Timothy Trengove-Jones crossfire
In the rather tautologous words of the famous song, the times they are a-changing. It was reported last weekend that President Thabo Mbeki has told the African National Congress’s national executive committee that he is to withdrawEfrom public debate over the science of HIV/Aids. His contributions, he repeated, have “caused confusion”. In keeping with the minister of health’s recent insistence that we focus on the government’s five-year strategic plan, it has also been announced that R2-million will beEinvested in a publicity campaign to promote “conventionalEapproaches” to combating the illness. A major pressure group, theETreatment Action Campaign (TAC) sent an open letter to all members ofEParliament ahead of last week’s parliamentary debate urging them toE”refrain from cynical point-scoring about HIV/Aids” and “to take seriously the enormous impact that HIV is having on our society”.E And, after a number of acrimonious exchanges, leader of the opposition Tony Leon has called for a united front to wage warEagainst this illness. All of this suggests a new mood characterised by a belief that, for the good of the country, we need to get beyond controversy in orderEto move ahead. This is evident in the TAC’s letter where it calls for an “end [to] the public debate on the link between HIV and Aids.” After all, we now have it on record that the government’s strategic plan and all its thinking is based on “the thesis that HIV causesEAids”. In what can be taken as a practical demonstration of this,Ethe health minister has authorised seven hospitals in KwaZulu-Natal toEadminister Nevirapine to HIV-positive pregnant women as a way ofEextending the feasibility studies on the drug.
So far so good? Yes and no. While one can – in politics at any rateE- kill two birds with one stone, the president’s decision to removeEhimself from public wrangling largely of his own creation is as muchEa sign that these disputes might have damaged his credibility asEthey are in the interests of promoting health. That said, let us beEgracious and acknowledge a small triumph of democracy: pressure from within and without the ANC has largely been responsible for theEpresident’s decision and that suggests, at last, that criticism stillEhas an effective place in our political life. To acknowledge thisEsmall, but important, victory is to baulk at talk of politicalE”point-scoring”. What one commentator last week referred to as “the desire to make political mileage” out of HIV is, in effect, sustainedly courageous criticism that has won these small recentEgains. At this moment of reappraisal and – one hopes – a turning tide, weEneed to be very cautious. Calls for the avoidance of “point- scoring”Eare essentially calls to depoliticise the debate. While at one levelEthis might seem absolutely axiomatic, from another perspective it is foolhardy because impossible. The HIV/Aids debate can’t beEdepoliticised because questions about Aids policies ask difficultEquestions about wider social and political forces. Tensions are highEbecause the stakes are high: misjudgement affects the lives of thousands. Questions, for instance, about the distribution of resources andEbenefits raise difficult issues of distributive justice. So, forEinstance, it is not possible to discuss the matter of the provisionEof mother-to-child-transmission prophylaxis outside theEescalating costs – now set at around R41-billion – of the armsEprocurement programme. This observation is not about point-scoring.E
In an irony that should be glaringly apparent, governmentErepresentatives and many commentators habitually invoke the metaphor ofE”war” when addressing the HIV/Aids issue. Both health and defenceEissues are about our security. Both matters affect crucially ourEeconomic prospects. But our health imperatives relate to current andEidentifiable security issues, whereas the arms procurement deal – increasingly a damp squib it seems – concerns some far fromEidentifiable “threat”.
