[DEBATE] : Structural processes behind SA AIDS policy

[Patrick Bond]

The structural forces behind Mbeki's AIDS policy
Patrick Bond (2008-05-13)
http://www.pambazuka.org/en/category/comment/48049

In response to the recent extract from William Gumede's book "Thabo 
Mbeki and the Battle for the Soul of the ANC" published by Zed Books 
(http://zedbooks.co.uk), Patrick Bond suggests that there is a need to 
go beyond the individual reasons and look at the structural forces that 
have informed Mbeki's AIDS policy such as international and domestic 
financial markets, pharmaceutical manufacturers and a large reserve army 
of labour.


With millions of South Africans dying early because of AIDS, the battle 
against the disease would become one of the most crucial tests of the 
post-apartheid government. Its systematic failure to address AIDS, and 
especially its ongoing sabotage of medicinal treatment for HIV+ 
patients, led to periodic charges of ‘genocide’ by authoritative figures 
such as the heads of the Medical Research Council (Malegapuru William 
Makgoba), SA Medical Association (Kgosi Letlape), and Pan Africanist 
Congress health desk (Costa Gazi), as well as leading public 
intellectual Sipho Seepe.

Aside from Mbeki, Pretoria’s main saboteurs were health minister Manto 
Tshabalala-Msimang and trade minister Erwin; the latter two were accused 
by the Treatment Action Campaign (TAC) of culpable homicide during a 
March 2003 civil disobedience campaign. Even in the weeks before the 
2004 election, Mbeki and Tshabalala-Msimang continued to practice 
denialism, obfuscation, delays, bureaucratic manoeuvres, and withdrawal 
of resources for treatment. Educational campaigns like LoveLife’s were 
based upon fatuous marketing to hip-hop youth, and there was virtually 
nothing done to combat domestic violence, rape, multiple partners and 
patriarchy. Across Africa more generally, the ‘ABCs’ of abstinence, 
being loyal and condoms were particularly ineffectual within the 
confines of male-dominated marriage, leading to the tragedy that young 
women’s infection rate was twice as high as that of men.[1]

A great deal has been written about Pretoria’s malfeasance.[2] The point 
of revisiting it here while documenting South Africa’s elite transition 
is to provide a structural explanation for the crisis. Beyond the 
oft-cited peculiarities of the president himself, there are three deeper 
reasons why local and global power relationships mean that the battle 
against AIDS has to date mainly been lost.[3]

One reason is the pressure exerted by international and domestic 
financial markets to keep Pretoria’s state budget deficit to three per 
cent of GDP. Recall the telling remark of the late Parks Mankahlana, 
Mbeki’s main spokesperson, who in March 2000 justified to Science 
magazine why the government refused to provide relatively inexpensive 
antiretrovirals (ARVs) like Nevirapine to pregnant, HIV-positive women: 
‘That mother is going to die and that HIV-negative child will be an 
orphan. That child must be brought up. Who is going to bring the child 
up? It’s the state, the state. That’s resources, you see.’[4] Instead of 
saving lives, Mbeki’s finance ministry adopted higher priorities: 
slashing corporate taxes, redeploying state resources to purchase 
high-tech arms, and repaying roughly $25 billion of apartheid-era 
foreign debt and a bit more in apartheid domestic debt, which could have 
been declared ‘odious’ in legal terms. Local and international bankers 
generally approved such examples of fiscal laxity, in contrast to 
expanding state health spending and other social budgets, which they 
have explicitly not supported.

The second structural reason is the residual power of pharmaceutical 
manufacturers to defend their rights to ‘intellectual property’, i.e. 
monopoly patents on life-saving medicines. This pressure did not end in 
April 2001 when the Pharmaceutical Manufacturers Association withdrew 
their notorious lawsuit against the South African Medicines Act of 1997. 
That Act allows for parallel import or local production, via ‘compulsory 
licences’, of generic substitutes for brand-name antiretroviral 
medicines. Big Pharma’s power was felt in the debate over essential 
drugs for public health emergencies at the November 2001 Doha World 
Trade Organisation summit, and ever since.

The third structural reason for the ongoing HIV/AIDS holocaust in South 
Africa is the vast size of the reserve army of labour, for this feature 
of capitalism allows companies to replace sick workers with desperate, 
unemployed people instead of providing them with treatment. The latter 
point deserves elaboration, simply because so many lives are at 
immediate risk, and so much evidence has mounted that corporate South 
Africa’s preferred approach has been, in essence, mass murder by denial 
of medical benefits.

