Envisage South Africa at the end of this decade. Thabo Mbeki will have left office after ten years as president. Debate over the merits of his conservative economic policies or his vision for Africa's revival will be a distant memory. Instead, South Africa will be reeling from a long-foretold catastrophe. By 2009, Aids will have dispatched roughly 6m to their graves, in a country of less than 50m people. The dead will mostly be in their thirties; 2m children will be orphans. Life expectancy will have plunged to 41 years. The consequences of a generation laid waste will overshadow life in every village and township.
If the predictions are accurate (and the scenario above is not the worst, only the most common) nothing short of a cure can save Mbeki's reputation. He protests that all he has done is ask questions. But Mbeki questions whether it is happening at all. He claims Aids is not the largest killer in South Africa, that murder or heart disease take more lives. When he does admit that Aids is a problem, he doubts the link to HIV. If the disease does exist, Mbeki says, it is caused by poverty. He is not entirely alone. His supporters do not consist only of outright denialists. There are also Aids sceptics who argue that the methods of gathering information about the spread of the disease are unreliable and that the doomsday scenario has been, if not invented, then exaggerated.
The truth is that everyone involved with Aids-scientists, doctors, politicians-question the numbers. There are no definitive statistics as to how many people have died of the disease in Africa over the past two decades, let alone accurate predictions of how many more lives Aids will claim. Cape Town's respected Medical Research Council (MRC) says more than 500,000 people have already died of Aids in South Africa (and that 40 per cent of all deaths between 15 and 40 are Aids-related). UNAids puts the toll at twice that number. Criticism of the figures has focused in part on the reliability of the Elisa (enzyme-linked immunosorbent assay) antibody tests which the UN uses to make forecasts about the epidemic. Sceptics say Elisa is up to 30 per cent inaccurate. The results can be affected by malaria, a problem in much of Africa (though not most of South Africa). Doubts are cast over how many TB deaths result from immune deficiency, and how many simply from TB.
Yet more and more people in Africa are dying of something. The residents of almost any village in Uganda, Rwanda or Kenya can point to a house that is home only to orphans. The government in Zambia says it has lost one in three teachers to Aids. For all the scepticism about antibody tests, even the most conservative estimates of those who accept that the disease exists (including South Africa's big insurers and the state's own statistical office) predict more than 2m deaths from Aids by 2010-three times the number of Tutsis murdered in Rwanda's genocide.
Meanwhile, Mbeki is still echoing the views of men long since condemned to the fringes of medical science. The "Aids dissident" Peter Duesberg, professor of biochemistry at the University of California, was briefly a darling of America's gay community for promoting the idea that HIV did not cause Aids. Mbeki is an internet enthusiast and discovered his work on sites such as "virusmyth.com" where Duesberg and his colleague David Rasnick argue that Aids is not infectious and that its spread in Africa is caused by poverty, not sex.
Mbeki-f?ted in the west for his stern adherence to the economics of globalisation-certainly makes for a curious "dissident." During his visit to Britain last June, Tony Blair hailed him as a new kind of leader, so different to the Mobutus and Mugabes who have dragged down Africa.
Does anyone know the numbers?
But in South Africa itself some have gone so far as to accuse Mbeki of genocide. The charge does not come from white racists trying to discredit the new order, but the likes of professor Malegapuru Makgoba, head of the MRC; and Rhoda Kadalie, a former commissioner of the government's own human rights body. It is a charge based on the UN estimate that South Africa has more HIV-positive people than any other in the world-4.7m, or one in nine of the population. It is a charge levelled at Mbeki because he wilfully stands in the way of unleashing the power and resources of the state to warn people of the danger of Aids, and to save those who might be saved.
One issue has galvanised criticism and mobilised activists like no other-his disinclination to provide drugs to prevent HIV-positive pregnant women from passing on the Aids virus to their newborn babies. The South African paediatric association says 70,000 babies were born with HIV in 2000. The risk of mothers passing on the virus to their children is as much as halved with a single dose of a drug, nevirapine, shortly before birth, and another for the child afterwards. The process costs less than ?2, and the drug's manufacturers are offering to supply it for nothing. Yet the government has not made the drug available in public hospitals, an act which could save tens of thousands of babies each year. To do that would be for Mbeki to admit his mistake.
