When South Africa's president Thabo Mbeki fired deputy health minister Nozizwe Madlala-Routledge for "insubordination" in late July, the government took a step backwards in dealing with that country's Sisyphean battle against AIDS.
A Legacy of Death
5.41 million people in South Africa are afflicted with AIDS, more than any other country in the world. Two million people have already died. The staggering death toll is testament to government decisions -- decisions to deny the virus existed; to question the viral connection between HIV and AIDS; and to refuse to use drugs to treat patients. Death is the price people pay when governments denying science.
Last year it seemed like this deadly precedent might be reversed when Nozizwe Madlala-Routledge took over for health minister Tshabalala-Msimang, who became sidelined with health problems due to liver failure.
The newly assigned Deputy Health Administrator Madlala-Routledge acknowledged that the African government had "been in denial at the very highest levels" and concertedly attacked the problem. But suddenly this summer Mbeki ousted Madlala-Routledge, and the reportedly alcoholic Tshabalala-Msimang, who has denied AIDS patients drugs with such fervor that she's been labeled "Dr. Beetroot", lunged back into the picture after being medically revived (at least temporarily) with a transplanted liver.
South African papers covered the news of the changing Health Minister situation intently, as did many international papers. News editors expressed well-founded foreboding about the effect the sacking of the effective Routledge might have on South Africa's revived AIDS campaign. The New York Times devoted an editorial to the issue, "Firing an AIDS Fighter" (August 18, 2007), predicting: "Unless [Mbeki] finally starts listening to sensible advice on AIDS, he will leave a tragic legacy of junk science and unnecessary death."
This seems like rational sounding warning from the NYT, about some future "tragic legacy". However Mbeki has been subjected to such warnings, such "sensible advice" for years, from South African AIDS patients, activists, international news media, very active local media, scientists around the world, government diplomats, rock stars, former and current U.S. presidents, and NGO's. He has been the recipient of gold bullion advice on AIDS ever since he took over the Presidency in 1999. Yet despite the abundant counsel, advice, warnings of future tragedies, the AIDS crisis in South Africa has gathered momentum while Mbeki continued denying the most basic science. The link between HIV and AIDS, for instance, which for years he denied, is established in hundreds of research papers and everyone in public health.
Public health advocates recognize that successful AIDS campaigns happen in states where at the highest levels of government coordination of treatment and prevention strategies is initiated, funded, supported, and given significant public relations effort. So it's of fundamental importance that Mbeki's government distracted and derailed any concerted strategy that could have stanched the epidemic; his South African government exacerbated the crisis.
Mbeki has proven over and over again that he will stubbornly support junk science rather than endorse "foreign" treatments; come up with a viable prevention plan; or lead his dying countrymen out of the ongoing crisis.
The New York Review of Books reported in July, 2000 that Mbeki accused pharmaceutical companies of being "marauders of the military industrial complex who propagate fear to increase their profits". For this reason, he denied newborns and mothers access to nevirapine and AZT.
Mbeki raised hopes both within and outside of his country when he (perhaps strategically) verbally supported anti-retroviral treatment for citizens in 2003, shortly before his 2004 re-election. But subsequently he assigned Health Minister Tshabalala-Msimang to be the voice of his unpopular anti-AIDS ideology. She proceeded to warn people off anti-retrovirals, suggesting instead garlic, sweet potatoes, beetroot, and lemon antidotes. Her ideas earned her the label "Dr. Beetroot", but although she has been criticized intensely, public opinion has not swayed her denialism. As for Mbeki's opinion on the matter, the two are revolutionary compatriots, and the Health Minister's actions against South African citizens seem to win his undying support.
Sketchy, Homegrown Alternatives
In the meantime, while slandering pharmaceutical companies, and pushing publicly supporting "natural remedies" Mbeki pursued his own sketchy homegrown solutions to the AIDS crisis. His government is linked to the development of Virodene, a chemical containing a dry cleaning solvent, for the treatment of AIDS. South African company founders were accused by Tanzania of running unauthorized clinical trials in a military hospital before the government of Tanzania rounded up and forcibly removed the founders and their trials from the country. But the company and its dubious claims and secret clinical trials still exist.
