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Mbeki's AIDS denial - Grace or folly?

08 May 2008

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by William Gumede

This is a chapter from William Gumede's book Thabo Mbeki and the Battle for the Soul of the ANC.

Part I

For too long we have closed our eyes as a nation, hoping the truth was not so real. For many years, we have allowed the HI virus to spread, and at a rate in our country which is one of the fastest in the world. – Thabo Mbeki, 9 October 1998

Now ... the poor on our continent will again carry a disproportionate burden of this scourge – would if anyone cared to ask their opinions, wish that the dispute about the primacy of politics or science be put on the backburner and that we proceed to address the needs and concerns of those suffering and dying. – Nelson Mandela, 13 July 2000

It is important that we recognise that we are facing a major crisis and that we want to invest as many resources as we did when we fought against apartheid. This is not a state of emergency but it is a national emergency. – Archbishop Desmond Tutu, 30 November 2001

As his international AIDS Advisory Council met for the first time, Thabo Mbeki mulled over the words of Irish poet Patrick Henry Pearse: ‘Is it folly or grace?’

Notwithstanding the conclusions of mainstream scientists almost a decade before, Mbeki set up the council to examine both the cause and most effective way of treating acquired immune deficiency syndrome (AIDS) in developing countries. His ‘folly’ in reopening the debate on what causes AIDS rather than focusing on practical ways to curb the pandemic sweeping Africa was roundly condemned. ‘Stop fiddling while Rome burns,’[1] chided Desmond Tutu, former Archbishop of Cape Town. But AIDS denial is not the exclusive province of presidents. Mbeki’s controversial health minister, Manto Tshabalala-Msimang, enthusiastically prescribed an alternative therapy that sounded more like a salad dressing than treatment for a sexually transmitted disease that kills around 600 South Africans a day[2].

After years of foot-dragging and obfuscation, the South African government finally rolled out antiretroviral drugs that could save the lives of millions at state hospitals two weeks before voters went to the polls in April 2004.The long-awaited plan to distribute ARVs to an estimated 5 million people had been approved in November 2003, but due to what officials claimed were ‘capacity constraints’, patients had to wait another five months for the first drugs to reach them.

Few were surprised when AIDS activists questioned the government’s timing and motives. ‘Even though we welcome the roll-out plan, we have mixed feelings about whether the government reached a turning point because of elections, ’said Tembeka Majali of the Treatment Action Campaign (TAC), the country’s most vocal and visible AIDS activist group.

Before the limited public roll-out, fewer than 20000 South Africans were taking ARVs, as only those with expensive private medical insurance could afford them. Zackie Achmat, head of the TAC and the country’s best-known AIDS activist, only started taking ARVs towards the end of 2003 after refusing for years to avail himself of the life-giving drugs until the government agreed to offer treatment through the public health system.

Leading black gay activist Simon Nkoli,a close friend of Achmat, died in 1998 after contracting AIDS-related thrush. He was among the millions who could not afford the drugs, and at his funeral Achmat announced that he was launching a campaign to make ARVs available to poor South Africans.[3] He had learnt that a single dose of the generic version of fluconazole, used to treat thrush but not sold in South Africa because of international patent laws, cost just eighty cents.[4]

Government blamed lack of efficacy, potential toxicity and high costs for ARVs not being made available at state expense, but scientific evidence indicates that the drugs are highly effective against mother-to-child transmission of HIV and, at least in the short term, the benefits appear to outweigh the risks.

In Europe, North America and Brazil, ARVs have reduced mortality due to HIV/AIDS-related illnesses by between 50 and 80 per cent. In South Africa, two critical barriers remain to the widespread availability of these life-saving medicines and a possible nett saving on the health budget in the long run: lack of political will, and resistance on the part of patent holders to generic competition.

Pharmaceutical companies are protected by intellectual property rights policed by the World Trade Organisation from the manufacture or import of cheaper versions of their drugs. The corporate view is that high prices are necessary to recoup research and development costs.

However, generic anti-AIDS drugs are sold in India for a quarter of the price charged by the big pharmaceutical companies, and have the added advantage of Thabo Mbeki and the battle for the soul of the ANC combining three drugs in a single pill that has to be taken twice a day. The Western ARV protocol requires patients to take up to twelve pills – all produced by different companies – a day, at different times, some with water, some without. Despite the obvious advantages of a simplified regimen, South Africa succumbed to pressure from the West and opted for the more expensive and complex therapy in its limited ARV roll-out.[5]

Private health care in South Africa makes up around 70 per cent of the total national budget, yet only about 7 million of the country’s 44 million citizens can afford private health insurance. The rest depend on government services. Until 1999, medical aid funds were allowed to cherry-pick their paying members, and typically accepted young, healthy, low-risk candidates.

The poor and unemployed were generally excluded due to the high premiums, and relied on the state for health care. An Act of Parliament put a stop to the rejection of certain candidates by insurance carriers, but most South Africans still cannot afford the astronomical costs of private care.

Drug costs are a significant factor in the national health budget. Only medication that is included on a list of essential drugs is available within the state system, and generics are encouraged where possible. When no generics exist, the health department buys in bulk from the pharmaceutical industry via a tender system. Drug companies have fiercely resisted parallel imports of cheaper generics, insisting that their patents be respected.

The social, economic and health consequences of AIDS for South Africa are devastating. Particularly harrowing has been the rise in the number of orphans and the emotional impact on millions of children who will grow up without parents. Not only are crime and social instability destined to follow in the wake of the pandemic, but current and future demands on the state coffers are astronomical. In alliance with COSATU, the SACP, churches and social organisations, the TAC has been at the forefront of attempts to shift government’s head-in-the-sand AIDS policies. The cabinet plan released in November 2003 promised that government would establish a network of centres for distribution of ARVs, beef up efforts to prevent transmission of the virus and increase support for families affected by HIV/AIDS.

The cost of offering treatment to all South Africans with AIDS by 2010 was estimated at between $2.4 billion and $3 billion a year. The cabinet cited the lower costs of ARVs as a major factor in the decision to go ahead with the roll-out, noting: ‘New developments pertaining to prices of drugs, the growing body of knowledge on this issue, wide appreciation of the role of nutrition and availability of budgetary resources [had] allowed government to make an enhanced response to AIDS.’[6]

But why had it taken so long to reach this point?

In the heady days following the unbanning of the ANC, little attention was given to AIDS. Although alarm bells were ringing, South Africa’s collective political focus was on the delicate and engrossing negotiations for a democratic dispen- sation. The apartheid regime had been deaf to calls for action, seeing AIDS largely as a disease that affected gays and blacks, constituencies the previous government was not particularly interested in, and was most prevalent among migrant workers from the southern African region.

AIDS was not high on the first democratic government’s ‘to-do’list either. The ANC alliance’s priority was trying to hold the fractured country together while getting to grips with governance, delivery and the economy. AIDS was one among many seemingly less urgent problems.

Given South Africa’s combustible social mix – a large migrant population, people displaced because of apartheid, the breakdown of traditional family bonds, a labour system that keeps men away from home for most of the year – it is hardly surprising that AIDS struck with such devastation. But when the full realisation sank in, there was first denial, then perplexity, and finally escapism, as confronting the situation became mired in foolish debate over what had caused the pandemic in the first place.

During his term of office, Nelson Mandela effectively ignored AIDS, avoiding the subject on the grounds that, in his culture, an elder did not publicly discuss sexual issues.[7] Since then, he has recognised the severity of the problem and become deeply involved in efforts to stop the spread of AIDS.

When Mandela assumed the presidency of the ANC in 1991, SACP general secretary Chris Hani and future health minister Nkosazana Dlamini-Zuma were the ANC’s most vocal harbingers of a looming crisis.[8]As deputy president, Mbeki barely mentioned AIDS, except for allusions in a couple of speeches to the disease being as great a threat as poverty in the new South Africa.

In fact, the AIDS time bomb threatened to decimate the world’s youngest democracy unless vast resources were made available to defuse it, but the initial response of the ruling elite was ‘this isn’t happening to us ... it cannot be as bad as people say’.[9]

But it was.

The ANC in exile had held a number of meetings on HIV/AIDS, and the first paper on the disease published in South Africa in 1985 forecast that it would remain largely confined to male homosexuals, as had been the case in America and Europe up to that time. In the same year, the government appointed an AIDS advisory group, followed six years later by a network of training, information and counselling centres.

