Re: [xmca] Papers for discussion: HIV, interventions and activitytheory

From: Steve Gabosch <stevegabosch who-is-at>
Date: Wed Nov 26 2008 - 01:53:57 PST

This NYTimes article "Study Cites Toll of AIDS Policy in South Africa"
provides more background on Mary's reports on the political struggles
within South Africa over AIDS policy.
- Steve

November 26, 2008
Study Cites Toll of AIDS Policy in South Africa
JOHANNESBURG — A new study by Harvard researchers estimates that the
South African government would have prevented the premature deaths of
365,000 people earlier this decade if it had provided antiretroviral
drugs to AIDS patients and widely administered drugs to help prevent
pregnant women from infecting their babies.

The Harvard study concluded that the policies grew out of President
Thabo Mbeki’s denial of the well-established scientific consensus
about the viral cause of AIDS and the essential role of antiretroviral
drugs in treating it.

Coming in the wake of Mr. Mbeki’s ouster in September after a power
struggle in his party, the African National Congress, the report has
reignited questions about why Mr. Mbeki, a man of great acumen, was so
influenced by AIDS denialists.

And it has again caused soul-searching about why his colleagues in the
party did not act earlier to challenge his resistance to broadly
accepted methods of treating and preventing AIDS.

Reckoning with a legacy of such policies, Mr. Mbeki’s’s successor,
Kgalema Motlanthe, acted on the first day of his presidency two months
ago to remove the health minister, Manto Tshabalala-Msimang, a
polarizing figure who had proposed garlic, lemon juice and beetroot as
AIDS remedies.

He replaced her with Barbara Hogan, who has brought South Africa — the
most powerful country in a region at the epicenter of the world’s AIDS
pandemic — back into the mainstream.

“I feel ashamed that we have to own up to what Harvard is saying,” Ms.
Hogan, an A.N.C. stalwart who was imprisoned for a decade during the
anti-apartheid struggle, said in a recent interview. “The era of
denialism is over completely in South Africa.”

For years, the South African government did not provide antiretroviral
medicines, even as Botswana and Namibia, neighboring countries with
epidemics of similar scale, took action, the Harvard study reported.

The Harvard researchers quantified the human cost of that inaction by
comparing the number of people who got antiretrovirals in South Africa
from 2000 to 2005 with the number the government could have reached
had it put in place a workable treatment and prevention program.

They estimated that by 2005, South Africa could have been helping half
those in need but had reached only 23 percent. By comparison, Botswana
was already providing treatment to 85 percent of those in need, and
Namibia to 71 percent.

The 330,000 South Africans who died for lack of treatment and the
35,000 babies who perished because they were infected with H.I.V.
together lost at least 3.8 million years of life, the study concluded.

Epidemiologists and biostatisticians who reviewed the study for The
New York Times said the researchers had based their estimates on
conservative assumptions and used a sound methodology.

“They have truly used conservative estimates for their calculations,
and I would consider their numbers quite reasonable,” James Chin, a
professor of epidemiology at the University of California at
Berkeley’s School of Public Health, said in an e-mail message.

The report was posted online last month and will be published on
Monday in the peer-reviewed Journal of Acquired Immune Deficiency

Max Essex, the virologist who has led the Harvard School of Public
Health’s AIDS research program for the past 20 years and who oversaw
the study, called South Africa’s response to AIDS under Mr. Mbeki “a
case of bad, or even evil, public health.”

Mr. Mbeki has maintained a silence on his AIDS legacy since his forced
resignation. His spokesman, Mukoni Ratshitanga, said Mr. Mbeki would
not discuss his thinking on H.I.V. and AIDS, explaining that policy
decisions were made collectively by the cabinet and so questions
should be addressed to the government.

The new government is now trying to hasten the expansion of
antiretroviral treatments. The task is urgent. South Africa today is
home to 5.7 million people who are H.I.V.-positive — more than any
other nation, almost one in five adults. More than 900 people a day
die here as a result of AIDS, the United Nations estimates.