This was the initial conclusion reached after a year of study at 
Africa’s largest company, Anglo American Corporation. Anglo has 160,000 
employees, of whom 21 per cent are estimated to be HIV-positive. Once 
Big Pharma appeared to retreat from its lawsuit, the company announced 
that it would provide antiretroviral medicines to its workforce, which 
meant literally tens of thousands of lives might be saved in the short 
term. But in June 2001, the Financial Times reported on Anglo’s ‘plans 
to make special payments to miners suffering from HIV/AIDS, on condition 
they take voluntary retirement.’ However, in addition to bribing workers 
to go home and die, Anglo told the Financial Times, ‘treatment of 
employees with antiretrovirals can be cheaper than the costs incurred by 
leaving them untreated.’ In August, Anglo’s vice president for medicine, 
Brian Brink, bragged in Business Day about a ‘strategy [which] involved 
offering wellness programmes, including access to antiretroviral 
treatment.’ According to that report, ‘The company believed that the 
cost of its programmes would eventually be outweighed by the benefits 
its received in gradual gains in productivity, [Brink] concluded. 
Although it was indeed a risky strategy, it was the only one Anglo could 
pursue in the face of such human suffering.’

Then in October 2001, Anglo simply retracted its promise, once 
cost-benefit analysis showed that 146,000 workers just weren’t worth 
saving. According to the Financial Times, Brink ‘said the company’s 
14,000 senior staff would receive antiretroviral treatment as part of 
their medical insurance, but that the provision of drug treatment for 
lower income employees was too expensive.’ Brink explained the criteria 
for the fatal analysis: ‘[Antiretrovirals] could save on absenteeism and 
improved productivity. The saving you achieve can be substantial, but we 
really don’t know how it will stack up. We feel that the cost will be 
greater than the saving.’ As the Wall Street Journal recorded:
‘In a controversial move that could have wide ramifications for how 
companies in poor countries handle AIDS, mining giant Anglo American PLC 
has put on hold a feasibility study to provide AIDS drugs to its African 
work force, according to people familiar with the situation. When it 
disclosed its plans for the study a year ago, Anglo garnered wide praise 
because it was one of the first major corporations to reveal measures 
aimed at treating AIDS cases among its rank and file African employees.’[5]

A few months later Anglo changed its mind once again, as AIDS ravaged 
the middle layer of the workforce, and the multi-class TAC raised 
consciousness sufficiently high as to get trades union support for 
members’ treatment. Indeed, in the cases of both Anglo and Coca Cola, 
the other factor that appeared in 2002 was the spectre of consumer 
protest over the firms’ refusal to treat employees. I was reliably 
informed by insiders that for Anglo, the prospect of demonstrators at 
the August 2002 World Summit on Sustainable Development dragging up many 
other bits of dirty laundry intimidated the company’s executives into 
taking pre-emptive action on the AIDS front. Coke’s main bottler in 
South Africa had also failed to insure two-thirds of its 4,000-strong 
workforce at a sufficient level to allow the HIV-positive workers access 
to ARVs, and was subject to international protest over African AIDS 
policies.

However, even though the costs of HIV/AIDS - absenteeism, declining 
productivity, payouts for early death - soared to as high as 25 per cent 
of payroll by 2003, according to the Financial Times, most employers are 
still hesitant to provide ARVs:

‘Untreated, HIV typically takes four to five years to manifest itself as 
full-blown AIDS, and companies are reluctant to pay for a risk that they 
cannot see… Persuading managers to part with fees [AIDS treatment 
programmes] today for costs that will hit company earnings years down 
the line has been a hard sell.’[6]

In sum, no matter the effectiveness of activism against government, Big 
Pharma and the corporate employers, all three structural factors are 
still deterrents to the provision of treatment. By late 2003, each was 
slightly mitigated, however, and that led to an ostensible change of 
policy by Pretoria. The budget deficit was projected to climb from just 
over one per cent of GDP during the early 2000s to nearly three per cent 
in 2004-05, allowing extra leeway for AIDS spending. Pharmacorps were 
cooperating more closely with the World Health Organisation, the Global 
Fund, the Clinton Foundation and governments to lower prices for Africa. 
Canada’s former prime minister Jean Chretien - spurred by the dynamic, 
outspoken UN advisor Stephen Lewis - even introduced path-breaking 
legislation to promote generics (although a sabotage clause was later 
included in the draft law to support patent rights, in turn attracting a 
new round of solidarity protests). And employers began waking up, in 
part because of the dramatic rise of AIDS-related disability claims as a 
percentage of all disability claims, from 18 per cent in 2001 to 31 per 
cent in 2002.

