Change, Change, Change
People chant for change, yet some political observers say change in presidency is of over-rated importance. Nevertheless, the US electorate has basically thrown George Bush out in their excitement to welcome a new chief executive who promises change. For his part, Bush addresses the nation with familiar threats about the nation's security and citizens' well-being, delivered with alarmingly monotonic disassociation, as if drugged.
Anxious to move on, the voters gather their remaining hopes and dreams in bundles and strew these along the campaign trail like flower petals at the feet of the new king and they vie for the attention of the incoming administration. The electorate anxiously tracks the presidential campaign and chooses, gaffe by gaffe, who to entrust with their future.
But there is a certain mystery to this all. People clamor for change but most of them just want security -- to work in the day and scurry to safety back at the den for food and sleep and family; they want their hunger abated and to be warm. With their fundamental securities established, the gold watch of yore really was icing on the cake. Today many people can't count on a job or a home. The change people yearn for is to feel more secure.
Of course it's never that simple. US presidential candidates also court constituents who would like to be assured that the dinosaurs roamed around with the humans 5000 years ago and that there's no such thing as evolution. Preachers urge parishioners to vote according to the bible, which of course means no evolution, no modern social awareness that reflects new science knowledge, no change. Perhaps being able to read your future from The Good Book feels secure for it certainly promises no change. To these people McCain also paradoxically promises "change", as he embraces the religious right via Palin. Those mavericks.
Change in the US, Change in the World
The US population is not alone in being seduced by the "change" promised by new leaders. In South Africa last month, Thabo Mbeki resigned as he was being ousted from his post of the last eight years as president representing the African National Congress party (ANC). As the successor to Mandela, the West considered Mbeki a steady leader of a nascent democracy on a continent with too few democracies. The west did well by the president who advocated neoliberal policies and expanded the economy with predictable policies.
In Mbeki's place, the ANC installed Kgalema Motlanthe as the interim president until Jacob Zuma, the presumed future winner of the 2009 election and future president is elected into office. Zuma was the populist choice to lead the ANC and has strong support of unions and the Communist Party. He was imprisoned during apartheid and still revels in the glory of liberation movement, singing "Bring Me My Machine Gun" at gatherings.
Zuma's strong populist appeal and support from unions makes investors and middle class South Africans very nervous and so to them, he promises no change. But his populist message appeals to many voters who were disenfranchised under Mbeki. Mbeki's South Africa was a fragile economy which created glaring gaps between extreme wealth and extreme poverty. The Mail & Guardian wrote of South Africa's growing discontent with Mbeki:
"the mounting failure of the criminal justice system to prosecute and convict criminals, the increasingly disturbing nature of violent crime, burgeoning inequality and unemployment, the HIV/Aids catastrophe and the culture of impunity for corrupt and incompetent public officials."
Change is needed on South Africa's domestic front, and Zuma's message promises a forum for the poorer populations. But will Zuma deliver this change? And can his policies at the same time appeal to international investors the way Mbeki's did?
Barbara Hogan, New Minister of Health for Africa
Before Zuma_The_Unnerving takes office, there is a chance for interesting, perhaps positive and real change in the form of the new interim government of Kgalema Motlanthe. Motlanthe has already appointed a new Health Minister, Barbara Hogan, to replace the infamous "Dr. Beetroot" -- Manto Tshabalala-Msimang -- who ably and stridently propagated Mbeki's AIDS denialism. Dr Molefi Sefularo is the new Deputy Minister of Health.
The proactive organization Treatment Action Africa (TAC) and the AIDS Law Project, along with many others both inside and outside of Africa -- scholars, public health communities, researchers and NGOs around the world -- have embraced the new choice for Minister of Health. TAC and the AIDS Law project joined to serenade Hogan at her Cape Town flat last Friday, toasting her appointment with champagne. Her neighbors wondered what all the ruckus was about, then joined the party. TAC expressed their opinion of Hogan on their website:
"We are confident that Hogan has the ability to improve the South African health system. She has been one of the few Members of Parliament to speak out against AIDS denialism and to offer support to the TAC, even during the worst period of AIDS denialism by former President Thabo Mbeki and former Health Minister Manto Tshabalala-Msimang. 0n 14 February 2003, she received the TAC memorandum to President Mbeki for a treatment plan. She was removed as Finance Portfolio Chairperson by Mbeki in part for her stand on HIV/AIDS. She has a reputation for being hard-working, competent and principled."
The new minister has her work cut out for her. Various groups clamor that she should work to clean up the "rot in public hospitals", to "protect us from toxic foods", and to intervene and uncover the truth beneath the secrecy surrounding "tragic deaths of 142 babies in the Eastern Cape" at Frere Hospital. They ask that Hogan stop the brain drain of medical personnel in South Africa and restore confidence in the public health system.
