South African president Thabo Mbeki has tapped “AIDS dissidents” in charting policy on the raging epidemic—and the global establishment is seeing red. Is he a pariah or a patriot? Kerry Cullinan and Anso Thom report from a nation in peril.
The strongly worded letter was delivered in April by diplomatic pouch to President Clinton, United Nations Secretary General Kofi Annan and other world leaders. A rare intrusion of a scientific dispute into high-level diplomacy, the missive from South African President Thabo Mbeki passionately defended his much-maligned questioning of established wisdom about how to handle the AIDS crisis ravaging his country. Most incendiary had been his highly publicized dialogue with leading “AIDS dissidents”— members of a global movement who insist that HIV doesn’t cause the disease and that antiretroviral drugs are poisonous. Citing vast differences between Western countries and Africa in the scale of AIDS deaths and in the modes of sexual transmission (homo- vs. heterosexual), Mbeki wrote, “A simple superimposition of Western experience on African reality…would constitute a criminal betrayal of our responsibility to our own people.” He argued that “our urgent task is to respond to the specific threat that faces us as Africans. We will not eschew this obligation in favor of the comfort of the recitation of a catechism that may very well be a correct response to the specific manifestations of AIDS in the West.”
And referring to the shrill and sustained outrage voiced both inside and outside South Africa, Mbeki criticized what he called “this orchestrated campaign of condemnation,” likening it to the attitudes that led to the burning of heretics in the Middle Ages, and to apartheid-era repression. “Not long ago, in our own country, people were killed, tortured, imprisoned and prohibited from being quoted…because the established authority believed that their views were dangerous and discredited. We are now being asked to do precisely the same thing…because, it is said, there exists a scientific view that is supported by the majority, against which dissent is prohibited.”
The mounting storm threatens to wreak havoc with this July’s International AIDS Conference, expected to draw thousands of doctors, researchers, advocates and reporters to Durban, South Africa—the first such event ever held in a developing country. In May, the prestigious medical journal The Lancet editorialized against calls by some advocates and experts for a boycott. And while motivations on all sides may be hard to discern, the issues are more complex than any of the rhetoric.
This unprecedented controversy has been brewing since last October, when—facing increasing demands to provide AZT to pregnant HIV positive women—Mbeki publicly asked Health Minister Manto Tshabalala-Msimang, MD, to investigate what he called the “large volume of scientific evidence alleging that the [drug’s] toxicity is such that it is a danger to health.” Then in January, Mbeki phoned and faxed several scientific questions to David Rasnick, MD, a California biochemist who says he helped invent protease inhibitors, but is now a close colleague of molecular biologist Peter Duesberg, PhD; today both are leaders in denouncing the entire body of beliefs held by mainstream AIDS scientists. (Mbeki later said he discovered the “AIDS dissidents” on the Internet.) It was Rasnick’s revelation in March of this conversation, confirmed by the president’s office, that sparked the intense international criticism of Mbeki. The health minister then announced that she would convene an international panel of experts, entitled “AIDS in Africa: The Way Forward,” to examine a broad range of scientific and policy questions, including the causes of the disease. When the commission finally convened in May, more than a third of its members were “dissidents,” including Rasnick and Duesberg.
For months, e-mails have flown among leading AIDS researchers, physicians and advocates—particularly in the United States—blasting the South African president and strategizing about how to convince him to stop engaging with what they call “AIDS denialists.” In March, Edwin Cameron, an HIV positive judge on South Africa’s highest court, issued a statement saying, “There are too many lives, too much happiness, too much human prosperity at stake for flirtation with dangerous and wayward theories.” Many critics say they fear Mbeki’s actions will induce the governments of other developing nations to challenge AIDS science and thus justify their refusal to adopt urgently needed policies. Indeed, the U.S. “AIDS dissident” group ACT UP/San Francisco—long denounced as a renegade faction by other ACT UP chapters—sent letters in February to all 200 United Nations member states’ missions in New York City, urging them to do precisely that.
The furor over theory comes against the backdrop of one of the world’s fastest-growing AIDS epidemics. According to the South African Health Ministry, some 4.2 million—more than 10 percent—of the country’s people were HIV positive by the end of 1999, an increase of 600,000 from the previous year. An estimated 1,500 people are infected daily. Projections are that infection rates may reach 17 percent by 2006, taking a grievous toll especially on young adults, creating a massive new class of orphans and further stressing an already grossly inadequate health care system.
Despite the grim statistics, the South African government has yet to come to terms with the disease. Official prevention policy is based on “ABC”: “Abstain. Be faithful. Use a condom.” In March, the country’s auditor general revealed that the Health Ministry had left 40 percent of its current AIDS budget unspent.
The roots of the current crisis lie in the AIDS policies of Mbeki’s predecessor, the legendary Nelson Mandela. After his landslide election in 1994 to head the first post-apartheid government, AIDS took a back seat to addressing the vast needs of millions robbed of their birthright, while dealing with a hostile, white-dominated civil service and inexperience among his own people. During his five years in office, Mandela made only one major speech on AIDS—in Switzerland. His health minister, Nkosazana Zuma, focused primarily on prevention and vaccine development. Charging pharmaceutical industry price-gouging, Zuma refused to supply AZT to pregnant HIV positive women—sparking formation of the Treatment Action Campaign, a South African lobby for accessible HIV meds.