In 1992, the ANC’s health secretariat, the government, non-governmental organisations, AIDS service organisations, representatives from business, trade unions and churches, and a diverse group of concerned individuals set up the National AIDS Coordinating Committee of South Africa (NACOSA). In the spirit of the CODESA talks, it was instructed to reach consensus on a national AIDS strategy for the new South Africa.

Their plan, adopted in July 1994,recommended the pooling of large amounts of money from government and donor organisations for expenditure on countrywide education and prevention programmes.

First, however, an AIDS infrastructure had to be established. The centrepiece was a special directorate in the department of health, and the government also appointed a ministerial AIDS task team, headed by Mbeki. Awareness campaigns and support for an HIV vaccine initiative followed.

By early 1996,it became apparent that the plan was full of holes. Much of the intended funding was diverted by the Treasury to more pressing needs, while money that was allocated to the health department remained unspent as the AIDS plan was buried by competing priorities in a health system in transition. Many of the AIDS policy targets were never attained.

Public controversy followed revelations that a hefty chunk of the AIDS budget – R14.27 million – had been spent on Sarafina II.The musical production by acclaimed playwright Mbongeni Ngema was designed to raise AIDS awareness among African youth,but the critics panned it as an ineffective and costly failure in terms of relaying the anti-AIDS message. Worse, it emerged that normal tendering procedures had been bypassed in awarding Ngema the funds, and the production was scrapped in midstream.

The resulting scandal strained the bond between government and AIDS activists. Opposition parties, the media and many NGOs unleashed a barrage of attacks on the health minister, who withdrew into a defensive shell. Government and Ngema claimed the criticisms were anti-government, anti-black and racially inspired,and on the eve ofWorld AIDS Day in 1996,activists and health workers denounced the entire National AIDS Plan as a shambles, greatly angering both Dlamini-Zuma and Mbeki.

The furore erupted just as the gloss of freedom was starting to give way to grassroots anger over non-delivery and thwarted expectations. Acutely sensitive to criticism, especially when it emanated from the ANC camp, political home to most of the AIDS activists, the government lashed out in anger. At the party’s national conference that year, President Mandela railed against NGOs that stood in judgement of government.

The dust had hardly settled when a new AIDS scandal broke out.

Part II

Pambazuka News continues to serialize William Gumede's chapter on Mbeki and the controversies surrounding his AIDS policies. This is from his book "Thabo Mbeki and the Battle for the Soul of the ANC." Be sure to look for parts three through five in upcoming issues.

In 1996,researchers linked to Pretoria University and representing a biotech company called Cryopreservation Technologies claimed they had found a cure for AIDS.[10] Zigi Visser and his ex-wife Olga lobbied senior officials in the department of health and in the ANC, who put them in touch with Nkosazana Dlamini-Zuma.

The go-between, Joshua Nxumalo, a former MK cadre, played a crucial role in setting up meetings between the Virodene drug researchers, Dlamini-Zuma and eventually Mbeki. Nxumalo was later part of a BEE consortium that bought the rights to Virodene. Dlamini-Zuma was sufficiently impressed with the Vissers’ report on their research to secure a quicker meeting with Mbeki, then deputy president and whose diary was notoriously almost always full. The Vissers were looking for government endorsement and money. Their scientific peers had been sceptical. The Medical Control Council had refused to issue the company with a licence to produce Virodene. Following a review of their research, the MCC, Gauteng health department and senior scientists at the University of Pretoria had rejected the application for a licence on the basis that the drug was ineffective, even dangerous. The Pretoria group hoped that Mbeki would prove more receptive. Shortly before Christmas 1996,Dlamini-Zuma and Mbeki set aside protocol and convention and secured for the researchers a cabinet hearing for their preliminary findings, which had not been subject to peer review.

The Virodene researchers arrived at the Union Buildings in January 1997 with a posse of ‘cured’ patients who testified to the ‘positive’ effects of the treatment. An excited Mbeki had primed his colleagues well. The cabinet received the group warmly, and almost without question accepted the researchers ’claims[11] and their accusation that the MCC had rejected them because it was in cahoots with inter- national pharmaceutical companies.[12] Jakes Gerwel, Mandela’s cabinet secretary, said later that ministers were overwhelmed with ‘awe and pride ’as the Virodene researchers’ ‘patients’ related tales of miracle cures.[13] Mbeki would later write in the ANC’s journal Mayibuyewhat a ‘privilege’ it had been to hear the moving testi- mony of AIDS sufferers who had been treated with Virodene,with seemingly very encouraging results.[14]

The Virodene team’s sales pitch was that not only was the product much cheaper, but it was also home-grown. The latter particularly aroused Mbeki’s interest. At the time, he and most of the cabinet ministers saw themselves as being under siege from a vast conspiracy of local white critics, black trade unions and civil society activists, Western governments and international business. The Virodene researchers appeared to be a godsend. The deputy president had already just about settled on an idea (after much contemplation) that would define his upcoming presidency.[15] Mbeki hoped his term of office would be defined by an African Renaissance, which would see the continent, under the leadership of a democratic South Africa, undergoing social, political and economic renewal that would finally make it an equal partner ofmore prosperous regions, especially the West. An important component would be African solutions for African problems.[16] Mbeki latched onto the Virodene proposal as a possible African solution to one of Africa’s greatest challenges.

Virodene was later shown by an independent panel, led by the South African Medical Research Council, to contain dimethylformamide,a toxic industrial solvent used in dry-cleaning. A month after the Virodene researchers so persuasively addressed cabinet, the MCC announced that Olga Visser and her associates were flouting accepted testing norms, and promptly banned them from testing their product on humans. Mbeki and Dlamini-Zuma were severely embarrassed. Oppo- sition parties and the media hit out at the government. DA leader Tony Leon accused Mbeki of being obsessed with finding African solutions to every problem’.[17] He said Mbeki’s support for Virodene amounted to resorting to ‘snake oil cures’ and ‘quackery’.[18] The Sunday Times lashed out at a cabinet whose ‘combined technical knowledge of the HI Virus fits on the back of a postcard’.[19]Both Mbeki and Dlamini- Zuma viewed the attacks as racist, if made by whites or the political opposition, or personal, if made by blacks or those associated with the ANC family. Mbeki called Leon ‘the white politician’ who ‘practices in Africa’.[20] Dlamini-Zuma said bitterly:‘If they [Leon and the DA] had their way, we would all die of AIDS.’[21]

Sadly, neither Mbeki nor Dlamini-Zuma admitted to being wrong, instead persistently presenting themselves as victims of racist baiting, and nursing grudges against their critics. In fact, Mbeki would continue to support Virodene’s pro- moters, later even mediating in a feud between the biotech company’s leading researchers.[22] Mbeki and Dlamini-Zuma now also saw the MCC, especially its chairman Peter Folb, as representatives of the ‘racist conspiracy’ against which battle must be joined. Folb was fired a year later.[23]Partly as a result of the Virodene conflict, Dlamini-Zuma abolished the MCC in March 1998 on the recommen- dation of a review team she set up to evaluate the council’s operations, which concluded that the MCC was too intimately linked with the pharmaceutical industry. A new institution, the Medicines Regulatory Authority, replaced the MCC in September 1998.In June 1998,a group of investors, including Nxumalo, who had originally introduced the Vissers to Dlamini-Zuma and Mbeki,bought the rights to their AIDS ‘cure’.[24] Virodene is not officially registered in South Africa, but it is still punted on the Internet as a cure for HIV/AIDS.[25]

However dubious these early government forays into the AIDS field were, they were based on the accepted scientific consensus that HIV is the principal carrier of AIDS, rather than the dissident argument that the virus is a ‘harmless’ passenger, and that symptoms associated with AIDS are due to ARV therapy, malnutrition and poverty. From the Virodene saga onwards, the AIDS issue became racially charged in South Africa, and it has remained so. All future responses would be coloured by race, as had already happened in some parts of greater Africa, and even among some Afro-American groups who gave credence to the urban legend that the deadly virus had been brewed in a laboratory as part of a covert Western intelligence plot to decimate blacks – the CIA’s ‘final solution’. For example, a study conducted by the Rand Corporation and the University of Oregon revealed that almost half of all African-Americans believe that the virus that causes AIDS is man-made; more than a quarter believe it was produced in a US government laboratory; and one in eight thinks it was created and spread by the CIA.[26]

Bizarre as they were, such rumours were fuelled by revelations from the mid-1990s that the apartheid defence force had run a top-secret germ warfare programme, which included experiments on ethnic-specific killer bugs. The Truth and Reconciliation Commission heard senior former security policemen confess that HIV-positive agents had been instructed to have unprotected sex with black prostitutes as part of a diabolical state-sponsored plan to spread the infection. In 1995,the South African government launched a battle against international tobacco companies by instituting stringent anti-smoking laws, and with the pharmaceutical giants over the high price of essential medicines.

