Playing politics with HIV

Tuesday, May 27, 2008

Dr Oliver Phillips, Vice-Chair of the Friends of Treatment Action Campaign UK, argues that the fight against the AIDS epidemic is being held back at the highest levels of government.

In May 2007, the South African cabinet and the South African National AIDS Council (SANAC) endorsed a national HIV & AIDS and STI Strategic Plan for 2007-2011 ('the NSP') that promised a new and effective engagement with HIV, including the delivery of Anti-Retroviral (ARV) therapies. This suggested a definitive turning point in the Government's approach to HIV, and came about as a result of the energetic leadership provided by Deputy President Phumzile Mlambo-Ngcuka, Deputy Minister of Health Nozizwe Madlala-Routledge and Dr Nomonde Xundu, Chief Director of HIV & AIDS, TB and STIs in the national Department of Health. Working with civil society organisations such as the Treatment Action Campaign (TAC), the NSP emerged from an exceptional window of opportunity presented by the prolonged absence of the Minister of Health, Manto Tshabalala-Msimang, who was ill at the time, and who has persistently refused to accept the efficacy of ARVs. As a reward for her key role in developing the NSP, the Deputy Minister was sacked soon after the Minister of Health's return to work, clearly reflecting the divisions within government on these issues. The Minister's rejection of the scientific evidence supporting ARV treatment is embedded in the same denial of the links between HIV and AIDS to which President Mbeki subscribed as recently as June 2007. Officially, the NSP is still being implemented, but in practice, contradictory measures continue to sabotage the process, so that its implementation might at best be described as ambivalent. A disbelief that can be construed as ideological continues to challenge the conventional scientific method and evidence on the efficacy of the ARVs that are central to the NSP, thereby threatening its promise to save many thousands of lives.

It is already over 10 years since academic Paula Treichler labelled HIV an 'epidemic of signification', and while there have been some significant changes in the global politics and availability of ARVs, the label seems as appropriate as ever. HIV continues to be invested with a parade-ground of signifiers, so that policy and discussion is persistently hostage to moral judgement, prejudice, and ideology in a way that often invokes the most absolutist (and thus counter-productively simplistic) positions. It may seem trite to recognise that this is the inevitable result of dealing with a disease so inescapably linked with sexuality, drugs and death, but it is difficult to imagine a combination of markers that offer greater potential for moral judgement. This has demanded a clear analysis of the problems that arise when stigma is used to divide 'innocent victims' from those infected people alleged to be guilty in their contraction of the disease. It is thus well established that refusing to engage with the 'stigmatised' sections of any community that are most vulnerable to infection only increases everyone else's vulnerability to infection, and that no community can be conveniently isolated from the rest of society. HIV has repeatedly shown us that the route of infection ignores the bounds of stigma and exercises no such 'respectable' discretion as it fails to map itself exclusively onto those alleged to be 'guilty'. Yet these facts, increasingly familiar to us, were unable to constrain the abstinence evangelism that dominated George Bush's interventions into US funding of HIV programmes, nor did it prevent him from excluding sex workers and any abortion related services (even purely informational) from US funding.

Sexuality is such a strong cultural and moral signifier that we might not be surprised that Bush is so interested in the moral framework through which HIV is addressed, but the shiny brilliance of often salacious debates about sexuality serves to blind us to the underlying assumptions that are being reconfigured through these contested approaches. Although his administration importantly acknowledged HIV to be a threat to national and global security, Bush's preoccupation with the morality (rather than the harm) of sexualities obscures the damaging dismissal of scientific methodology and evidence-based assessments that has informed his policies and many related programmes the world over. In 2005, the Union of Concerned Scientists (UCS), a non-profit advocacy group based in Cambridge, Massachusetts, documented dozens of alleged cases where it argued that the Bush administration sacrificed scientific integrity in the interests of big business, big oil and the religious right. Controversy over the treatment of science erupted around national security and defence, myriad environmental issues and endangered species programmes. The hostility towards science is manifest in localised attempts to promote 'intelligent design' or other faith-based creationist myths as being of equivalent veracity to the theory of evolution, but evidence that this 'anti-scientific revolution' was reaching into medical and other research institutes funded by (a supposedly and constitutionally secular, rationalist) government is a far more insidious development in view of the global reach of US money, and the fact that HIV policies can and do have fatal consequences.

Similarly, in South Africa in 2000, Mbeki's inclusion of both dissident and conventional scientists on his Presidential AIDS Advisory Panel not only offered them an equivalence of impact that ignored the value of their contributions and the strength of their evidence, but it implicitly rejected the authority and credibility of the established scientific expertise that had emerged from other locations, where these debates had already been exhaustively rehearsed.

The USA and South Africa are by no means exceptional in their Presidents' embrace of anti-scientific tendencies, as political narratives of HIV so puffed with symbolism develop strong anxieties and so offer a real resource for mobilising power in many different countries. Nor are these anti-scientific tendencies shared by the Presidents' senior colleagues, let alone supported by their entire Governments; the strategic importance of this dissent at senior levels of government in South Africa is evidenced by the drafting and approval of the NSP during the Health Minister's sick leave. This was a rapid advance on a long obstructed issue and the process indicated clearly the extent to which the science around HIV is a source of huge disagreement within government; there are many senior figures who reject President Mbeki's denialist position, and who push for a more evidence-based approach and a return to scientific rigour. Furthermore, the extent of HIV infection and the need for treatment in South Africa compounds the implications of this disagreement significantly, as the denialist position obstructs the development of treatment action that elsewhere has been unquestionably effective.

