`silent killer’, is disastrous
Twenty-three year old “Malock” has a two- year-old child and is HIV-positive. Since receiving her test results in December, she has sought counselling and told her boyfriends, all of whom denied being positive.
She worries about her daughter’s future. “I want to see her grandchildren but I know that won’t be possible,” she says. “I live for every day, and I feel well.”
Malock is one of the newly infected. She looks healthy; she is gaining weight. She has a positive outlook, has kept her job, and one of her boyfriends is sticking by her.
She can’t tell her family, though. “I must be very sick before I’d tell my family,” she says. Malock has joined the more than 3,6-million people in the country who are infected with HIV, with 1 500 new cases every day.
Aids did not sneak up on South Africa. Experts and researchers have been sounding the alarm since the early 1980s, when central and eastern African countries like the Democratic Republic of Congo and Uganda were hit with the first stages of the epidemic.
Sub-Saharan Africa, with Zimbabwe and Zambia at the core, is now the world’s Aids epicentre. The region has suffered more Aids-related deaths than anywhere else, and almost two-thirds of the world’s current Aids cases are located in this region.
Fate handed South Africa fair warning about Aids, sophisticated medical tools to fight the epidemic, as well as the brains and the media power to formulate a message and deliver it. Yet the result has been dismal failure. Aids is set to engulf South Africa in exactly the same way it devastated the rest of the continent.
“What’s really depressing is that countries seem to have a very hard time learning from each other. They all seem to have to learn the same lessons,” says Dr Alan Whiteside, an Aids researcher at the University of Natal in Durban. “We’ve reached the panic stage, and now everyone is looking for a quick fix. In reality, there is no quick fix.”
A risk scenario conducted by the Metropolitan Life insurance company predicts that more than six million people in South Africa will be infected by 2005, and by then more than 2,5-million people will have died. Even if there are “significant changes in sexual behavior occurring 12 years into the epidemic”, the scenario still predicts that almost five million people will be infected by 2005, and 2,3-million will die. The death toll won’t change much because it is those 3,6- million people already infected with Aids who will be dying.
Based on these warning signs, the flames of panic should have already consumed the country. Although initially dangerous, this panic eventually would have galvanised the leaders of South Africa – government, business, non-governmental organisations and the masses – to jumpstart a national effort to control the disease and care for those already sick.
Instead, South Africa’s chance to stem the tide of Aids has been lost. “Despite the commitment of the democratically elected government of 1994 to the HIV epidemic by allocating substantial human and financial resources, the scale and magnitude of these efforts have not been sufficient to turn the epidemic around,” says Aids researcher Quarraisha Abdool Karim of the Medical Research Council. She calls South Africa’s HIV epidemic “explosive”, and notes that it has increased 30-fold since 1990.
The “silent killer” is projected to infect between 25% and 30% of all South Africans by 2010. Most will be poor and black. Many will be the primary breadwinners in their household. And most of them will die within five to eight years of contracting the disease. As parents die, an estimated 700 000 Aids orphans will be left behind by 2010, according to UNAids.
The government’s response to the Aids crisis has been disastrous. The Cabinet adopted a national aids plan in 1994, which stressed the need to formulate a strong, shared vision of mobilisation to focus all of the country’s resources on fighting the disease.
There was high hope among Aids activists, NGOs and people living with Aids that South Africa would show the rest of the continent how to combat the disease effectively. Instead, the country’s Aids vision has become clouded, its organisation disjointed, its policies largely ineffective.
Dr Robert Shell, director of population research at Rhodes University, calls the health department’s record on HIV/Aids “atrocious”. He places the bulk of the blame on former health minister Nkosazana Zuma. `
“She’s up there in my mind as a war criminal,” he fumes. “While she was persuading the country to give up smoking, the country sank into a deadly epidemic that will wipe out every single development gain we’ve made. This is going to take 25 years to work itself out, and if there was a cure tomorrow, it wouldn’t help.”
The 1996 Sarafina II scandal, in which Zuma’s department spent R14-million on an Aids play, “threw the national Aids directorate into disarray, and with it came the demise of a shared vision for Aids in this country”, argues Gary Adler, executive director of the Aids Foundation.
Adler says the national directorate cut funding for NGOs from R19-million in 1996 to R2-million in 1998, as a punishment for those who dared to demand accountability of the department. Adler argues that the Virodene scandal of 1998, where Zuma backed expensive funding of an Aids cure with an active ingredient of dry- cleaning solvent, led to the disbanding of her national Aids advisory council.
“The malaise in the national Aids directorate has meant that provinces have not been able to identify with a national vision of what needs to be done,” Adler says. “It also means that provincial MEC’s for health have been let off the hook and not been pressured into taking bold steps to do something about Aids in their provinces.”
Not everyone is convinced that government has failed. Dr Nono Simelela, a young obstetrician, has been heading the country’s R50-million National Aids Directorate for the past six months, its third director in three years. She says the Interministerial Committee on HIV/Aids in 1997, formerly chaired by President Thabo Mbeki and containing all Cabinet ministers, is bringing government action together on Aids.