The ANC had worked hard to make medication more accessible and more affordable to the majority black population. This led to repeated skirmishes with drug manufacturers, and a protracted trade dispute with America and various countries in the European Union. At the heart of the matter was an amendment to the Medicines and Related Substances Control Act, which gave government the power to fast-track compulsory licensing and parallel imports of medicines.

The government argued, correctly, that this was consistent with the World Trade Organisation’s Trade Related Intellectual Property Rights Agreement (TRIPS), which stipulates certain exceptions to normally strict commercial regulations. In times of health emergencies, for example, poor countries are allowed to circumvent patent laws in order to produce cheaper generic versions of desperately needed drugs. Compulsory licensing allows a country to manufacture a drug in such circumstances without the permission of the patent holder, provided that ‘adequate remuneration’ is paid to the company. Parallel importing permits a country to buy a drug from the lowest bidder without the consent of the patent holder. But there is huge resistance from developed countries and pharmaceutical companies to these concessions, and South Africa was placed on an American ‘watch list’ of potential offending countries. The drug manufacturers exerted enormous pressure, both directly and indirectly, on the South African government, outraging Mbeki, Dlamini-Zuma and the ANC leadership.[27]

The pharmaceutical industry in the US lobbied the Clinton administration, which threatened sanctions if South Africa went ahead with plans to push through legislation to facilitate the import of cheaper generics. American vice-president Al Gore found support in the South African media and with opposition parties for his demand that the amendment be repealed.

It was particularly galling for Mbeki, his policy guru Joel Netshitenzhe, his ‘enforcer’ Essop Pahad and his trusted ally Nkosazana Dlamini-Zuma to have their political opponents and the predominantly white-owned media support foreign opinion against what they saw as South Africa’s interests.[28]

The tussle ended when thirty-nine companies joined forces under the banner of the Pharmaceutical Manufacturers’ Association of South Africa and took the government to court. They poured millions into their campaign, which was vigorously opposed by the government and, importantly, the TAC and several trade unions.

Dlamini-Zuma herself was an energetic campaigner against both international pharmaceutical and tobacco companies. This made her very unpopular with busi- ness groups, so much so that many business leaders view the possibility that she could replace Mbeki as leader of the ANC at the end of 2007 with undisguised horror. Shortly before the 1999 elections, she told members of the TAC: ‘If you want to fight for affordable drugs, then I will be with you all the way.’[29] Marking the end of his first six months as president of South Africa, Mbeki launched a tough attack on pharmaceutical companies:‘(A)s long as [AZT] is only available at exorbitant prices, it is impossible for the government to make it available to ordinary people.’[30]

In the face of local and international protests organised by the TAC, the pharma- ceutical companies reached an out-of-court compromise with the government and withdrew their legal action. By that time, the amendment to the Medicines Act, which applied to all drugs, not just ARVs, had become law.

Finally, government seemed to waken to the gravity of the AIDS crisis. Billboards were erected, condom distribution increased and the ABC (Abstain, Beware, Condomise) campaign put in place. Yet, despite what amounted to a victory against the pharmaceutical companies, the government still refused to make ARVs available to the masses.

Activists were enraged when the health department announced that AZT would not even be given to pregnant women as a matter of course. There was ample evidence that the drug greatly reduced the risk of foetal HIV infection, but the government stuck to its claim that AZT was both toxic and unaffordable.

In December 1998, Zackie Achmat announced that he would go on a hunger strike until ordinary South Africans could be given ARVs at state hospitals. ‘On principle, I won’t take ARVs until they are freely available to the poorest,’[31]he said. His decision coincided with the TAC’s launch of a campaign to prevent mother- to-child infection. By 1999,an estimated 40 000 babies were being born with HIV in South Africa annually, their mothers too poor to pay $75 for a short course of AZT,which would lower the risk of transferral by half. The TAC would maintain its relentless pressure on the pharmaceutical companies for the best part of a year, with NGOs in America staging solidarity protests at various points on US vice- president Al Gore’s campaign trail until the threat of sanctions was withdrawn.

The TAC’s sustained efforts to shame Western governments and highlight their indifference to the plight of AIDS victims in South Africa compelled President Bill Clinton to pledge in 2000 that the US would ensure that ‘people from the poorest countries won’t have to go without medicines’. His announcement came as the United Nations revealed that it had negotiated a deal with five multinational pharmaceutical companies to reduce the price of AIDS drugs in the developing world.

The South African government’s response was guarded. Mbeki, Pahad, Netshitenzhe, Manto Tshabalala-Msimang, who had replaced Dlamini-Zuma as minister of health, and trade and industry minister Alec Erwin now argued that price reductions negotiated with manufacturers were neither substantive nor a permanent solution. If costs could not be decreased any further, it would be better to obtain the drugs through local generic production or parallel importation from Brazil, Thailand or India, where they were successfully being made at a fraction of even the discount price.

In the event, it soon became clear that the high-profile offers of cheaper drugs from the US administration came with punishing strings attached. South Africa could avail itself of some $1.5 billion in the form of export–import loans, at commercial interest rates, to buy American drugs at market prices. In addition, by May 2001, five of the world’s biggest pharmaceutical companies had agreed to enter into talks with African nations on reduced prices, provided the countries concerned agreed to health action plans being drawn up by McKinsey, a leading business consultancy!

The offers were turned down, but they had reinforced suspicions that Western governments and the drug manufacturers were locked in a conspiracy against Africa. As Mbeki’s views hardened, the relentless pressure applied by the TAC and various NGOs was starting to pay dividends. Drug companies squirmed under accusations of greed, and some began privately to offer significant discounts on their products. By mid-2001,Boehringer Ingelheim was offering Nevirapine, a drug commonly used by HIV/AIDS sufferers, free for a limited period to pregnant women in South Africa. Glaxo offered AZT at 30 per cent of the average inter- national price.

But government still refused to buy the drugs, claiming they were toxic. According to some of Mbeki’s close advisors, the offers were seen as a piecemeal strategy to stave off production of cheaper generics. Yet no moves were made to launch local production or import generics. In fact, keen to play a leading role in the global economy and to be seen as playing by the market rules, the government started back-pedalling on earlier threats to import generics.

In November 2001, British trade minister Richard Caborn wrote to the London-based Action for Southern Africa, an organisation that campaigns for Thabo Mbeki and the battle for the soul of the ANC peace, democracy and development across the region: ‘I don’t believe that this or related measures such as parallel importing are the answer here.’[32]

South Africa had had the option all along of circumventing TRIPS by citing ‘national emergency’, but Mbeki had come to believe that the pharmaceutical companies were greatly inflating the AIDS threat in order to exploit developing markets.

Part III

What made Mbeki turn to the AIDS dissidents? In July 1999,Anthony Brink, an advocate and the author of the online book Debating AZT, had given him and senior health department officials copies of his book, which argued that the so-called life-giving drug was highly toxic.[33] His interest aroused, Mbeki began doing further research on his own, via the Internet.

While surfing the Net, he stumbled on, a website favoured by the international dissident community. On 28 October 1999, Mbeki told the National Council of Provinces that he had examined ‘a large volume of scientific literature’, which showed that AZT was dangerous.[34]

The orthodox scientific community has never claimed that AZT is not toxic, but makes the point that all drugs have side effects, and that those known to be caused by AZT were far outweighed by its benefits to AIDS patients.

But Mbeki had been seduced, and before long his meanders along the inform- ation highway led him to question whether HIV caused AIDS and whether the virus was sexually transmitted.The dissidents argued that HIV was a benign ‘passenger virus’, and that AIDS was a lifestyle disease caused by poverty, malnutrition and narcotic abuse by homosexuals. They claimed that, far from helping the infected, ARVs caused even greater damage to their compromised immune systems.[35]

The World Health Organisation and the MCC had classified AZT safe, but Mbeki, newly installed as South Africa’s president, decided that his health minister, Manto Tshabalala-Msimang, would be entrusted with determining the ‘truth’ about the disease and its treatment once and for all. On 2 December 1999 she met with AIDS dissident Charles Geshekter, and came away from their discussions convinced that the president was right to question views that had already gained wide international acceptance.

