CHAPTER 13

Vol 1 No 4, 2001 of the journal, ANC Today, carried an article about some of these questions. It said:

" The New York Times (carried an) article entitled "The AIDS Questions that Linger" written by Lawrence K. Altman, M.D. of the NYT. It was published on 30 January (2001)." Early in his article, Dr Altman quotes Sandra Thurman, the top AIDS official in the Clinton administration, saying:

"People say that the more we learn about HIV, the more we realise we don't know a whole lot." (Our emphasis)."

On the contrary, our own (South African) opposition alliance is convinced that it knows everything that needs to be known about HIV. Undoubtedly, it has the answers to the questions posed by Dr Altman, who writes that the list of unanswered questions about HIV/AIDS "could fill a newspaper, and even then would create debate".

" Among others, Dr Altman poses the following questions:

· "Why does AIDS predispose infected persons to certain types of cancers and infections and not others?"

· "Equally puzzling is why AIDS patients are also more prone to infections like pneumonia. Studies of the immune system have not answered the question, and 'we do not know very much more about why that is than we did 20 years ago when the first work was done,' said Dr Henry Masur, an official at the National Institutes of Health."

· "What route does HIV take after it enters the body to destroy the immune system?"

· (What) is not known is how the virus proceeds to destroy the body 's CD4 cells that are needed to combat invading infectious agents. 'We need a breakthrough' said Dr David A. Cooper, an AIDS expert in Sydney, Australia."

· "How does HIV subvert the immune system?"

· "(There) is widespread variation in the rate at which HIV-infected people become ill with AIDS. So scientists ask: Can the elements of the immune system responsible for that variability be identified? If so, can they be used to stop progression to AIDS in infected people and possibly prevent infection in the first place?"

· "Anti-HIV drugs suppress replication of the virus, which should give the funct ioning parts of the immune system a chance to eliminate remaining virus. That does not happen. 'So something is bizarre about that that we don't understand,' Dr Fauci (the director of the US National Institute of Allergy and Infectious Diseases) said."

· "What is the precise function of HIV genes? HIV's nine genes have multiple functions, but they are only partly known. One gene was called nef (for negative factor) because it was thought to inhibit HIV. But now it turns out to have an opposite effect. Nef accelerates HIV's ability to infect. In the United States, an experimental vaccine made by deleting the nef gene from a simian AIDS virus provided strong evidence of protection against an AIDS-like virus in early tests in monkeys. However, longer-term follow-up showed that the vaccine caused the disease it was designed to prevent."

· "What is the most effective anti-HIV therapy? What combinations of drugs should be started first and when? Why do side effects like unusual accumulations of fat in the abdomen and neck develop? Is it possible to predict who will get them or how best to treat them?"

· "One avenue being explored is treating for a period of time and then stopping in hopes of stimulating the immune system to combat HIV. An unanswered question is: will it work any better than standard therapy?"

· "Another critical unanswered question is: what is the best way to deliver anti-HIV therapy in the third world where medical facilities are scarce?"

· "Is a vaccine possible. There is little question that an effective vaccine is crucial to controlling the epidemic. But many unanswered questions exist about whether and when one can be developed. When HIV-1 was isolated in 1984, Margaret Heckler, the US secretary of health and human services, promised an AIDS vaccine within a few years. Seventeen years later prospects for an AIDS vaccine still appear quite remote, said Dr Neal Nathanson, the former head of the National Institutes of Health's Office of AIDS Research."

· "It is not known whether a vaccine derived from one type of HIV will confer protection against other types."

· "Scientists also do not yet have some basic information about vaccines against HIV. For instance, they do not yet know which antibodies produced in response to a vaccine indicate the greatest likelihood of protection, a crucial step in developing any vaccine. 'Unfortunately, we still don't have the knowledge to create an effective vaccine, and I honestly don't know if we will ever have one because the problems are so great,' Dr Wainberg, an AIDS researcher at McGill University in Montreal, said."

· "Why do most babies born to infected mothers escape infection? Why do 75 percent escape? Do these infants manage to mount a successful immune response to avoid infection? Relatively little research has been done to answer these and other questions, said Dr Esparza, the UN official."

· "Why do HIV rates differ so greatly among regions in Africa and elsewhere? Despite studies, there is no simple explanation for the regional differences, said Dr Piot, the UN AIDS official."

· "Where did AIDS come from? We can only guess. Determining the answer would be important because discovering how AIDS came to be epidemic might prevent a similar catastrophe in the future."