In 1997, as Mandela’s deputy president, Mbeki set up an inter-ministerial AIDS committee, elevating the disease beyond the confines of the Health Ministry. Upon taking office in June 1999, he declared AIDS a top priority. But his recent flirtation with “dissidents” shows that he is still trying to come to grips with the epidemic.
What motivates Mbeki’s iconoclastic effort? Presidential spokesperson Parks Mankahlana maintains that Mbeki has “never said that HIV does not cause AIDS,” but insists on hearing from everyone with a unique perspective on the disease. Trained as an economist at Sussex University in Britain, Mbeki prides himself on his intellectual curiosity. He lived much of his adult life in exile and in fear of assassination by the notorious South African security police. Like other South African political-prisoners-turned-new-order-politicians, Mbeki may, as his letter suggests, view criticism of his interests as a threat to his country’s hard-won freedom of association.
Attacks by Westerners have particularly irked South African officials. Mbeki has accused his opponents of dancing to the tune of Western pharmaceutical companies that are, he says, “enriching themselves from the AIDS epidemic,” comparing them to “warmongers who propagate fear to increase their profits.” Those companies are currently blocking South Africa’s efforts to produce and import low-priced generic drugs, claiming that such products undermine their patent rights. Mbeki and his aides believe that wealthier nations see the solution to the epidemic in terms of drugs alone, whereas these officials believe that improving basic conditions, such as clean water, would go a long way toward boosting the immune systems of all South Africans.
But some experts countercharge that Mbeki’s real motivation is to find an excuse for his failure to pay for drugs to give to HIV positive South Africans. Critics point to his health minister’s decision in March to continue withholding AZT and nevirapine (Viramune) from pregnant HIV positive women, claiming that the safety of both drugs remains in question, and, in AZT’s case, its high cost could severely damage the medical budget for disease treatment.
Asked what may lie behind Mbeki’s actions, leading South African AIDS consultant and former Health Ministry adviser Clive Evian, MD, says, “I think it’s about arrogance, it’s about baggage with the pharmaceutical industry and, most of all, it’s about delaying dealing with the issue.” Evian brands the study panel a “waste of money,” and adds, “We need the president and health minister to kick out the pseudo-scientific dissidents who talk nonsense.”
Apparently unfazed by the storm of criticism, Health Minister Tshabalala-Msimang defends the study panel. Its purpose, she told POZ, is to develop African solutions to the epidemic, rather than rely on “models developed around gay, rich men from America and Europe.” The official first assigned to assemble the panel, Ian Roberts, MD—who was the health minister’s AIDS adviser at the time POZ interviewed him—explained that the body would examine the “significant difference between how you approach AIDS in a developed country with the strength of the social infrastructure and wealth of the state” as compared with “in a developing country where you have an unpredictable health care infrastructure and high levels of poverty, and you can’t afford many of the initiatives in the developed countries”—especially antiretroviral therapy. “But that doesn’t mean you can’t treat people,” he said, adding that the panel would consider such immunity-strengthening strategies as supplying vitamins and minerals and treating parasitic infections. Among the many issues to be examined will be the adequacy of testing and diagnosis, epidemiology (population patterns) of the disease, treatment of opportunistic infections, and prevention of mother-to-infant transmission—all in the African context. (At press time, Roberts announced his resignation, telling POZ that “I did not feel that I was being very effective.” While declining to elaborate, he did express disappointment that so few AIDS treatment experts were appointed.)
The body’s membership includes 33 scientists, doctors and advocates from every continent (11 Americans). The initial May meeting will be followed by Internet discussions. The health minister says that at a final meeting in early July—just before the Durban conference—the panel is to “come up with recommendations that will buttress the government’s framework on AIDS.”
Besides at least 12 HIV-doesn’t-cause-AIDS scientists, the panel includes two who support the virus-plus-cofactors theory—HIV codiscoverer Luc Montagnier, MD, and New York City AIDS clinician Joseph Sonnabend, MD. Tshabalala-Msimang defends the inclusion of the AIDS denialists, saying they have “discovered new things” relevant to understanding AIDS. One of those is Sam Mhlongo, MD, head of the Primary Health Care Department at the Medical University of Southern Africa. “We cannot close our minds to other paradigms,” Mhlongo says. “I want to debate with other scientists why purified HIV has not been isolated. Academics still believe that the majority consensus must be right. But they must remember that Newton was found to be wrong by Einstein.” Some observers fear that such a polarized panel may lead to dueling reports rather than a consensus document.
While the scientific tug-of-war proceeds, those whose lives are directly affected are becoming frustrated. PWA Zackie Achmat, a cofounder of the South African Treatment Action Campaign, grants that the panel could be beneficial if it raised the AIDS ed levels of the population, which he describes as “scientifically illiterate.” And he acknowledges that “it is crucial that the government gets the information it needs to move forward,” especially since “we have a very different scale of the epidemic in South Africa than in the developed world.” But his ultimate message about Mbeki’s action is one of concern: “The debates around the causality of AIDS and the toxicity of antiretrovirals are obscuring the real issue: drug-pricing policies that have left many essential meds unaffordable for the vast majority of South Africans with HIV. Rather than waste precious time reopening dead debates, the government should commit sufficient resources to addressing this crisis.” —Health e-News Service