In an interview with News24 radio last week, Barbara Hogan acknowledged the amount of work that needs to be done in her new post as Minister of Health and warned that with such a short tenure she can only focus on a couple of things. Top of her list was the "morale of healthworkers" and revamping healthcare to a "system that is functional and responsive to people who are using it". Hogan said the "biggest challenge is HIV/Aids and all the strains that it places on the health system." None of these seem like low-hanging or modest, easily achievable goals for Hogan's short tenure, nevertheless, she seems sincere, which is why there is so much hope.
Change You Can Believe In?
However last week the science journal Nature cautioned in Nature News that a new law passed by the South African parliament may hamper the country's adoption of more progressive HIV policies. ("Incoming South African health minister raises hopes on HIV" (doi:10.1038/news.2008.1138))
The law creates a regulatory authority (South African Health Products Regulatory Authority (SAHPRA)) which will oversee all medicines including "medicine, medical device or cosmetic in respect of which a medical claim is made". The Minister of Health will become the final arbiter of which drugs get to market according to criteria that includes nebulous goals like "public interest", the experience of other countries, and consideration of whether the product is "supportive of national health policy goals". The agency is not independent, rather its under the thumb of the Health Minister.
The previous Minister of Health had had run-ins with the former science based drug regulatory agency, so the law seems tailored to Manto Tshabalala-Msimang's reign and Mbeki's intense suspicion of Western pharmaceuticals. As Nature sees it, the concern is that the new bill gives the new minister "sweeping authority over the approval of new medicines and a remit to regulate traditional medicines alongside of conventional pharmaceuticals", Considering all the enthusiasm for the new Health Minister, Nature's observation seems almost ill-conceived. Or does it?
Mbeki's Legacy
Hogan has a lot of obstacles to overcome with the standard Mbeki set for public health. When he emerged from prison after apartheid with strong ideas about African solutions. The growing HIV/AIDS epidemic must have seemed cosmically unfair as the nation finally sloughed off apartheid. AIDS treatment is costly, especially for a country with a fledgling public healthcare system. Yet rather than approaching the national crisis head on, Mbeki for years refused to acknowledge that HIV was the viral cause of AIDS. As a result, according to the Mail & Guardian, "Death certification by Stats SA shows more than 1.5-million deaths in the ages 0-49 and more than two million new infections during his rule." Now, almost 30% of pregnant women in antenatal clinics screen positive for HIV and best estimates show that approximately 50% of patients with Stage IV AIDS who need AIDS drugs, do not receive anti-retroviral treatment (ART).
Throughout his tenure, Mbeki steadily dragged his feet on the HIV/AIDS crisis. He juggled the tensions of his mixed world-view -- his South African heritage, his survival during apartheid, and his education as an economist in Europe. He mixed up neoliberalism, anti-colonialism, and crony politics, and ended up intensifying public unrest during his tenure as his policies created increasingly stressful social conditions. These tensions were apparent in the long, oblique letters he wrote to the citizens published by a weekly newspaper and at the website of the African National Congress (ANC). Here he spent considerable energy trying to diffuse serial national outcries.
Last year Acronym Required wrote about Mbeki's mini-skirt memo, in which he took the media to task for their criticism of the infant death cover-up at the Frere Hospital in Eastern Cape. At the time of that August 2, 2007 memo, Mbeki had just fired the assistant health minister Nozizwe Madlala-Routledge who had been addressing the AIDS crisis and who had devised an HIV/AIDS strategy while she stood in for Manto Tshabalala-Msimang. Tshabalala-Msimang had received a liver transplant and newspapers were reporting that she was a heavy drinker before and after the transplant, had skipped the organ donor cue, and was abusive to hospital staff during her transplant operations.
Mbeki addressed the outcry of the public health situation again in his 6000 word August 31, 2007 memo. The memo shows his cunning ability to twist the facts around, to say first one thing, then the opposite. He accused anyone who criticizes Manto Tshabalala-Msimang (("cadre of the revolution") of being a traitor or weakling:
"...some, at home and abroad, who did nothing or very little to contribute to the immensely difficult and costly struggle to achieve our liberation, have chosen to sit as judges over who she is, what she has done for the welfare of our nation, and what she represents, today, with regard to the pursuit of the goal of a better life for all our people."
He defended his administration's handling of HIV/AIDS and railed on national and international papers for questioning his stance, including The New York Times, BBC and The Guardian. He eviscerated all media for distorting his and Manto Tshabalala-Msimang's position on nutrition as it relates to AIDS:
"Manto Tshabalala-Msimang's mortal sin in the eyes of our opponents, in which regard she has faithfully represented the convictions of the ANC and the ANC directive to those we had deployed in government, is that she upheld this view, insisting that it must constitute an important and integral part of our national response to the serious challenge of HIV and AIDS....they [her critics] will continue to do their best to denigrate a principled fighter for a democratic, non-racial and non-sexist South Africa, who has dedicated her entire life to the achievement of this outcome, Dr Manto Tshabalala-Msimang, whom history will honour as one of the pioneer architects of a South African public health system constructed to ensure that we achieve the objective of health for all our people, and especially the poor."
