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 Collections under
which this article appears: HIV
Infection/AIDS Sociology
Other
Ethics Other
Public Health Medicine
in Developing Countries Culture
International
health |
Didier Fassin
a Centre de Recherche sur les Enjeux Contemporains en Santé Publique, Université Paris 13-Inserm, 74 rue Marcel Cachin, 93 017 Bobigny, France, b Centre for Health Policy, School of Public Health, University of Witwatersrand, PO Box 1038, Johannesburg 2000, South Africa
Correspondence to: D Fassin dfassin@ehess.fr
Discussion of AIDS in South Africa needs to move beyond a simplistic "for or against" stance on President Mbeki's denial of a connection between HIV and AIDS. The authors propose ways to widen the debate and hence to increase understanding of the epidemic
At the beginning of 2000 Thabo Mbeki sent a letter to world leaders expressing his doubt that HIV was the exclusive cause of AIDS and arguing for a consideration of socioeconomic causes. He subsequently invited scientists who shared his view to sit with orthodox experts on AIDS on a presidential panel to advise him on appropriate responses to the epidemic in South Africa. Until April 2002, when Mbeki formally distanced himself from the AIDS "dissidents," the international scientific community's interest in South African policies on AIDS was almost exclusively focused on the polemic raised by the president. His statements questioning the AIDS statistics, on poverty as a cause of immune deficiency, and on the dangers of antiretrovirals, together with government stalling on the roll out of nevirapine to prevent transmission of HIV from pregnant mothers to their babies, dominated the debate.1-3
However, the July 2002 Constitutional Court judgment ordering the government
to make nevirapine universally available to pregnant women infected
with HIV, followed in October by a cabinet statement supporting wider
access to antiretrovirals, may have finally ushered in a new era. It
should now be possible to discuss the reality of AIDS in South Africa
without reducing the argument to simple dualisms (such as being for
or against a viral cause of AIDS, for or against the president). We
propose an approach to discussing AIDS in South Africa that is rooted
in political economy and political anthropology. Such an approach
will shed light not only on the objective determinants of the
epidemic, especially social inequalities, but also on subjective
responses, such as those of Mbeki.
| Summary points
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Causes and processes: the political economy of AIDS |
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With an estimated five million people infected, South Africa has the highest number of people with HIV in the world. The most striking epidemiological fact is the extremely rapid growth in HIV seroprevalence, for example from 0.7% in pregnant women in 1990 to 24.5% in 2000, reaching 36.2 % in KwaZulu Natal.4 The impact on adult mortality has been dramatic. In 2000 AIDS accounted for 25% of all deaths, and mortality was 3.5 times higher than in 1985 among 25-29 year old women and two times higher among 30-39 year old men.5 This rapid evolution, unprecedented even on the African continent, is often seen as yet another symptom of South African "exceptionalism," a phenomenon often referred to in the social sciences.6
Yet one need not look far
whether
historically or in other countriesto
appreciate that social conditions are important in determining
exposure to disease. 7 8
Had a coherent social epidemiology of HIV been more prominent in the
scientific arena, rather than the dominant biomedical and behavioural
approach, Mbeki might have found interesting alternatives to the
explanations of the epidemic given on the dissidents'
websites.
Three social factors seem to place South Africa at a higher risk of HIV.
Firstly, social inequalities in income and employment status are
powerful predictors of HIV infectionalthough,
interestingly, the correlation is neither linear nor unequivocal.