These factors converged in a November 2003 cabinet statement, finally 
endorsing a roll-out of antiretrovirals. Pretoria cited factors which 
included:

‘a fall in the prices of drugs over the past two years…new medicines and 
international and local experience in managing the utilisation of ARVs… 
[sufficient] health workers and scientists with skills and 
understanding… and the availability of fiscal resources to expand social 
expenditure in general, as a consequence of the prudent macro economic 
policies pursued by government.’

However, these factors were minor compared to intensive activist 
pressure, which Pretoria did not dare mention lest it encourage further 
protests. TAC’s victory statement was explicit: ‘The combination of the 
Constitutional Court decision on mother to child transmission 
prevention, the Stand Up for Our Lives march [of 15,000 people on 
parliament] in February, the civil disobedience campaign and the 
international protests around the world have convinced Cabinet to 
develop and implement an ARV roll-out plan.’

Another factor, of course, was the 2004 presidential election, which 
Mbeki would win easily but which would be characterised by high levels 
of apathy and no-vote campaigning by the Landless Peoples Movement. An 
AC Nielsen survey in November 2003 confirmed that Mbeki’s AIDS policy 
was hurting the chances of the ruling African National Congress of 
turning out the vote. The cabinet statement promised that ‘within a 
year, there will be at least one service point in every health district 
across the country and, within five years, one service point in every 
local municipality.’ In addition to medicines, the state would provide 
an education and community mobilisation programme, promotion of good 
nutrition and traditional health treatments such as herbal remedies, 
support for families affected by HIV and AIDS, and funds for upgrading 
health infrastructure. The health system was already massively 
overextended, with far too few essential medicines, much less ARVs, 
available in South Africa’s under-funded rural clinics.

As TAC was the first to concede, ARV availability could generate 
negative unintended consequences. One would be non-compliance with 
treatment regimes by poor people, and the concomitant emergence of 
drug-resistant strains. Another would be the black market smuggling of 
cheap drugs to Europe and North America which would reduce access in 
Africa. Another would be that, although stigmatisation would decline 
given the availability of hope-giving drugs, so too might the practice 
of safe sex. These would remain major challenges to TAC and other 
health-sector groups, although the Khayelitsha operation of Médecins 
Sans Frontières was already proving high levels of treatment compliance.

Moreover, the conflict between neo-liberalism and life, so explicit in 
the case of access to AIDS medicines, was severely compounded by 
patriarchy, traditional and modern sexual practices such as multiple 
partners for men, and domestic violence against women. Rape continued at 
scandalous levels.

But the primary contradiction involved the regime in Pretoria. In 
February 2004, TAC attacked President Thabo Mbeki in the wake of more 
government prevarication on AIDS treatment.[7] Claiming that Mbeki 
‘misrepresented facts and once again caused confusion on HIV/AIDS’ on 
national television, TAC’s Zackie Achmat accused him of ‘denialism.’ 
Moreover, Pretoria had originally promised to distribute AIDS medicines 
to at least 50,000 people within a year, and to reach everyone in need 
of treatment within five years. Tshabalala-Msimang blamed slow drug 
procurement – Pretoria’s own fault – and the lack of qualified health 
personnel. TAC strategist Mark Heywood commented, ‘Many hospitals have 
the capacity, they just don’t have the medicines.’ The finance ministry 
also cut the budget dramatically for medicine purchases in February 2004.

At the same time, Tshabalala-Msimang suggested that while HIV-positive 
people waited for medicines, a diet of lemons, beetroot, (extremely 
expensive), olive oil and garlic would improve the body’s immune system. 
A week earlier, the minister had come under fire by the SA Medical 
Association, whose chairperson Dr Kgosi Letlape accused her of ‘dividing 
the profession when we have gone to great lengths to unite it.’ The 
minister unsuccessfully attempted to halt a protest march of 2,000 
medics against poor conditions in public health facilities by implying 
that the demonstrating doctors were white, whereas black medics 
supported the government.

Mbeki continued supporting his minister, no matter how outrageous this 
became. He told the SA Broadcasting Corporation on 8 February 2004 that 
the major problem was inaccurate mortality statistics, which made it 
impossible to know whether AIDS was as fatal as claimed. According to 
Mbeki, his doctors informed him that diabetes is also an epidemic, and 
he questioned why no-one talks about diabetes. Achmat replied:

‘Drugs for treating diabetes are heavily overpriced; there should be a 
campaign for their reduction. But unlike HIV until November 2003, 
diabetes is treated in the public health sector. However, the President 
should be aware that according to an initial investigation into the 
burden of disease estimates in South Africa released in 2003 by the 
Medical Research Council, AIDS was responsible for 39 per cent of lost 
life-years in 2000 - more than the next 10 worst diseases. Diabetes is 
the 12th worst disease and is responsible for slightly more than one per 
cent of lost life-years. The two diseases are incomparable in scale.’