Since the party forced Mr. Mbeki from office and some of his loyalists
split off to start a new party, rivalries have flared and stories
about what happened inside the A.N.C. have begun to tumble out,
offering unsettling glimpses of how South Africa’s AIDS policies went
so wrong.

 From the first year of his presidency in 1999, Mr. Mbeki became
consumed with the thinking of a small group of dissident scientists
who argued that H.I.V. was not the cause of AIDS, his biographers say.

As president he wielded enormous power, and those who disagreed with
him said they feared they would be sidelined if they spoke out. Even
Nelson Mandela, the revered former president, was not immune from

In a column in The Sunday Times of Johannesburg on Oct. 19, Ngoako
Ramatlhodi, a senior party member now running the party’s 2009
election campaign, recounted how Mr. Mandela, known affectionately as
Madiba, was humiliated during a 2002 A.N.C. meeting after he made a
rare appearance to question the party’s stance on AIDS.

Mr. Ramatlhodi described speakers competing to show greater loyalty to
Mr. Mbeki by verbally attacking Mr. Mandela as Mr. Mbeki looked on
silently. “After his vicious mauling, Madiba looked twice his age, old
and ashen,” Mr. Ramatlhodi wrote.

Mr. Ramatlhodi himself acknowledged in a recent interview that in 2001
he sent a 22-page letter, drafted by Mr. Mbeki’s office, to another of
Mr. Mbeki’s most credible critics, Prof. Malegapuru Makgoba, an
immunologist who was one of South Africa’s leading scientists. The
letter accused Professor Makgoba of defending Western science and its
racist ideas about Africans at the expense of Mr. Mbeki.

In 2000 Mr. Mbeki had provided Professor Makgoba with two bound
volumes containing 1,500 pages of documents written by AIDS
denialists. After reading them, Professor Makgoba said in an interview
that he wrote back to warn Mr. Mbeki that if he adopted the
denialists’ ideas, South Africa would “become the laughingstock, if
not the pariah, of the world again.”

But Mr. Mbeki indicated last year to one of his biographers, Mark
Gevisser, that his views on AIDS were essentially unchanged, pointing
the writer to a document that, he said, was drafted by A.N.C. leaders
and accurately reflected his position.

The document’s authors conceded that H.I.V. might be one cause of AIDS
but contended that there were many others, like other diseases and

The document maintained that antiretrovirals were toxic. And it
suggested that powerful vested interests — drug companies,
governments, scientists — pushed the consensus view of AIDS in a quest
for money and power, while peddling centuries-old white racist beliefs
that depicted Africans as sexually rapacious.

“Yes, we are sex crazy!” the document’s authors bitterly exclaimed.
“Yes, we are diseased! Yes, we spread the deadly H.I. virus through
our uncontrolled heterosexual sex!”

In 2002, after a prolonged outcry over Mr. Mbeki’s comments about AIDS
and the government’s policies, Mr. Mbeki agreed to requests from
within his party to withdraw from the public debate. That same year,
the Constitutional Court ruled that the government had to provide
antiretroviral drugs to prevent the infection of newborns. And in
2003, the cabinet announced plans to go forward with an antiretroviral
treatment program.

“We did an enormous amount of good in the early days in South Africa,
not because of the Health Ministry, but in spite of the Health
Ministry,” said Randall L. Tobias, who was appointed by President Bush
in 2003 to lead the United States’ $15 billion global AIDS undertaking.

In the same years, former President Clinton and his foundation were
also deeply involved in helping South Africa get a treatment program
going. Mr. Clinton attended Mr. Mandela’s 85th birthday celebration in
Johannesburg in 2003. During the dinner, he and Mr. Mbeki slipped away
to talk about AIDS, Mr. Clinton recalled in a recent interview.