In another unorthodox drug development plan, tax dollars funded Enerkom, an affiliate of South Africa's state energy company, along with the University of Pretoria, to produce a coal derivative called Oxihumate-K. Patients received Oxihumate-K in little black pills that the makers claimed bolstered the immune system. The pills apparently contained dangerous levels of chrome, but were tested just like Virodene in controversial clinical trials at the same hospital in Tanzania. Soon after the trial was halted by Tanzania, South Africa auctioned off the company and its proprietary formulas, for a substantial loss born by the taxpayers.
Why Then, Do We Still Ask What South Africa Doesn't Understand About AIDS?
We note that the New York Times' did write an editorial about the dismissal of Nozizwe Madlala-Routledge, "Firing an AIDS Fighter" at a time when many other papers didn't write anything, and when public interest in AIDS is flagging. Also to note, throughout the years, the NYT has devoted significant coverage, hundreds of articles, to all aspects of the AIDS crisis. But despite their collective attention and wisdom of the situation, the writer of the recent August 14th editorial dared only to ask weakly : "What is it about South Africa's devastating AIDS epidemic that President Thabo Mbeki just doesn't want to understand?"
Seven years ago, in 2000, Mbeki's stance on AIDS might have more reasonably been considered mystery. But then their take in "Comments on AIDS Weaken Mbeki" (November 1, 2000), sounded not very different than their recent August editorial. Seven years ago, they wrote:
"The real question now may be how seriously he has damaged himself....Mr. Mbeki has often been his own worst enemy, repeatedly disregarding the advice of his government's doctors and seemingly oblivious to the impact his statements were having on efforts to prevent the spread of the virus.
Perhaps those who haven't followed the AIDS crisis in Africa would say this is a good question-- what he doesn't he understand? But we know Mbeki's history now, so its strange that the NYT, and by extension the US seems so chronically puzzled about Mbeki. Or perhaps their just little flat-footed.
The Tragedy of the "No Offense Doctrine"
South Africa, on the other hand, has had no choice but to wake up quickly to Mbeki's politics. On May 16, 2000 when the South African president was planning to visit the U.S. to brief President Clinton on his ideas about AIDS learned from American AIDS denialists, the Washington Post wrote an article titled: "Mbeki vs. AIDS Experts; S. African's Radical Views on Epidemic Baffle Allies". While they described AIDS "experts" as "baffled", here's what the Washington Post wrote about the AIDS situation as it afflicted children whose disease could have been prevented with AZT:
"We have 600,000 children admissions each year," said Gray [the perinatal unit at Baragwanath Hospital in Soweto's] director. "Forty percent of those children are HIV positive. We're spending a lot of time and resources every day dealing with something that is almost preventable."
She paused. "If they're not going to provide us with AZT," she said, "then the best thing that the government can do is to ask us to strangle them all at birth."
So we're left to wonder, why the understatement in the most recent August NYT editorial? Why the kid glove treatment given the scope of Mbeki's malfeasance? Is it Mbeki's charm, his pivotal position in Africa, our ambivalence, our implicit acceptance? endorsement? of his solution?
In another article in the New York Times "Mbeki's Visit To U.S. Puts AIDS Activists In a Quandary" (May 21, 2000), the Times wrote that the United States government itself may be dictating the diplomatic strategy of muting criticism about AIDS:
"...activists and those who treat AIDS are wondering how to greet Mbeki. Most seem to have decided that the best offense is to give no offense, an approach that they say is being counseled by the Clinton administration."
This "no-offense" diplomatic approach seems like a policy that's still being embraced. Mbeki once claimed that he knew no one with AIDS. Everyone scoffed. But European, Canadian and North American patients generally have access to life-prolonging AIDS drugs. No one in the Western world ignores the disease when it effects their citizens, only when it effects poorer countries. Perhaps we are all rather like Mbeki in a way -- knowing of no such AIDS crisis.
Am I being unduly cynical. Most people, of course, will recognize that AIDS is a pandemic or pandemics, a global problem. But why then are we writing editorials couched so as to "not offend"? With two million people dead in South Africa, who do we fear we will offend, exactly?
AIDS on a Distant Planet
AIDS often seems like a far away problem, not our problem. Thomas Friedman wrote in his book "The World is Flat", that he actually "knows the world isn't flat". He then described four groups of people who inhabit the "Unflat World". Among the unfortunate, he wrote, are those who are "sick" who inhabit "...communities in the grip of HIV/AIDS, malaria, tuberculosis, [who] simply can't plug and play into the flat world."
