Mbeki's AIDS denial - Grace or folly?

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 Pah