The Actuarial Society of South Africa (ASSA) has estimated the number of people requiring treatment but not receiving it to be over 500,000 (for an accurate explanation of the relevant statistics, see www.tac.org.za/community/keystatistics). Yet in 2006, when presented with research conducted by the South African Human Sciences Research Council (HSRC) indicating that 10,000 teachers urgently needed to be given ARV treatment to prevent a crisis in education, President Mbeki continued to refute the suggestion that HIV causes AIDS, and that HIV might be responsible for any significant number of deaths in the public sector. Mbeki's history of 'AIDS denialism' is by now well-known, and challenges to his authority on the issue appear to have hardened his distrust of the scientific establishment as a whole. In addition to challenging the methodological expertise of such august research bodies as the ASSA and the HSRC, Mbeki and his Health Minister, Tshabalala-Msimang, have found themselves in conflict with the most authoritative scientific bodies in the land (including the Medicines Control Council (MCC) and the Medical Research Council (MRC)), as well as in the world at large. Indeed, the very internationalism of this scientific authority feeds their refusal to trust it, as it plays into their deep suspicions that 'science' is once again being harnessed to serve the interests of global capital, and to perpetuate racial and sexual stereotypes as a distraction from issues of poverty and dispossession. On a number of occasions, Mbeki has characterised claims about the extent of HIV prevalence in Southern Africa as attempts to resuscitate colonial stereotypes of Africans as sexually promiscuous, corrupt, and perverse, and as a smear on African post-colonial governance. Similarly, the historical complicity of corporate capital and medical science in the establishment and exploitation of colonial relations is used not only to discredit the bulk of scientific evidence on HIV today, but to gild Mbeki's position with a post-colonial anti-imperialist gleam. Thus, HIV and the disparate availability of treatment did offer real evidence of the injustice of the global economic order, and the pharmaceutical industry's initial resistance to making ARVs cheaply available simply served to reinforce the impression that African bodies were once again being subjected to profiteering and careless exploitation. The fact that significant changes in the pricing structures and availability of ARVs have had no impact on these suspicions about the science behind HIV highlights the ideological dogma that underpins Mbeki's position. Thus, the grassroots South African organisation (TAC), which, in 2001, assisted government to defend legislation for cheaper drugs (the Medicines Act) from attack by the Pharmaceutical Manufacturers Association is repeatedly accused by government of being in league with pharma capital. This claim has shifted from being simply spurious to deeply ironic as TAC has become highly instrumental in initiating and organising actions that have forced significant reductions in the pricing of ARVs around the world, and as these achievements are gained in spite of opposition from a Health Minister who herself engages in promoting pseudo-medicinal substances that might be characterised as exploitative quackery in the name of profit.

The politics of HIV in South Africa are therefore deeply connected with the politics of post-colonialism, as a problematic colonial history lends vastly disproportionate force to the discrediting of good science. Yet this is not inevitable, for a choice is made to infuse HIV with a dose of scepticism that is not served up to discredit other medical, scientific, and technical advances rooted in the same history, let alone those of far more dubious origin.

Accusations of collusion in the exploitation of the African body and in the promotion of profiteering quackery have, in reverse, been levelled at the South African Minister of Health, as her rejection of scientific method has led her to support various alternative 'therapies' of dubious reputation. She is best known for repeatedly highlighting the side effects of ARVs and stressing the benefits of 'nutrition' (particularly garlic, lemon and olive oil) while saying that patients must exercise 'choice' in their treatment strategies. At the same time, the Minister has demonstrated far more active support for a number of alternative untested remedies, including one touted by German doctor Matthias Rath, who claims his multivitamin solutions effectively treat or cure cancer, heart disease, diabetes, asthma and AIDS. Rath campaigns vigorously against ARVs, which he describes as 'toxic', and engages in aggressive advertising to persuade people to discontinue ARV treatment in favour of his solutions. He has had a number of warnings and rulings issued against him by regulatory authorities in several countries (including Britain), yet in South Africa, he not only enjoys the support and confidence of the Minister of Health, but is able to parade that support as an advertisement for his products.

But the Minister of Health's challenge to scientific and medical expertise is perhaps most worryingly demonstrated in the recently (April 2008) released draft of a new Medicines and Related Substances Amendment Bill. This proposes finally to do away with a Medicines Control Council whose autonomy and power has been increasingly constrained by the Minister in recent years. The new Bill proposes to abolish the MCC altogether and establish a new health authority directly accountable to the Minister of Health alone. This would centralise all authority to register medicines and related substances in the Minister of Health. In light of her repeated rejection of scientific method, and the ready embrace that she has offered to substances that are untested and quickly discredited, these proposals do not bode well for effective implementation of the terms of the NSP under the current Minister. But even once this Minister is replaced, as she most surely will be, such a centralisation of power in the hands of one person will ensure that scientific and medical expertise are constantly subject to the greater authority of political will, moral and ideological judgement. Regardless of who the incumbent Minister may be, the dangers of such a situation are self-evident. One can only hope that the debates and contests within the ANC will lead the party to rediscover its rational judgement, consider properly the value of scientific method and expertise, and prevent these provisions of the Bill from ever being enacted.

For more on these topics, please see www.tac.org.za.