Mr. Clinton said he told Mr. Mbeki how antiretroviral treatment had
reduced the AIDS mortality rate in the United States and reminded him,
“I’m your friend and I haven’t joined in the public condemnation.”
That evening, when Mr. Clinton offered to send in a team of experts to
help the country put together a national treatment plan, Mr. Mbeki
took him up on it.

The Clinton Foundation helped devise a plan and mobilized 20 people to
travel to South Africa in 2004 to help carry it out. But the South
African government never invited them, Mr. Clinton said. So the
foundation, which had projects all over Africa, was to have none in
South Africa.

Changes since Mr. Mbeki’s fall from power have prompted many to hope
for forceful South African political leadership on AIDS. Mr. Mbeki’s
rival and successor as head of the party,Jacob Zuma, who is expected
to become president after next year’s election, himself made a
famously questionable remark about AIDS.

In his 2006 rape trial, in which he was acquitted of sexually
assaulting a family friend, he testified that he sought to reduce his
chances of being infected with H.I.V. by taking a shower after sex.
Nonetheless, he seems to have more conventional views on the pandemic.

“Who would have thought Jacob Zuma would be better than Mbeki, but he
is,” said Richard C. Holbrooke, the former ambassador to the United
Nations in the Clinton administration who heads a coalition of
businesses fighting AIDS. “The tragedy of Thabo Mbeki is that he’s a
smart man who could have been an international statesman on this
issue. To this day, you wonder what got into him.”

For South Africans who watched the dying and were powerless to stop
it, the grief is still raw. Zackie Achmat, the country’s most
prominent advocate for people with AIDS, became sick during the almost
five years he refused to take antiretrovirals until they were made
widely available. He cast Mr. Mbeki as the leading man in this African

“He is like Macbeth,” Mr. Achmat said. “It’s easier to walk through
the blood than to turn back and admit you made a mistake.”

Copyright 2008 The New York Times Company

On Nov 14, 2008, at 1:43 AM, Mary van der Riet wrote:

> Dear Steve, Andy, Mike and others who have commented on the HIV/AIDS
> issue
> Steve wrote
> I am curious about contrasts >between white, black and coloured
> South
> Africans in regard to the AIDS crisis and sexual >practices. My
> guess
> is that the higher levels of employment in skilled and career jobs,
> professions >and small businesses by whites creates a very different
> situation from the one you are describing >among the black
> ethnicities
> in SA, many of whom experience extreme poverty and economic
> >pressures,
> as you describe.
> Mary:
> Yes, the AIDS stats in relation to race reflect socioeconomic
> differences (poverty and extreme economic pressure. Estimates from the
> Nelson Mandela/HSRC survey for persons aged two years and older were
> Blacks, 13.3%; Coloureds, 1.9%; Indians 1.6%; Whites, 0.6% (Shisana,
> et
> al, 2005). Race is one of the strongest predictors of HIV status in
> South Africa. Marginalisation and discrimination on the basis of
> race or
> ethnicity must be understood as a factor that shapes vulnerability to
> HIV infection in South Africa. In the post-apartheid era, racially-
> based
> disadvantage continues to occur in relation to exposure to poverty,
> place of residence, education, job opportunities, skills and training
> and access to services. In contexts with constrained opportunities and
> resources, risky behaviours are more likely
> Steve continues
>> concurrency (and the expansion of non->traditional sexuality in
> general) in places like the US and Europe, among both gays and
> straights, >occurs for very different reasons. Reasons that occur to
> me at the moment for this emergence >include: a new-found relative
> freedom from the risk of pregnancy through birth control;
> Mary comments:
> Another significant factor in SA is the high rate of teenage
> pregnancies
> – even though birth control is readily available (in injectable form).
> There have been arguments that young girls fall pregnancy in order to
> access the child care grant (about R190-R200/month – at the current
> exchange rate about $20 per month) – but this has been contested and I
> don’t think this is a major reason for early pregnancy.
> Steve continues
>> a general relaxation of social coercion against non-traditional
>> sexual
> behavior, including women, >(although women's sexuality outside
> marriage is still more discouraged than men's); new resources >for
> mobility and privacy for individuals, especially for youth, and
> including for women (although >men continue to have much more access
> to
> such resources); more opportunities to socialize >outside the
> traditional family framework, also including, with the same
> qualifications, women; new > opportunities for gays and others
> interested in alternative sexual practices to socialize; a relative >
> proliferation of accessible commercial social venues to meet and date
> sexually active people in, >especially in urban areas, although they
> are by no means ideal and are largely unavailable to >teenagers; a
> radical increase in public knowledge about how to have sex
> recreationally and >pleasurably, something never before generally
> available, especially to women; much more >knowledge about
> relationship
> issues and consciousness about making sexual and intimate
> relationships
> more egalitarian and meaningful for both partners (these latter two
> are
> ones I would especially attribute a significant role to the womens,
> and
> also the gay movements); and until the AIDS crisis, the relative
> ability to rely on the health care system and antibiotics, personal
> hygiene, partnership, and protective barriers to try to minimize
> catastrophic consequences of sexually transmitted diseases.
> Mary comments:
> Many of these conditions are evident for wealthier, educated people in
> SA (suggesting it is also mostly about class, not only race – in SA
> the
> two are confounded), and the phenomenon of barebacking that you
> mention
> below has also been found in the SA gay community – in the AIDS
> literature this is also linked to a ‘death wish’ and the need to
> engage
> in high risk practices for the thrill of it (partly in the face of the
> dreaded disease)
> Steve:
> You would think that condoms would be used at near 100% levels by
> such
> people in the US, but they aren't - "barebacking" is considered an
> acceptable practice in many circles, especially among those who feel
> immune from AIDS because they assume they are sufficiently segregated
> from it.
> …
> Judging from your report, another social movement, which currently
> exists, that could be brought much more on board is the ANC itself.
> This historic movement led the struggle to overthrow apartheid, but in
> a way, its work has only begun. Getting the big political movements
> and governments of SA and in every country on board is clearly
> essential.
> Mary:
> the problem with the ANC at the moment is that they are facing a lot
> of
> internal battles and re-positioning which detracts from developing
> good
> policy. Having a new minister of health as I mentioned in my earlier
> post makes a big difference, but she may only be there until April
> next
> year – not a lot of time to change government policy.
> Steve:
> As for the possibility and potential for a women's movement in SA,
> I do
> hold high hopes. Women in SA and Africa in my mind can develop the
> power to change a great deal of things, including reversing many of
> worse effects of the global AIDS crisis, but such power will take
> time
> and changing conditions to harness, especially in a place like SA,
> where economic capital in many regions is weak and the labor force is
> consequently highly underdeveloped and in extreme conditions of
> poverty. In contrast, the deep entry of women into the workforces of
