THIS week’s unexpected Cabinet announcement clearly signals a shift in South Africa’s policy on the treatment of HIV/Aids, and it would be churlish not to praise the government. But it has taken more than two years of relentless pressure, both within and outside the corridors of power, to achieve it – and it is too early to regard the chapter as closed.
Conceptually, the major advances are the government’s admission that there is an Aids crisis in South Africa and that anti-retroviral drugs can be beneficial. These are the first clear statements by a leadership which, deeply tainted by Aids dissidence, has tended to minimise the epidemic and view anti-retrovirals as deadly poisons.
Just how foolish it was to pretend that hysterical commentators were hyping the disease, and just how much precious time has been needlessly lost, emerges from the latest annual report of labour relations consultants NMG-Levy. This forecasts that Aids will drive down the life expectancy of South African women to 43 in 2005 and 37 five years later, and that 30% of the workforce will be infected in three years’ time.
For the first time, the government has officially recognised the right of rape survivors to drug prophylaxis and pledged the universal rollout of nevirapine to prevent mother-to-child transmission. Public health institutions have been instructed to comply with the high court order to provide nevirapine.
For the government to suggest that these are organic developments in existing Aids policy is simply untrue. It is mere weeks since the Minister of Health, Manto Tshabalala-Msimang, slapped down Gauteng for announcing plans for universal nevirapine provision.
Because of central government ambivalence, Gauteng Premier Mbhazima Shilowa delayed a statement on rape prophylaxis beyond the promised date of end-March. It is mere weeks since former president Nelson Mandela was cold-shouldered by the African National Congress leadership after arguing that anti-retroviral treatment was a matter for doctors and patients, not politicians, to determine. A witch-hunt was launched to uncover who leaked Medical Research Council statistics on Aids mortality. Orthodox scientists came under growing pressure to toe the line, while the misguided ANC MP Peter Mokaba was given free rein to hawk his dissident fantasies.
That the shift is a reluctant one is evident from the Cabinet statement, which clings to the idea that nevirapine must continue to be monitored at pilot sites and re-emphasises the need to counsel patients on the dangers of the drugs “so that they can make an informed choice”.
Many pressures have fed into the about-face, including successful court challenges by the Treatment Action Campaign, international and local media censure and mounting rebellion within the ruling party, its allies and the health authorities. The ultra-nationalist wing of the ANC would have us believe that all activist resistance to this government is ipso facto undemocratic. What has been underscored is the central importance of a vibrant, critical media and non-government sector in bolstering democracy and uplifting South Africa’s people.
A number of concerns remain, and the new policy will have to be closely monitored. The government is to press on with its Constitutional Court appeal on nevirapine, which can be justified on the grounds that large constitutional issues are at stake. But it must make an unequivocal commitment not to reverse the universal roll-out policy if it wins the case.
No deadline has been set for general access to nevirapine, which will happen only after December this year. The government must bind itself to a final implementation date, and take active and visible steps to overcome logistical problems such as the absence of drug stocks.
A large, unresolved question is that of drug treatment for those who are already ill. Given the scale of infection, and South Africa’s modest resources, the country cannot treat everyone. What is needed is a clear commitment to doing as much as possible within the constraints of the budget, and public debate on what, in the circumstances, is realistic.
One final step is needed, requiring courage and true patriotism. It is the public repudiation of Aids dissidence by government leaders, and particularly President Thabo Mbeki. It is not enough for the president to distinguish his views from government policy – the one has consistently bled into the other, and this has been the major cause of official foot-dragging and confusion on Aids. While his disastrous flirtation continues, the new policy will not be safe from subtle deviation, obstructionism and backtracking. Given the sudden spate of dissident literature in South Africa, reported in this edition, the suspicion remains that the new “right to choose” policy will be undermined by a “hearts and minds” campaign to persuade South Africans not to use the drugs.
More is at issue than health policy. Raising large questions about his judgement and leadership, Mbeki’s dissidence has been enormously damaging to South Africa in the eyes of the world. More than policy change, what is needed is a change in philosophical outlook.