In his nocturnal online research, Mbeki also found the writings of American biochemist David Rasnick, a leading rebel against the conventional premise that AIDS stems from HIV. Mbeki contacted him by fax and spoke to him at length by phone, and soon the two were in regular e-mail contact. Rasnick enthusiastically agreed to support Mbeki’s quest for the ‘truth’. The president also made contact with another prominent AIDS dissident, Peter Duesberg, a professor of molecular and cell biology at the University of California in Berkeley.

There was a major stir when a South African newspaper published Rasnick’s assertions that ‘condoms don’t prevent AIDS because AIDS isn’t a sexually transmitted disease. In fact it isn’t contagious at all. AIDS in Africa is just a new name for the diseases of poverty caused by malnutrition, poor sanitation, bad water, parasites and so on. Using condoms to prevent the diseases of poverty is the leading obscenity of our time.’[36]

Mbeki was sincere in challenging mainstream science and in his support of AIDS dissidents. He stoically believed that he was a modern-day Copernicus who would ultimately be vindicated, even if posthumously. Needless to say, the dissidents, long banished to the scientific wilderness, latched on to the new legitimacy that the president provided, and it would prove all but impossible for Mbeki to dissociate himself from them later.

His next mission was to persuade unsuspecting world leaders of the dangers of treating AIDS with conventional methods. In a brazen and bizarre letter to Bill Clinton and UN secretary general Kofi Annan dated 3 April 2000, South Africa’s head of state defended an alternative approach to dealing with AIDS. In the five-page document, Mbeki passionately defended Duesberg and the other dissidents, and suggested that factors other than HIV could be the cause of AIDS in Africa. He called for a uniquely ‘African solution’[37] to the problem, as AIDS seemed to affect Africans differently to those who live in the developed world. He also defended his right to consult dissident scientists, and accused unnamed foreign critics of waging a ‘campaign of intellectual intimidation and terrorism’ akin to ‘the racist apartheid tyranny we opposed’. In an earlier period in human history, Mbeki wrote, Duesberg and his followers ‘would be the heretics that would be burnt at the stake. The day may not be far off when we will, once again, see books burnt and their authors immolated by fire by those who believe that they have a duty to conduct a holy crusade against the infidels.’[38]

The letter, copies of which were delivered by hand to Clinton and Annan, concluded: ‘It would constitute a criminal betrayal of our responsibility to our own people to mimic foreign approaches to treating HIV/AIDS.’[39]

The Clinton administration initially thought the letter was a hoax. Upon realising it was genuine, the contents were leaked to the Washington media. Mbeki was suitably embarrassed, and furious, convinced more than ever that Western leaders were conspiring against their African counterparts.

Bolstered by the counsel of the AIDS dissidents, Mbeki and Tshabalala-Msimang reiterated that the government would not provide ARVs through the public health system, adding the inability of existing infrastructure to implement the drug protocols to their earlier claims of toxicity and cost. Tshabalala-Msimang now argued that anti-AIDS drugs alone would have scant effect, and that the state simply did not have the money to simultaneously offer recipients clean water, sanitation, nutritional food and adequate housing.

Mbeki would charge his AIDS critics, especially those who were ANC members or belonged to the TAC, of being willing ‘to sacrifice all intellectual integrity to act as salespersons of the product of one pharmaceutical company.’[40] Later, he would use this accusation again, to attack ANC MPs critical of his policies,[41] and when he opened the international conferences on AIDS in Durban in July 2000, he lambasted activists in the same manner. He blocked every effort by civil society and private organisations to set up AIDS treatment projects involving ARVs, prompting Desmond Tutu to comment: ‘In South Africa we have to introduce a vibrant and lively education for the people. Churches and religious communities are already playing a role but are hamstrung by the constant worry about what government will say, when they ought to be on the same side.’[42]

Mbeki has consistently placed poverty at the heart of all South Africa’s health problems, and few disagree with him, in general. But he found no broad support for his insistence that AIDS should be treated as just another disease, like malaria or TB.The scariest realisation for many people was that Mbeki genuinely believed that a number of factors, including poverty, caused rather than exacerbated AIDS, and that HIV was not to blame.

Tshabalala-Msimang drew hoots of derision when she famously announced that people with AIDS should preserve their health not with drugs, but with a diet of garlic, lemon, olive oil and the African potato.[43] In March 2003,her credibility took another dive when she appointed Roberto Giraldo,a leading AIDS dissident and one of the most vocal naysayers regarding the link between HIV and AIDS, as a consultant on nutrition.

Amid mounting evidence of AZT’s effectivity and growing criticism of the government’s opposition to ARV distribution, he Mbeki-ites began searching for compliant scientists who would support them.

In October 1999, Tshabalala-Msimang had rejected a report favouring the use of AZT by South Africa’s MCC on the grounds that it had not been subject to a satisfactory review process. A month later, she commissioned the Cochrane Centre, an international health-care NGO that reviews clinical trials on new drugs and has branches all over the world, to research the risks of ARVs, especially AZT. Their preliminary study found strong evidence that both an intensive or shorter course of AZT was effective in decreasing the risk of mother-to-child transmission of HIV, even in breastfed babies. The most serious adverse effect the researchers identified was anaemia, but this condition tended to disappear once the full course of drugs had been concluded. Nevirapine, less expensive than AZT, was found to be both safe and effective.

These findings were given to the health minister in December. She filed the report and allowed it to gather dust while she turned to the National AIDS Council for an outcome more in line with dissident opinion, as well as her own. Tshabalala-Msimang appointed new members, renamed the former AIDS Advisory Council the Presidential AIDS Advisory Council, and extended the council’s influence to sectors not previously involved in AIDS programmes.

Activists saw through the ploy and criticised the council as just another attempt by Mbeki and his health minister to muzzle and marginalise those with a different viewpoint. In due course, the council would issue a report that did nothing but reiterate both the orthodox and dissident views on AIDS, without attaching particular weight to one or the other.

In a new affront to activists, government revealed that in the 1999/2000 financial year,40 per cent ofthe AIDS budget had gone unspent. Worse, it announced that funding of AIDS service organisations was to be cut by 43 per cent the follow- ing year. In March 2000, dismayed by government’s persistent obfuscation and continuous flirting with AIDS dissidents, Judge Edwin Cameron, Archbishop Njongonkulu Ndungane (head of the Anglican Church in Southern Africa),Bishop Mvume Dandala (head of the Methodist Church in South Africa), Professor Jerry Coovadia,(chairman of the 2000 International AIDS Conference) and Merci Makhalamele (a prominent AIDS activist) wrote a personal letter to Mbeki, expressing anxiety over the government’s head-in-the-sand policies. They also asked him to reconsider the decision not to provide life-saving drugs to pregnant, HIV-positive women.[44] The Sunday Independent was given a copy of the letter. Mbeki responded by fax, again questioning available evidence that AZT was safe and effective. He warned the signatories that a similar consensus had existed over the use of thalidomide, with deadly consequences. He urged them not to fall into the same trap.

Throughout all the polemic, Mbeki was telling senior ANC leaders that the magnitude of the AIDS crisis in South Africa had been exaggerated to serve the interests of the drug giants and NGOs. Unfortunately, South African AIDS statistics have been the subject of dispute for several years, but it remains the only country in Africa that has even remotely reliable figures, even though, as author Rian Malan45 points out, they are computer projections based on surveys on antenatal clinics.

The situation has not been helped by international studies of dubious credi- bility. As recently as 2003, the World Bank warned in a report that South Africa faced imminent economic collapse as a result of HIV/AIDS, and, even though respected local experts such as Standard Bank chief economist Iraj Abedian and the South African Business Coalition dismissed the report as inaccurate and unreliable, Mbeki grasped at hyperbole to defend his claims that the figures were inflated.

But the first extensive and broadly credible surveys on the incidence of HIV/ AIDS, conducted independently by the South African Medical Research Council and Statistics SA in 2000 and 2001, painted a bleak picture. They estimated that 5.3million South Africans would be infected with the virus by the end of 2002, and that it would be killing 600 people a day.[46]A government report leaked in late March 2004 said 100 000 public servants were HIV-positive, presenting a very real threat to normal government administration.

