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A Political Economy of South African AIDS


Patrick Bond 

Johannesburg,

South Africa

Up to a point, Danny Schechter is absolutely right to focus on the power and the

appalling discursive-policy mistake of a single personality, SA president Thabo

Mbeki, in this country’s recent HIV-AIDS fiasco ("Mbeki’s Muddle: South

Africa’s AIDS Debate, ZNet Commentary, July 13).

Explains

Schechter, "Staring down the barrel of drug costs that could bankrupt his

treasury and plans for economic development, he provoked a debate about the

proper strategies to pursue that is still reverberating globally."

The

larger problem, however, is not just that the cost of anti-retroviral drugs like

AZT has hampered treatment. It is, I want to argue, that the class/race/gender

character of South African health and social policy under conditions of a

failing free-market (known here as "neo-liberal") economic strategy is

inhibiting prevention.

As

Schechter points out, Mbeki spent several months trying (unsuccessfully) to

shift attention from South Africa’s ineffective HIV-AIDS policies: "We

cannot blame everything on a single virus. Poverty is the underlying cause of

reduced life expectancy, handicap, disability, starvation, mental illness,

suicide, family disintegration and substance abuse." This is also the

policy conclusion that the conservative "AIDS dissidents," better

termed "denialists"–a small, marginalized bloc of researchers who

deny a link between HIV and AIDS–keep asserting.

But

come off it: no African public health professional needs a lecture on the

relationship between class and health indicators. (In a future column I’ll

explain how hypocritical it is for Mbeki to advance this case at a time most of

his underlings exacerbate poverty and inequality in virtually all areas of

post-apartheid development policy.)

Beyond

the illusory talk of fighting poverty, Schechter correctly points out,

"Mbeki had been the darling of South Africa’s business community for years,

a champion of the type of neo-liberal economics that pleases cheerleaders for

globalization. A close friend of the Clinton Administration, Mbeki was

considered a man `we’ could work with."

If

so, what are the implications? I’ll briefly highlight three:

  • First,

    a presumption made by Al Gore that US pharmaceutical companies could get

    away with mauling SA’s 1997 Medicines Act (which condoned "parallel

    imports" and generic local production of life-saving medicines, thus

    threatening those firms’ ability to exploit their monopoly market power);

  • Second,

    ongoing pressure on the health and welfare budgets caused by repayment of

    apartheid-era debt (in part to US banks) and adoption of a

    Washington-friendly macroeconomic policy; and

  • Third,

    the closely-related indifference of top policy-makers to the masses of

    superfluous low-income people, who will never have a role as laborers in the

    formal capitalist sectors of the economy.

Let’s

start with the last, for no one has made the argument more simply and clearly

than Mbeki’s key spokesperson, Parks Mankahlana, when off-guardedly he justified

to Science Magazine why the SA Department of Health refuses to provide a

relatively inexpensive anti-retroviral treatment to pregnant, HIV-positive

women: "That mother is going to die and that HIV-negative child will be an

orphan. That child must be brought up. Who is going to bring the child up? It’s

the state, the state. That’s resources, you see."

(Mankahlana

has personal experience that is perhaps worth citing here. He has been the

subject of two paternity suits based on failure to pay child maintenance, one of

which was settled out of court last week in the mother’s favor, with the other

to be resolved by a blood test on July 17.)

The

scandalous quote was released to the general public here on Friday. Apparently

ashamed that the cat was out of the bag, Mankahlana–who a week earlier said he

would toss the 5,000-signature Durban Declaration on AIDS into Mbeki’s

"dustbin" because it strongly refuted the dissident camp– immediately

denied making the statement: "Their story is a complete fabrication." Science’s

editor replied that he had recorded Mankahlana in his Pretoria office on March

24, and offered to play the tape.

