Health hazard / AIDS

Paul Farmer reveals how the
President of South Africa broke the
AIDS establishment’s inequality taboo.

Travelling from rural haiti to Durban was instructive to say the least. To my eyes – and I grew up in Florida – Durban looked a lot like Fort Lauderdale. But as President Thabo Mbeki pointed out, there are several Africas in South Africa, and I knew that hard-by its glittering seaside towers were slums to rival those seen elsewhere on the continent. And it is there, in these poor and often transient communities, that HIV is now exacting its heaviest toll. Certainly, there are white South Africans with AIDS; I met some of them. But HIV incidence varies dramatically across South Africa’s social divides. Here, as elsewhere, AIDS is a disease of the poor. In South Africa, the poor are disproportionately black.

Peter Barker / Panos Pictures

Mbeki was the featured speaker of the opening ceremony of the thirteenth AIDS conference in Durban, which drew over 12,000 participants. Much of the ceremony was rather embarrassing: it reminded me of my own culture, since it was far more Hollywood – or perhaps Las Vegas – than Africa. Oh, there were drums, and all that, but it was a made-for-television event with singers in sequined gowns and breaks for station identification.

Mbeki makes several sound points, and compares favourably on AIDS policy to many heads of state. But we can’t hear what he has to say because of the torrent of abuse that his views have drawn. One of the reasons I went to South Africa was to hear the man for myself.

There are so many AIDS-related debates that one is tempted to create an acronym, ARDs, and look for subtypes. There are pressing ARDs: How do we bring effective therapies to the destitute sick, wherever they live? How do we improve prevention for the most vulnerable? How might we develop a truly protective vaccine? Most people living with HIV are to be found on a single continent; so ARDs involving Africa always deserve more than passing notice.

Little wonder the excommunication of Thabo Mbeki drew my attention. I’ve found myself in conferences in which friends of mine, fellow AIDS specialists, go practically purple with rage when discussing Mbeki. One colleague accused him, in a very public forum, of genocide. Don’t get me wrong: I am not in the business of rushing to the defence of heads of state. But let’s look at The Mbeki AIDS Controversy as if we were dispassionate sociologists of knowledge.

Heresy Number One:
Peter Duesberg
Last year, with HIV incidence rising rapidly in South Africa, Thabo Mbeki’s Government pulled together what Americans call a ‘blue-ribbon panel’. Most of the 30 people Mbeki recruited were AIDS specialists, but one was the US biochemist Peter Duesberg. This was Heresy Number One: Duesberg claims that HIV is not the etiologic agent of AIDS. Duesberg’s theories find their main audience far from the scientific and medical communities, but this hardly means they have ‘popular’ support. As an infectious-disease doctor dealing with HIV I know that physicians regard Duesberg as hardly worthy of note, and their poverty-stricken patients have never heard of him. Among AIDS specialists, Duesberg is regarded as either a bête noire or a crackpot, and irrelevant to the job of treating patients or developing vaccines.

So the choice of Duesberg was unfortunate. But surely Mbeki was surprised by the vehemence of the response. Even Bill Clinton entered the fray. But let us look at the substantive contribution of South Africa’s Government to the welfare of its citizens now suffering from, or in danger of acquiring, HIV. Are Mbeki’s AIDS policies any less well-intended, any less compassionate, than those of other African or Southern states? Not really. Indeed, if anything has curbed post-apartheid South Africa’s investment in social services, it has been outside advisers from the International Monetary Fund, the World Bank and other ‘Western’ advisers – the same lot, often, that deride him for his AIDS policy. Indeed, in acquiescing too speedily to economic counsel from such quarters, Mbeki may have had a more adverse impact on HIV prevention than any misguided choices in constituting his AIDS advisory board.

Heresy Number Two:
Defying the drug companies
Mbeki failed to make AZT universally available for HIV-infected pregnant women, an unfortunate piece of budget-cutting, but certainly nothing new in the heavily indebted countries of the South. He and others in his Government called for lower prices for antiviral therapies. They also called for less toxic formulations and evidence of effectiveness. Some went further – let us make our own AZT. There was much talk at Durban about parallel importing and generic production. These are subjects that had not figured much in previous AIDS meetings – sponsored, let us not forget, by the pharmaceutical industry. Playing with the price and supply of patented drugs was definitely heretical.

Jorgen Schytte / Still Pictures

Was it now possible to harness existing hostility to Mbeki to assail this new and greater heresy, the local production of lifesaving drugs? There were loud declamations from the pharmaceutical industry and the US Government about violation of international trade agreements and a ‘rogue state’ approach to patent laws. So ANC apparatchik Thabo Mbeki, who consorts with communists and who questions the logic of capitalism – at least as far as the diseases of the poor go – was made an international pariah.

Six years after the end of apartheid, it’s jarring to hear the head of the ANC classed as a hazard to humanity. ‘Genocide’ is an atrocious label for such mild infractions as Mbeki may have committed. He has never denied that HIV is the etiologic agent of AIDS. He knows a good deal about the complexity of disease distribution and outcome in a post-apartheid South Africa in the thrall of neo-liberalism. Mbeki is no dabbler. He led the new South Africa’s first task force on AIDS and was far more engaged in AIDS-related activities than Mandela ever was.