In August 2001, the government was back in court as the TAC and various NGOs claimed it was acting unconstitutionally by refusing to make ARVs available at state hospitals. In its March 2002 judgment, the Constitutional Court agreed, ordering that pregnant women should start receiving the drugs immediately. Still the government prevaricated, claiming that state hospitals did not have the infrastructure necessary to administer ARVs. It was not until seven months later that Nevirapine became available at some urban hospitals as part of a pilot scheme, and not until the eve of the 2004 election that distribution was extended.

Costs have unquestionably played a role in the government’s response to the AIDS crisis. GEAR, the economic policy adopted in June 1996,calls for economic austerity and financial prudence, and structural adjustment programmes have seen jobs frozen and public service cuts. In 2000,finance minister Trevor Manuel and Manto Tshabalala-Msimang sketched a gloomy picture for Mbeki of the costs involved in the proposed ARV roll-out, and the government concluded that it was not financially feasible to make the drugs available to all HIV-positive patients at state cost.

Thenjiwe Mtintso, assistant secretary general of the ANC at the time, pointed out: ‘Making antiretroviral drugs available is only one side of the story; the state will have to take responsibility for all the costs ofAIDS-infected individuals. The state doesn’t have that kind of capacity or resources.’[47][ Manuel was more blunt: ‘The rhetoric about the effectiveness of ARVs is a lot of voodoo and buying them would be a waste of limited resources.’[48]

Underlying the decision was an unspoken belief among Mbeki’s inner circle that spending money on ARVs would be futile, since the real problem lay with the reasons for South Africa’s masses being particularly vulnerable to AIDS. At its most cynical, the view suggests that the exchequer was to be spared the cost of subsidising treatment for the poor and unemployed, who were a drain on resources rather than contributors to the state coffers. It suggests that in the long term, resources would be better utilised by creating jobs, educating people, and fighting poverty and malnutrition.

Manuel said as much at a closed hearing of the committee that investigated the feasibility of a basic income grant: ‘It does not make financial sense to spend money on people dying anyway, who are not even productive in the first place.’[49] He apologised when he realised that the commissioners were shocked by his comments, but, far from being an isolated aberration, such sentiments were the driving spirit behind the economic mandarins’ response to the pandemic. The tendency to focus on the healthy has been the overriding objective of govern- ment’s financial managers.

In June 2003, Mbeki’s media spokesman, Parks Mankahlana, asked in an interview with Science magazine: ‘Who is going to look after the orphans of AIDS mothers, the state?’[50] The clear implication was that prevention of mother- to-child transmission of HIV would be counterproductive, since the children saved would end up as welfare cases in any event.

Of course, no one in government could say this publicly – it would simply be too cold-hearted. But Tshabalala-Msimang apparently had no qualms about allegedly telling London’s Guardianin 2002 that South Africa could not afford AIDS drugs because it needed submarines to deter US aggression, though she later denied saying anything of the kind. However, many authoritative studies show that public provision of ARVs with an uptake of around 50 per cent reduces the impact of HIV and AIDS on economic growth and greatly justifies the cost involved. One study calculated that a roll-out of ARVs could reduce the number of HIV/AIDS deaths by around 100000 a year between 2008 and 2010.[51]

Mbeki’s attitude to the AIDS problem was almost certainly strongly influenced by his great personal distaste for the stereotypical Western portrayal of black sexuality, which he condemns as racist and neo-colonial. In his mind, this viewpoint extended to scientific postulations that AIDS originated in the African jungle and was primarily spread through sexual transmission. Many share these views. In a lecture at Fort Hare University in 2001,Mbeki said: ‘And thus it happens that others who consider themselves to be our leaders take to the streets carrying their placards...convinced that we are but natural born, promiscuous carriers of germs, unique in the world, they proclaim that our continent is doomed to an inevitable mortal end because of our unconquerable devotion to the sin oflust.’[52] The argument found support among many ANC leaders and intellectuals outside the party. Tshabalala-Msimang is a great believer in this precept, to which Achmat responds: ‘The president doesn’t want to believe that people in Africa have a lot ofsex.’[53]

In autumn 2002,Mbeki sent an e-mail to members of his cabinet, expanding on this thesis. A 114-page document, chiefly authored by former ANCYL head Peter Mokaba, virulently attacked pharmaceutical companies, ARVs and mainstream opinions on HIV. The sarcastic monologue lashed out at the bigotry that equates blacks with promiscuity and portrays Africans as diseased and poor, and always running to the West for aid:

Yes, we are sex crazy! Yes, we are diseased! Yes, we spread the deadly HIV through uncontrolled heterosexual sex! In this regard, yes, we are different from the US and Western Europe! Yes, we, the men, abuse women and the girl-child with gay abandon! Yes, among us rape is endemic because of our culture! Yes, we do believe that sleeping with young virgins will cure us of AIDS! Yes, as a result of all this, we are threatened with destruction by the HIV/AIDS pandemic! Yes, what we need, and cannot afford because we are poor,are condoms and antiretroviral drugs! Help![54]

Within weeks of writing the paper, Mokaba, like Parks Mankahlana, died from what is widely believed to be an AIDS-related disease, though their families persistently denied this.It was around this time that Mbeki announced that he would launch an international advisory council to investigate the high incidence of heterosexual infection in southern Africa and assess drug-based responses. Renowned medical scientist Jerry Coovadia urged him to leave science to the scientists.

Mbeki’s stubborn AIDS denial epitomised the ANC’s battle to keep its traditions of internal democracy alive as it underwent transformation from a liberation movement to a governing political party. The debate split the tripartite alliance down the middle, with COSATU and the SACP siding with the TAC, as did two ofthe great post-apartheid moralists, Nelson Mandela and Desmond Tutu. COSATU president Willie Madisha accused Mbeki of wasting his time on scientific speculation and hindering the fight against the disease. ‘The current public debate on the causal link between HIV and AIDS is confusing,’[55] Madisha worried publicly.

Privately, government officials warned that Mbeki’s intellectual approach was preventing the government from getting across the message that people should use condoms. Indeed, AIDS educationists frequently encountered resistance based on the argument that if the president did not believe there was a link between HIV and AIDS, unprotected sex posed no danger of infection.

A disturbingly high number of ordinary South Africans saw Mbeki’s views as an endorsement that, since AIDS was not sexually transferable, they had no reason to alter or modify their sexual behaviour.

The health department was as divided on the issue as the general public, with individuals having to battle their own consciences and decide whether they should administer ARVs and risk being fired, or follow orders. Many senior health officials at national and provincial level supported ARV distribution, and though he refused to talk publicly about the reasons for his departure, Tshabalala-Msimang’s director-general, Dr Ayanda Ntsaluba, quit and went to work for foreign affairs, allegedly because of his inability to reconcile his own beliefs with those of the minister and president.

Health professionals at state hospitals were also confused. Should they admin- ister life-saving ARVs or not? If they did, would they be punished? At grassroots level, health-care workers were dealing almost daily with the fatal consequences of confusion over government’s policy, which led the uninformed to believe that the disease was not transmitted sexually.

The greatest tragedy was that Mbeki failed to see that his refusal to acknowledge the effectivity of ARV treatment was undermining the entire AIDS education programme. It had been designed around the premise that HIV causes AIDS, and condom use was a mainstay of the government campaign that was being waged through awareness projects, educational television, radio, posters and in classrooms throughout the country.

Part IV

For COSATU, the link between HIV and AIDS was irrefutable. General secretary Zwelinzima Vavi pointed to the success of Brazil, a country with similar income disparities to South Africa, in providing medication to its infected citizens, and called on the government to declare a national emergency in terms of TRIPS so that ARV delivery could start.

Formal criticism from inside the ANC was slow to emerge, with those who differed from Mbeki scared of reprisals if they spoke out. Most criticism was uttered in hushed tones, but Madisha’s and Vavi’s relentless public attacks on Mbeki’s AIDS stance opened the way for other prominent black figures to join the choir.

Some had kept their own counsel for fear of being lumped with white conservatives who had taken up the AIDS cudgel only because they could use it to bash the ‘inept’ black government. Thanks to Madisha, Vavi and prominent scientist William Makgoba, the Mbeki-ites could no longer charge that criticism was confined to white reactionaries bent on undermining the black government.

Once the wall of silence had been breached, the AIDS policy came under fire from within. Some of the harshest critics were members of the ANC’s health committee, one of the party’s constitutional structures, while former health minister Nkosazana Dlamini-Zuma told Mbeki privately that his stance was undermining not only the government’s own policy, but his presidency.

