A Political Economy of South African AIDS
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).
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."
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
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.
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.)
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."
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.
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."
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.)
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.
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.
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.
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.
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"?
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.
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.
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.
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.
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
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.
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.
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.
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.
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!
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.
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
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.
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
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."
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."
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."
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.
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
poli-econ of AIDS points out the need for a yet more profound struggle against
the underlying assumptions and characteristics of South African-- and
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.)