Mankahlana

should indeed be ashamed. For underlying the logic is a triple trumping of

Cost-Benefit Analysis. When people like Dr Costa Gazi originally began arguing

for prevention of mother-child transmission, they conclusively showed that

treating HIV+ children for AIDS-related ailments would cost the state far more

than the expense ($15 million or so) of two antiretroviral jabs for roughly

70,000 HIV+ expectant mothers annually, for whom HIV transmission could thus be

prevented in roughly half the cases.

But

first, the cost-savings associated with future treatment only holds true if the

state healthcare system actually has capacity–and if its personnel even

intend–to care for sick HIV+ infants. Gazi, who is health secretary of the Pan

Africanist Congress, says that such an assumption is now in question, and not

merely because the public health service has collapsed in many impoverished

communities. Worse, after HIV+ infants get treatment for an initial ailment, he

says, caregivers (mainly grannies) are now sent home by local clinic staff and

simply told not to return.

Second,

a false presumption (explicit in Mankahlana’s comment) is that the state will be

forced to look after orphans. In reality, the South African state has a

practically non-existent social safety net for black orphans. As a result,

kinship networks are the only fallback when the HIV+ mother dies. The

HIV-negative orphan is usually looked after by desperately poor relatives. The

likelihood thus increases of the orphan dying by the age of five (in a country

with amongst the world’s highest infant-mortality rates for black children).

This practical reality lowers the likelihood of a future productive life for an

AIDS orphan (even if the HIV+ mother is treated with anti-retrovirals). Hence

another negation of the benefit side of the treatment equation.

Third,

what if, against all the odds, the orphan does grow up to be a productive member

of society? What jobs exist, now and in future, for her/him? If South Africa’s

40% unemployed mass already provides an overstocked reserve pool of labor, why

keep the 50,000 or so potentially HIV- children of HIV+ mothers alive by

preventing mother-to-child transmission? Why not, to invoke the mock-"Lugano

Report" that the brilliant social critic Susan George "liberated"

from sinister elites (in her 1999 Pluto Book of the same name), allow AIDS to

"depopulate the vast underclass"?

A

related position is that AIDS is killing workers and low-income consumers at a

time when South African elites in any case are adopting capital-intensive,

export-oriented accumulation strategies. Already a decade ago, a top banker

explained, on-record (when I was reporting for National Public Radio): "As

the numbers of sick and dying soar, the entire nature of the labor market will

change drastically. There is likely to be even added incentive towards

mechanization and automation. The market could shift from a volume market to a

quality market. The overall ceiling to the domestic market makes it imperative

to promote South African exports and to widen and strengthen the range of

exports." AIDS and neo-liberalism are thus synthetic in cause and effect.

I’ve

begun this critique by focusing on the most insane reasons for not treating HIV+

pregnancies with anti-retrovirals, and for not taking AIDS seriously. Some, like

Gazi and Professor Thomas Coates of U. Cal’s AIDS Research Institute conclude

that the SA government is "genocidal." Making the case for

mother-child transmission treatment to the public last year, Gazi was suspended

from a government hospital supervisory position for asserting that the SA health

minister should be charged with murder. Instead of shutting him up, the state

made Gazi a martyr, and in his Eastern Cape province public health practice, he

has been spending his own personal funds giving pregnant HIV+ women the needed

doses of AZT.

However,

if Gazi is trying to reverse the basic logic of South African capitalism, as

articulated by representatives of a fundamentally uncaring state and capitalist

class, which simply refuses to pay the bill for kids deemed unnecessary for

capitalism’s reproduction, his will be a long professional martyrdom.

The

second broad point above is a fear by the state that the floodgates might open

if mother- child transmission becomes an initial wedge for providing more

general treatment to low-income people. Giving anti-retrovirals to the country’s

4.2 million HIV+ residents would–under present pharmaceutical-pricing

constraints–cost roughly $12 billion per year, according to Zwile Mkhize, the

KwaZulu Natal provincial minister of health. The vast majority of treatment

costs would have to be subsidized by a state whose entire annual budget is less

than $40 billion and whose budget for HIV prevention is less than $25 million.