The most serious opposition came from individuals serving on the ANC’s powerful NEC, but only as late as mid-2000. At an NEC meeting in Johannesburg, Dlamini-Zuma and Shepherd Mdladlana cautiously warned that Mbeki’s high-profile international advisory panel on AIDS was adding to confusion over the official AIDS message. They couched their arguments in a way that spared Mbeki from direct criticism, emphasising that the government’s message was not being effectively conveyed. They also warned that AIDS had the potential to undermine the ANC’s efforts in the 2000 local elections, given that opposition parties and civil movements were threatening to make AIDS, as well as slow social delivery to the poor, central campaign issues.

Mbeki loyalists such as Essop Pahad and Manto Tshabalala-Msimang responded dismissively that government was doing enough, within its capacity, to deal with the AIDS crisis. They listed AIDS education programmes and the amounts spent on them, arguing that it would cost too much to accede to calls by NGOs, trades unions and churches for the government to supply ARVs to all AIDS sufferers. Tshabalala-Msimang reiterated that the toxicity of ARVs had not been unequivocally determined, and cited warnings by the American government that some ARVs were believed to be so toxic that their use could prove fatal.

Mbeki was adamant that he would not backtrack on any of his AIDS statements, and continued to believe that his views were correct.

But he did agree, albeit reluctantly and unhappily, to refrain from further public comment on AIDS, at least until after the municipal elections. His chief policy guru, Joel Netshitenzhe, was assigned the unenviable task of extricating Mbeki from the hole he had dug for himself, without repudiating anything the president had previously said on the subject of HIV and AIDS.

Fully aware of the damage that had been done to the government’s reputation, Netshitenzhe fell back on the spin doctor’s hardy annual and attacked the media for colluding with critics of the official AIDS policy. Insisting that the government’s programmes were fully effective but not ‘on message’, he got the go-ahead for a R2-million advertising blitz that would somehow make it clear that neither the president nor anyone else in a position of authority had ever said that there was no link between HIV and AIDS.

‘We want to put the theorising behind us and programmes to fight the pandemic in front of us,’ said one senior NEC member optimistically. Mbeki’s international AIDS advisory panel would continue to meet, but behind the scenes, and the president would avoid all public reference to the pandemic until the local government ballots were cast.

The advertising campaign failed to clear up the confusion, not least because no one could admit what lay behind Mbeki’s withdrawal from the public AIDS debate. And since the dissidents continued to use his name in support of their own agenda, his silence was widely interpreted as confirmation that he did not agree with the messages imparted by official government policy.

In the wake of the NEC meeting, members of the ANC’s parliamentary wing became emboldened enough to make their voices heard on a range of issues, including the economic policy, Mbeki’s ineffective ‘quiet diplomacy ’with Zimbabwe and AIDS.

Nelson Mandela tried to meet with Mbeki to raise his concerns over the AIDS policy, but the president was smarting over what he saw as his predecessor’s constant criticism on the subject, and refused to take Mandela’s calls.

At a special meeting of the ANC’s parliamentary caucus in October 2000, Mbeki raged against senior leaders who criticised him in public, specifically on AIDS and Zimbabwe, and slammed the media for its coverage of the AIDS debate.

In contrast, he spoke approvingly about a conference in Uganda the previous month, where some 60 dissident scientists had argued convincingly that there was no scientific proof that HIV caused AIDS. He quoted from a document stating that the virus had never been isolated, and said reports that Uganda had scored significant successes in the fight against AIDS were untrue.

He told the gathered MPs that if one agreed that HIV causes AIDS, it followed that the treatment lay with drugs manufactured by Western corporations. The pharmaceutical companies therefore needed people to believe that HIV and AIDS were linked, in order to peddle their products. One drug company, which he did not name, had confessed, he said, that it had spent vast amounts of money on the search for an AIDS vaccine, but had abandoned the effort after failing to isolate the virus. This fact remained hidden from the public, Mbeki claimed, because the company’s share price would plummet if the truth were told.

He accused the CIA of being involved in a covert plot to spread the belief of an HIV/AIDS link, and cited statistics showing that 10 per cent of Africans died of AIDS. It made no sense, Mbeki argued, to focus the bulk of a state’s resources on this 10 per cent, to the detriment of the remaining 90 per cent. Drug companies continually urged governments to pay attention to a growing number of AIDS orphans, but how, asked the president, were the authorities to distinguish between the needs of AIDS orphans and orphans of any other kind?

He claimed he had the support of the editor of South Africa’s conservative daily newspaper, the Citizen, but said it was less clear that members of his own cabinet stood with him on this issue. They should declare their positions, he said, and the ANC’s MPs should join him in fighting off attempts by international forces to undermine him and the government’s agenda.

Those within the ANC who criticised him were playing into the hands of the local and foreign media – some of whom had dared to describe his views on AIDS as deranged – and unwittingly supporting the campaigns of the powerful drug companies and their allies, Western governments opposed to Mbeki’s vision of success for developing countries.

Before launching his tirade, Mbeki had made it clear to caucus chair Thabang Makwetla that he would take no questions. Deeply shocked by the virulence of his attack, none of the ANC MPs challenged anything he said. According to one, ‘there was a stunned silence in the room’.

Throughout his presidency, Mbeki’s Achilles heel has been his uncompromising ‘you are either with us, or against us’ attitude. He sees all criticism of government policy as a personal attack, and those who dare express views that contradict his own are categorised as secretly hating him, or, worse, wanting to topple him.

His censure of the AIDS critics choked any further criticism of the government’s policy. Not even the bravest ANC leaders would risk being labelled allies of a hostile ‘white’ media, greedy drug manufacturers or covert Western intelligence conspiracies.

In October 2001, during question time in parliament, it emerged that a number of ANC parliamentarians were taking ARVs, paid for by their state medical aid. The inescapable conclusion among activists was that the government could afford to pay for medicine for its own officials and representatives, but such help was too costly for the masses. Former opposition Pan Africanist Congress firebrand Patricia de Lille openly denounced the government’s ‘absolute hypocrisy’, but Mbeki’s response was merely to warn the ANC MPs that the drugs could be toxic. Having successfully drawn a curtain of silence over AIDS critics within the ANC, the president broadened his attacks to include black intellectuals, activists and individuals of all political persuasions who agitated against the government’s policies. A particularly vicious campaign was launched against outspoken physicist and political analyst Sipho Seepe, while Essop Pahad slammed local medical experts as ‘pseudo-scientists’.

Mbeki accused William Makgoba of deliberately leaking a long-awaited MRC report on the devastation wrought by AIDS in South Africa to the media before it was handed to him or the cabinet. Tshabalala-Msimang ordered a forensic audit to sniff out the source of the leak.

Achmat and TAC activists, many of them ANC cadres, were next to face Mbeki’s ire. He refused to meet any TAC representatives, telling confidants: ‘I will not give them the credibility of my presence.’ The vilification of Achmat as a pawn in the hands of Western interest groups intensified, and he was publicly accused of defying ANC discipline.

Achmat had infuriated Mbeki by travelling to Thailand in late 2000, buying 5000 fluconazole pills for 28 cents each, and bringing them back to South Africa in a well-publicised stunt. The government had him arrested for smuggling, and the attacks on the TAC only let up after Mandela visited a very sick Achmat at home in 2002 to plead with him to take ARVs.

Mandela lauded Achmat’s commitment to the ANC and praised him as a role model and loyal member, pledging to ensure that his protests were heard in the right government circles. ‘We were really under siege', Achmat later reflected, ‘and Nelson has given us protection. It was not for us that he did it. He’s not interested in opposing the government. He’s interested in doing what is right.’ Mandela had visited a clinic where the international humanitarian agency, Médicins Sans Frontières, was treating 400 patients with ARV and achieving a compliance rate that exceeded that of most AIDS clinics in America. After his emotional meeting with Achmat, the former president broke his own rule of non-interference with his successor’s governance and increasingly began criticising both Mbeki and the official AIDS policy in public. Mandela was greatly concerned about a growing perception that ‘the ANC does not care about the death of millions’.

He tried again to arrange a meeting with Mbeki, hoping to advise him that he and the First Lady, Zanele, should lead the anti-AIDS campaign. But every time Mandela called, Mbeki’s aides would say he was not available.

