Review: The Political Management of HIV and AIDS in South Africa
November 29th, 2006Review of Pieter Fourie “The Political Management of HIV and AIDS in South Africa: One Burden Too Many?”
At August’s International Aids Conference in Toronto the South African government once again came under fire from AIDS activists – and from a senior UN official – for its continually inadequate response to a growing AIDS epidemic. UN special envoy Stephen Lewis lambasted the Mbeki government’s “lunatic fringe” approach to HIV/AIDS policy, while the Treatment Action Campaign and the AIDS Law Project jointly called for the dismissal of health minister MantoTshabalala-Msimang, after she repeated her insistence that lemon and garlic would help boost the immune system. Events in Toronto mark the latest clash in a familiar and long running struggle on access to treatment between the government and AIDS activists in South Africa, and the latest in resounding criticisms of the political leadership of Mbeki and Tshabalala-Msimang. They follow swiftly after the recent scandal of Jacob Zuma’s publicly aired belief that showering after sex constituted an effective way of minimizing risk of infection, and show a leadership which, over HIV and AIDS at least, is in crisis.
In this context, Fourie’s new book is a welcome and much-needed analysis of the political commitment and public policy approach underpinning – or more accurately undermining – the South African AIDS epidemic. 25 years since AIDS was first recognized – and 24 since the first cases in South Africa – histories of the course of, and response to, the disease are now not only possible, but vital to a fuller understanding of why public policy has failed to curb the spread of infection. Fourie contributes a clear and detailed analysis of the government response to the disease in South Africa, charting the course from 1982 to 2004, from apartheid rule through two successive ANC administrations under Mandela and Mbeki. While the political course of the epidemic will be familiar to many activists and academics, the precise focus on the process and environment of policy making offered in this study is particularly insightful. It asks important questions and teaches key lessons – for South Africa, and for the world as a whole – about the response to date, and ends with clear recommendations for future policy research. Most importantly it warns that these insights must be carefully heeded for the course of the epidemic to be changed.
Fourie grounds his study in a consideration of the theoretical approaches of public policy. In doing so he shows that far from being an academic side-show, such an analysis has a lot to contribute to the overall understanding of a very real policy problem. Policy, he argues, constitutes two key aspects – the policy document that is produced, and the policy making process that is involved. It is the process with which he is primarily concerned, rather than the technical details of the final strategy. In doing so he sketches the way in which this process has been interpreted and the changing philosophies which underlie this – from moral through racial, biomedical, human rights, scientific and monetary-focused conceptualizations – and the ideological foundations these have actively or unwittingly drawn on – from pluralistic, through rationalist, elitist, incrementalist, Marxist and corporatists positions. With the latter he demonstrates, for example, how the ANC response can be shown to have unwittingly drawn on two very different discourses. A Marxist discourse blamed the pharmaceutical firms of denying the poor access to generic medicines, while a rationalist approach focused on the economic cost claimed they were beyond government means.
The book is essentially a history of the policy failures of the South African government, a response which, he argues, has so far been “a dismal failure”. It is widely predicted that the epidemic will be seen to stabilize soon – Fourie suggests it will do so this year – but this leveling off will certainly be due to the natural attrition profile of the disease, rather than any successful government intervention. In particular he shows that in the South African experience, it has been civil society, the private sector and the biomedical community who have been more powerful and more involved in the shaping of a public policy response, forced to intervene in the absence of any centralized leadership. The book is an important project and a valuable contribution both to the policy debate, and to an understanding of how a governance response can feed into, and be shaped by, the socio-political environment of a country epidemic. It is only by stepping briefly out of the current political debate to engage in a thorough and considered appraisal of the policy response to date, that future policymaking will be improved.
