Business Day
 

Anthony Butler
IT IS nearly five years since President Thabo Mbeki denounced the attribution of HIV/AIDS to degenerate African sexuality, questioned the causal relationship between HIV and AIDS and posited the potential toxicity of AZT.
He was labelled a "denialist", unable to acknowledge with his mind a fear that he felt in his heart: that the pandemic would bring the African renaissance to an end before it had even begun.

After Mbeki's recent remark in the Financial Times that 53000 antiretroviral treatment places were available, but only some had been taken up, it is time to consider whether denial might simply be a convenient cloak. Behind it may lie a calculated approach to government's AIDS policy dilemmas.

There is one inescapable truth about HIV/AIDS treatment that government's critics tend to evade: shortages of health workers mean that, at least in the short to medium term, antiretrovirals will not reach more than a small minority of those who need them.

The drugs are now cheap, but treatment is complex, demanding clinical, psychosocial and nutritional expertise. The tuberculosis-control programme is failing. In poor provinces, childhood immunisation - the most basic primary health intervention - is in disarray.

According to a report on southern African antiretroviral programmes in The Lancet late last year, 80000 health workers emigrated between 1989 and 1997, and Mbeki's presidency has brought no reversal of the trend. Those that remain drift from public to private sector, and from rural to urban areas. Three-quarters of rural physicians are immigrants. While the AIDS treatment plan proposes 12000 new posts, tens of thousands of unfilled vacancies strain hospitals and clinics. Moreover, we are beginning to see the effects of HIV infection among health professionals themselves.

There is much that can be done to recruit, train and retain health practitioners, but more money cannot suddenly precipitate new human resources.

Whatever government does - and there is no question it should do much more - the grim fact remains that, at least in the medium term, most HIV-positive citizens will die of AIDS- related illnesses without receiving antiretrovirals.

Far from the turning away "denial" suggests, government has been active across a wide front with ameliorative measures. Health Minister Manto Tshabalala-Msimang has emphasised nutrition and built alliances with traditional healers, who dominate rural palliative care. Social Development Minister Zola Skweyiya has overseen a huge social welfare expansion, his child-support and disability grants promising gains to communities living with HIV/AIDS.

Yet government is still under fire. Why do senior politicians send out confusing messages about how HIV is spread and the value of condom use? Why can they not mobilise society in a crusade against the pandemic? Why do our leaders condone stigmatisation?

It appears that equivocation and obfuscation may be part of a wider attempt to defuse the consequences of unequal access to treatment.

Government is exploiting stigmatisation and confusion to encourage the notion that AIDS victims have no automatic right to treatment - while moving quietly ahead with publicly funded treatment for social groups seen as economically or politically essential. The rich and the political elite have access to privately financed antiretrovirals, and we can soon expect government to make access for health professionals a priority.

Business has been slow to address the effect of HIV/AIDS on productivity and skills, but is waking up. AIDS kills skilled workers in their 20s and 30s. Extending their productive life is essential if a fiscal and productive crisis is to be avoided. Organised workers are politically powerful, propelling them towards the front of any antiretroviral queue.

AIDS also undermines the state's coercive capacity, its ability to collect taxes and provide services, and the support of the new middle classes whose commitment to democracy is crucial to its survival. We can expect bureaucrats, skilled military personnel, the police, and other public servants vital to the functioning of the state to be next in the state-funded antiretroviral queue.

As the pandemic progresses, organised demands for antiretrovirals will grow from those who have been excluded. The African National Congress's (ANC's) most loyal constituency - the rural poor - is the group most certain to be shut out from any antiretroviral programme. Government has forged a new alliance with traditional leaders, presumably in part with the intention of reinforcing social cohesion in the areas hardest hit by the pandemic. But it cannot insulate itself from discontent.

Concern over business confidence makes an HIV/AIDS crusade unattractive to our political leaders. Government must help business weather the skills storm, but it must avoid any sense of crisis. The reticent investors who have balked at major commitments out of fear of civil war, tribalism, and crime might well take real fright at the prospect of an AIDS catastrophe. The presidency's rhetoric of "first" and "second" economies may be designed in part to sooth business fears about AIDS' effect on the "real economy".

The rationing dilemma also helps to explain government's hostility to the language of entitlement. SA's extensive social welfare system creates expectations of assistance. If antiretrovirals are a right, a discriminatory and rationed antiretrovirals programme must arouse anger. Formal sector workers would demand treatment for relatives and friends. New social movements would arise, dwarfing today's water and electricity protest groups. Inability to deliver rural antiretrovirals would result in movement to the cities, overwhelming health facilities and worsening public service backlogs.

The carrot of social grants is not enough: government also needs the stick of stigmatisation.
Ministers disperse responsibility for HIV/AIDS across society, refusing to accept ownership of the national strategic plan itself. The celebrated discussion document whose title begins "Castro Hlongwane", circulated to the executive of the ANC by the late Peter Mokaba in 2002, directly rejected "as fundamentally incorrect and antidemocratic the attempts to transfer the responsibility to look after oneself to the state.. Each one of our citizens has a responsibility to take all necessary measures to protect his or her health."
Such a shift of responsibility for HIV/AIDS to its victims promotes shame and encourages stigma. Perhaps ministers fear that only shame can limit open defiance, curtail protest against the injustice of selective treatment, and inhibit the urge to seek treatment in the urban health system. If not, why do they not speak out?
If government's unspoken policy is based on calculation rather than denial, it is nevertheless a long way from the best that society could accomplish.
Claims that our president suffers from irrational denialism have for too long inhibited debate and prevented us from constructively asking our leaders to justify their actions.
- Butler teaches public policy at the University of Cape Town. Ran Greenstein Johannesburg, South Africa