HEALTH: by John WhitehallNews Weekly
The politics of AIDS in South Africa
, May 18, 2002
John Whitehall is an Australian paediatrician who worked in a mission hospital in South Africa some years ago, and returned for two months as visiting professor in child health in one of its universities in order to observe the impact of the AIDS epidemic.In a welcome but surprising reversal of official policy, the Health Minister of South Africa, Dr Manto Tshabalala-Msimang, recently announced "Cabinet noted that (antiretroviral drugs) could help improve the conditions of people living with AIDS if administered at certain stages in the progression of the condition."
The statement is welcome because South Africa is suffering an epidemic of Human Immunodeficiency Virus (HIV) in which a tenth of its African population is believed to be infected.
It is surprising because it appears to reverse the objections of the President, Thabo Mbeki, to the provision of specific antiviral therapy for public patients because of his rejection of the evidence that HIV is the primary cause of the Acquired Immune Deficiency Syndrome (AIDS).
Very stubbornly, Mbeki has contended that AIDS is the result of poverty, malnutrition and secondary infections. Rejecting the primacy of HIV, Mbeki has denied specific anti-HIV drugs to scores of thousands of mothers who are at risk of transferring the infection to their newborn, to rape victims at risk of contracting the disease, and to people with established AIDS.
He has maintained this extraordinary imposition on his people despite medical evidence that HIV is the cause of AIDS, that specific antiviral therapy may reduce infection of a baby from a mother by 50% and is likely to prevent infection after rape, and that combined, long term therapy may markedly reduce the effect of established disease permitting a return to more or less normal life.
The effect of AIDS on South Africa is profound. The medical system is overwhelmed: people are suffering very badly. Poverty is increasing as breadwinners die. Family structures are disintegrating and orphans accumulating as mothers die.
The potential of an African middle class is threatened. The contribution of educated Africans is threatened, because they are at particular risk. There is increasing hopelessness, lawlessness and violence. HIV is the virus of anomie.
The threat has not been unrecognised. Former President, Nelson Mandela declared in June 2000:
"Let us not equivocate, a tragedy of unprecedented proportions is unfolding in Africa ... AIDS today in Africa is claiming more lives than the sum of all wars, famines and floods, and the ravages of such deadly diseases as malaria ... we have to rise above our differences and combine our efforts to save our people."
But President Thabo Mbeki has not displayed any similar sense of urgency or clarity of purpose. To the contrary, his pronouncements have been evasive and vague, and he has pursued alternative causes and therapies for AIDS in the company of the unorthodox rather than the scientific.
His actions have cost him dearly. His denial of treatment has provoked the formation of activist organisations whose zeal has begun to rival the anti-apartheid demonstrators of old. He has been criticised within his party, the African National Congress (ANC) and there has been increasing tension with the partners of the ANC, the Council of South African Trade Unions and the South African Communist Party (SACP), who have both begun to campaign for specific therapy against HIV, in opposition to Mbeki. Unions, churches, non-government agencies and media have joined in the criticism. Nationally and internationally, Mbeki has been pilloried.
Yet he has remained apparently unmoved and has wielded such singular dominance that the very future of democracy in South Africa has begun to be questioned. In particular, the apparent disdain by the leadership of the ANC for the recent ruling of the High Court of Pretoria, that specific therapy should be provided for prevention of perinatal infection, has raised fears that the revolutionary discipline of the anti-apartheid struggle may not be transformed into parliamentary democracy.
It was complained to this writer, by a former member of the SACP, no less, that it had become more difficult to campaign publicly against the AIDS policies of Mbeki than it was to campaign against apartheid! Therefore, the suggestion of reversal of Mbeki's position is very welcome, indeed.
The question that has received no satisfactory answer is why does Mbeki believe the way he does? Why does he risk so much on a medical matter?
Some insights into his thinking may be gleaned from a speech he made at Fort Hare University, last October, when he accused the AIDS epidemic of being used as a slur against black people whereby they are "reminded of their role as germ carriers" and condemned as "natural born, promiscuous carrier of germs, unique in the world ... doomed to an inevitable moral end because of our unconquerable devotion to the sin of lust".
Furthermore, in a speech to ANC members of the National Assembly and to some Cabinet members, as reported by the Mail
newspapers last October, Mbeki said be believed the CIA, drug companies and international financial organisations were linked in an attempt to exploit South Africa. This exploitation would result from the claim that HIV caused AIDS and could only be cured by Western drugs. Also, Mbeki may share the unorthodox opinion he has promoted in South Africa that AIDS may, in fact, be a side effect of those drugs.
This writer was tempted to dismiss Thabo Mbeki's beliefs as the result of one round too many of revolutionary dogma on the way to the Presidency. After all, Mbeki grew up in a communist family, was a member of that Party, trained in the Soviet Union, and became a prominent leader of the ANC, which functioned as the political front of the SACP.Profit motive
For decades, it was dogma that the West was exploitative, Western governments represented capitalism, and capitalism's only interest was profit.
Surely it was revolutionary paranoia for Mbeki to believe Western governments are more committed to the profit of international companies than compassion? Surely international drug companies would not exploit the worst epidemic since the Black Plague? Would they?
In 1995, after victory over apartheid, the ANC sought to fulfil an election promise that the supply of essential drugs would be ensured. To do so, in 1997, the ANC passed a "Medicines Act" with a clause that restrictions imposed by patents could be bypassed in conditions of national emergency. Though this principle of escape in national emergency is at least implied in World Trade Organisation agreements, the international drug companies mobilised vigorously against South Africa.
Ultimately, a consortium of some 40 companies took Nelson Mandela's Government to court in order to try to force it to remove the escape clause and, thus, secure their market.
