... and by people (at least in Pretoria) who are deeply suspicious of fiscal laxity, of offending int'l capitalists, and of overpopulation in a permanent labour-surplus economy ... and thus turn to solutions to these dilemmas by using the wacko AIDS-dissidents' theory to justify killing tens of thousands each year (I kid you not):
(oh, apologies if I've posted this already on lbo-talk, but an update may be of interest: late last year Mbeki's mouthpiece, Mankahlana, died of AIDS -- but on this too, the ANC leadership chose denial, causing a furore because, in comparison, Musoveni and Kaunda at least admitted the scope of the pandemic and didn't hesitate to personalise it, so as to destigmatise AIDS, as leaders ought to)
A Political Economy of South African AIDS ZNet Commentary, 17 July 2000
by Patrick Bond Johannesburg, South Africa
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).
Explains 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."
The 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 inhibiting prevention.
As 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.
But 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.)
Beyond 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."
If 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.
Let's 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."
(Mankahlana 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.)
The 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.
Mankahlana 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.
But 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.
Second, 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.
Third, 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"?
A 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 mechanisation 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.
I've 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.
However, 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.
The 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.
But 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 year.)
Yet 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 kickstart to the economy through widespread public-works projects (rejected by the neo-liberal Department of Finance as inflationary), would change the basic parameters.
The 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.
But 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.
The 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.
Not 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!
Two 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.
In 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 firms.
Luckily 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.
Within 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 materialized.)
The 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."
According 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."
But 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."
Activists 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.
But 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 sufficient.
The poli-econ of AIDS points out the need for a yet more profound struggle against the underlying assumptions and characteristics of South African-- and international--capitalism.
***
Bond's new books are Elite Transition (Pluto Press) and Cities of Gold, Townships of Coal (Africa World Press); his 1999 paper "Globalization, Pharmaceutical Pricing and South African Health Policy: Managing Confrontation with US Firms and Politicians" was published in the International Journal of Health Services, v29, #4, pp.765-792. (Thanks much to Julie Davids and Paul Davis of ACT UP Philadelphia, my housemates last night, who helped with corrections.)