But

while the cost of treatment access to all who need it does initially appear

insurmountable, two rebuttals quickly emerge. First, determinations of fiscal

priorities still reflect durable apartheid-era political-economic power. The

society’s transformation was closely monitored by financial interests, who

demanded drastic cuts in the state budget deficit (from 9% of GDP in 1993 to

less than 3% today) in the context of a "homegrown" structural

adjustment program and dramatic corporate tax cuts (from 48% in 1994 to 30%

today). Moreover, activist campaigns like Jubilee 2000 South Africa’s call to

repudiate tens of billions of dollars in inherited apartheid-era local and

foreign debt were dismissed as dangerous by financiers and their comprador

friends in the new government’s Department of Finance. (The revolving door works

well, as the three main authors of the structural adjustment plan left

government to join Deutsche Bank, Investec Bank, and Standard Bank earlier this

year.)

Yet

debt repayment is the second-largest budget expense, accounting for more than $6

billion a year. A controversial new high-tech military spending package adds

nearly another billion dollars a year. Dramatic shifts in spending priorities,

including a dramatic kick start to the economy through widespread public-works

projects (rejected by the neo-liberal Department of Finance as inflationary),

would change the basic parameters.

The

even more decisive rebuttal to the argument that treatment for all HIV+ South

Africans is cost-prohibitive comes, ironically, from the government itself. This

is the crucial initial point, above. For in 1997, parliament passed the

Medicines Act, which provides for the Department of Health to override the

Trade-Related Intellectual Property (TRIPS) provisions of the World Trade

Organisation agreement which South Africa joined in apartheid’s dying months.

Those legal provisions indeed are malleable, allowing violation of patents in

cases of extreme emergencies, such as AIDS. It should therefore have been

uncontroversial for the SA government to import cheap drugs (at less than 5% the

cost they are sold locally) from markets like India and Brazil, or to permit

local generic production of such drugs. That in turn should have negated the

cost-prohibitive argument entirely.

But

given the lucrative upper-income (mainly white) medicines market in South

Africa, the major transnational pharmaceutical companies quickly objected to the

Medicines Act. The country lost many thousands of people to curable

opportunistic infections while the legality of the patent violation clause was

contested in court. The often explicit threat was that if the Medicines Act

prevailed, the companies would disinvest from SA. Only late last year did the

firms put their opposition on hold, and that was only because another

extraordinary barrier to cheaper treatment of HIV+ South Africans was finally

overcome: Al Gore.

The

US vice president conducted a "full-court press"–in the words of a

rabid US State Department official bragging to Congress in a February 1999

report–against Mbeki to drop the "offending language" in the

Medicines Act. The pressure included various punitive trade and aid measures.

South Africa’s crime was not only its 1997 law, but also advocacy of similar

global provisions in the form of a mid-ranking health official’s 1999 speech to

the World Health Organisation.

Not

only did Gore directly assault South Africa’s ability to conduct economic

policy-making and cheapen vitally-needed medicines, he was now also attacking

the newly-democratized government’s freedom of speech in international fora!

Two

crucial reasons seemed to motivate Gore: the broad principle that US companies

with intellectual property rights should not concede any exception to their

product hegemony; and campaign contributions by major pharmaceutical firms.

In

a May 1999 report, The Center for Responsive Politics recorded recent bipartisan

gifts to politicians by Pfizer, Bristol-Myers Squibb, Eli Lilly, Glaxo Wellcome,

Novartis and five other firms: "Long one of the most powerful lobbies on

Capitol Hill, the pharmaceutical industry spent nearly $12 million in soft

money, Political Action Committee, and individual donations during the 1997-98

elections–a 53 percent increase over donations during the last mid-term

elections." Ralph Nader’s associates in the Consumer Project on Technology

also documented other close personal links between Gore and major pharmaceutical

firms.