No one blames Mbeki for the fact that Aids set down firm roots in South Africa. The apartheid regime perceived it as a gay condition and ignored the early spread of the disease and the bitter lessons from blighted countries such as Uganda. After the end of white rule in 1994, Mandela's government was slow to realise the depth of the problem. Even now, with the value of new drugs still in dispute, real questions persist about what might be done to combat the disease.
Nor is it in doubt that the South African government faces hard choices over how to use its limited resources-although its decision to spend ?4 billion buying weapons (including submarines) has raised questions about its priorities. Mbeki is grappling with an apartheid legacy of 25 per cent unemployment, more than 20,000 murders and 50,000 rapes a year, and millions still condemned to live in squatter shacks while the rand collapses.
Yet the accusation against Mbeki is more specific and more serious. It is that he has sought to replace the fact of Aids with a fantasy of neo-colonial bondage to drug companies.
In September 2000, Mbeki told the South African parliament that HIV and Aids numbers were not nearly so serious as scientists claimed. The president cited World Health Organisation (WHO) statistics for Africa which purport to show that the single largest killer on the continent is heart disease and then malaria. Aids was in third place-responsible for just 12 per cent of all deaths. What he did not say is that most statistics distinguish between the north of Africa and sub-Saharan Africa. The north has a big problem with heart disease, but not Aids. South of the Sahara, the HIV infection rate rises dramatically.
Mbeki was back a few months later with more WHO numbers. He ordered the health minister-Manto Tshabalala-Msimang-to consider a cut in the Aids budget, on the basis of five year-old statistics which purportedly show that the disease causes little more than 2 per cent of deaths in South Africa. "Needless to say, these figures will provoke a concerted propaganda campaign among those who have convinced themselves that HIV-Aids is the biggest cause of death in our country," Mbeki wrote.
Mbeki presented the figures as endorsed by the WHO; they actually originated with the South African government. They reflected what was recorded on death certificates as the cause of death, an extremely unreliable source of information about Aids, because of the stigma attached to the disease and because it is usual to record only the immediate cause of death, such as TB. The WHO pointed to figures for 2000 which show that one in five South African adults is HIV-positive and that Aids is the single largest cause of death in the country. A WHO official accused Mbeki of "deliberate misinterpretation of old statistics for political ends."
Mbeki later falsely claimed in a BBC interview that murder is a bigger killer in South Africa than Aids. The murder rate is shocking-about 20,000 a year. But UNAids estimates 250,000 people died of Aids in South Africa in 2000. Even sceptics who query this figure find Mbeki's claim preposterous.
Nevertheless, the numbers are confusing. Sceptics make much of the fact that the rise of total registered deaths in South Africa since 1990 does not square with UNAids figures. Up to 30 per cent of all deaths in South Africa go unrecorded, so the register is not comprehensive. But the increase in total deaths over 10 years is somewhere between 180,000 and 230,000. Is this sufficient to account for the figures on Aids deaths in 2000? Pick your figure. The UN is adamant about 250,000; SA Stats claims 230,000; the MRC says 165,000.
Whatever the exact numbers, to claim they are not serious flies in the face of evidence from hospitals and mortuaries. Glenda Gray is a paediatrician at the largest hospital in Africa-the sprawling, understaffed and underfunded Chris Hani Baragwanath in Soweto-and her work with HIV-positive children has won her the Nelson Mandela Award for Health and Human Rights. "When I started in 1993, three women in 100 tested HIV-positive in my hospital," she says. "Now it's 31 women in 100. Half the kids admitted to my hospital are HIV-positive. Three-quarters of all the deaths of kids in my hospital are because of Aids. I'm getting pissed off with all this questioning. Something is killing people in this country. Only two things have changed: the end of apartheid and Aids. If you don't believe HIV is killing people, then what is it? Don't tell me it's the same diseases that have always killed people in Africa. Why now, why only now is it explosive?"
In a recent report, the MRC predicted nearly 800,000 deaths a year in South Africa from Aids by the end of this decade. The research was the most rigorous of its kind to date and it was subject to wide peer review, including approval by Peter Goldblatt, chief medical statistician for England and Wales. The president's chief enforcer, Essop Pahad, and the health minister derided the report as "propaganda." When the official census body, SA Stats, tried to refute the MRC figures, its attempt was so clumsy that it concluded South Africans were having sex at several times the rate of the rest of the world. Even in the midst of its attempt to disprove the figures, SA Stats were still forced to conclude that 2m-3m South Africans will die of Aids this decade.
