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The Mystery of AIDS in South Africa

1.

One Sunday evening in early May, I went for a walk in one of Johannesburg’s prosperous suburban neighborhoods. The whitewashed stucco houses on well-tended lawns with hissing sprinklers and swimming pools, the twittering birds, the leaning jacaranda trees lined up on quiet streets, resembled similar scenes in Los Angeles or Melbourne, Australia. That is, if it were not for the barbed wire curled above the gates, or the dogs that roared at me from behind each fence as I passed by. By the time I had walked half a block, it seemed as though all the dogs in Johannesburg were barking. I didn’t go far. South Africa lives under a kind of self-imposed curfew. By sundown, the streets from the Cape to the Transvaal are eerily empty. Gates are bolted, alarms are set, car doors locked, and windows rolled up.

South Africa is one of the most dangerous countries in the world that is not at war. Everyone I met warned me to be careful. One acquaintance spent ten minutes listing all the people he knew who, in the past six years, had been shot, killed, raped, or who had been hijacked in their cars, robbed, thrown in the trunk, and then deposited, naked, by a roadside. Another South African told me that the bank in his ordinary, middle-class neighborhood had been robbed five times in six months. A Johannesburg taxi driver said that, in his company alone, a driver is murdered every month. There were more than 50,000 reported rapes in South Africa last year, and this number has recently been rising. Reported rapes are believed to represent only a fraction of the actual number committed, and according to some estimates, as many as a million rapes may have occurred last year. A doctor I met who has worked in black hospitals in the Eastern Cape for decades, through the worst years of apartheid, told me she now sees a growing caseload of gonorrhea and syphilis in children as young as two years of age, the result of an epidemic of child sexual abuse.

Crime in South Africa affects everyone, black, white, Asian, rich, and poor. Last year, someone walked off with an entire automatic teller machine that had been installed inside a police building in Johannesburg. In Cape Town, rapes and burglaries have been committed by members of Parliament, within the Parliament buildings themselves. The sense of suspicion and paranoia seemed to me to pervade even the fancy shopping malls, tourist beaches, and expensive hotels. It even informs the country’s policies, including its response to the greatest health threat in its history.

I went to South Africa for three weeks in May to write about the AIDS epidemic there. AIDS is caused by the HIV virus, which is passed from person to person through sexual fluids, blood, or blood products, or from mother to unborn child in the womb or through breast-feeding. The virus destroys the immune system that protects the body from infectious diseases. A person may live for ten years or more with HIV and have no symptoms, but eventually his immune system begins to disintegrate, and other viruses, bacteria, and fungi, which a healthy immune system would normally fight off, take hold. AIDS is the name given to the syndrome in which the patient slowly rots alive from these opportunistic infections.

The South African Ministry of Health estimates that 4.2 million South Africans carry the HIV virus, and about 1,700 more people are infected every day. Those most at risk are poor black people, particularly those who have been socially displaced, such as migrant workers, truck drivers, sex workers, and miners from rural areas, and their wives, girlfriends, and children back home.

I became particularly interested in the AIDS crisis in South Africa last winter, when I heard that President Thabo Mbeki had begun to solicit the opinions of a murky group of California scientists and activists who believe that AIDS is caused not by HIV but by a vague collection of factors, including malnutrition, chemical pollution, recreational drugs, and by the very pharmaceutical drugs that are used to treat the disease. These “AIDS dissidents” may not agree among themselves about what the cause of AIDS actually is, but most of them seem to believe that the tens of thousands of scientists who work on HIV and AIDS are, largely unwittingly, part of a vast conspiracy cooked up by the pharmaceutical industry to justify the market in anti-AIDS drugs, such as AZT, worth billions of dollars a year. This conspiracy, the AIDS dissidents argue, relies on the demonization of HIV, a harmless virus in their eyes, and the promotion of wildly expensive, toxic drugs that have serious, even deadly, side effects. Mbeki is the only head of state known to have taken the views of the AIDS dissidents seriously, and many doctors and AIDS activists in South Africa and in the West have begun to wonder whether the President and his health minister have taken leave of their senses.

In the 1980s, the AIDS dissidents received considerable attention from journalists and even mainstream scientists who felt that the evidence that HIV caused AIDS was not strong enough. By now, however, the evidence that HIV is the cause of AIDS is very strong indeed,1 and the implications for countries like South Africa are horrifying. During the past five years or so, the AIDS dissidents seemed to fade from the scene. They continued to publish their views on the Internet, but journalists and scientists paid little attention to them. Many people were surprised when President Mbeki began expressing interest in their ideas. When Mbeki invited a group of them, including Berkeley professor Peter Duesberg, to South Africa to present their views to a presidential panel on AIDS in Africa in May, observers were even more surprised. One scientist told me, “It’s like the movie Friday the 13th. Just when you think you’ve finally killed the monster, it just keeps coming back to life.” The interest that Mbeki has taken in the AIDS dissidents is more than an intellectual diversion. It is contributing to a pub-lic health disaster by distracting the Health Ministry and other official institutions from addressing the epidemic, and by failing to prevent HIV infection in South African children.

Western pharmaceutical companies now sell a range of some fifteen drugs known as anti-retrovirals for people with HIV infection and AIDS. In 1998, researchers in Thailand and the US found that a cheap, short course of AZT taken around the time of childbirth can reduce by half the chances that a mother will transmit HIV to her baby. Many developing countries, including Thailand, Botswana, and Uganda, are now putting programs in place so that eventually every HIV- positive pregnant woman will be offered AZT, or another anti-retroviral drug called nevirapine, which has also proved effective in preventing transmission of HIV during childbirth.