> the US and Europe, and the growth of post- WWII technologies for
> semi-mechanizing domestic work, speeding up shopping and meal
> preparation, and so forth, have combined, mostly in the advanced
> capitalist countries, to create underlying conditions and social
> opportunities for women to demand their full rights in ways never
> before seen in history.
> The women of Africa and throughout the world, in my opinion, will join
> forces on these fundamental issues, issues that are fundamental for
> all
> working people - but not overnight, and not all at once, and not in
> the
> same way or for the same reasons, and will do so in unique ways from
> region to region, culture to culture, and individual to individual.
> Sisterhood truly is powerful, and I think the world has so far only
> gotten a taste of it. When the women of Africa rise, the world will
> rock.
> Mary: the expression in SA would be Viva Amakhosikazi, Viva! (Long
> live
> women, long live) and Amandla ngawethu (power to the people!!!). Yes
> Steve, I really hope that something happens, and maybe it will
> ‘naturally’ as people get more and more fed up. But, the desperation
> is extreme ito poverty, death and illness. I am peripherally
> involved in
> an NGO that is building capacity for people to run their own SAveings
> and Credit Groups (outside of the formal banking system) and this
> might
> have an effect on social capital. There is also a drive to train
> children in financial literacy as many of them have to manage
> household
> budgets with ill or absent adults. These are important movements,
> and if
> they can grow and be sustained, this might have an indirect effect on
> people’s power and capacity to mediate their own risk of infection.
> And thank you for your comments and inputs. It’s a huge issue, not one
> any one person can handle or solve on their own and there are many
> in SA
> who are working quite actively in the field to resolve some of the
> issues. Thank you for your comments and inputs, it really has been
> useful to discuss these issues in this forum – to have them aired, but
> also to discuss possibilities.
> And to Andy, thank you also for linking me to various people and for
> the
> range of resources which you have mentioned,. I am tracking them down
> and engaging with them.
> Andy commented:
>> I think like in Uganda, if we can find out what works at a local >
> level, the an intthose who are prepared to fight, rather than
> intervening from on
>> high, so to speak. Government can provide education, publicity, >
> money, .... What the government says always affects how the people >
> think. If the government does no more than praise People Fighting >
> AIDS, then that will be a help.
> I think this is true, and the SA government’s stance on HIV has not
> been
> very helpful over the last 10 years, so anything that is more positive
> (in attitude and resources) will make a difference
> Andy:
>> On a side note, governments which help women by providing generous >
> resources for them to stay home as sole carer for a child, may >
> reinforce exploitation of women. In other countries, resources are >
> provided to women who want to continue in the workforce and need to
>> pay for child care or get their husband to give up work.>
> Yes, I can see that the gender politics remain if women are restricted
> to the home environment.
> And your colleague in the SACP here in SA who speaks of another
> colleague who did not go for medical help but went to a traditional
> healer, partly because of the stigma, provides an important example of
> how complex the problem is. Many traditional healers have been
> incorporated into programmes which inform them about HIV/AIDS, risks
> in
> treating clients – cutting with the same blade etc – and many adopt
> very
> progressive positions on this (referring clients to hospitals,
> admitting
> that they cannot cure AIDS), but there are others who claim to cure
> Mike also commented:
> This may seem like a backwards way to approach the issues you raise,
> Mary &
> Andy, but William Mazzarella wrote a book titled "Shoveling
> smoke" (Duke
> U
> Press) which was a study of how an advertising campaign in india made
> condums accrue the meaning of sexiness when they had the opposite
> meaning
> before. Seems like despite opposite sign valence the book might be of
> use.
> Mary
> thanks Mike, I will follow that up – it seems to pick on Andy’s point
> about changning the ‘image’ of condomless sex – and is spot on, rather
> than ‘backwards’
> Thanks to all who have, both on and off the list, made suggestions and
> comments and referred me to people and references. I have really
> benefited from the discussions.
> South Africa is a fascinating place – defeating apartheid, Mandela,
> the
> Truth Commission – but we still have major challenges:
> We might be on strike next year as university staff because of the way
> the university management is disciplining two staff members for
> questioning their practices.
> on another matter: A colleague of mine argues that we are at the coal
> face of many of the issues which are reflected in the world – one of
> them is that of race, and how one is affected by race, racism and
> racial
> policies, how this might affect the way we/me/staff/lecturers assess
> students etc. It raises issues of the more long term effects of
> apartheid policies and how one addresses legacies of colonialisation
> today, in 2008 in our own practices. Its tough dealing with this
> process
> of ‘transformation’ on a daily basis!
> Mary
> Mary van der Riet; School of Psychology; University of KwaZulu-Natal
> Private Bag X01, Scottsville, 3209
> email:
> tel: 033 260 6163; fax: 033 2605809
> Please find our Email Disclaimer here:
> _______________________________________________
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