The death of Dr Manto Tshabalala-Msimang - "Dr Knoffel", as the Afrikaans press dubbed her - in December 2009 less than two weeks after World AIDS Day, reminded us, of how disastrous the handling of the AIDS pandemic has been in South Africa since the late 80s and more particularly under ANC leadership. It has been a national and international scandal and a shame to South Africa . No wonder there have been calls for former President Mbeki and his former Ministers to apologise for their stubborn neglect which has caused unnecessary early deaths from AIDS. Yet supporters of the "San Francisco Agenda" are not without culpability themselves.
In the late 80s the National Party Health Ministry knew what was coming when AIDS began to manifest itself outside of the white male homosexual ghetto, but the Nats had sat on their hands. Until the ANC/UDF bought into a vigorous campaign, anything that the Nat government did about AIDS would have been seen as a conspiracy by the whites to stigmatise the blacks.
Promoting condom use would have been castigated as a ruse to reduce the black population. The ANC's minds were on other things from the time of the release of Nelson Mandela. The President, as the man on whose desk the buck stops, has to take responsibility and the first apology needed to come from Mandela. Humble man that he is, once he had grasped the enormity of the problem including deaths in his own family, he accepted responsibility for that failure in his leadership.
Mbeki is notorious for his views on AIDS. His opinions and the vigorous and distressing debate around them is well chronicled but perhaps no better than on pages 667-672 of Martin Meredith's chilling but not unsympathetic book "The State of Africa - A History of Fifty Years of Independence". RW Johnston's history of South Africa since 1994 --" South Africa 's Brave New World" -- records, in detail, the impact of Mbeki's AIDS denialism and what lay behind it.
Indeed, COSATU, the Treatment Action Campaign (TAC) and others are completely justified in asking that Mbeki apologise for his views on AIDS. There is no doubt that his inaction and strange views have caused tens of thousands of deaths to occur sooner than necessary.
Yet, the South African backers of the "San Franciso Agenda" - many of whom weresome of Mbeki's most consistent critics - are not themselves without blame. This includes the Judges of the Constitutional Court who were unwise enough to give judgements which empowered this Agenda. The San Francisco Agenda is the name commonly given to a programme and goals that were set by the Northern Hemisphere gay lobby to add a human rights dimension to the sexually transmitted disease (STD) of AIDS. In the Northern Hemisphere the vast majority of AIDS infections were amongst people who practised male to male intercourse.
In South Africa AIDS infections are overwhelmingly transmitted through heterosexual intercourse. There are tried and tested public health principles and practice going back for over a century, for responding to STDs. Those include the history of the patient and the centuries old medical tradition of circumspection and respect for a patient's privacy within the medical necessity of dealing with as sensitive and embarrassing a condition as an STD. Admittedly, unlike other STDs such as syphilis and gonorrhoea, AIDS is incurable. The San Francisco Agenda sought, and largely succeeded, in placing hurdles and stumbling blocks on the path of treatment for public health practitioners by changing the well established rules for responding to the STD which the AIDS pandemic actually was.
These burdens were in not allowing people, even between hospital staff, to disclose a patient's HIV status. However, one could, within the protocols of medical ethics disclose that a person had syphilis or diabetes or eczema etc. South Africa's Health Authorities have had their work in dealing with AIDS infections severely impeded by this Agenda.
In the book "Defiant Desire", Zackie Achmat and Edwin Cameron set out why they sought to establish the San Francisco Agenda in South Africa --- "(In North America and in Western Europe) there was an appropriate gay political movement in place to lead the fight against AIDS, but (in South Africa) this fight could actually be used as a mobilizing tool, to further buttress and strengthen the gay movement itself" (p301). Their objective was thus to promote this gay rights agenda by riding on the back of the HIV/AIDS issue which primarily affected heterosexual people. The AIDS Law Project also has assiduously pushed this Agenda.
The TAC has been an enormously important and successful lobby group in relation to better treatment and the provision of anti-retrovirals. They have been the major and appropriately aggressive counter to Mbeki's wicked denialism.
The TAC's charismatic leader, Zackie Achmat, however, has been much less outspoken when it comes to trying to change the personal behaviour (namely having multiple concurrent sexual partners) which is the main driver of the AIDS epidemic in Southern Africa.
Sadly, the response to AIDS over the last twenty years in South Africa , instead of staying firmly within the realm of public health, became entangled in the politics of apartheid and liberation, the politics of the denialists and the gay lobby. It is not only Mbeki, nor his compliant Minister of Health, the late Manto Tshabalala-Msimang, who should take a long hard look at the effects of their response to the disease. We must all try to put that behind us and concentrate on prevention, treatment and care, especially for the orphans.
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