Could Mbeki make a difference?
Inside South Africa's public health service, Mbeki's pronouncements have created a climate of bewilderment. Civil servants conduct a quietly subversive campaign to bring some sense to the most important public health issue of the age. But confusion and fear are such that two years ago the health department failed to spend 40 per cent of its Aids budget, and almost every province in the country also underspends because local government does not know what it is, and is not, allowed to do.
While the governments of Botswana, Nigeria and Mozambique press ahead with plans to provide anti-retrovirals to their HIV-positive citizens, Mbeki says the jury is out on such drugs. Almost no one in his cabinet agrees with Mbeki's views, except perhaps his health minister, Manto Tshabalala-Msimang. But the president wants acquiescence not agreement, and that is what he has got from most ANC members of parliament-even the several dozen of them who are HIV-positive. Parliament's medical scheme, paid for from the public purse, provides those MPs that need them with the same anti-retroviral drugs the government has banned from state hospitals.
Africans listen to their leaders. Uganda's president, Yoweri Museveni, can regularly be seen on television telling viewers to use a condom or die. He calls radio stations to ask why he has not heard anything on Aids recently. The result can be seen in the latest UN statistics. HIV infection among young women in Uganda has dropped substantially.
The ANC remains among the most revered organisations in South Africa. If Mbeki were to make Aids a priority, there is not much doubt that his compatriots would take notice. But the president has never visited an Aids ward. By disputing the link between HIV and Aids, Mbeki has refused to endorse testing for HIV or the use of condoms. Hospital workers tell of a stream of men who say they don't use condoms because the president doesn't believe HIV causes Aids. The depth of ignorance is so profound that, at the end of last year, South Africans long inured to violent crime were horrified by a series of rapes of small babies. Some of the attackers believed it would rid them of HIV. A survey by Love Life, a US-backed Aids education programme, has revealed that one in four young South Africans believes that sex with a virgin is a cure.
The South African president's unconventional views on Aids first came to public notice not long after he took power in 1999, when he suggested that expensive drugs to treat the disease would do more for the white-owned pharmaceutical industry's profits than black people with HIV. Who would not be sceptical of the drug companies which stood to make massive profits from the Aids pandemic? It was only natural that Mbeki would seek out all opinions, even including the "Aids dissidents."
Mbeki's history of denial
But the illusion that Mbeki merely had an inquiring mind was shattered by a letter to Bill Clinton, Tony Blair and other foreign leaders in April 2000. It announced the formation of Mbeki's "President's Advisory Panel on Aids"-a committee of denialists and conventional scientists assigned to revisit questions settled a decade ago in America and Europe. Although he said he was just searching for answers, Mbeki launched into an extraordinary tirade in defence of the Aids dissidents.
"Not long ago, in our country, people were killed, tortured and imprisoned because the authorities believed that their views were dangerous," wrote Mbeki. "We are now being asked to do the same thing that the racist apartheid tyranny did, because there is a scientific view against which dissent is prohibited."
The letter so astonished the White House that it checked to make sure it was not a hoax and then tried to keep it under wraps, for fear of embarrassing Mbeki. Britain no doubt dismissed the letter as marginal in the grand scheme of Africa's problems. Yet, in South Africa, Aids is the grand scheme of things.
Scientists who challenge the president have been vilified for "getting rich" through a "corrupt Aids industry," and of being in the pay of the drug companies. Not long after the 2000 Durban Aids conference, Mbeki's office issued a statement accusing those who wanted the government to provide anti-retroviral drugs in public hospitals of trying to poison black people. "Our people are being used as guinea pigs and conned into using dangerous and toxic drugs," it read, describing this as an onslaught "reminiscent of the biological warfare of the apartheid era."
