about the fact that anyone indulges in unsafe sex to his or her own detriment. That message was clear enough and was going out all the time ever since the democratic government came to power – but never to the same degree under Apartheid, when the problem was still manageable. What was difficult to understand, even for a person who had never been to school, is the fact that during sexual intercourse an unwrapped penis puts the man and the woman at risk. Nine out of 10 South Africans knew HIV/Aids kills, is contracted or spread through sexual intercourse, and can be averted by engaging in safe sex – for which purpose the government distributed free condoms. We cannot agree that the South African government sowed nothing but confusion on the issue – the media did.

A true measure of a society’s strength is the health of its citizens. As a matter of common sense, poor health is indisputably the companion of extreme poverty. And that is not to say that poverty causes the common cold and the flu, etc. But it helps if one can afford warm clothes and fruit with lots of vitamin C. We cannot glibly brush aside the fact that the underdevelopment that racism has created and maintained in the developing countries debilitates the health of citizens. The countries that are responsible for, and that profit from, underdevelopment also find ways to capitalise on the poor health it causes. We also know for a fact that they then sell over-priced drugs – often surplus, sometimes banned from use in their own countries because of harmful side effects – to the developing countries. Newer or patented drugs (such as AZT) are proffered at exorbitant prices, often unaffordable to developing economies.

Faced with this ‘take it or die’ proposition, countries that have the audacity to assert their independence, and the ability to develop their own solutions to the problems of their society, come under severe attack from the developed world. Thus, when Mbeki dared to suggest that there might be another approach to the HIV/Aids crisis in South Africa, Western medical experts and the Western media, including South Africa’s, vilified him. Yet questions still remain that cannot simply be brushed aside upon the insistence of lobby groups, no matter how powerful.

‘A strong public health perspective is needed in the current HIV-AIDS debate’

In the sphere of health reform in general, the South African government has rightly put the stress on primary, preventive and public health. We concur with Mike Muller, Director-General in the Ministry of Water Affairs and Forestry, who writes in The Sowetan (October 9 2000):

There have been huge improvements in health in the ‘developed’ world, but most of these life expectancy improvements occurred before 1940 when effective medical interventions against infectious diseases started becoming available. Up to then what really made a difference to public health was people’s ability to get enough food, clean water and adequate housing. Education was also helpful. Only recently did medicine – notably immunisation – begin to have a real impact on community health. Even before they realised that cholera was caused by a ‘germ’, Britons beat the disease not with drugs and immunisations but by establishing effective local governments that built sewers and supplied clean water.

The example of cholera is most apt. The September 2000 outbreak of cholera in KwaZulu-Natal’s poorest areas drives Muller’s point home. He argues that ‘diarrhoea, of which cholera is an acute example, is among the most common killers of young children in poor communities’. A range of infectious agents causes diarrhoea and the list of unknown bacteria, viruses and protozoa gets longer every year. The strategic approach to diarrhoea prevention is, not so much to prescribe medicine in order to attack specific virus or particular bacteria as, to make the environment in which they are transmitted healthier. ‘For children with diarrhoea the important thing is… to protect them from dehydration,’ Muller says. There is a simple reason for this: ‘Some popular diarrhoea remedies worsen rather than improve child health.’ Only in a few cases, including cholera, are drugs useful. Generally, however, drugs are discouraged. Naturally, drug companies become upset when told that their products exacerbate the problem and they launch massive advertising campaigns.

The parallels with HIV/Aids should be obvious. Indeed, the example of approaches to other overwhelming health problems such as cholera may be relevant to the way we manage the HIV/Aids pandemic. ‘A strong public health perspective is needed in the current HIV-Aids debate,’ Muller says. The spread of HIV/Aids is greatly assisted by poverty and the organisation of society. There is a reason why the disease is rampant in the squatter camps of Khayelitsha but not in the affluent neighborhood of Kyalami. Economic policy and social planning can aggravate the problem or contribute to the solution. Migrant labour and poverty, squalor and malnutrition, growing unemployment and rising prostitution, single-sex hostels and rape, cultural conservatism and miseducation, all contribute to the HIV/Aids pandemic. ‘While the use of drugs to minimise the impact of HIV is crucial, neither drugs nor the exact biology of the human immune virus are key to combating the epidemic,’ Muller concludes. ‘The challenge is to understand how we can respond to the crisis in public health terms.’

Without a public health model, how do you explain the comeback of tuberculosis or outbreaks of cholera? We reiterate: Britain rid itself of cholera without explicit knowledge of the bacterium by simply increasing sanitation. Waste disposal at the village level in KwaZulu-Natal and the Transkei is appalling; in places like Soweto and Mdantsane and other model townships Apartheid planners developed it is unspeakable. Rejecting this observation is another way of saying ‘Apartheid planning wasn’t so bad for Africans, after all.’ South Africa simply needs a public health care model that it may address the health care needs of the vast majority of its citizens that Apartheid failed dismally.

There is thus a pressing need to look, not only at combating the HIV/Aids pandemic but also, at providing better health services to all sections of the population. Here the key lies in reforming South Africa’s differentiated and in the main dysfunctional health care system so that it can respond comprehensively, not only to the HIV/Aids pandemic that is without doubt devastating but also, to every contingency.

Select Bibliography
Folkers, Greg. NIAID Researchers Identify Second Fusion Cofactors for HIV. (301) 402-1663. Fokers@nih.gov. June 19 1996.

Maugh II, Thomsa H. Key Molecule that Lets HIV Enter Cells Found. Los Angeles Times and Times Mirror Square. Los Angeles, CA. June 20 1996.

Ross, Emma. Associated Press Medical Writer. Women Make up Half HIV Cases. Yahoo! News. November 26 2002.

Shell, Robert C.H. and Rebecca Zeitlin. Positive Outcomes: The Chances of Acquiring HIV/AIDS during the School-going Years in the Eastern Cape, 1990 – 2000. The Social Work Practitioner Researcher. Volume 12. Number 3. December 2000. pp. 139-154.

Mbulelo Mzamane is Professor and Interim Director of the Es'kia Mphahlele Institute of African Studies at the University of Venda for Science and Technology. He returned to South African in 1993 after three decades in exile. he has held academic posts in the USA, Australia, UK, Botswana, Swaziland, Lesotho, Nigeria and Germany.