A response to Anthony Butler's explanation of the state's AIDS policy under Mbeki

Judge Edwin Cameron and I have published an article titled The deadly hand of denial: Governance and politically-instigated AIDS denialism in South Africa (see here - PDF). Much of it has been written in one or another form before. However, there are two aspects of the article which merit wider discussion.

(1) We put forward three research questions which have received too little attention:

(a) How did former president Thabo Mbeki's views manage to prevail in the ANC and influence policy, at least from 1999 until March 2004 when the antiretroviral (ARV) rollout began in earnest? (b) What were, indeed perhaps still are, the weaknesses in governance structures that allowed a pseudo-scientific response to aggravate the country's catastrophic health problem? And conversely, what were the strengths in South Africa's democratic structures that enabled a public sector ARV rollout ultimately to occur? (c) What are the long-term consequences for South Africa of the disastrous flirtation with AIDS denialism, both from a health policy perspective and for the scientific governance of medicine?

We propose preliminary and speculative answers to these questions, which hopefully will stir others to answer them more comprehensively and better.

(2) We respond to a position put forward by Anthony Butler to explain Mbeki's response to AIDS. At the request of Politicsweb, here is a slightly edited extract from the part of the paper that deals with Butler:[1]

Anthony Butler has published a widely-cited analysis, the central argument of which is that the AIDS struggle in South Africa was between two competing paradigms which he labels (1) the "mobilisation/biomedical" paradigm and (2) the "nationalist/ameliorative" paradigm.[2]

He contends that as a rational process of contested policy formulation the ANC accommodated proponents' of both. His central assertion is that far from Mbeki's AIDS views being bizarre or irrational, an "instrumental calculation of the dangers of an inequitable and unsustainable ARV programme best explains the government's continued adherence to a cautious prevention and treatment policy".[3] This argument would relieve Mbeki and his supporters (in government) of responsibility for their grievously misguided AIDS policy.

But Butler's argument is fatally flawed on at least five counts.

First, contrasting a response to AIDS based on science and reason - what he calls "biomedical" - with one based on superstition and irrationality - what he calls "ameliorative" - as two paradigms of similar truth fundamentally errs as a presentation of the options available to the Mbeki government. The impression of moral, rational and discursive equivalence created by Butler's presentation is simply false. Mbeki's policy pick was always out on a very extended limb.[4]

Second, despite his contention that the ANC accommodated both paradigms, Butler's article offers no evidence that Mbeki accommodated proponents of the "mobilisation/biomedical" paradigm.[5] In fact, it ignores evidence to the contrary.[6]

Third, Butler argues that the ANC made an instrumental calculation that implementing Highly Active ARV Treatment (HAART) would have been inequitable and unsustainable.[7] This is not just wrong, but palpably far-fetched. It implies an unlikely conspiracy (that the ANC supported a wrongheaded policy that was highly costly in the long-term to save in the short-term) without any evidence that such a cost calculation was ever even attempted.[8] Moreover, if the difficulties of equitably implementing government treatment for diseases including TB, diabetes, and cancer did not lead the government to promote pseudoscience so why would it have done so in the case of AIDS? Every available indication suggests that Mbeki was specifically and irrationally preoccupied with HIV because of (i) its sexual transmission, and (ii) its peculiar African demography.

Fourth, Butler asserts that "Attributions of `irrationality' and `denial', no matter how many people hold them to be true, do not constitute adequate explanations of human behaviour".[9] This does not stand up to scrutiny. If one were to apply Butler's logic here to World War II, for example, it would suggest that Hitler's determination to exterminate Jews, gypsies and homosexuals must have been rational.

Finally, a major conceptual failing is that Butler neglects to distinguish adequately between ordinary psychological denial, and Mbeki's racially-obsessive and conspiratorialist ideology of denial.[10]

Several other problems with Butler's analysis warrant mentioning here.[11]

