South Africa as the Epicenter of HIV/AIDS: Vital Political Legacies and Current Debates

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Introduction
South Africa now is the world's epicenter for the rapid increase of HIV and AIDS.It is spread predominantly by heterosexual activity and mother-child transmission, and the particular subtype is HIV-C.Antenatal surveys in 1999 showed that the incidence varied from 7 to 27.9 percent in different parts of the country.In 1990, the overall incidence was only 0.7 percent (Department of Health, 1999).This paper addresses some educational and health angles in the HIV/AIDS pandemic, highlighting the impact of apartheid and discussing the reasons for South Africa's lead in the global increase of HIV/AIDS.When searching for effective responses to this epidemic, it is particularly important to embrace disciplines other than medical services, such as education, and to dissect the socio-political structures that continue to enable the disease's spread.This article is based on my own experience in the South African sociopolitical arena of HIV/AIDS, the HIV/AIDS &STD Strategic Plan for South Africa 200-2005(Department of Health, 2000) and the Managing the Impact of HIV/AIDS on the Education Sector (Coombe, 2000).

The Legacy of Apartheid
Since 1994 there has been a democratic government in South Africa.However, the legacy of the apartheid years still critically affects the present in all walks of life, not least of all in the health and education arenas.It is important to understand that apartheid aimed at segregating not only black from white, but also the different ethnic groups within the Black population, according to ethnic origin.The government of the time claimed that this segregation was separate but equal.It is now well known how unequal it was, with a well-developed white community whose living standards were equivalent to that of the most advanced industrial countries, and a predominantly black community whose living conditions were equal to some of the least developed countries.Some of the vagaries of the apartheid years are particularly relevant to facilitating the spread of HIV and AIDS today.

Geographical displacement
Over four million Black people were displaced from urban to rural areas designated as "homelands" for the different ethnic groups.In addition, within the urban areas, people of color were moved from designated "white spots" to designated "black spots".These were mainly grossly disadvantaged areas on the periphery or outside the urban areas.There were also forced removals within the urban areas.In Cape Town, Johannesburg, and other cities, hundreds of thousands of people were summarily displaced from near the center to the periphery, and sometimes outside the city.Thus Soweto (South West Township) was the home for citizens removed from the center of Johannesburg.The effect was to leave behind the grave of a viable community and establish an outskirts conglomeration.Soweto became another segregated township outside the city.The inhabitants had to endure long distances to travel to work, inadequate health and educational services, disrupted families and exceptionally poor housing.South African Blacks were also forced to carry identity books commonly known as "passes."These were established to control and bully the citizens, and often used to endorse a person out of the urban and peri-urban areas back to their so-called Homelands [1].
An individual born and bred in Johannesburg could be "endorsed out" to his/her designated Homeland even though s/he had never been there before.There were all sorts of restrictions on Blacks living in the city and one of the most common reasons for endorsing out was temporary unemployment.The effect of all of this was to create an enormous reservoir of people in the barren countryside with little hope of work or even a subsistence existence.By the nature of apartheid, these areas were also grossly deprived of inter alia health and educational facilities.In such areas it will be very difficult to inform the communities of the dangers of HIV and AIDS, how to prevent their spread and indeed provide the infrastructure and facilities to do so.

Migratory labor
The migratory labor system was particularly diabolical.Male Black workers were brought in from the Homelands to supply the mines and industrial complexes in the urban areas.They were not allowed to bring their families with them, and they lived in overcrowded single-sex hostels with little recourse to study, recreation or even basic living conditions.Furthermore, following the breakdown of apartheid there was an influx of people from other parts of Africa, some political but most economic refugees.They came from countries where HIV and AIDS were rife.In addition, many miners had been recruited into South Africa from north of the border.While there are no formal statistics on the HIV status of these immigrants, it can be assumed that they would reflect the incidence in their home countries, which were amongst the highest in the world.
Following the break down of apartheid and the ensuing democratic elections, the pass laws were, of course, abolished, and people had the right to move where they pleased.This caused an influx of individuals and families into "informal settlements" which often had no water, electricity or sanitation, and minimal health and educational services.The impact on this demographic change on the spread of HIV is self-evident.

Education and health segregation
Educational and health facilities were, of course, segregated.The system of Bantu Education applied to Black schools was one of the tenets of apartheid which has left a legacy of a substandard educational system, with poorly qualified or unqualified teachers, overcrowded classrooms, insufficient resources particularly in the previously disadvantaged schools for Black children and a tradition of disruption.The system was aimed at educating Blacks to read and write so as to serve the White community.Similarly, health facilities were not only grossly maldistributed and under funded, but also fragmented in the Black areas leaving an inadequate infrastructure throughout the poverty stricken regions of the country.
School children played a role in the disruption of the apartheid system.The controversial slogan 'liberation before education' led to various boycotts and disruptions of schools, and vicious responses by the authorities.The school revolts in Soweto in 1976 were particularly damaging.The overall result was that many of the best pupils went into exile, and the school system became laced with political activity.This left a legacy of conflict and contempt for the authorities.The considerable difficulties with discipline this caused remain to this day.

