By Professor Hoosen Coovadia
I was thrust into the vortex of International AIDS Society’s 13th International AIDS conference in 2000 as chairperson by my close colleagues Professor Quarraisha Abdool-Karim and Dr Gustaaf Wolvaardt, presumably due to the absence of any suitable alternatives, because of my academic record (such as it was at that time) and my leadership roles in the struggle for freedom.
Quarraisha was on the one of International AIDS Society`s highest bodies, the General Council, at the time and had already resigned as head of the Department of Health’s National AIDS programme.
The Durban Conference was the first time the International AIDS Conferences had come out of their comfort zones in the richer parts of the world to a developing country. Though I had never attended an AIDS Conference before, I had an untrammelled view of events at the meeting, for which I had taken a year’s prior sabbatical. I realise that I was in a privileged position, less for subjective, individual factors, than because of the force and uniqueness of the events swirling around me and sucking me into the white heat of the central controversies.
I describe the most striking circumstances, discourses and incidents I witnessed.
Our dark age
I became aware, during the conference, that I was living through a dark age in South Africa`s history of monumental political blunders, some of which, to my utter astonishment, are being reprised over these last few months.
The fairly large themes which underpinned the drama and illustrated the disasters in 2000 included the gratuitous intrusion of government and state institutions in scientific methodology; the impact on a nascent democracy of misguided national policies narrowly based on irrational decision-making; the unforgivable error intrinsic to these policies which negatively influenced health services and caused preventable deaths of thousands of vulnerable people; and finally, attempting to undermine long-established and critical processes in vigilance over the quality of pharmaceutical products.
The very important, practical and life-saving outcomes of the Durban Conference were the establishment of The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the President’s Emergency Plan for AIDS Relief (PEPFAR) global programmes, which led to an unprecedented global response to the pandemic.
The critical role of activists, globally and locally, in catalysing treatment access, requires its own narrative and is too extensive to include here. However, from my own involvement and my perspective for this paper, centre-stage in this vulgar enactment of those ancient and tragic Greco-Roman and European dramas, and indeed similar global theatre, stands then-President Thabo Mbeki, and his unquestioning acolytes and courtiers.
Unwarranted intrusion of government in scientific methodology and the Mbeki travesties
I do not suggest that there is no role for the government in science. That would be absurd. The government and state contribute in numerous ways to the scientific endeavour, but this is well documented and beyond the scope of this contribution.
It is when the government crosses a boundary beyond its mandate, and often outside its competence, that serious problems arise. We have, in the Mbeki period, the perfect example.
The more egregious actions of this period were presaged by the following: I had chaired a widely representative government-appointed AIDS Advisory Committee in mid-1990s. The carefully derived recommendations of this committee were completely ignored. In a discussion between me and state personnel (who reflected the Mbeki views on ARVs) on prevention of mother-to child-transmission of HIV, which could decrease infant mortality, a government spokesperson calmly declaimed “…there was nothing to suggest that in impoverished rural areas, saving the life of a child would affect mortality statistics later on”.
The Ministry of Health had supported a very generously funded, aesthetically weak and educationally ineffective play called Sarafina 2 that premiered on World AIDS Day, 1995. My professional colleagues and I saw the play and walked out in disgust halfway at the agonising quality of the production. It was an unqualified communication disaster.
Mbeki was directly or indirectly responsible for a number of policy disasters which cost the loss of lives. He derided the use of ARVs and asserted that poverty could result in the AIDS epidemic. He promoted “Virodene”, an industrial solvent, as a potent drug against HIV, “discovered” by a group of researchers from Pretoria with a dubious record of previous work, but paraded before the National Cabinet. Another phony product was “uBhejane”, promoted at the time by the Minister of Health and by tribal leaders. It never caught on.
The disastrous effects of these things are encapsulated in a Harvard study reported in the South African Medical Journal. “Between 1999 and 2007,” says the report, “an additional 343 000 deaths could have been averted if the National Government had rolled out mother-to-child-transmission prevention and antiretroviral programmes as did the Western Cape.”
I suspect Mbeki considered himself a modern-day Galileo, the 16th century Italian physicist, astronomer, and philosopher, closely associated with the scientific revolution, and the Laws of Motion, which were in opposition to the views of the Church. He appeared before the Holy Office in Rome. A sentence of condemnation forced him to abjure his theories, he was confined in Siena, and in 1633 he retired.
Mbeki’s undigested internet knowledge of the scientific basis for attribution of cause and effect in any biological phenomenon led him to arrange a debate between “denialists” – with little rationality in their arguments against HIV as a cause of AIDS – and the rest of us “conventional scientists”.
We were unable to find the words to initiate a rational discussion. It was hopeless.
The 13th IAS Conference
It was in this atmosphere – of the science world’s unmitigated hostility towards Mbeki, his Minister of Health, the late Manto Tshabalala-Msimang, and various segments of the South African State – that IAS 2000 took place.
When Doctor David Ho, an American HIV/AIDS researcher who has made pioneering contributions to the understanding and treatment of HIV infection, gave the first presentation and said that HIV was the cause of AIDS, he received a thunderous ovation.
In the event, IAS 2000 was a gratifying and unprecedented success in the short history of the AIDS Conferences.
The huge cost of ARVs was contested. The restrictions in global trade, which through the World Trade Organisation (WTO) prevented free access to drugs, and the role of the WTO in promoting the exclusivity of intellectual property rights, became legitimate targets of criticism. The Indian Pharmaceutical Company Cipla made the first offer to make generic ARVs affordable. The subsequent fall in the cost of ARVs is shown by the following: the price of three commonly used first-line ARVs for adults fell from $568 a month in 2000 to $51 a month over five years. Within two years of the conference, the number of people on ARVs for treatment had increased from 0.4 million to one million.
A major achievement of the conference then was that the voices of scientists and others from all over the world, supporting the scientific foundations of the cause of AIDS, were heard.
The Durban Declaration has an organising committee of over 250 members from over 50 countries. The Declaration was published in Nature (Volume 406, 6 July 2000, www.nature.com). It had been signed by over 5 000 people, including Nobel prizewinners, directors of leading research institutions, scientific academies and medical societies, notably the US National Academy of Sciences, the US Institute of Medicine, the Max Planck Institute, the European Molecular Biology Organisation, the Pasteur Institute in Paris, the Royal Society of London, the AIDS Society of India and the National Institute of Virology in South Africa.
The following is the concluding quote from the Nature publication: “Science will one day triumph over AIDS, just as it did over smallpox. Curbing the spread of HIV will be the first step. Until then, reason, solidarity, political will and courage must be our partners.”
The impact on democracy
The worrying impact on democracy of this episode is more than conjecture. The unmeasured pervasiveness of unscientific beliefs – including by the president of the country, his cabinet and Parliament – compromised the trust and belief so necessary in an inchoate political system based on regular and unflinching engagement between the ruler and ruled. The essential fabric and character of democracy was contaminated, disgraced and compromised during this period.
It may therefore not be too far-fetched to suggest that the warped reactions by President Jacob Zuma, his Cabinet, the Speaker of Parliament and Parliament itself to the Constitutional Court ruling on the Nkandla case and the responsibility of the President, are the lasting consequences of Mbeki’s misguided stance on HIV/AIDS.
Professor Hoosen Coovadia is the Director of Maternal, Adolescent, and Child Health Systems at the School of Public Health in the University of the Witwatersrand, Emeritus Professor of Paediatrics and Child Health and Emeritus Victor Daitz Professor of HIV/AIDS Research at the University of KwaZulu-Natal