• Butler suggests that the "ameliorative" approach focused on poverty and implies that those advocating ARV treatment ignored it. He fails, however, to identify any meaningful social welfare policy proposed by the "ameliorative" forces. He also ignores the fact that groups advocating ARV treatment, like TAC, incorporated an analysis of poverty and inequality into their organizing work (TAC organised the first large demonstration for a Basic Income Grant).
• Similarly, Butler's suggestion that the "ameliorative" approach emphasized appropriate nutrition is misleading: the state did not produce a single accurate widely distributed pamphlet on HIV and nutrition during the Tshabalala-Msimang era. Conversely, TAC, Soul City, and groups advocating ARV treatment did.
• Butler correctly points out examples of how Mbeki promoted the "ameliorative" paradigm at the expense of the "biomedical" paradigm, thus providing evidence against his own argument (p. 594).
• Butler may be right that Mbeki would have been unable to influence public perception on the issue (pp. 596-97). But to the extent that Mbeki tried to have influence in this area it was ill-informed and harmful ­ for example discouraging testing because it would confirm a particular "paradigm" as he once told ETV.
• Butler's suggestion that the medium-term budget framework would have been beyond the control of the executive is misguided (p. 597). Nearly every budget decision under Mbeki was taken with the approval of the relevant government bureaucracy and when the decision to implement HAART was taken, the money to treat hundreds of thousands of people has been made available (albeit that it is still insufficient to meet much of the demand for HAART, partly because it was left so late).
• Butler rightly points out that there are real human resources shortages in the health system but fails to acknowledge the extra burden caused by the systematic decision to leave AIDS untreated (p. 598).
• Butler states that "COSATU has periodically indicated that it is very much behind TAC's campaign for ARVs, however it has been obliged to maintain a troubled silence on AIDS in the public sphere" (p. 601). This is false. Leaving aside the public disagreement between TAC and COSATU over TAC's 2003 civil disobedience campaign, COSATU spoke out publicly on AIDS and supported the TAC position at the risk of exacerbating tensions between it and the ruling party.
• Butler's description of shortcoming of the medical field, scientists and foreign governments in terms of the AIDS epidemic, even if accurate, in no way explains or justifies a denialist position (pp. 605-06).
• Butler attempts to paint dubious government statements as rational, including favourably quoting from the infamous Castro Hlongwane denialist document (pp. 611-12). In considering only Mbeki's and his supporters' words he ignores their actions such as their systematic obstructing of PMTCT and HAART programmes.

Geffen is the TAC treasurer. The complete paper can be found here - PDF.

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[1]    Thanks to my co-author Judge Edwin Cameron, Chesa Boudin for his extensive edits, David Biles and Nithya Krishnan who found many of the references and ASRU for publishing. Also thanks to Nicoli Nattrass for convincing us to respond to Butler in this paper and reviewing it.

[2]    Butler, A., "South Africa's HIV / AIDS Policy, 1994-2004: How Can It Be Explained?",  African Affairs Vol. 104, pp. 591-614 (2005).

[3]    Id. at p. 591.

[4]    The AIDS denialist forces were weak at the time that Mbeki began publicly supporting AIDS denialist positions. Traditional healers, for example, while a significant force in South African society were never so powerful as to have to influence or expect to influence AIDS health policy, especially more so than COSATU and the SACP which never embraced denialism. Moreover there was no organised traditional healer movement that embraced denialism before Mbeki. The alternative health industry, for its part, was indeed strengthening in the 1990s. Nevertheless, its influence was confined to influencing government in a very narrow way: to allow changes to the Medicines Act that would enable it to sell its products. The organised part of the industry made no significant attempt in the 1990s to promote an anti-ARV position or "HIV does not cause AIDS" position and certainly not at a high political level.

[5]    Indeed prominent members of the ANC, including Pregs Govender and Saadiq Kariem, who expressed criticism of the Mbeki policy were subsequently marginalized. Butler's contention that "ANC activists have been at the forefront of campaigns against government policy and in support of ARV provision", does not hold up in light of these same activists subsequent marginalization by the party (595).

[6]    See for example, Cameron, E., Witness to AIDS (2005); Powers, S., "The AIDS Rebel", The New Yorker, 19/5/2003. http://www.newyorker.com/archive/2003/05/19/030519fa_fact_power. Accessed 8/7/2009; and Sparks, A., Beyond the Miracle: Inside the New South Africa (2003).

[7]    The current widespread accessibility of ARV programmes suggests that this concern was misguided at best. Moreover, the challenge of equitably and sustainably providing ARV treatment to all in need was greatly exacerbated by the denialist policies.

[8]    Economics cannot explain the Mbeki AIDS policy position. See Nattrass, N., Mortal Combat (2007). The costing study eventually carried out by civil servants showed that HAART was affordable and consequently the study was covered up, but TAC got hold of it and leaked it.

[9]    Butler (2005) at 598.

[10]  Id. at 603-04.

[11]  These are footnoted in the original.