His extensive rationale for promoting nutrition to help prevent AIDS included citing the judgment of everyone from small babies to Romans, all who he claims understand, as he does, the importance of nutrition.
"they [the critics] have deliberately falsely presented the arguments of our Minister of Health about the known nutritional (and micro-nutrient) value of olive oil, lemon, beetroot, garlic, and other foods, as well as the efficacy of traditional medicinal prescriptions based on herbs and other natural plants, as an argument against the use of modern drugs and medicines, including antiretrovirals (ARVs)."
He wrote that the media and critics contorted his message to represent that he proposed nutrition and opposed ARV's. Mbeki criticized the national Cape Times for reporting the Minister of Health's own words:
"Nutrition is the basis of good health and it can stop the progression from HIV to full-blown Aids, and eating garlic, olive oil, beetroot and the African potato boosts the immune system to ensure the body is able to defend itself against the virus and live with it."
He didn't deny that Manto Tshabalala-Msimang said that, but recruited to his side a doctor who wrote in a letter to the editor that good food bolsters the immune system. Mbeki quoted the doctor, then re-established his party's position: "It is our sustained opposition to the fundamentally wrong proposition that in our response to HIV and AIDS we must rely almost exclusively on ARVs." He added that because of "our poverty", the country had "fallen victim to three pernicious influences", as he put it:
"One of these is the medicalisation of poverty. Another is the politicisation of disease. The third is the commercialisation of health care, in all its elements. As a revolutionary movement we have fought against all these, and must continue to do so.
Mbeki recruited the US as an ally for his position:
"US Secretary of Health Mike Leavitt had the courage and honesty to acknowledge this reality, fully understanding the need to respond to the health needs of our people, liberating our health care obligations from the dictates of partisan political and commercial interests."
Secretary of Health Leavitt, who now has his own disapproval to face on a controversial contraception bill, unsurprisingly didn't mention anything about "liberating South African from commercial interests" on his blog back in 2007 when he visited South Africa.
Mbeki managed to play all angles in his August 31, 2007 memo. He bragged about the excellent modern health care system, describing at length the surgical excellence and technology afforded to the Minister of Health during her liver transplant. Meanwhile his administration was busy covering up the Frere baby death scandal and mounting evidence of a failing public health care system. He accused anyone who complained about Tshabalala-Msimang of being either a traitor, someone who wanted to see South Africa fail, or someone who would "have allowed Manto Tshabalala-Msimang to die." He accused the media and any critic of misrepresenting the ANC's position on AIDS drugs vis a vis nutrition. Then he defended the importance of nutrition to the immune system and his government's advocacy of nutrition in AIDS, recruiting to his side a letter to the editor and the US Secretary of Health.
Neoliberal Economic Policies or Public Health -- One or the Other?
Despite outcry from the international public health community for his AIDS policies, Mbeki built relationships in the West because of his adherence to neoliberal economic policies. He welcomed foreign investment and freed up capital from the demands of deteriorating infrastructure in order purchase goods abroad and foster national participation in the world economy. Supporters from the west, including many consultants, would argue that Mbeki made progress with his motions to rebuild shantytowns and provide better healthcare. They will point to Zimbabwe, which roils at South Africa's northeast borders, and note that similar unrest that could just as easily overflow into S. Africa -- as it recently did. Some of these business leaders talk about the new struggling capitalist economy and say -- 'isn't it obvious? Public health just couldn't be the highest priority with the economic stakes so high'. People are apparently able to look past the charges against Zuma, for extortion, for reportedly having unsolicited sex woman who had AIDS, among other charges, and see someone who's "change" promises more security.
In the meantime, will the interim government and Minister Hogan be able to balance international economic pressure for open markets with the yawning gap in public healthcare and carry through her stated mission? Were Mbeki and Manto Tshabalala-Msimang merely carrying out the demands of the ANC as Mbeki always emphasized? Will party politics of the ANC to which Barbara Hogan is so loyal to allow reform? Or will the ANC continue to let laggard public health policies associated with Mbeki's reign prevail? Or will the ANC give the people reason to trust in the ANC and reason to hope -- as they did during the short tenure of Nozizwe Madlala-Routledge, before Zuma takes office? Can you grow a liberal state without tending to the population's basic needs for shelter, security and healthcare? Will change really come to Africa's public health system? We remain hopeful.
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Acronym Required previously wrote on this subject in these posts:
"Mbeki's AIDS Legacy and Ours"
"South Africa: Peddling Beetroot, Courting AIDS"
""Not in Paradise Anymore - AIDS in Africa - Reason for Optimism?"