So what did Thabo Mbeki say in front of a large crowd of mostly white, mostly foreign researchers, doctors and AIDS activists in Durban? Mbeki’s message was this: poverty and social inequality serve as HIV’s most potent co-factors, and any effort to address this disease in Africa must embrace a broader conception of disease causation. This is precisely the point many of us have tried to make, and though our views have not always been welcome, we haven’t been branded as AIDS heretics. And Mbeki consistently referred to the disease as ‘HIV/AIDS,’ clearly making the connection between the virus and the syndrome.

Sitting to my left and right were two of my favourite medical students, who had come all the way from Harvard. ‘Did the man say HIV or did he not?’ They agreed that he had. They also heard him suggest that a globalizing economy that condoned such dramatic differences in life expectancy between rich and poor was a central part of the AIDS problem.

Heresy Number Three:
The inequality taboo
But the deciding factor couldn’t be poverty alone: after all, Mbeki’s country was one of the wealthier ones on the continent. Other factors must be involved. I looked around the crowd while some sort of Cirque du Soleil act was passing diaphanous streamers over people’s heads. The toughs up in the cricket stands – the local crowd had been let in after the best seats were filled – stared down in stony silence. I knew that many of my colleagues there had written about ‘local cultural practices’ accounting for increased HIV risks among black, but not white, South Africans. Most such claims were splendidly undersupported by serious research. Mbeki’s comments about social inequality struck me as far more relevant. Inequality was built into this very conference, yet the topic itself was clearly unwelcome. The glossy conference programme assured participants that medical care is ‘readily available in South Africa’ and that the water was potable. But in the same setting it was confidently proclaimed that using antiretroviral therapy in Africa was ‘not cost-effective’, ‘not sustainable’, ‘not appropriate technology’. White South Africans with HIV, at least the ones I met, were receiving more or less the same care as my patients in Boston. It was the poor black South Africans living with HIV who were shut out from medical progress in the name of ‘cost-effectiveness’. In comparison, much of what Mbeki said sounded like common sense.

By the next morning, it was clear that the rest of the world did not agree. Paper after paper in the United States and Europe ran headlines about Mbeki’s terrible speech. The New York Times was displeased that Mbeki ‘opened this conference on Sunday night with a speech in which he described extreme poverty, rather than AIDS, as the biggest killer in this country’. The St Louis Post-Dispatch offered a completely incoherent commentary, noting that: ‘Mr Mbeki has seized upon the discredited idea that African AIDS deaths are really caused by traditional diseases like tuberculosis compounded by malnutrition and poverty.’ Most Africans infected with AIDS do in fact die of tuberculosis, a disease of poverty.

Meanwhile real AIDS issues go unnoticed. According to one recent scholarly study: ‘Somewhat surprisingly, towards the end of the second decade of the AIDS pandemic, we still have no good evidence that primary prevention works; there is a need for randomized controlled trials of primary prevention packages.’ This should have triggered the mother of all ARDs. Billions are spent on AIDS prevention, but there is no solid data to suggest it has worked where it is needed most: among the poorest.

But no. The AIDS community was busy focusing on Mbeki.

What about research suggesting that migration triggered by internationally mandated economic restructuring (often termed ‘structural adjustment programmes’) might increase risks of HIV infection among, again, the most vulnerable? Shouldn’t this link have alarmed the architects of AIDS-prevention policies, so focused on changing individual behaviour? No, these hypotheses did not trigger knowing smiles at cocktail parties. It was the Mbeki heresies that dominated the whole bandwidth of attention.

Despite the furor, what Mbeki says will little alter rates of HIV transmission. Surely it would be easier to argue that labour policies the practices of De Beers diamond mines, and the programmes of the International Monetary Fund are more tightly tied to rates of HIV transmission than some imputed ‘culture of denial and confusion’. Clearly, much more should be done to stem the HIV/AIDS pandemic in Africa. More and better prevention strategies are needed; a vaccine protective against the African variant of HIV is urgently needed; therapy of active HIV disease, with antiretroviral drugs, is long overdue, as is effective treatment of opportunistic infections, including tuberculosis. So what does the Clinton administration propose? Loans with which African nations could purchase US pharmaceuticals. And the loans didn’t even carry terms as favourable as those offered by the World Bank. Mbeki, a trained economist, turned Clinton down.

So far, few AIDS specialists of any stripe have come to Mbeki’s defence on the issues of debt relief, parallel importing of drugs, or the need to redistribute resources in favour of the world’s poorest. Few agree that the priority is for vaccine development for the African variant of HIV. Fewer still acknowledge that Mbeki’s comments on AIDS causation are less heretical than many would have us believe. There’s no need to excommunicate the man for pointing out the obvious – that inequality is the major co-factor in this epidemic, as in most epidemics. And that inequality’s origins are neither fated nor mysterious.

helps run a rural clinic in Central Haiti and is associated with Harvard’s Program of Infectious Diseases and Social Change. His most recent book is Infections and Inequalities. [email protected]