In 1998, a number of maternity wards in South Africa’s public hospitals were also getting ready to establish pilot projects to see how feasible it would be to offer AZT to every South African HIV-positive mother-to-be, no matter how poor. Almost immediately, then Minister of Health Nkosazana Zuma suspended public funds for these projects, because, she said, even these short courses of AZT were too costly.2 AIDS activists and doctors mounted protests, but the Ministry of Health maintained its anti-AZT policy. Last winter, after the President began to entertain the ideas of the AIDS dissidents, he stated in an address to Parliament that AZT was not only expensive, it was also alleged to be toxic, or so he had learned from some of the AIDS dissidents’ websites. AZT would not, therefore, be administered to pregnant women attending public hospitals until it had been thoroughly investigated.3

Then in March, Parks Mankahlana, Mbeki’s spokesman, shed new light on the President’s thinking about AZT in an article in Business Day newspaper. The drug was not only expensive and toxic, he said, but was part of a corporate conspiracy to rip off Africa’s poor:

Like the marauders of the military industrial complex who propagated fear to increase their profits, the profit-takers who are benefiting from the scourge of HIV/AIDS will disappear to the affluent beaches of the world to enjoy wealth accumulated from a humankind ravaged by a dreaded disease‌.

Sure, the shareholders of Glaxo Wellcome [the company that makes AZT] will rejoice to hear that the SA government has decided to supply AZT to pregnant women who are HIV-positive. The source of their joy will not be concern for those people’s health, but about profits and shareholder value.4

Today, about two hundred babies are born in South Africa every day with the HIV virus. If all of their mothers had been given AZT around the time of delivery, as many as half of those babies might have been spared HIV infection and AIDS.5 In 1997 Glaxo Wellcome had offered the drug at a discount to the Health Ministry for use in public maternity wards, but the Health Ministry turned the offer down.6

Have you ever seen a child dying of AIDS? I worked on AIDS research in Uganda in the early 1990s, and what surprised me about the pediatric AIDS wards I visited there was how quiet they were. The thin, breathless children were too sick to cry. Before I left for South Africa, I had arranged to speak to some of South Africa’s most important scientists and government officials about the government’s anti-AZT policy, which did not make sense to me. What I found when I got there was even more disturbing than what I had expected.

2.

In the mid-1990s, scientists in the United States discovered that com-binations, or “cocktails,” of anti-retroviral drugs can help people with HIV live longer. The cocktails are expensive, must be taken according to complicated schedules, can have unpleasant side effects, and don’t help everyone. However, for many AIDS patients, the right cocktails of anti-retrovirals can add years of health to their lives. Since these drugs were developed in the early 1990s, hospital AIDS wards have been closing across the US and Western Europe, and many patients once on the verge of death have gone home, to contemplate a future they never thought they’d have.

The annual cost of AIDS drug cocktails is more than $10,000 per patient, and these days the only way a poor HIV-positive South African can obtain them is by participating in a clinical trial sponsored by one of the large Western pharmaceutical companies that make the drugs. These companies test their drugs in Africa because there are so many HIV-positive people there who have never taken anti-retroviral drugs before. Such patients are unlikely to have developed resistance to any of the individual drugs in the cocktails, and this gives the cocktails a better chance of success, which in turn allows the companies to obtain clearer results. At present hundreds of such trials are underway across the country, and HIV-positive South Africans seem eager to sign up for them. “People are desperate,” Florence Ngobeni of the Township AIDS Project in Soweto told me. “There is so much confusion and fear.” A doctor who runs clinical trials of AIDS drugs at the University of Pretoria told me that she has no trouble finding participants. “They come to me,” she said.

  1. 1

    Interested readers can find a discussion of the evidence that HIV is the sole cause of AIDS on the website of the National Institutes of Health (www. niaid.nih.gov/factsheets/evidhiv.htm). See also Richard Horton, “Truth and Heresy about AIDS,” The New York Review, May 23, 1996.

  2. 2

    See Howard Barrell and Stuart Hess, “Zuma Defends AZT Policy,” Mail and Guardian (Johannesburg), October 16, 1998. An AZT pilot project is underway in Khayelitsha Township in Western Cape Province, with funding from the provincial government and Doctors Without Borders. The project has been allowed to continue, and is likely to be expanded, because Western Cape Province is under the control of the National Party, which has been critical of the anti-AZT policy. South Africa’s other provinces have suspended AZT pilot projects. They are all under the control of the ANC, except for KwaZulu Natal, which is controlled by the Inkatha Freedom Party.

  3. 3

    See “AIDS Exists. Let’s Fight It Together,” Mail and Guardian, February 11, 2000. AZT and other anti-retroviral drugs are unlikely to be toxic to unborn children in the doses needed to prevent HIV transmission. The Centers for Disease Control has followed the cases of more than 20,000 children born to women in the US who took AZT during pregnancy, and found no evidence of long-term toxic effects. In France, two children died from what seemed to be toxic exposure to AZT and another anti-retroviral drug, 3TC. These children were exposed to higher doses of the drugs than would be administered in South Africa. See “Timeline of events related to follow-up of children exposed to anti-retrovirals perinatally,” Centers for Disease Control, 2000.

  4. 4

    Parks Mankahlama, “Buying Anti-AIDS Drugs Benefits the Rich,” Business Day, March 20, 2000.

  5. 5

    For logistical reasons, the actual proportion of babies that might be spared infection with HIV if a universal AZT program were implemented in maternity wards would be lower than 50 percent, at least at first.

  6. 6

    See “Ministry Refuses Anti-HIV Drug Discount,” Mail and Guardian, May 7, 1999.

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