But it wasn't so long ago that Mbeki took an entirely opposite view of Aids. In early 1997, three Pretoria scientists claimed to have discovered a cure, called Virodene. Mbeki, then deputy president, hinted that funding for the drug's development would be forthcoming. But it was soon revealed that the active ingredient in Virodene was a solvent used in freezing animal organs, with zero impact on HIV. When South Africa's horrified Medicines Control Council (MCC) demanded a halt to tests on humans, Mbeki accused it of sacrificing lives by holding up a "miracle cure" amid "the pressing crisis of an escalating pandemic of HIV/Aids." When the MCC's chairman, Peter Folb, refused to allow human testing of the drug, the government sacked him and stripped the council of much of its powers. It was the first indication that South Africa's new leaders were willing to subordinate medical science to politics.
A sign of Mbeki's change in thinking came in October 1999. In an address to the second house of parliament, Mbeki still called Aids a "scourge" but now questioned the value of anti-retroviral drugs by suggesting that AZT-the first and most widely used anti-Aids drug-was so toxic as to do more harm than good. "It would be irresponsible for us not to heed the dire warnings which medical researchers have been making," he said.
The medical researchers he was referring to were the Aids dissidents, like Duesberg and Rasnick. Rasnick claimed that anti-retrovirals are themselves the cause of Aids. How he squared this with the fact that most of South Africa's nearly 5m HIV-carriers have never taken AZT or similar drugs is not clear. But if Duesberg and Rasnick were right and if anti-retrovirals are useless or worse, he no longer had to consider dedicating scarce resources to save the doomed. Mbeki could point the finger at poverty and the legacy of apartheid.
No doctor denies that AZT and other anti-retrovirals have side effects, from short term nausea to liver toxicity. But clinical trials show that the risks are far lower than those from chemotherapy. While millions of South Africans are still consigned to squatter camps with no ready sanitation-and with malnutrition still prevalent in Transkei, KwaZulu-Natal and parts of the former black homelands-diseases of all kinds quickly take hold. But that is merely the context, not the cause, of Aids. By denying a cause, Mbeki is also able to deny the possibility of a cure.
Certain remedies are available, if he wishes to take them. After the South African government won last year's court battle against drug companies over patent rights, the public standing of the big drug companies across the globe was little better than that of tobacco firms. It was a golden opportunity for South Africa to pressure the companies into sinking some of their profits into supplying Aids medicines free, or at prices the country could afford. But Mbeki has not used the court victory either to buy or manufacture cheap anti-HIV drugs.
Does Mbeki believe his arguments to be true? Can it be that the Sussex University educated president-who quotes Shakespeare and is renowned for his sharp intelligence-is unable to understand the most basic arguments of medical science? Mbeki has repeatedly said he was just asking questions. It has become a mantra from his office that he has never denied that HIV causes Aids. But last year in parliament, Mbeki ridiculed the link between the virus and the disease. "Aids is Acquired Immune Deficiency Syndrome. I don't believe it's a sensible thing to ask: 'Does a virus cause a syndrome?' It can't. A virus will cause a disease." When 5,000 doctors signed a declaration before the 2000 international Aids conference in Durban stating that the disease is the direct result of HIV, Tshabalala-Msimang dismissed it as an "elitist document."
After the conference, western governments began to question whether it was worth sinking money into Aids education in South Africa. Amid scepticism abroad and a barrage of criticism at home, Mbeki said at the end of 2000 he was "withdrawing from the debate."
In March last year, however, he went on a more general public relations offensive. It was launched with an interview on a Cape Town television station, e-tv. After a stiff start, during which he failed to rise to soft-ball questions such as "what kind of music do you like?" (apparently everything and nothing), Mbeki was asked if he would take a test for HIV. He fell back on his favoured tactic of obfuscation:
"Whether I would take an HIV test or not, I think is irrelevant to the matter. It might be dramatic and create newspaper headlines."
Interviewer: "But would it not set an example, the president taking an Aids test?"
Mbeki: "No. But it is setting an example within the context of a particular paradigm."
Mbeki's prevarications have rippled through the medical establishment in South Africa, particularly the medical schools at the big universities. There are probably more than 1m HIV-positive people in Johannesburg, Pretoria and the surrounding province of Gauteng. Yet, the crisis is apparently not grave enough to merit an infectious diseases unit at Johannesburg General Hospital or an Aids clinic for more than one morning a week. In all of South Africa there are just five infectious disease specialists who really know what Aids is about.
