Can Victory On Aids Medicines Catalyse Wider Change?
A rare activist-driven win for some of Africa's wretchedly poor women, men and children leaves me humbled. In June 2002, I wrote a ZNet column-'Corporate cost-benefit analysis and culpable HIV/AIDS homicide'-in which the main prediction proved partly wrong within a few weeks. I have been waiting for a chance to correct the mistake. My error, excessive pessimism, was compounded by another event I would not have considered possible: the November 19 announcement that the South African government will now finally begin providing anti-retroviral (ARV) medicines to hundreds of thousands of people who are HIV+.
Activists hope that five million infected, who now account for more than a quarter of South Africa's adult population, will eventually get the desperately needed medicines, notwithstanding some practical barriers to implementation. Exultant relief was expressed by South Africa's Treatment Action Campaign (TAC), along with allies including ACT UP, Oxfam and Medicins sans Frontiers, which is running successful treatment pilot projects in Cape Town township clinics, where compliance with treatment regimes is higher than 90%.
TAC also restrained itself from launching protests against president Thabo Mbeki's extraordinary comment in late September to the New York Times: 'Personally, I don't know anybody who has died of AIDS.' In mid-November, the hated health minister, Manto Tshabala-Msimang, also revealed her reluctance to attribute AIDS to the HI Virus, just as she announced the medicines roll-out. In previous statements, she has termed ARVs 'poison.'
Given such attitudes, I didn't think Pretoria or its corporate friends would get this far along the path to civilised behaviour, this fast. For the chance to commit these errors, I am delighted, because far worse would have been to claim deadly accuracy.
My prediction was that at least three structural forces in South African capitalism would overwhelm the struggle capacity of AIDS treatment activists. Structure/struggle is always a dialectic, but it's wonderful to see history written from the bottom up, for a change. I will briefly rehearse the argument that I confidently made in mid-2002; some of that analysis is still valid, even if my main point-that the dynamics of state power and corporate profits tend to overwhelm progressive resistance-must be revised.
The first factor is the pressure exerted by international and domestic financial markets to keep Pretoria's state budget deficit to 3% of Gross Domestic Product. This pressure led Mbeki's spokesperson Parks Mankahlana (who died of AIDS three years ago) to remark to Science magazine in early 2000 that pregnant, HIV+ women would not be receiving Nevirapine to prevent mother-to-child transmission, because '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.'
Second is the multinational pharmaceutical corporations' interest in maintaining exclusive patents on ARVs so as to monopolize profits, profits which come from sales to wealthy markets, not low-price deals for Africa. As the actions of US Trade Representative Robert Zoellick prove, pharmacorp pressure remains intense, although some firms have offered cheap drugs, but mainly so as to head off the possibility of mass imports (or local production) of generics. To illustrate, staff at the Bill and Melinda Gates Foundation, which provides medicines to some African countries, certainly don't want to see the World Trade Organisation's protections on 'Trade in Intellectual Property Rights' undermined, for obvious reasons.
Third, South Africa's huge unemployed labor pool-more than 40% of the potential workforce-means that local capitalists can readily replace unskilled workers who start developing AIDS symptoms with desperate, jobless people. This is less expensive than providing medicines, with Anglo American Corporation's 2001 cost-benefit analysis demonstrating that only the highest-paid 12% or so of employees justified receiving AIDS medicines, given the cost of recruiting and training replacements at the higher end of the spectrum.
But within a few months, the calculus changed sufficiently for two of the largest employers in Africa, Anglo and Coca Cola. The main ingredient was protest-and in Anglo's case, I was reliably informed by insiders, the prospect of demonstrators at the August 2002 World Summit on Sustainable Development dragging up many other bits of dirty laundry. Coke's main bottler in South Africa has failed to insure two-thirds of its 4,000-strong workforce at a sufficient level to allow the HIV+ workers access to ARVs, and it too was subject to international protest over African AIDS policies.
However, even though the costs of HIV/AIDS-absenteeism, declining productivity, payouts for early death-have soared to as high as 25% of payroll, according to the Financial Times in a September 18 report this year, most employers are still hesitant to provide ARVs: 'Untreated, HIV typically takes four to five years to manifest itself as full-blown AIDS, and companies are reluctant to pay for a risk that they cannot seeâ€¦ Persuading managers to part with fees [AIDS treatment programmes] today for costs that will hit company earnings years down the line has been a hard sell.'
In sum, all three structural factors are still deterrents to provision of treatment, though each has been mitigated recently. The budget deficit will climb this year from just over 1% of GDP to nearly 3%, allowing extra leeway for AIDS spending. Pharmacorps are cooperating with the World Health Organisation, Clinton Foundation and governments to lower prices for Africa, in part because Canada's outgoing prime minister Jean Chretien-spurred by UN advisor Stephen Lewis-has introduced legislation to promote generics. And employers are waking up, in part because of the dramatic rise of AIDS related disability claims as a percentage of all disability claims, from 18% in 2001 to 31% last year.
