Sorrow in South Africa
JOHANNESBURG
THE RIGHT to health care is granted explicitly to all citizens in the new South African Constitution, so it was a relatively easy decision this summer for the country's constitutional court to order government health officials to provide the anti-AIDS drug nevirapine to all expectant mothers on demand. Because a single dose of nevirapine greatly reduces the chances of a mother passing on the AIDS virus to her child, the court found that a small government pilot program providing the drug to some mothers discriminated against other expectant mothers.
The court suit - brought against the government by the nonprofit Treatment Action Campaign - was an important test for civil society in the fledgling South African democracy. Now the difficult task of rolling out a national nevarapine program begins. South Africa, unlike other parts of the continent, does have top-quality medical centers - Dr. Christiaan Barnard performed the first heart transplant in Cape Town in 1967. Until the end of apartheid in 1994, however, the top hospitals were for whites only.
Shifting the benefits of health care to the black majority while not taking ''major teaching institutions and turning them into AIDS centers'' is just one of the daunting tasks facing Dr. Ayanda Ntsaluba, director general of the Ministry of Health, a man with perhaps the most thankless job in government. Ntsaluba's boss, health minister Manto Tshabalala-Msimang, has come under intense criticism for reportedly calling nevirapine ''poison'' at the annual AIDS conference in Barcelona this summer. Her boss, president Thabo Mbeki, had famously rejected world medical opinion that AIDS is caused by the HIV virus, insisting instead that its causes are social and economic. No one doubts that AIDS is exacerbated by poverty, but ignoring the medical reality of HIV was reckless and wasted valuable time. Mbeki finally conceded the point in a Cabinet statement in April.
The Anglican Archbishop Njongonkulu Ndungane - successor to Desmond Tutu - has called on the health minister to resign if she won't deliver on promises to fight the disease, expected to kill 7 million South Africans by 2010. ''We are disappointed at the lack of forthright and decisive leadership from the government,'' he told a group of visiting journalists. But the archbishop, who was imprisoned on Robben Island for three years, added with a bit of a twinkle: ''We have been trained by apartheid to deal with a government that is stubborn on issues. We will not be quiet.''
Ntsaluba, the health director, admits to ''a bit of a drift in our policy in terms of delivery over the past five to seven years,'' but he vows that the uncertainty is at an end. The government has built 800 clinics since 1994, though medical staffing is still inadequate. The Mbeki administration authorized about $330 million this year for AIDS programs, and private donations can also be tapped. But in rural areas even more than in the sprawling urban townships, the health care infrastructure to monitor drug use is lacking. Ntsaluba fears that rushing into drug delivery programs that challenge the ability of rural patients to stick with complex medical regimens might result in even deadlier drug-resistant viral strains.
In many ways South Africa is ground zero of the worldwide battle against AIDS. On a two-week tour of the country sponsored by the International Reporting Project, we found a societywide mobilization to fight AIDS. Huge billboards promoting the non-profit youth program loveLife with explicit safe sex messages are everywhere. The business community has joined with organized labor to train factory shop stewards in AIDS prevention techniques to pass on to the rank and file. Businesses regularly provide anti-HIV drugs to affected workers. In August, the Johannesburg Stock Exchange agreed to require companies to disclose the prevalence of HIV among their workers and plans to combat the disease as conditions for being listed on the exchange. The government distributes 350 million free condoms a year.
Many speak of the AIDS crisis as a new liberation struggle for South Africa. The challenges are manifest: Besides treating the 20 percent of the population estimated to be infected with HIV, the country must prevent HIV in the 40 percent who are under age 15, most not yet sexually active. Meanwhile, massive unmet demand for housing, electricity, water, and other pressing needs threatens to overwhelm the government, as do two other health hazards endemic in South Africa: tuberculosis and rising violence and crime.
In the Cape Flats township of Khayelitsha, volunteer organizations are struggling to establish informal buddy systems to watch over AIDS patients in their makeshift shacks, making sure they take their medications and keeping tabs on nutrition and sanitation. Nosisa Dyasi is a 37-year-old mother of four with full-blown AIDS. She displays her prescription bottles, but they are only for infections and other symptoms. She is not on retroviral therapy. Inside her one-room shack, which has no electricity or plumbing, her 16-year old son sobs over the realization that she may not live much longer.
This woman and millions like her are the massive human resource that will be lost to South Africa's future if AIDS is not brought under control. The future is what animates Vuyiseka Dubula, 24, a volunteer with the Treatment Action Campaign whom we meet in a Khayelitsha clinic. ''Who is going to live if we don't take care of this?'' she asks. She has lost friends and knows AIDS cannot be wished away. ''The government must act,'' she says. ''This is not a world of miracles.''
Copyright © 2005 International Reporting Project. All Rights Reserved.