Doubts among officials in the health department were laid bare in September with the leaking of a departmental document spelling out the need for increased funding to cope with a rise in Aids and TB. It challenged many of the president's assertions about the crisis by conceding that HIV is the cause of Aids and that anti-retroviral drugs do extend lives. The document admitted that the health department had failed to provide "any meaningful care for a proportion of those sick with HIV/Aids." It then confirmed that Aids is the single largest killer in the country: "South African models of likely mortality from HIV/Aids predict that cumulative deaths will have reached between 3.4-4.5m by 2010 with profound effects on almost every aspect of life and even national security." The health minister later said that the document was "an early draft."
The roots of irrationality
The real mystery is not how many millions of people will die, but why Thabo Mbeki is an "Aids dissident" at all. Is he a desperate man in denial? That does not sound like Mbeki. He is far too much in control. A clearer key to Mbeki's self-deception lies with an extraordinary speech he gave at Fort Hare university in October. He does not mention Aids or HIV, but his intent is clear as he implies that those scientists who believe the disease is a catastrophe for South Africa are denigrating black people as vice-ridden germ carriers. When black people themselves say there is a crisis, Mbeki dismisses them as "negroes of enslaved minds."
"And thus does it happen," he intoned in his lecture, "that others who consider themselves to be our leaders... demand that because we are germ carriers, and human beings of a lower order that cannot subject its passions to reason, we must perforce adopt strange opinions, to save a depraved and diseased people from perishing from self-inflicted disease."
So Aids becomes an imaginary disease conjured by the new forces of colonialism to denigrate Africans as sub-humans driven to collective suicide by the unstoppable pursuit of sex. Even by the standards of post-apartheid South Africa, Mbeki is obsessed by race. Perhaps it is because he spent almost all his adult life in exile, much of it in the west. But Aids seems to have drawn out his extremes. He sees the disease as a means of demonising black people in the way homosexuals were demonised for their lifestyle when Aids first hit America. In October 2000, Mbeki told ANC parliamentarians that criticism of his Aids policies was a CIA plot in alliance with the drug companies.
It was a claim which has prompted the theory that Mbeki was dabbling in populist rhetoric to divert attention from his conservative economics. To be in thrall to the demands of globalisation must be gruelling for a man so suspicious of western intent. Hence, the speculation goes, Mbeki thought he could gather popular acclaim for his radicalism on Aids.
Mbeki's views are popular with many uneducated black males. But the attempt to portray Aids as part of a racial conspiracy has not convinced his elite black critics-trade union leaders, clergymen and doctors. Aids drew the trade union confederation, Cosatu, to make its first public criticism of Mbeki in late 2000. Cosatu is a close ally of the ANC, but it is watching its own members die in droves.
In early February, Nelson Mandela himself criticised the government's Aids policies. And the courts have waded into the most contentious issue-the provision of nevirapine to save babies. At first the government refused to supply the drug on cost grounds. Parks Mankahlana, then Mbeki's spokesman, put it bluntly in an interview with Science magazine in the US. It was cheaper to let the children die, he said. But Mankahlana himself has since died. The newspapers said it was of Aids. Mbeki's office said it was a "private matter."
In December, a high court judge ruled that the government had behaved unconstitutionally by denying children the right to life, and ordered that it begin dispensing nevirapine. The government recognised that it had lost public support and declared that it would reassess its policy. But when the Inkatha-led government of KwaZulu-Natal said it would begin distributing nevirapine to HIV-positive mothers-to-be in January, Tshabalala-Msimang blocked it. A few days later, the health ministers of all nine South African provinces met her to plead for the national government to lift its ban on the drug. She said she could not decide while Mbeki was out of the country. A decision was delayed, but KwaZulu-Natal and the ANC-controlled Gauteng took the prevarication as a signal to go ahead and distribute nevirapine-and not to make too much noise about it.
To describe what is happening as a genocide-as Malegapuru Makgoba, head of the MRC, does-is not legally accurate. Under international law, however, anyone who has the power to prevent a crime against humanity and fails to use it is also guilty of a crime. It is not enough for a politician or army officer to say that he did not give the order to kill. Inaction is not a defence. Without that cure for Aids, a nation will surely come to judge Thabo Mbeki guilty for failing to use his powers to try and contain what many will come to view as a crime against the humanity of South Africa.