The Constitution’s guarantee of the “right to access health careEservice including reproductive health” is “subject to available resources”. In largely denying women the choice of mother-to-child- transmission prophylaxis and using,Ein part, the “costs too much argument,” in doing this while spendingEan estimated R41-billion on new military hardware for a guaranteedEreturn of R3-billion, the state surely opens itself to searchingEquestions about the just and responsible deployment of resources,Equestions that any movement towards a national consensus – or unitedEAids front – must not be allowed to silence.E
If we look at the publicity to promote “conventional approaches” ofEcombating the illness, we see the fruits of the strategic plan’sEcommitment to an “information, education and communications strategy”. For R2-million we now have the “ABC strategy”. As its nameEimplies, it is elementary, the start of what the programmers hopeEwill be an alphabet of survival. It aims to be an exercise in healthEpromotion rather than therapeutic intervention. The latter, we are told, is too costly, the former emphasises prevention as the best ofEcures, and seems to be eminently commonsensical: Abstain, be faithfulEto your sexual partner, condomise “if you do have sex”. But this is all too elementary. Researchers and workers in the fieldEreport a high incidence of HIV/Aids awareness in South Africa. TheEproblem, perversely, is that this goes along with the highestEincidence of sero-conversion in the world. What is the point ofEtelling people what they already know? Moreover, all researchEindicates that generalised campaigns of the sort represented by theEABC ads don’t work. What is required, rather, are highly specific,Etargeted interventions. As with the debate around the HIV-Aids link,Eso with the ABCs: we seem intent on reinventing the wheel and soEsquarely at that. Ironically, the ABC adverts ignore the very elements of contextEstressed by the president’s emphasis on poverty. All epidemiologicalEdiscourse operates within perceptions of risk factors that, broadlyEspeaking, concern behaviour on the one hand and environment on theEother. The ABC adverts are a waste of money in that they emphasiseEbehaviour at the expense of environment. They urge specificEbehaviours without taking into account the material constraints orEpossibilities individuals may have of following through on them.E Theoretically, “the nation” or we its citizens, may all be equally at risk of HIV infection, but the risk factors that affect on the dailyErealities of different groups within our society are not equallyEdistributed. Any useful health promotion campaign has to begin withEthis insight. And the ABC campaign does not.E It needs to be openly acknowledged that, in many ways, health promotion campaigns are trickier than therapeutic interventions. ThisEis because they have to work through cultural and social contexts.E Health promotion is itself not value free – the religious right condemns the advocacy of condoms as this leads to “promiscuity” – butEis intimately concerned to promote a view of the “good life”. As withEthe provision of therapies, so with this education programme,Esquabbles over “morality” will make it inevitable that no consensusEcan be achieved. The ABC adverts themselves contain an implicitEcritique of those who operate sexually outside conventional “familyEvalues”. Rather than seeing health as involving an evolving set ofEcontinually revised decisions and possibilities, different inEdifferent material conditions, the programme seems to opt for aEstatic, prescriptive view of sexual morality. One need not be aEprophet to forecast limited success.E
We have just had the second anniversary of the Mbeki-led “Partnership against Aids”. With the government facing legal actionEfor its refusal to supply mother-to-child- transmission prophylaxis and with its beingEincreasingly asked to deliver results that deliver us from a graveEnational crisis, that partnership seems to be in tatters. As we tryEto reconstitute it, do not expect controversy to die down. The debate is inherently contentious if only because what is required is a hugeEexercise in social engineering. A national Aids programme will needEto change structures of society as well as individuals’ behaviours. As such, it has to recognise and address the deep inequalities that exist within this culture. That is why it seems easier to hide behind a “strategic plan”, or to set up further committees to conductEfurther “research”.
Rather than belittling criticism as point- scoring, we need toEunderstand that the key practical issue is not whether a specificEprogramme is beyond criticism, but whether it will improve things or not. Planners need to decide whether a programme should exist andEwhat is its optimal form. On the matter of the ABC adverts, theEanswer is that they should not exist. On mother-to- child-transmission prophylaxis, we shouldEnot praise the new seven test sites, but ask why there is noEnationwide implementation. If it is necessary to demonstrate withoutEany doubt whatsoever that a specific intervention is beyond allEcriticism, no policy could be implemented. And, on the mother-to-child- transmission issue,Ethat is what we’ve been landed with for the past five years. As theEtimes change, this is my criticism aimed at encouraging a necessaryEand sufficiently defensible policy decision. Timothy Trengove-Jones is a Wits academic and Aids researcher