Stop Blame Game In AIDS Crisis

This column was written by Roger Bate.

Lewis' very un-U.N. speech continued as he described the government as "obtuse, dilatory and negligent about rolling out treatment." This was, quite simply, the cheapest of cheap shots, and says more about the U.N.'s impotence to combat the disease than South Africa's. Rather than just ignore Lewis's outburst, South African Health Ministry official Sibani Mngadi responded with the observation that Lewis had a "vendetta" against South Africa.

Bad policy causing rampant AIDS has become the master narrative of U.N. officials when it comes to South Africa, with Lewis leading the way, eagerly echoed by Western media — so much so that the bad news still dominates the headlines, even though the tide has turned and there is good progress to report.

The outlook for one of the worst affected countries in the world is not exactly rosy, but it is improving. And the doom and gloom merchants are not only unfair, but counterproductive. By maintaining the dogma of South African failure, they deflect attention from other AIDS actor's mistakes and contribute to the perpetuation of poor policy.

South Africa's president, Thabo Mbeki, has indeed flirted with fringe scientific opinion on the disease, and he failed to respond to the disaster as it unfurled in the late 1990s. The health minister, Manto Tshabalala-Msimang, is often ridiculed for her opinions about dietary supplements being as important as ARVs to combat AIDS. She has said some silly things, most regrettably when she overplayed the toxicity of the drug Nevirapine for pregnant women. Nevirapine is quite toxic when taken every day as part of triple drug therapy, but it is vital for preventing mother-to-child transmission of HIV, for which only one dose is necessary.

She has also stressed the importance of diet in the context of speaking about fighting AIDS/HIV — something that is indeed crucial in most rural African settings. She has pointed out that 90 percent of people seeking testing for HIV were malnourished and were being provided with nutrient supplements.

I have met many adult patients who had access to ARVs in Zimbabwe and South Africa but couldn't take the adult dose because of a poor diet. As their diet improves they are put on the adult dose. The health minister's correct remarks about diet are often taken out of context by reporters who love to maintain the narrative that she is just a silly woman complicit in a genocide.

The South African 2004 comprehensive treatment program, which she is overseeing, established all the steps required for sustainable treatment, and the government now has well over 100,000 patients on treatment. It is a far cry from the half a million or so that probably require treatment, but the program is sustainable, which is more than can be said of many programs in Africa.

It also reflects more responsible planning than that on display in the targets set by the World Health Organization, which aimed to have 3 million on treatment worldwide by the end of last year ("3 by 5"). South Africa was supposed to have 375,000 people on treatment as part of this plan, but, according to the health minister, South Africa was not even consulted on this figure: "Government is not withholding treatment for opportunistic infections, including ARVs, but our objective is to promote quality healthcare. We are not just chasing numbers."

Without cheap testing or the medical personnel to oversee it, WHO's demand that hundreds of thousands receive treatment was unlikely to meet with success. There were many valid reasons for delaying drug roll-out until it could be done in a sustainable fashion: difficulties with obtaining consistently supplied, bioequivalent and reasonably priced drugs, testing costs (viral loads as well as CD4 counts), resistance build-up and the cost of second-line therapy, and lack of personnel (technicians to do testing, and doctors to change desired regimens based on testing and other knowledge).

WHO intervention, driven partly by the U.N.'s Stephen Lewis, is pushing countries into unsustainable treatment programs in order to garner Western dollars and a good name for the U.N. Lesotho, for instance, was being pushed to achieve a totally unrealistic target — and was largely failing.

A few thousand people are currently on treatment there; half of them are not being treated properly with triple therapy, a deficiency that encourages resistance and demoralizes health workers. The WHO's "3 by 5" campaign target for Lesotho was to have 28,000 on treatment — a figure still laughable given current skills and infrastructure.

Eighteen months ago, Stephen Lewis was already vitriolic about the South African government's approach. Lewis wrote that "every senior U.N. official engaged directly or indirectly in the struggle against AIDS, to whom I have spoken about South Africa, is completely bewildered by the policies of President Mbeki."

More worrying still is that WHO (a U.N. organization) blamed countries such as South Africa, Nigeria and India for missing the treatment targets it set for them. Stephen Lewis called WHO's admission that it would miss the "3 by 5" global target "one of the UN's finest hours," claiming it "unleashed an irreversible momentum for treatment."

Having met doctors in the field who have been utterly demoralized by the "3 by 5" experience, it is hard to agree with this rosy interpretation. Certainly the patients deserved better, but "3 by 5's" failure has not brought about any remarkable changes. Indeed, the WHO has simply set a new target of universal access by 2010 — a target that is in all likelihood as meaningless as that of "3 by 5."

Tshabalala-Msimang was adamant last year that she would not be pressured on the WHO target and refused to allow South Africa to become the scapegoat: "ARV rollout is not about chasing numbers but about the quality of healthcare … what is good for Europe must be good for Africa. Just because Africa has fewer resources does not mean regulatory precautions should be ignored."

For once South Africa has the moral high ground — whether it will get reported is another matter.

All in all, South Africa is heading in the right direction. Testing and treatment are being ramped up as quickly as is sustainable, which is providing hope for the millions who need treatment. It is vital that treatment be taken up, but it must be done such that it is sustainable; WHO's current wild target-setting approach, and the vitriol from Lewis, fails this vital test.
By Roger Bate
Reprinted with permission from National Review Online