Despite its pursuit of the necessary answers to these and other unanswered questions, the South African Government has nevertheless put in place an anti-AIDS programme, as good as any other anywhere in the world. This is contained in the "HIV/AIDS/STD Strategic Plan for South Africa: 2000-2005."

Included in the goals of the Plan, which are currently being pursued, are:

· to promote safe and healthy sexual behaviour;
· to improve the management and control of STDs;
· to reduce mother-to-child HIV transmission;
· to address issues relating to blood transfusion and HIV;
· to provide appropriate post-exposure services;
· to improve access to voluntary testing and counselling;
· to provide treatment, care and support services in health facilities;
· to provide adequate treatment, care and support services in communities;
· to develop and expand the provision of care to children and orphans;
· to ensure AIDS vaccine development;
· to investigate treatment and care options;
· to conduct policy research;
· to conduct regular surveillance;
· to create an appropriate social environment; and,
· to develop an appropriate legal and policy environment.

Nevertheless, the omnipotent apparatus is not satisfied with this programme, which is based on the thesis - "HIV causes AIDS causes Death". It denounces the South African government as being "in denial" and not doing much to fight the 'HIV/AIDS pandemic'.

To achieve its purposes, once more it takes care that this Strategic Plan that is known becomes unknown. It creates the perceived reality that what exists does not exist. It convinces people who should know, that nothing is being done when something is being done. Thus does the message spread throughout the world that ours is a genocidal government.

The question arises - why is the omnipotent apparatus so angry when the kind of programme that is closest to its heart has, in fact, been adopted and is being implemented!

The simple answer to this question is that this programme, as implemented in South Africa, does not include wide-spread availability of anti-retroviral drugs within the public health system.

The South African government is not spending the billions of Rands on these drugs that would be like music to the ears of those who sell these drugs.

This is happening in a situation in which economic surveys have told those who are interested, that among the countries of sub-Saharan Africa, South Africa (and Botswana) are in economic terms, potentially the most lucrative markets for anti-retroviral drugs.

If, tomorrow, the government were to announce that it was making these drugs generally available within the public health system, it would be showered with praises and a surfeit of congratulations. Overnight, our country would be redefined as one of the best fighters against HIV/AIDS.

This is in spite of what The New York Times said, as we have already reported, that - "such drugs are not a cure for AIDS nor do they prevent the spread of HIV, the virus that causes AIDS".

The question that the South African government will have to answer for itself is whether it chooses an A-rating because it is making anti-retroviral drugs generally available, or it addresses the real health concerns of the millions of our people!

Our government, and the country, are, of course, also awaiting the report from Statistics South Africa (SSA) and others, on health and mortality statistics.

This will provide as accurate a basis as possible of the burden of disease in our country. It will help to ensure that our health and other programmes are properly focused to address all the actual diseases and health risks our people face, and not just AIDS.

In the meantime, despite the fury of the omnipotent apparatus last year generated by reference to this table, and therefore the truth about the health of our people, we reproduce below the latest figures available to us.

SELECTED WHO NUMBERS AND
CAUSES OF DEATH IN SOUTH AFRICA - 1995

INCLUDES DATA RECEIVED SINCE
PUBLICATION OF 1996 EDITION

MALE FEMALE TOTAL RANK % OF 29 CAUSES

All causes 137751 101547 239298
External causes 36138 10337 46475 1 19.83923708
Diseases of the circulatory system 19854 21045 40899 2 17.45895551
Signs,symptoms&other ill-defined conditions 17278 14678 31956 3 13.64136977
Malignant neoplasms 12743 10427 23170 4 9.890804156
TB of the respiratory system+other forms 8414 3946 12360 5 5.276233896
Bronchitis,emphysema,asthma&other respiratory 6647 4220 10867 6 4.638902407
Pneumonia 5394 4690 10084 7 4.304655551
Senility without mention of psychosis 3096 5714 8810 8 3.76081073
Birth trauma&other originating in perinatal period 4456 3770 8226 9 3.511512947
Diabetes mellitus 3145 4900 8045 10 3.43424771
Other intenstinal infectious diseases 3405 3169 6574 11 2.806307575
HIV disease 2653 2568 5221 12 2.228739253
Septicaemia 1864 1827 3691 13 1.575613213
Nephritis,nephrotic syndrome&nephrosis 1661 1628 3289 14 1.404007547
Other diseases of the digestive system 1593 1056 2649 15 1.130804498
Chronic liver disease&cirrhosis 1421 590 2011 16 0.858455208
Malnutrition&nutritional deficiencies 924 822 1746 17 0.74533207
Epilepsy 1053 559 1612 18 0.688130181
Other diseases of nervous system 824 638 1462 19 0.624098216
Meningitis 626 503 1129 20 0.481947255
Ulcer of stomach & duodenum 556 407 963 21 0.411085214
Other infectious & parasitic diseases 397 183 580 22 0.247590264
Other viral diseases 319 259 578 23 0.246736504
Anaemias 202 299 501 24 0.213866762
Mental disorders 362 119 481 25 0.205329167
Congenital heart anomalies&circulatory system 241 217 458 26 0.195510932
Sexually transmitted diseases 109 78 187 27 0.079826516
Malaria 88 39 127 28 0.05421373
Typhoid fever 61 46 107 29 0.045676135
TOTAL FOR THE 29 CAUSES 234258