The South African Government refused to abolish the clause and the case lasted until April last year when the companies withdrew their action in the face of mounting negative publicity which was bound to worsen if they were obliged by the court to reveal the extent of their profits. Also, activist groups had gathered statements by leading researchers that contested the companies' claims that the high costs of the drugs were generated by the expenses of preliminary research.
The researchers revealed that the cost of much basic research had not been borne by the pharmaceutical industry but by universities and government institutions: by taxpayers, not drug companies!
Though not surprised that drug companies should try to protect their profits, it was surprising for this writer to learn of the extent of the support given to their campaign by US government agencies and politicians, even to the rank of Vice-President and the realm of the White House.
This support was outlined in a State Department report of 1998, written by Assistant Secretary for Legislative Affairs Barbara Larkin who declared:
"Since the passage of the offending amendments in December 1997, US government agencies have been engaged in a full court press with South African officials from the Departments of Trade and Industry, Foreign Affairs, and Health to convince the South African Government to withdraw or amend the offending provisions of the law, or at the very least, to ensure the law is implemented in a manner fully consistent with South Africa's TRIPS obligations."
The report reveals the US Government, under President Clinton, waged a relentless campaign, empowered by the threat of economic sanctions.
The French and Swiss Governments were persuaded to join the campaign and South Africa was added officially to a US "Watch list" of countries suspected of dishonouring intellectual property agreements.
US Trade officials prepared a decision to "withhold preferential tariff treatment from certain South African exports" and it was announced by the White House in June 98, that four items "would be held in abeyance pending adequate progress on intellectual property right protection in South Africa".
In August 1998, no less than Vice President Gore met with his counterpart in South Africa, Thabo Mbeki, and "made the issue of intellectual property rights protection, and pharmaceutical agents in particular, a central focus of his discussions".Response
In the US, Congressman Frelinghausen, in whose district the pharmaceutical industry is prominent, advocated suspension of development aid to South Africa if intellectual property rights were abrogated. And forty members of Congress wrote a letter to President Clinton, supporting the drug companies.
The support was not one way. It was reported by the Centre for Responsive Politics that the pharmaceutical industry made nearly $12 million specific political donations during the 1997-98 US elections.
The Common Cause Education Fund claims the pharmaceutical industry spends almost $50 million a year on lobbying by Washington insiders who include former politicians, staff workers and advisors.
The campaign to support the drug companies by US and other governments occurred in the face of escape provisions in the Trade Related Aspects of Intellectual Property agreements (TRIPS) of the World Trade Organisation which permits waiving of agreements in cases of national emergency.
The US, itself, has bypassed agreements. Also, during the recent anthrax scare in North America, it appears the Canadian Government was prepared to ignore patent laws when it appeared the producers of the specific antibiotic might not be able to meet the challenge of an epidemic.
Coincident with the publicity of the court case, the price of antivirals began to be reduced by the drug companies with the result that the cost of a month's treatment of established AIDS with patented drugs has fallen from some R2,300 to R700. The cost of perinatal prevention has fallen to a mere R10 (less than A$2 on current rates).
Were the companies struck by conscience, forced by bad publicity, or merely responding to the offer by patent breaking companies in Brazil and India to provide the drugs to South Africa for as little as R460 and R340, respectively?
The feelings of this writer softened to Mbeki. In the wards and hospices of South Africa, there was incredulity that one man could deny antiviral therapy to so many gasping skeletons.
Later, there was incredulity that the world's most powerful governments should fight for the profits of the world's most powerful companies and, effectively, deny therapy to those same gasping skeletons!
I found it hard to blame Mbeki for being a bit suspicious of Western intentions and the collusion between its governments and international co-operations.
The Clinton Presidency might be remembered for personalising Lenin's theories on imperialism and capitalism. Nevertheless, though Mbeki may be excused for suspicion and perhaps desperation to find other causes and treatments for AIDS, it is hard to excuse his denial of science.
Whatever Mbeki thinks, it is now time to support South Africa. It is time for unprecedented generosity. No country in Africa can afford antiviral therapy, even at the lowest prices. The developed world should cause the drugs to be supplied free of charge and in as much volume as can be distributed, and now.
This should be an international mission of compassion though, as Shakespeare knew, mercy is twice blessed, favouring giver and receiver.
The West benefited by generosity to Japan and Europe after the last war. Their political and financial stability was a reciprocal blessing. Third World stability is important for everyone.
Certainly, patent protection is important and Western drug companies have transformed life on earth, justifying much of their self-interest. The question is the compromise between the preservation of the well-being of the companies and the lives and societies of those suffering with HIV.
How wounded would the companies be if they lost protection of their patents on AIDS drugs in developing countries? As the companies refuse to disclose their real costs, the answer is unknown but it has been estimated that less than 1% of their profits are derived from developing countries. The majority comes from sickness in the West.
It is hard to see how the well-being of the drug companies would be challenged by the loss of the AIDS market in the developing world. Let them convince us by disclosure. Conversely, generosity would be good for publicity.
The pharmaceutical industry might fear competition from drugs produced in developing countries and then imported to the West, but the US Government has a long record of successful denial of "free trade". Ask Australian farmers.
The pharmaceutical and other industries might fear the precedent of successful patent abrogation, but the definition of national emergency is clear and substantiated, and is already part of the TRIPS agreement. Local production of AIDS drugs is hardly a precedent for abrogation of patent restrictions by, for example, China with electronics.
The health of the drug industry is important but not paramount to the demands of humanity. There is a profound need in Africa. Western governments should not oppose local production of antivirals. On the contrary, the cost of that production should be underwritten. It is the time for mercy.