You have AIDS? Or rather you "inhabit" a community in the "grip of HIV/AIDS"? Bummer, you can't "plug and play". Granted, the book is a primer for global business, a compendium of catchy phases for busy people. Nifty labels like the "The Dell Theory", update "The Golden Arches" from his previous ode to business. We acknowledge that it's not book dedicated to an analysis of public health policy. Thus "plug and play".
But which is it? If the world is flat, and the "playing field" for business "level", how does this unfortunate "unflat world" even exist? How do flat world people manage to saunter unaffected past the vast ghettos of Mumbai, or the 5 million people who have AIDS in South Africa?
Friedman says we should objectify this other world, take a glance at it dispassionately running past the newsstand, perhaps. Do we view it like we look through a telescope at some distant moon on a planet eons away, some faraway place where the vagaries and violence of global warming, dust storms, crime, terrorism and pandemic disasters play out?
We may indeed live this dichotomy. We may believe, as Mbeki once said, that AIDS is just a problem of poverty. He's is right, of course, poor people do die from AIDS. Wealthier ones often don't and this may explain the SA president's laser focus on trade rather than AIDS treatments. But Mbeki's statement could be taken a number of ways, well-meaning and realistic, or far more sinisterly. Diseases stemming from what can be labeled as "poverty" give we who live in well-off countries a sneaky excuse to accelerate wealth making policies that benefit "us", and to not care about those who, oh shucks, can't "plug and play". Can't "plug and play" yet, we perenially promise.
But can we peacefully assure ourselves that this option, ignoring the issues, is a livable solution? Will our insurance rates will go up after the next Hurricane Katrina? Will we someday be forced to flee our home after the next 9-11? Will our portfolio will take a dive because of a subprime lending scheme on the next continent? When will we receive a call from the airline informing about the man sitting next to us flying from Paris who had multiple drug resistant TB? Oh, you only fly charter planes? Then it was the witty fellow who spoke at your conference, or the woman who ate the chicken cacciatore and green beans amandine while sitting across from you at conference table L24...And when can you come in and get tested -- sir?
Aside from flat world ditties, we should care about issues like pandemics that seem far away if not out of altruism, then because they threaten our personal economics and health. HIV/AIDS is costly to prevent and treat, but more costly to ignore. Prevention and treatment are uphill battles, but the cost of not confronting the problem leaves 20-40 year old populations in many sub-African countries decimated from death and disability. South Africa's wealth demands that it to do better then let working age adults who could be contributing to national economies just die. Children left parentless may not have food, get an education, or find a job. Not only will they not fulfill their potential, they may not even live to be adults. In a humane global economy this is our loss.
What We Don't Understand About AIDS: It's Our Legacy
The AIDS crisis is a complicated set of problems intertwined in confusing ways, never to be resolved perfectly. It's not only a medical crisis but also a compilation of history, funding, international attention and talking points.
AIDS has been isolated as it's own issue for the sake of public awareness and fundraising. So when Mbeki said that deputy health minister Nozizwe Madlala-Routledge was fired, purportedly for attending an international AIDS conference in Spain, the reaction from the those who work on this "issue" was reflexive. Media condemnation was similarly reflexive, because this is our custom.
But as I have outlined, "what doesn't Mbeki understand" isn't the right question. The South African president earned a Master's of economics and is by all accounts very intelligent. The South African stance is one of a country that understands AIDS fully, but is making economic choices that don't allow an option of "redistributing wealth" to AIDS patients. Or perhaps Mbeki shunned foreign pharmaceutical companies because of his "African Renaissance" philosophy. Or maybe defiance still seems like the only path. We don't know. But when all of us ask, over and over and over again, "what doesn't Mbeki understand?", we should acknowledge that there's no knowledge barrier holding up progress on South Africa's AIDS crisis. Rather the economic system that we embrace objectifies life and death in ways that we're not accustomed to nor comfortable confronting.
What we should be asking is what is it we don't understand about the South Africa's AIDS crisis that compels us to keep asking the same questions? Or, why are we asking softball questions that we know the answers to? Or, how do our habits of asking the same questions about AIDS over and over again as the decades pass us by ease our consciences, fulfill our editorial duties? We should be asking, what do dying people look like?
Mbeki has successfully put-off doing anything about AIDS for years. That may be his legacy. But AIDS is well-established global catastrophe that citizens in wealthy countries often turn our backs on. This is our legacy.