“The political commitment goes beyond just lip service,” she says. She notes that the transportation industry has responded to government prodding by educating truck drivers about their susceptibility to Aids, and that information sessions with commercial sex workers has increased prostitutes’ condom use.
Legislation and policy on HIV/Aids has been a mixed bag. Aids activists have aggressively supported the government’s attempt to strip patents from foreign Aids drugs, which would allow local pharmaceutical companies to manufacture the drugs’ generic equivalents.
But United States and European drug companies cried foul. They rushed to Congress and the US trade representative for help, and to court in South Africa to try to block the law. Industry executives won an injunction. The issue has sparked loud protests from Aids activist groups in the US and in South Africa, even becoming a campaign issue in Vice-President Al Gore’s campaign for the presidency. The law is currently mired in its legal challenges.
Last week Aids activists protested in front of the US consulate in Johannesburg. Singing, dancing and brandishing signs that said “Cheap HIV/Aids drugs NOW”, they demanded that the US explain why it is keeping Aids medications out of the financial reach of most Africans. The activists pledged to continue protesting until the US withdraws its legal challenges to the South African law.
Other legal initiatives on Aids have also faltered. Aids activists have expressed outrage at the government’s attempt to make Aids a notifiable disease, saying that it “would offer no positive benefits to people living with HIV/Aids, and that it could prevent openness about HIV/Aids”, according to Morna Cornell, director of the Aids Consortium.
But the government believes that making Aids notifiable will help eliminate stigmas surrounding the disease, improve data collection and therefore improve public health planning. The legislation is currently open for public comment until July 31, before it heads back to Parliament for debate.
Activist groups also mocked Zuma’s balking at a US company’s offer of a drastically reduced price for the anti-viral AZT drug, which has been shown to reduce mother-to-child transmission of HIV by between 50% and 80%. Zuma first claimed the drug was too expensive, then said its efficacy has not been proved. An initial trial use of the drug at Chris Hani Baragwanath hospital has been threatened with closure.
Health Director General Ayanda Ntsaluba
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feels that criticism leveled at Zuma because of her decision to withhold AZT treatment from mothers was grossly unfair. “You can fault minister Zuma about many things, but you cannot fault her on her policy towards women and children,” he said.
Although government officials, including Mbeki, have reiterated their commitment to fighting Aids, that commitment has yet to translate into proper care and services for the people who need it most: the poor.
Government continues to categorise Aids a health care problem, not a social problem to be tackled with equal zeal by all departments. The result has been a fragmented, piecemeal strategy that has failed either to stem the tide of infection, or care for the people who are HIV positive.
The Reverend Barry Gibbs-Hughes, who runs a private Aids clinic at Kalafong Hospital in Pretoria, tells this sad story. “A man came to me after going to the hospital for treatment. He said, `Father, I’m thankful that I have this medicine. But I don’t have a job; I don’t have any food. How am I going to survive?'”
The government has particularly failed those who need its support most: the people who are already infected.
In 1994, the new ANC government placed an emphasis on primary health care clinics, to bring health care directly to more people and reduce the load on hospitals. This impacts negatively on Aids patients in two ways: clinic staff, many of whom work without adequate doctor backup or even enough nurses, are not properly trained in how to deal with Aids patients.
A doctor at Baragwanath says: “Many of the nurses at clinics hear a person has Aids and figure, `They’re going to die anyway, I won’t waste medicine on them.’ They give them two aspirins and send them home.” Worse still, the medicines Aids patients need are often not available at some clinics.
That sends Aids patients flooding to major hospitals. But according to the government’s strategy on health care delivery, hospitals should be downsized and the role of local clinics enhanced. So one of the ways hospitals cut costs is to close their Aids clinics, believing Aids patients can get proper care at clinics. Meanwhile, clinics specifically for Aids patients, like the one at the University of Pretoria Academic Hospital, are closed.
Others are facing closure or serious cuts. The Aids clinic at Johannesburg General Hospital is facing a 25% to 30% slash in its meager staff, which consists of five full-time health care workers for up to 150 patients. Hospital administrators recently chastised the staff for holding clinical trials on Aids medicines, even though pharmaceutical companies sponsored the drug trials.
Dr David Spencer, who works at the Johannesburg General Hospital clinic, says: “It was their feeling that because of the hospital’s financial difficulties, we should be diverting HIV-infected patients away from the hospital, rather than attracting them. But where will they go?”
Most likely, they will keep coming to the hospitals, but only when they are at their sickest point.
Esther, who lives in Alexandra, has had HIV for the past three years. She was infected by her husband, who later died of the disease. She tells of waiting six hours to see a doctor, of three- and four-hour waits for her medicine.
Yet she remains upbeat about her care at the JGH clinic. “I come sick this week, sometimes, and I then I feel very much better,” she says. “The doctors and nurses, they are very good to me.”