Achmat also ridiculed Mbeki’s claim that ‘few countries can hold a 
candle to South Africa’s HIV/AIDS programme.’ Achmat replied:

‘A number of developing countries do much better than South Africa when 
it comes to HIV prevention and treatment, often with far fewer 
resources. Currently, South Africa treats approximately 1,500 people in 
its public sector, who are not on drug trials, paying for their own 
medicines or being sponsored. By contrast, Brazil’s government treats 
over 100,000 people and has less than a quarter of South Africa’s HIV 
infections. Botswana is treating approximately 15,000 and Cameroon 
approximately 7,000 people.’

In March 2004 the need to harass Pretoria to ensure roll-out was 
confirmed again, when TAC was forced to threaten an urgent court 
interdict in order to permit the urgent acquisition of antiretroviral 
medicines consistent with the November 2003 cabinet decision. 
Tshabalala-Msimang was sufficiently threatened by yet more embarrassing 
court proceedings that she finally agreed, just before a deadline 
provided by TAC lawyers. TAC declared victory, though remarked that ‘by 
implementing the interim procurement mechanism and thereby avoiding a 
three-month delay of the treatment programme, approximately 6,000 excess 
deaths could be avoided.’ [8]

What is the way forward, given persistent presidential denial, state 
bureaucratic sabotage, and structural factors that mitigate against 
access to treatment? One major stumbling block would probably emerge in 
subsequent months and years: the nature of political alliances within 
South African politics. TAC had been effective in attracting support 
from the most forward-looking trades unions, the SA Communist Party, 
churches, NGO activists and technical supporters (lawyers, health 
workers, academics, journalists). Yet these alliances did not stray far 
from the ANC. Would TAC forge sufficient linkages to non-ANC 
communities, especially those devoted to building the new independent 
left? In coming years, would the myriad of problems that cause 
opportunistic infections, especially dirty water and air (thanks to 
coal/wood/paraffin), also be addressed? At a time that the South African 
government was disconnecting water and electricity at a lethal rate, 
alongside evictions for those who could not afford expensive rental and 
mortgage bond payments, the need to address the links between AIDS and 
the diseases of poverty/homelessness was obvious.

Moreover, would TAC and its allies make the case that access to ARVs is 
a human right and that people should not pay user-fees or partial 
cost-recovery for the medicines? By 2004 they were taking this position, 
but only in the event that people were too poor to pay for medicines. 
Yet means-testing of black South Africans with irregular informal 
incomes is notoriously difficult. In contrast, a more explicit ‘free 
lifeline’ strategy would parallel the demands of the water and 
electricity campaigners.

Nevertheless, whether or not TAC continues to tackle the three 
structural impediments to ARV access – neo-liberal fiscal policy, 
pharmacorps and corporate control of health perks - the immediate 
victory of November 2003 will potentially make a huge difference. For 
the half million South Africans who are symptomatic with AIDS or who 
have a CD4 blood count less than 200, there was suddenly hope. Across 
the world, for three million people who die each year of AIDS, and for 
40 million others infected, the treatment activists and their 
international allies deserve a standing ovation.


* Patrick Bond directs the Centre for Civil Society at the University of 
KwaZulu-Natal in Durban. This article is an extract from his book 'Elite 
Transition: From Apartheid to Neoliberalism in South Africa'.

**Please send comments to editor at pambazuka.org or comment online at 
www.pambazuka.org


For additional notes, please follow this link:
1. See the excellent anti-patriarchal arguments in Lewis, S. (2004) 
‘Keynote Lecture at the 11th Conference on Retroviruses and 
Opportunistic Infections,’ San Francisco, 8 February.

2. One of the best surveys is in Lodge, T. (2002) 'Politics in South 
Africa', Cape Town, David Philip.

3. I have earlier made this case in three articles for ZNet commentaries 
(http://www.zmag.org), in The International Journal of Health Services 
(vol. 29, no. 4, 1999), and in two prior books ('Against Global 
Apartheid', Chapters 8 and 9; 'Unsustainable South Africa', Chapter 7).

4. Mail & Guardian, 21 July 2000.

5. Wall Street Journal, 16 April 2002.

6. Financial Times, 18 September 2003.

7. The following quotes are from Treatment Action Campaign (2004), 
‘President Mbeki misrepresents facts and once again causes confusion on 
HIV/AIDS,’ Cape Town, 11 February.

8. Treatment Action Campaign (2004) ‘TAC electronic newsletter,’ Cape 
Town, 25 March.