Epidemic Denial

CAPE TOWN, SOUTH AFRICA -- In late December 2002, South Africa's ruling party, the African National Congress (ANC), gathered in the plush university town of Stellenbosch for its 51st National Conference. That members elected President Thabo Mbeki to lead the ANC for another five years came as no surprise; more noteworthy was the announcement of a policy shift on AIDS, which plagues more than 10 percent of the country's population. "Given the progression of the AIDS epidemic . . . our program of transformation should not only acknowledge this danger, but it must also put the campaign against it at the top of the agenda," read the conference's statement. After years of international incredulity and outrage regarding Mbeki's contention that HIV does not cause AIDS, it seemed that the ANC leadership was finally coming to its senses.

But two months after the supposed shifting of gears at Stellenbosch, there is precious little evidence that Mbeki and his party are moving any faster to combat AIDS. Indeed, National Health Minister Manto Tshabalala-Msimang made her priorities clear at the Stellenbosch meeting, where she insisted that South Africa could not sacrifice submarine purchases in a $6 billion arms deal in order to pay for AIDS drugs. "Look at what Bush is doing," she told the Guardian. "He could invade." As yet, Tshabalala-Msimang has failed to recognize that AIDS is killing 200,000 South Africans per year, a substantially greater national security threat than her imagined foreign invasion.

At the epicenter of the current AIDS battle is the northeastern province of Mpumalanga. As early as April 2002, a group of 80 doctors and staff at Mpumalanga's largest hospital wrote to Sibongile Manana, the provincial executive council member in charge of health policy, protesting her ban on distributing the antiretroviral drug nevirapine. The drug has been shown to dramatically reduce mother-to-child HIV transmission. The doctors warned that failure to provide nevirapine amounted to condemning babies to death. Invoking the Hippocratic oath, they vowed to treat patients with the drug regardless of Manana's decision. Manana's position has barely changed since then. She has refused to comply fully with a July 2002 Constitutional Court order to provide nevirapine to pregnant women who wish to take it, despite the fact that the court is the highest in the land and its ruling cannot be appealed.

Before the court's decision, the Mbeki government had vehemently denounced the use of nevirapine, questioned its safety and insisted on further study of the drug despite its approval in the United States and in numerous other countries. In this atmosphere, Manana's Northern Cape counterpart felt free to denounce a hospital for providing antiretrovirals to a 9-month-old baby who had been gang-raped. That was January 2002. Now ANC leaders have pledged to comply with the Constitutional Court order, but they have been reluctant to discipline their provincial representatives who cling stubbornly to old practices.

While the ANC delegates sat in Stellenbosch pledging to put AIDS at the top of the agenda, the Treatment Action Campaign (TAC) -- South Africa's largest AIDS activism organization -- was petitioning the High Court of Pretoria to hold Manana and Tshabalala-Msimang in contempt for failure to comply with the Constitutional Court order. The TAC argues that Manana has not made information about nevirapine available to the community, does not allow doctors to dispense antiretrovirals without her approval and has not expanded nevirapine availability beyond two pilot hospitals. She has also repeatedly tried to evict a rape intervention nongovernmental organization that gives antiretrovirals to HIV-positive rape victims.

In addition to the contempt applications against Manana and Tshabalala-Msimang, TAC leader Zackie Achmat is planning a massive demonstration for universal treatment in Cape Town later this week. Posters advertising the march -- with a picture of Nelson Mandela wearing a TAC trademark "HIV Positive" T-shirt -- are plastered on walls and street signs throughout the city. Achmat promises a "massive peaceful civil-disobedience campaign" if the government does not sign a comprehensive treatment plan by the end of February. Yet despite his mobilization of protesters, Achmat insists TAC is willing to work with the government. "We want to work with them," he says. "But in order to get them to work we have to subject them to merciless criticism when lives are at stake." He is adamant that civil society and the business community cannot carry the burden themselves.

Some of South Africa's largest companies have recently rolled out treatment programs for their employees. Most notably, mining giant Anglo-American is providing treatment, testing and HIV-education programs for its workers. While the firm's initiative has received nearly universal praise, some editorials and activists have raised an ethical dilemma: "[W]hat happens when workers receiving the anti-retroviral therapy free of charge lose their jobs or can no longer work?" wrote Business Day. Though admirable, activists argue that Anglo-American's efforts are not a substitute for the safety net that government-subsidized treatment would provide, regardless of employment status.

As the TAC deadline for a treatment plan approaches, the prospect of mass protests against the government is once again on the horizon in South Africa. Given the overwhelming support TAC has received from the country's trade unions, there is no doubt it can turn out high numbers of protesters. Meanwhile, most South Africans remain skeptical of whether their government is truly committed to fighting AIDS. According to a 2002 Nelson Mandela Foundation/Human Sciences Research Council study, only 47.5 percent of South Africans believe the government allocates sufficient resources for AIDS control.

Which is not surprising, given the views of some ANC officials. On Monday, Tshabalala-Msimang, the national health minister, declared her solidarity with Manana in the event that Manana is found in contempt of court. "If she goes to prison, I'm going with her," Tshabalala-Msimang told newspapers. Nonhlanhla Nkabinde, a spokesperson for the opposition party United Democratic Movement, welcomed the health minister's statement: "Going to jail in solidarity with [Manana] is the first constructive proposal she has ever made in her entire term of office."

Sasha Polakow-Suranksy is a fomer Prospect writing fellow. He will study in England on a Rhodes Scholarship next fall.