Fourie begins his analysis with the apartheid government, “a rich societal Petri dish in which HIV and AIDS could flourish”. The policy environment in the 12 years from the beginnings of the epidemic until the transition to democracy rule was characterized by racial separation and discrimination, a lack of democracy, pronounced inequality, high migration and political instability. Representations of the emerging epidemic were couched in homophobic and subsequently racial language, with a response led by an ugly marrying of morality and biomedicine. Fourie also argues critically that “powerful elements within the biomedical community did a disservice to the early battle against AIDS in South Africa by contributing to defining and responding to the epidemic…in racist and heterosexual terms”. He explains that such was the lack of incentive for policymakers to act, that it was not until 1986 – four years after the first HIV infections – that anything was actually done. Observations that, despite epidemiological surveillance capabilities, surveying did not start until 1990, and that the first demographic model was developed by a private insurance agency and not government policymakers, are illustrative of this lack of commitment. Attention was not accorded to the social aspects of the epidemic, Fourie argues, until ten years in with the launch of the National AIDS Research Programme in 1992.
A lack of leadership shown by the government is also highlighted in his account of workplace intervention programmes. No guidance was offered by the apartheid government, such that industry was forced to – and given free reign to – formulate its own response. This apparent inability to deal with the socio-political structures of the epidemic, he argues, leaves the establishment open to charges of pursuing a policy of conscious inaction. The nation instead was left to “muddle through”, and government compounded its initial stigmatization of people living with HIV/AIDS by attempting to isolate the virus through criminalization and legislation, rather than proper epidemiological surveillance. It is from this root that Fourie tracks the rise of the now prominent South African civil society, in response to the abject inaction of the state.
Having dealt with the beginnings and development of the South African epidemic during the apartheid regime, Fourie moves his narrative to the subsequent Mandela and Mbeki government response to AIDS under the newly elected ANC. He shows that despite great developmental hopes for a new South Africa, the new government failed to act strongly, and the state response deteriorated as new infections steadily rose. As Fourie rightly acknowledges, the new ANC-led government inherited “a polity in disarray”, a country where HIV/AIDS had become an endemic disease. The National AIDS Plan launched with the new government in power in 1994 was a solid and broad policy blueprint, moving intervention away from a health-aligned problem in what is generally agreed to have been an “ideal policy drafting process”. As Fourie notes, however, it was developed primarily before the ANC came to power, without a realistic budget, and with several of its key architects not involved beyond 1994. A continued rise in seroprevalence during Mandela’s term indicated the failing of the policy when it came to implementation. In agreement with other analysts, Fourie concludes that it was evidently too ambitious a programme for a fledging government during a time of major political transition.
An interesting aspect of Fourie’s study is his analysis of civil society engagement over AIDS policy in South Africa. One of the most significant features of the policy landscape in recent years had been the prominent and vigorous Treatment Action Campaign, a movement that grew directly out of government inaction over ARV provision, a string of public scandals, and an increasing interference – which has become particularly pronounced with Mbeki – in the science of HIV and ADS. While civil society involvement in public policy is essential, Fourie also shows the problems this can sometimes bring. While recognizing that activists have been vital agents for change, and have done much for the expansion of AIDS treatment, he also demonstrates the negative fallout of a forceful civil society. He argues that such was the nature of the confrontation between government and activists, that there was a hardening of their respective stances, leading to a further radicalization of civil society. This has, he suggests, led ultimately to a destructive rather than constructive relationship, driving the two increasingly further apart. Antagonism between the two groups, which could most profitably work together in a relationship of constructive criticism, has continued into Mbeki’s presidency. It has often centered round Mbeki’s insistence to seek to re-appraise the science of HIV and AIDS, courting controversial AIDS denialists and renegade scientists and refusing to implement the necessary ARV treatment programmes so badly needed. Civil society have responded, as Fourie notes, by attempting to bypass the government through the judicial system. AIDS treatment has become an increasingly political issue – rather than a health issue – with sharp lines drawn between a government focusing on prevention and a civil society focusing on treatment.
The politics of HIV/AIDS are, as Fourie correctly points out, one of the least-understood and least-studied aspects of the epidemic. As a contribution to this he offers a readable and intelligent explanation of the overall social impact of AIDS and sets this within the context of a socio-political environment undergoing major upheaval. In doing so he shows the imperative of a strong government leadership, but moreover draws vital attention to the policy process on which this ought to be based. Not only does he illustrate vividly the dynamics of the policy debate to date, but shows how a careful analysis of mistakes and failures in turn can offer the understanding needed for a stronger and more inclusive future response – a considered but no less resounding “truth to power” call.
Jon Harle, Justice Africa, September 2006