In November 2001, Mandela, frustrated at his inability to see Mbeki, used a speech at an ANC rally in the Cape Town settlement of Khayelitsha to extend the challenge to Mbeki and his wife to be the visible faces of government’s attempts to combat AIDS. ‘We have wasted time,’ he said, ‘but the more vigorous and focused we are in what we do, the greater the chance we have of moving forward.’ Mbeki was outraged. Yet again, he took the criticism personally, and privately accused Mandela of overstepping the line. He instructed aides to telephone Madiba and demand an explanation. Mandela denied that he had been attacking the president, and Mbeki finally agreed that they should meet, along with the ANC’s national working committee, to discuss the subject.

At the appointed time and place, however, Mbeki was conspicuously absent. Mandela joked that Mbeki was ‘too busy’, and told the committee that the government’s AIDS policy was creating the impression that it did not care if millions of South Africans died. He urged the immediate introduction of ARVs for pregnant women, as a start.

Jacob Zuma, standing in for the president, assured Mandela that the government was serious about the pandemic, but was not ready to roll out the ARV programme because the effectiveness of the drugs was still being tested in a pilot project. The only problem the government would admit to was one of communication, in keeping with Netshitenzhe’s earlier strategy.

Mandela agreed to reserve his doubts and questions for the next NEC meeting, which Mbeki would hopefully attend, but urged Zuma to play a leading role in the fight against AIDS, because Mbeki’s busy schedule frequently took him abroad.

Archbishop Tutu, just as exasperated as Mandela over the government’s vacillation on AIDS, went public with what was undeniably a rebuke of Mbeki:

'It would be tremendous if our president said this is the common enemy. The stance adopted by the president has harmed his image. He has done wonderfully well – the world thinks the world of him, I want to see him succeed. I think it is silly to hold on to positions that are untenable. At the present time, everybody recognises that the president’s position is undermining his stature in the world. When the New York Times is constantly bashing us over this issue, it is not good for us or for him. He has so much going for him.'

Tutu threw his full support behind efforts to prevent mother-to-child transmission of the virus. ‘Yes, this means the use of Nevirapine if that is what is available. It is irresponsible of us not to save lives we could save. It makes us appear hard-hearted where we are not. We are seen to be lacking in compassion and [seem] uncaring. Women who are raped should be put on a course to ensure that they are not infected.’

He also made the point that, whereas AIDS was considered a chronic condition in the United States, it was tantamount to a death sentence in South Africa. At a January 2001 cabinet meeting, Mbeki finally acknowledged that negative perceptions of South Africa’s AIDS policies were based not on bad communication, but on a lack of consensus over what the government’s message should be. A year later, he and his cabinet accepted, for the first time, that confusion over the policy was no longer a medical or scientific matter, but a major issue that was undermining the country’s interests.

The opposition Inkatha Freedom Party leader, Mangosuthu Buthelezi, decried the lack of leadership on the AIDS front and proposed more stringent monitoring of the activities of Mbeki’s international AIDS advisory council. In his State of the Nation address at the opening of parliament, Mbeki hinted at finally putting the issue to rest when he spoke of government’s intention to ‘intensify its comprehensive programme against AIDS’.

Ahead of the NEC meeting in March 2002, Nelson Mandela was attacked by a number of Mbeki-ites, including one of the president’s loudest cheerleaders, Dumisani Makhaye, a KwaZulu-Natal ANC leader. Thami Mazwai, the black entrepreneur in charge of a publishing house, also launched a broadside against Mandela in the mass-circulation Sunday newspaper City Press, accusing him of unprecedented interference in government affairs.

The NEC spent a whole day discussing the government’s AIDS policy. All the provincial health MECs had been invited to the meeting, but members of the ANC’s health committee, who had been critical of the failure to make ARVs freely available, were barred. When Mandela voiced his concerns, he was heckled and jeered by Mbeki supporters.

The loyalists urged Mbeki to bulldoze ahead with the controversial AIDS policies rather than reverse or revise them, lest this be seen as caving in under pressure from Mandela and others. After hearing impassioned arguments from the likes of Peter Mokaba, the NEC resolved that rape victims, health workers and pregnant women should not be provided with ARVs, because the effectiveness of the drugs remained unproven. The hardliners also pushed through a bizarre decision that the government would appeal against the recent judgment by Judge Chris Botha in the Pretoria High Court ordering that Nevirapine be given to pregnant women.

This was one of several truly extraordinary reactions by the government to a high court ruling. Immediately after it was handed down, then justice minister Penuell Maduna, a trained lawyer, said the judgment could be enforced only in the province where the case was heard. He later retracted his statement, but Tshabalala-Msimang said on national television that the government would not obey the court order. For Mandela, the NEC’s decision to appeal against the ruling was the final proof that people were justified in seeing the ANC as a party that did not care about those who were dying of AIDS.

Part V

In the end, economics rather than compassion would force Mbeki’s hand on HIV/AIDS. Members of his international investment council warned him at roughly the same time as the NEC meeting that investors found the confusion over the government’s approach to the disease unsettling, if not downright frightening. Mbeki’s association with the AIDS dissidents was fuelling negative perceptions about South Africa as a potential investment opportunity, and unless a clear and unambiguous change in policy could be discerned, his meeting with the G8 in June to discuss NEPAD could be blown off course.

Trevor Manuel and Reserve Bank governor Tito Mboweni were also starting to feel the pinch as foreign investors probed them on government’s AIDS policy, and they, too, began dropping cautious hints to the president of looming economic consequences.

When the cabinet met in April 2002, Mbeki proposed that ARVs be made available to pregnant women and rape survivors without further delay, pointing out that despite the absence of conclusive evidence that they worked, they were already being routinely used by medical staff who suffered puncture wounds sustained from hypodermic syringes.

It was a landmark decision and a radical departure from Mbeki’s position to date. He followed through by starting to distance himself from the AIDS dissidents, and gave cabinet an undertaking that no longer would the dissidents or Mokaba be allowed to speak on his behalf regarding the disease.

In an interview with the Star, Mbeki denied that there was a lack of govern- ment leadership on AIDS. ‘Perhaps we are not communicating that message loud enough, ’he said. ‘But I think there’s been very strong leadership on the matter. It is critically important that I communicate correct messages.'

Since then, like many other developing countries, South Africa has increasingly channelled funds into AIDS programmes, albeit at the cost of poverty alleviation or opening up their markets to trade with poorer countries. Development funding is now earmarked almost exclusively to halt the infection rate and treat the victims.

But in fairness, the business community has not been a partner to govern- ment in this battle. The South African Business Coalition on HIV/AIDS surveyed 1006 companies throughout the country on the impact of the disease in commerce and industry, and found that only 25 per cent of them had implemented a formal HIV/AIDS policy. Less than 20 per cent had introduced voluntary counselling and testing programmes, or provided care, treatment and support to infected workers.

Having previously announced with great fanfare that it would make ARVs available to employees free of charge, mining giant Anglo American subsequently withdrew the offer, saying it would be far too costly.[68]Incredulously, trade minister Alec Erwin would claim as late as April 2002 that AIDS had ‘no impact on the South African economy or workforce’.

The harsh reality is that South Africa is now faced with creating the largest AIDS treatment programme in the world. The ARV roll-out in the public sector will require a major upgrading ofthe existing health-care infrastructure,recruitment and training of a vast corps of health workers, and a well-coordinated national programme for HIV tests and counselling.

It is a daunting prospect, to be sure, but it can be done. In the mid-1980s,the picture looked equally grim in Thailand, but thanks to a dedicated monitoring programme, concentration on high-risk groups, general AIDS education combined with 100 per cent condom use and vigorous efforts to dispel the stigma attached to the disease, the situation has been brought under control and infection rates appear to have stabilised. The secret ingredient to success, however, has been large doses of political will.

Worryingly, Mbeki still firmly believes that those who contract the disease should assume individual responsibility for their care and not simply expect the state to pick up the tab. He remains unconvinced that HIV causes AIDS, and many senior ANC leaders share his view. Said Smuts Ngonyama, the party’s official spokesperson and one of Mbeki’s closest associates: ‘It’s based on a scientific assumption, and like all assumptions, it can be disproved.’

Small wonder, then, that Mbeki could tell the world, without blinking an eye, ‘I don’t know anybody who died of AIDS’ in an interview with the Washington Post in September 2003.