Several factors are involved in the association. A low income or
level of employment is associated with9:
Secondly, mobility is a well known determinant of epidemics, but in South
Africa the situation is particularly complex. Mass resettlements of
populations under apartheid, seasonal labour migrations, movements
along major trade routes, refugees fleeing war in other parts of
Africa, and, since 1990, return of political exiles and liberation
armies have all contributed to the spread of infections.10
Thirdly, sexual violencewhether
by known or unknown perpetrators, in commercial or conjugal sexfacilitates
viral transmission. Sexual violence is linked with common forms
of social and political violence that have long been part of the
everyday life of townships and inner city areas.11
The combination of the three factors can be seen in the practice of
"survival sex," whereby young women in the townships, often migrants
from impoverished rural areas, use their bodies as an ordinary
economic resource outside the context of prostitution but within the
culture of male violence.12
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Inequality, mobility, and violence are partly the legacy of centuries of colonial exploitation and racial segregation, culminating in the institution of apartheid in the second half of the 20th century. Epidemiologically this segregation translates as differential HIV seroprevalence between black and white groups and between social classes (figure 1). The case of the mining industry illustrates this legacy. The extraction of a black male labour force from the villages to work the mines has been the motor of the South African economy since the end of the 19th century. These men are accommodated in barracks or hostels, far from their spouses, and commercial sex and access to alcohol are more or less institutionalised social activities in hostel compounds. This social situation explains why educational programmes have had little success in fostering preventive practices, such as condom use.13 Furthermore, environments where men far outnumber women seem to create explosive conditions for the spread of HIV. In the mining town of Carletonville, even adults with a single lifetime sexual partner face an extraordinarily high prevalence of HIV (figure 2).14 In this instance, social context has a far greater bearing on risk of infection than individual sexual behaviour.15
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Suspicion and denial: towards a political anthropology of AIDS |
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A political economy of HIV/AIDS falls short, however, of explaining the
suspicion in South Africa of science and orthodoxya
suspicion that is widespread and not confined to the president
and his advisers. Examining objective social causes does not preclude
an understanding of the politics of AIDS as a subjective phenomenon.16
A political anthropology may make some sense of what is often
presented as merely irrational.
The global controversy created by the president was preceded by several local controversies involving the government. In 1996 the government was accused of wasting public money on a musical show that was supposed to spread the message of prevention. In 1997 it was criticised for officially supporting a treatment, Virodene, that was later identified as an industrial solvent with no benefit. And from 1998 it was denounced for blocking the use of antiretroviral drugs, which the government justified by citing the drugs' side effects.17 In all these arguments, as well as in the virus versus poverty controversy from 2000, two closely linked features appear. The first is the racialisation of the issues, with the government accusing its opponents, whether activists or politicians, of racism. The second is the theme of conspiracy against Africans, either from the country's white conservatives or from the pharmaceutical industry. Both features combine in the somewhat contradictory notion that the AIDS epidemic and its treatments are part of a plot to eradicate the black population.
In South Africa racialisation and conspiracy are rooted in history, and the realm of public health is not exempt from their effects. Epidemics have often been used to enforce racial segregation. The bubonic plague of 1900 in Capetown was used to justify the mass removal of Africans from their homes to the first "native locations" under the first segregationist law, passed in 1883 and called, significantly, the Public Health Act.18 When AIDS appeared in South Africa it was immediately interpreted in racist terms: some white leaders evoked a supposed African "promiscuity;" they denounced the danger that infected black people posed to the nation; and they even publicly rejoiced over the possible elimination of black people by the disease, as one member of parliament did in 1992.19 As has recently been shown, in the last years of apartheid government laboratories were developing chemical and biological weapons (including anthrax, intended to eliminate black leaders), were researching contraceptive methods to induce sterility in the African population, and were allegedly attempting to spread HIV through a network of infected prostitutes.20
So, what could be seen elsewhere as unfounded suspicion was in South Africa plain reality, historically attested. Remarkably overlooked for purposes of national reconciliation, this history still remains deeply present to many South Africans and explains much of the mistrust towards Western science, medicine, and public health.
An understandable defiance is thus an important element of what is usually
termed denial.21 In fact, deniala
common response among people facing an intolerable situationhas
two facets.22 One is a denial of
reality: a reaction that something can't be true, that it is not
possible. The other is a denial of the unacceptable: a reaction that
something is not normal, that although it exists it should not. Both
facets are involved in the denial of the reality of HIV/AIDS. It is
difficult for anybodyeven
a state leaderto
fully comprehend the magnitude of the epidemic and its demographic
consequences, such as the loss of 20 years of life expectancy
within two decades. Also, it is seen as morally unacceptable that a
plague can affect the population so massively and so unequally
precisely at the point when democracy has at last been achievedin
what seems a remorseless prolongation of the suffering of the
weakest people in society.