In our work, concretely to respond to our actual burden of disease, the approach taken would do well to draw on such experience as that of the United Nations Development Programme (UNDP) in India. In August 2001, the UNDP explained its approach to health matters in India in the following way:

" Recognising a close nexus between poverty and powerlessness, and given UNDP's global mandate of poverty eradication, UNDP India in close consultation with the Government decided to support interventions which promote access to basic services in the areas of health, education and prevention of HIV/AIDS. (Our emphasis).

" UNDP interventions focus on empowerment of communities as a basic prerequisite for human development, and are being implemented in convergence with ongoing UNDP-supported initiatives in other areas.

" The lack of access to quality health care has been identified as a leading cause of human deprivation in India.

" Expensive disease-oriented programmes tend to enhance dependency and weaken community capacities to cope with the issue of prevention. Experience has shown that wherever people have been empowered and provided appropriate information, resources and encouragement, the efforts have yielded better results at a much lower cost. (Our emphases).

" UNDP interventions with the Government in the health sector are directed towards facilitating a fresh consideration of these issues from a social perspective. The effort is to make visible the links between health and poverty, and to demonstrate a range of equity-based interventions that would have a direct, even critical bearing on public health.(Our emphasis).

" UNDP is extending support to a Government project that has been created to develop and demonstrate three inter-related but independent model interventions in the areas of Multi-sectoral Approach to Health, School Health and Community Health Care Financing. The project is based on the assumption that empowered communities, in partnerships with local government units and Community-Based Organisations/Non-Governmental Organisations, can plan, implement and manage their own health programmes.

" The pilot interventions focus on diseases which basically emanate from poverty and ignorance, and which have their roots in the social, economic and political system. These diseases account for more than 80 per cent of all disease incidence and are mainly preventable infectious diseases caused by the lack of adequate nutrition, safe drinking water, a healthy habitat, basic maternal and child care and health awareness. (Our emphasis).

" Since subjects like public health, sanitation, drinking water supply and women and child care form a part of the functions of the Panchayats (local self-government) and municipalities, this pilot initiative focuses on developing capacities of these institutions of local self-government to respond to the health needs of communities.

" Two initiatives with somewhat varying strategies and emphasis are being simultaneously undertaken under this pilot programme :

" Urban School Health Initiative: Assisted by a local health NGO, this pilot initiative focuses on building capacities of school teachers, Parent Teacher Associations (PTAs) and Government health personnel in select clusters, and has helped to develop a common perspective and understanding of the health of children.

" The intervention supports training of one teacher from each class to do the initial screening of children in her/his class. PTAs are playing a critical role not only in monitoring the programme interventions but also in carrying the issues of hygiene and sanitation into their own neighbourhoods.

" Initiative for Learning Disabilities: With technical backstopping and assistance in networking from the Society for Rehabilitation of Cognitive and Communicative Disorders, this initiative builds on the experience of Government's District Primary Education Programme (DPEP) in community mobilisation for advocacy on issues of learning disabilities. Educated youth in the community are being identified and trained along with school teachers and Primary Health Care (PHC) doctors and other health personnel to assist in screening children, providing ongoing support for children with mild learning disabilities and in maintaining a record of the progress of each child.

" UNDP-supported interventions are being carried out in select sites in the state of West Bengal and Karnataka. Women's groups already working among communities in the area under various government projects are being supported to mobilise resources, including premiums for risk, for managing health care financing, so as to ensure access to quality primary health care and services. The intervention is helping to establish a linkage between NGOs and the existing health practitioners in the area and building their capacities to respond appropriately to the health care demands of the community. The project is also, in close collaboration with the National Insurance Company trying to evolve insurance packages of the poor (through shared risks) for better utilization of the existing primary health care facilities.