What, specifically, was behind the November 19 Cabinet statement? Pretoria cited factors which included: 'a fall in the prices of drugs over the past two yearsâ€¦new medicines and international and local experience in managing the utilisation of ARVsâ€¦ [sufficient] health workers and scientists with skills and understandingâ€¦ and the availability of fiscal resources to expand social expenditure in general, as a consequence of the prudent macro economic policies pursued by government.'
However, these factors are, in my view, minor compared to intensive activist pressure, which Pretoria did not dare mention lest it encourage further protests. TAC's victory statement was explicit: 'The combination of the Constitutional Court decision on mother to child transmission prevention, the Stand Up for Our Lives march [of 15,000 people on parliament] in February, the civil disobedience campaign and the international protests around the world have convinced Cabinet to develop and implement an ARV rollout plan.'
Another factor, of course, is the 2004 presidential election, which Mbeki is expected to win easily but which will be characterised by high levels of apathy and no-vote campaigning by the Landless Peoples Movement. An AC Nielsen survey in November confirmed that Mbeki's AIDS policy is hurting the ruling African National Congress' chances of turning out the vote.
High visibility is an important antidote, and the Cabinet promised that 'within a year, there will be at least one service point in every health district across the country and, within five years, one service point in every local municipality.' In addition to medicines, the state will provide an education and community mobilisation programme, promotion of good nutrition and traditional health treatments such as herbal remedies, support for families affected by HIV and AIDS, and funds for upgrading health infrastructure. The current health system is massively overextended, with far too few essential medicines, much less ARVs, available in South Africa's underfunded rural clinics.
The programme's resources-US$40 million through March, rising to US$680 million per year in 2007-are all new (not drawn from existing allocations to social programmes. The cost of medicines will rise from 20% to 33% of the programme budget.
Will ARV availability generate negative unintended consequences? One would be noncompliance with treatment regimes by poor people, and the concomitant emergence of drug-resistant strains. Another would be the black-market smuggling of cheap drugs to Europe and North America which would reduce access in Africa. Another is that although stigmatisation will decline given the availability of hope-giving drugs, so too might the practice of safe sex. These are all major challenges to TAC and other health-sector groups.
The Cabinet also repeated one of Mbeki's tired truisims, namely that immune systems in townships and villages are 'assaulted by a host of factors related to poverty and deprivation.' In spite of a recently-published ten-year government review aiming to show increased delivery of old-age pensions and child support grants, there is no disguising the role of the allegedly 'prudent macro economic policies pursued by government' in creating poverty and inequality.
The conflict between neoliberalism and life was rarely as explicit as in the case of AIDS medicines, and was compounded by patriarchy, traditional and modern sexual practices such as multiple partners for men, and domestic violence against women. Rape continues at scandalous levels.
The TAC leaders, some of whom (like the brilliant activist Zackie Achmat) learned politics in highly vulnerable Trotskyist cells within the ruling party, are more than capable of simultaneously fighting capitalism, racism and sexism together. But a few other political choices may also become more urgent.
One relates to their alliances within South African politics, which have been effective in attracting the most forward-looking trade unions, the SA Communist Party, churches, NGO activists and technical supporters (lawyers, healthworkers, academics, journalists). Yet these alliances have not strayed far from the African National Congress.
Does TAC have sufficient linkages to non-ANC communities (especially those devoted to building the new independent left)? Will the myriad of problems that cause AIDS opportunistic infections-especially dirty water and air (thanks to coal/wood/paraffin)-also be addressed? At a time that the South African government is disconnecting water and electricity at a lethal rate, alongside evictions for those who cannot afford expensive rental and mortgage payments, addressing links between AIDS and diseases of poverty/homelessness are crucial.
This leads to another problem: will TAC and its allies make the case that access to ARVs is a human right and that people should not pay user-fees or partial cost-recovery for the medicines? They do make this case, but only in the event that people are too poor to pay for medicines. Yet 'means-testing' of black South Africans with irregular informal incomes is notoriously difficult. TAC may need to consider a more explicit 'free lifeline' strategy, as the water and electricity campaigners have done, partially successfully.
After all, I see TAC as integral to the overall politics of 'decommodification' and 'deglobalisation' that are so crucial to social progress across the world. To decommodify is to take that which is life-giving-our medicines and healthcare, water and a decent environment, clean energy, education and childcare, support for the elderly, even food and culture, as well as employment-and remove them from the market, as much as is required to ensure a lifeline access to all, on a universal basis.
Such socio-economic human rights can be won, in my view, only through deglobalisation, namely the delinking of countries and regions of the world from the bureaucratic straightjackets designed in Washington and Geneva-structural adjustment, TRIPs, etc-on behalf of corporate interests.
Nevertheless, whether or not TAC continues to tackle the three structural impediments to ARV access-neoliberal fiscal policy, pharmacorps and corporate control of health perks-the immediate victory will make a huge difference. For the half million South Africans who are symptomatic with AIDS or who have a CD4 blood count less than 200, there is now hope.
Across the world, for three million people who died this year of AIDS, this breakthrough has come too late. But for 40 million others infected, the treatment activists and their international allies deserve a standing ovation. Those who help Washington-based Africa Action protest Bush health policies on December 1, World AIDS Day, will gather strength from the South African breakthrough, and they will be louder and prouder than ever.