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Conclusions |
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Change occurs rapidly in South Africa, but history continues to show through the surface of present events. The marks of apartheid are still deeply inscribed in the bodies and minds of the people who had to suffer under it, a decade after its end, and the country's AIDS crisis manifests the legacy of the politics of the past.23 To limit the explanation of HIV infection to poverty is certainly an oversimplification: public health policies need to take into consideration the interdependence of inequality, mobility, and violence. Conversely, to focus attention solely on behaviour change or on treatment is to overlook the powerful social determinants of HIV in South Africa.
Clarifying the objective and subjective dimensions of the reality of the epidemic can help people understand otherwise incomprehensible issues and thus ease the dialogue between apparently irreconcilable positions. For instance, understanding people's suspicion and denial is vital in the management of the HIV epidemic. An effective politics of AIDS entails a "politics of recognition": contrary points of view should be understood rather than discredited.24
But a better understanding rooted in history does not mean indulgence of
errors or acceptance of conservatism. On the contrary, recent events
have shown that the HIV/AIDS debate has increased people's awareness
of health inequalities and has advanced the battle for social rights.
In South Africa, AIDS is not just a tragic and dramatic phenomenon:
through the mobilisation of activists as well as lay people and
through the fight for social justice it has also come to be a
resource for democracy.
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Footnotes |
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Funding: DF and HS collaborate in a research programme on the politics of AIDS that is funded by the French National Agency for AIDS Research (ANRS).
Competing interests: None declared.
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References |
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1016 |
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| 12. | Wojcicki JM. "She drunk his money": survival sex and the problem of violence in taverns in Gauteng province, South Africa. Med Anthropol Q 2002; 16: 267-263[Medline]. |
| 13. | Campbell C. Selling sex in the time of AIDS: the psycho-social context of condom use by sex workers on a Southern African mine. Soc Sci Med 1997; 45: 273-281[CrossRef][ISI][Medline]. |
| 14. | Williams B, Gilgen D, Campbell C, Taljaard D, MacPhail C. The natural history of HIV/AIDS in South Africa: a biomedical and social survey in Carletonville. Pretoria: Council for Scientific and Industrial Research, 2000. |
| 15. | Bloom SS, Urassa M, Isingo R, Ng'weshemi J, Boerma JT.
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| 17. | Schneider H. On the fault-line: the politics of AIDS policy in contemporary South Africa. African Studies 2002; 61: 145-167[CrossRef]. |
| 18. | Swanson M. The sanitation syndrome: bubonic plague and urban native policy in the Cape Colony: 1900-1909. Journal of African History 1977; 18: 387-410[Medline]. |
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| 20. | Gould C, Folb P. Perverted science and twisted loyalty. The Sunday Independent, 2000 Oct 8: 7. |
| 21. | Schneider H, Fassin D. Denial and defiance: a socio-political analysis of AIDS in South Africa. AIDS 2002; 16(suppl): S1-S7[Medline]. |
| 22. | Cottereau A. Dénis de justice, dénis de réalité. In: Gruson P, Dulong R, eds. L'expérience du déni. Paris: Editions de la Maison des Sciences de l'Homme, 1999:159-178. |
| 23. | Fassin D. Embodied history: uniqueness and exemplarity of South African AIDS. African Journal of AIDS Research 2002; 1: 65-70. |
| 24. | Taylor C. The politics of recognition. Princeton, NJ: Princeton University Press, 1992. |
(Accepted 5 December 2002)
© 2003 BMJ
Publishing Group Ltd
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Collections under
which this article appears:HIV
Infection/AIDS Sociology
Other
Ethics Other
Public Health Medicine
in Developing Countries Culture
International
health |
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