The apartheid police system
The police were geared to protect the White community and enforce apartheid.They applied the pass laws rigidly and cruelly.In the Black areas, crime was rife with little recourse to the police or courts for redress.The police, both Black and White, were seen as representatives, and indeed instruments, of apartheid, and were hated by all Black people.In the past, the attitudes and policies of the police force were of racial discrimination.South Africa is involved in transforming all its services, and the police force has been one of the most challenging agencies, with poor resources, low morale and some senior police with their own hidden agendas of disruption.There is also a legacy of corruption.Creating a responsible and effective police force is of concern to the Government, and all South Africans.There was thus contempt for the police force, which had been seen as an instrument of the apartheid system of the previous government.This could lead to the rejection of any messages, particularly if they are unwelcome, from authority.At another level, the inability of the police to control the incidence of rape contributes directly to the spread of HIV.

Current Political Debates
Above I have outlined some of the legacies of apartheid affecting the spread of HIV and AIDS in South Africa.I will now address some of the debates influencing current perceptions and public discussion of the pandemic.

The AIDS myth
If one wanted to generate a Machiavellian plot to undermine the containment of the spread of HIV in a particular country, one would induce the President of that country to publicly doubt the accepted theory that HIV causes AIDS.This is indeed the situation in South Africa.President Mbeki was concerned about why the spread of HIV in Africa was so rapid and different from the spread in developed countries.Mbeki also questioned the use of anti-retroviral drugs to contain the spread of HIV and progression to AIDS, postulating that it was perhaps a deliberate strategy of the pharmaceutical companies to increase their sales.
There are a few but disproportionately vocal proponents of this so-called AIDS myth around the world, representing a kind of dissident's viewpoint of those who urge further research into the causes behind the spread of HIV/AIDS.President Mbeki has embraced the "dissident's" viewpoint: HIV does not cause AIDS but AIDS is rather due to poverty, malaria, drug abuse, TB, malnutrition, among other factors.According to this thesis, AIDS is a syndrome caused by a number of different etiological factors, including drugs, poverty, malnutrition, TB and other infectious diseases; if HIV does exist, it is incidental.This thesis has no clinical or scientific credibility, and is strongly rejected by the international scientific community.President Mbeki was, in my view, seduced by their rhetoric against the use of anti-retroviral therapy for use in treating HIV positive individuals, including the prevention of transmission of HIV from mother to child.In addition he would remember only too well how the ANC was considered a dissident organization.Their argument is that these anti-retroviral therapies (ART) are toxic, and indeed are responsible for the development of AIDS.The medical view is that these drugs may well have some toxic effects, but the benefit obtained from them far outweighs the potential hazards.
Despite the President's exploration of alternative theories, the government strategy on the prevention of spread of HIV and AIDS (as outlined elsewhere) is based on the concept that HIV causes AIDS.However, the message from the President was confusing, and gave an at-risk population mixed messages.Recently, the President has stepped away from the debate, and the government is proceeding on the basis that HIV causes AIDS.

The advisory panel
In the meantime, the President has set up an advisory panel with dissidents comprising about half its members.The report of the advisory panel is still awaited, but the likelihood of any positive outcome is negligible.Besides the waste of resources to fund the advisory panel, an opportunity was lost to set up a more relevant, ongoing forum.Invited could have been scientists, clinicians, human rights activists, health care workers, economists from South Africa, Africa and other successful and unsuccessful countries confronting AIDS and HIV.The question would center on: what strategies have worked in other developing countries; how to get the prices of ART and other drugs down; how to best implement the infrastructures to deliver health care appropriate for preventing the spread of HIV, and how to provide compassionate care for people living with HIV/AIDS (PWA) in a country with limited resources.

Maternal-child HIV transmission (MCHT)
The use of ART in the prevention of MCHT has generated some controversy in South Africa.The debate between the activists and the Department of Health on the use of Nevapicrine for the prevention of MCHT highlights some of the difficulties in controlling the spread of HIV and AIDS.Behind the polemic is the exorbitant cost of anti-retroviral drugs and others used to combat opportunistic infections in AIDS.The government has been in constant conflict with the multi-national pharmaceutical companies and has been thwarted in the courts from using generic drugs often sold at a tenth of the price.On the other hand, the activists are aware that ART could reduce the transmission rate by more than 50 percent and are frustrated by the prevaricating of the government's Department of Health (DOH).However, the DOH argues that the infrastructure for delivering the drugs and monitoring its effect will be crucial, and has set up centers in the different provinces where Nevapcrine is being provided to pregnant mothers.Consequently, structures for testing for HIV, counseling and followup are also needed and currently being established.