Cynics have no doubt that the only reason the government backed down on the ARV roll-out was to deny opposition parties the chance to use the issue as a vote-catcher in the 2004 elections. Many claimed that the ANC still lacked the political will to tackle AIDS head-on, and predicted that the issue would be moved to the back burner again once the election was over.

In August 2004, Tshabalala-Msimang confirmed that the government would not meet its target of supplying ARVs to a paltry 53 000 people by March 2005. After all, she sighed, ‘we are just a developing country’. Somewhat tellingly, she added: ‘If you say to the nation that you are providing ARVs then you will wipe out all the gains made in the promotion ofa healthy lifestyle and prevention.'

Government’s AIDS policy soon regressed to such an extent that, at the Make Poverty History rally in 2005, Nelson Mandela urged Mbeki to ‘recognise that the world is hungry for action, not words’.

Although by the end of 2006 there was a noticeable increase in government’s delivery of ARVs, with about 200000 patients receiving the drugs through the public health system, making it one of the world’s largest ARV treatment pro- grammes, a further 800000 were in desperate need of them. In many other respects, government rapidly returned to doing things the old way. The AIDS plan was heavily undermined when Jacob Zuma said during his rape trial that, after having unprotected sex with an HIV-positive family friend, he had taken a shower to prevent infection. His testimony showed that AIDS denial was endemic within the highest echelons of government and the ANC. Zuma was the former head of the country’s National AIDS Council.

At the World AIDS Conference in Toronto in August 2006, international activists, medical doctors and the media accused South Africa of ‘lunatic’ negligence regarding HIV/AIDS. The official South African stand prominently displayed lemons and garlic, along with condoms and ARVs, as ways to deal with AIDS. At the start of the conference, the display had also included apples, nectarines and grapes, but these were quickly eaten by passing delegates. Such was the inter- national criticism that investor perceptions of South Africa slumped, which spurred Mbeki into action. The AIDS issue again became part of a political football game. A day after being acquitted of rape in May 2006,Zuma publicly apologised for the irresponsible statements he had made during his trial. Cynical as this apology was, his position was immediately contrasted with that of Mbeki, who had elected to maintain a stony silence on the topic of AIDS. In addition, the SACP and COSATU rained fresh hammer blows on Mbeki over the government’s approach. AIDS activists stepped up their criticism and embarked on a strategy to shame government, particularly at prestigious international forums.

In September 2006, the TAC was joined by eighty-one leading scientists to demand the sacking of Tshabalala-Msimang.This was particularly effective, as Mbeki and his cabinet are super-sensitive when it comes to international, and especially business, perceptions of government. Deputy health minister Nozizwe Madlala-Routledge broke ranks with her superiors in October and admitted that government was failing to fight the pandemic. ‘Our country is in pain. We are all in pain,’ Madlala-Routledge said. She later demanded that all government leaders – including Mbeki – should take public AIDS tests, but backtracked quickly after being reprimanded by senior officials in the presidency and denied that she had singled out the president. On World Aids Day at the end of November, the government announced it would cobble together a new five-year plan to expand treatment and prevent new HIV infections. Mlambo-Ngcuka and Madlala-Routledge became the first government leaders to meet with civil society groups and activists such as Zackie Achmat, previously shunned like the plague. The new plan would make those aged between fifteen and twenty-four a priority, halve the rate of new infections and provide treatment for 750000 adults and children by 2011.‘This is a sea change, ’exclaimed Mark Heywood, a leading AIDS activist. ‘We’ re not across the ocean yet, but now the government is sailing in the right direction.

Mbeki’s strategists blamed Tshabalala-Msimang for previous failures, and she was quickly sidelined. Although government strategists grudgingly conceded that the health minister had become identified with the abysmal failure to manage the disease, Mbeki still refrained from firing her. Ironically,it would take Tshabalala- Msimang falling seriously ill in late 2006 for Mlambo-Ngcuka, with the help of Madlala-Routledge,to finally wrest control of government’s AIDS policy from the health minister. Mlambo-Ngcuka was assigned to lead the new AIDS approach, and was appointed as head of South Africa’s National AIDS Council. Some of Tshabalala-Msimang’s responsibilities were transferred to her deputy, who had previously been excluded from making decisions on AIDS policy. Mlambo-Ngcuka promised to consult non-governmental groups and outsiders on government’s future AIDS policy. However, Tshabalala-Msimang has tried to fight back in-between bouts of illness, attacking both Madlala-Routledge and Mlambo-Ngcuka: ‘The incident of my illness was portrayed as an opportunity to turn others into champions ofa campaign to rid our government of the so-called “HIV and AIDS denial at the highest level.”

Nevertheless,Mlambo-Ngcuka and Madlala-Routledge – with Mbeki’s backing – have revitalised the moribund battle against the pandemic and have deservedly been showered with praise by HIV/AIDS experts and civil society groups. However, some long-suffering AIDS veterans remain sceptical: they have been here before and have seen many false dawns.

Practical considerations aside, there is much work yet to be done, by govern- ment, the TAC and other civil society organisations, to destigmatise the disease. Gugu Dlamini was stoned to death by a mob near Durban after she disclosed her HIV-positive status on radio. The veil of secrecy surrounding the deaths of Peter Mokaba and Parks Mankahlana show how pervasive the stigma is.

The Sisulu family proved a rare exception when they went public after a family member died of AIDS. Buthelezi, an arch-traditionalist, also broke the silence by acknowledging that both a son and a daughter had died of AIDS within months of one another in 2004, and publicly speaking of the devastation the disease has caused within the family circle. And when Nelson Mandela announced that his son, Makgatho, had died of AIDS in January 2005, it was a move aimed at breaking one of the most stubborn taboos surrounding the pandemic.

It is true that there are cultural taboos against speaking about death, but the continual denials perpetuate the terrible stigma surrounding AIDS in South Africa. The vast majority of the population still see the disease as something that happens to ‘other’ people – prostitutes, migrant workers and moral lepers. Only those who have done something bad, behaved immorally or been sexually promiscuous get AIDS, and ‘decent’ folk are right to treat them as outcasts. Sex, too, is something that polite people don’t discuss in public. It happens, but one does not talk about it, hence Zuma’s mind-boggling statement that those who dare to mention oral sex are ‘un-African’.

The fact that Mbeki has never led the way in talking openly about AIDS, as President Yoweri Museveni did in Uganda, has seriously undermined all government efforts to combat the disease. Mbeki’s refusal to acknowledge that HIV is sexually transmitted is a major obstacle to facilitating behaviour modification and greatly diminishes the dedicated attempts of sex educators to protect another generation from wholesale infection. A more enlightened leader such as Chandrababu Naidu, chief minister of the Indian state of Andhra Pradesh, for example, insisted that all his ministers should make mention of AIDS in their public addresses, no matter what the topic.

Mbeki’s role is crucial. Though South Africa has the most progressive Constitution and Bill of Rights in the world, with women’s rights firmly entrenched, gender relations are far from being democratised. Age-old perceptions of women as ‘possessions’ run deep, and in November 2003,a South African Medical Research Council study offered conclusive evidence of links between gender-based power inequalities and the risk of South African women contracting AIDS.

The study recommended that reducing gender inequalities and making men more respectful of women are crucial weapons in the fight against AIDS, and in building a society in which women have the right to live free from violence. The most recent research shows that women aged between fifteen and twenty-nine are three to four times more likely to be infected than males. As the country’s president and leading male role model, Mbeki could be extremely influential in changing attitudes towards women.

Recent official surveys show a high level of HIV infection – 20 per cent – among young people between the ages of fifteen and twenty-four. In addition,1.5 million children under the age of eighteen are maternal orphans, who have lost either a mother or both parents, and 66 per cent of them have been orphaned as a result of HIV/AIDS. In all, 1.8 million AIDS-related deaths have occurred in South Africa since the start of the pandemic.

Mbeki’s handling of the AIDS issue has reinforced his image as a lone, remote intellectual and contrarian battling against the world. It has also illustrated the president’s Don Quixote side, which caused his mentor, Oliver Tambo, many headaches. Tambo once told an associate: ‘That Thabo is such a clever young man, but I always have to keep a close eye on him,because he tends to wander off[on intellectual pursuits].He would cause my death,if I am not careful.’

In dealing with AIDS, Mbeki may have wandered off on a deadly diversion that has helped place an entire nation in denial and needlessly taken the lives of millions of its citizens.

This is a chapter from William Gumede's book "Thabo Mbeki and the Battle for the Soul of the ANC."

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