" UNDP support focuses on creating an enabling environment for selected groups such as people infected and affected by HIV/AIDS. The activities cover counselling at the individual level, education and alternative vocational training, micro-credit facilities for setting up small enterprises at the community level and night shelters for children of commercial sex workers.

" Policy issues such as accepting children in schools without requiring the father's name are being supported at the state level. In partnership with the Confederation of Indian Industry (CII), the workplace activities include interventions for health/medical insurance and job replacements for those affected with the epidemic.

" The project envisages support and endorsements from political leaders, religious leaders, opinion-makers, health care practitioners, lawyers and police so that people living with HIV can continue to contribute to society.

" The strategies and interventions under the UNDP-supported project will also converge with the work of the Regional project on HIV/AIDS for South and South West Asia. The Regional project is focusing on issues such as mobility and migration, and is exploring a range of legal and ethical issues related to HIV/AIDS."

In addition to the directions suggested by the UNDP, we must continue to focus on the established policies with regard to health care. These include:

· primary health care;
· prioritising the prevention and treatment of the main diseases affecting our people;
· strengthening of our health infrastructure, including clinics, hospitals and equipment;
· increasing the number and professional competence of our health personnel; and,
· providing safe and affordable drugs and medicines.

Recently, Professor Jeffrey Sachs of Harvard University chaired a commission of the WHO called the "Commission on Macroeconomics and Health". When he presented the findings of the Commission at the Novartis Foundation for Sustainable Development 'Health and Development' Symposium, on December 4, 2001, Professor Sachs said:

" The commission found the disturbing, distressing, but not surprising fact that literally millions of people - perhaps it is to save more than ten million people per year - are dying of readily preventable or treatable conditions. An overwhelming proportion of these are unnecessary deaths in the low income countries. And overwhelmingly among those deaths are deaths due to communicable diseases of course. The overwhelming proportion of the avoidable mortality falls into a small subset of categories which all of you know well: malaria, AIDS, tuberculoses, diarrhoeal disease, acute respiratory infection, micronutrient deficiency, vaccine preventable diseases and unsafe childbirth, basically because of unattended childbirth which results in mortality rates for mothers a thousand times higher in the poor countries than in the rich countries. So it is a relatively well defined group of diseases which accounts for the overwhelming access of disease burden - both morbidity and mortality - in the poor countries.Everybody knows that higher income would improve health outcomes. People are probably not as aware of how poor health impedes economic development in the economic growth. We pulled together a great deal of evidence - and some of it original - showing indeed that poor health is a major barrier to economic development itself.So we have a situation where even for the most basis and humble diseases - like measles where there is still almost a million deaths per year - as well as for the complex treatments for anti-retroviral therapy, treatments are not reaching poor people.The poor in the world are unimaginably poor." (Our emphasis).

Professor Sachs went on to address the issue of the resources needed to address the health challenge in the developing countries. He reported that that, because they are poor, these countries have no possibility whatsoever to generate the funds that are urgently and desperately needed. He said:

" And we costed out with considerable care in more detail than has ever been done before the levels of donor assistance spending that will be needed to meet these essential health interventions: it all comes down to about one tenth of one percent of GNP of the rich countries. One tenth of one percent of the current twenty-five trillion dollars of the high-income economy GNP combining the US, Europe, Japan and a few other rich countries, that is about 25 billion dollars per year. With that level of commitment from the rich countries, we believe it would be possible to make very deep inroads into disease control against the great pandemic diseases - to treat AIDS-patients, to address malaria, to get substantial coverage for patients on directly observed therapy for tuberculoses, to increase immunisation rates, to address diarrhoeal and acute respiratory infectious diseases and to dramatically scale up access to save child birth. And at the same time to put in about three billion dollars a year into increased research and development (R&D) spending for new medicines in partnership between private industry and the public sector. So we believe that it would be possible to make a comprehensive approach."

During the last two years or so, our political leadership, and others in the world condemned and marginalised as 'dissidents', have advanced exactly the same arguments presented by Professor Sachs and his Commission. In response, this leadership, and the scientists, have been denounced as genocidal and therefore criminal, a bunch of blackguards that must be excommunicated from human society - neutralised!

An example of what our government has been saying is reflected in the speech made by our President at the opening of the Durban 13th International Aids Conference, as reported earlier in this monograph.

The anti-HIV paid professional civil society (the NGO's), a powerful regiment of scientists, including some of our own, and the mass media, condemned this speech, which was based on what the WHO had said in its published official documents.