Luckily

for HIV+ South Africans, a vibrant "Treatment Action Campaign" emerged

in 1999, held protests at US consulates in Johannesburg and Cape Town, and began

networking with the Consumer Project as well as with the Philadelphia core of

ACT UP. Activists pledged to dog the 2000 presidential campaign with banners and

in-your- face hits: "No Medical Apartheid!," "Gore’s Greed

Kills!" "AIDS Drugs for Africa Now!" Gore was confronted

repeatedly and aggressively in Tennessee, New Hampshire, California and

Pennsylvania at the very outset of his campaign. Numerous newspapers carried

front-page stories on Gore’s quandary.

Within

weeks, the vice president’s own Cost- Benefit Analysis showed the danger of

siding with the corpos, whose millions would not offset a campaign fiasco. In a

September 1999 meeting with Mbeki in New York, Gore conceded the validity of the

SA Medicines Act. With Thailand also making noises about obscene drug prices and

with tens of thousands of protesters in the streets, President Clinton agreed at

the Seattle WTO summit not to push for a harder-line TRIPS protection for US

pharmaceutical companies. (The firms reacted with promises of cheaper, though

not free, drugs, which in turn were spurned by activists as too little, too

late. When faced with the prospect of local production, drug companies changed

the subject by announcing offers of free medicine, which in fact have never

materialized.)

The

South African government then failed to take advantage of the space, as Mbeki

searched for excuses not to implement aggressive anti-AIDS strategies instead of

pursuing the parallel importation or generic production options. Indeed, so

retrograde was the recent backsliding that at the Durban AIDS conference last

week, maverick member of parliament Winnie Madikizela-Mandela accused her

government of being "an obedient servant of multinational companies that

continue to put their profits above our people."

According

to greatly-respected HIV+ activist (and acting SA Constitutional Court justice)

Edwin Cameron, in his keynote speech to the conference, "The drug companies

and African governments seem to have become involved in a kind of collusive

paralysis. International agencies, national governments and especially those who

have primary power to remedy the iniquity–the international drug

companies–have failed us in the quest for accessible treatment."

But

even if in retrospect it was pyrrhic, South Africa’s victory over Gore and his

corporate chums was especially sweet to activists because Mbeki had just three

years earlier discounted any such alliance. He approved official endorsement of

an ANC discussion document ("The State and Social Transformation")

which concluded: "The democratic movement must resist the illusion that a

democratic South Africa can be insulated from the processes which characterize

world development. It must resist the thinking that this gives South Africa a

possibility to elaborate solutions which are in discord with the rest of the

world, but which can be sustained by virtue of a voluntarist South African

experiment of a special type, a world of anti-Apartheid campaigners, who, out of

loyalty to us, would support and sustain such voluntarism."

Activists

in South Africa point to the Medicines Act’s drug-pricing challenge as precisely

such a "voluntarist experiment"–one that was indeed ONLY sustained

(to the extent it was) by virtue of heroic international campaigning solidarity.

It is all the more tragic, therefore, that just as the David-v-Goliath battle

against pharmaceutical companies–and Imperialism Central in the White

House–was won, Mbeki grabbed defeat from the jaws of victory and began his

bizarre questioning of the link between the HIV virus and AIDS. The broader war

against AIDS took a quick turn for the worse.

But

if the arguments above are valid, the fiasco unfolded not only because of

Mbeki’s mercurial personality, and won’t be resolved by a change of mind–or

even by ex-President Nelson Mandela’s closing exhortation on Friday to the

Durban conference that preventing mother-to-child transmission should be of

highest priority. Necessary as these personal interventions are, they are not

sufficient.

The

poli-econ of AIDS points out the need for a yet more profound struggle against

the underlying assumptions and characteristics of South African– and

international–capitalism.

More

details are in my new books, Elite Transition (Pluto Press) and Cities of

Gold, Townships of Coal (Africa World Press); and a 1999 article,

"Globalization, Pharmaceutical Pricing and South African Health Policy:

Managing Confrontation with US Firms and Politicians," published in the

International Journal of Health Services, v29, #4, pp.765-792.

(Oh,

and thanks much to Julie Davids and Paul Davis of ACT UP Philadelphia, my

houseguests last night, who helped with corrections.)

 

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