By Richard Horton, Lancet 2000; 356: 225-232
In an uncompromising rebuttal of criticism aimed at South Africa's HIV/AIDS policy, President Thabo Mbeki called on scientists to have "sufficient tolerance to respect everybody's point of view". He spoke of the "desperate and pressing need to wage a war on all fronts" against an epidemic that affects one in five adults in his country. Mbeki used his opening address to the XIIIth International AIDS conference in Durban, South Africa, to compare the campaign against AIDS with the struggle against apartheid.
Mbeki emphasized that "the world's biggest killer and the greatest cause of ill-health and suffering across the globe, including South Africa, is extreme poverty". He told a personal story of how he discovered Africa's "health crisis of enormous proportions", and his conclusion that "we could not blame everything on a single virus". Despite this important African dimension to the pandemic, Mbeki assured delegates that "there is no substance to the allegation that there is any hesitation on the part of our government to confront the challenge of HIV/AIDS".
During Mbeki's speech people in the audience shouted that such views had "nothing to do with our lives". And later Jerry Coovadia, the conference chairman, noted that although poverty "exacerbated" HIV/AIDS, it was "not the basic cause".
But the most moving plea for a more vigorous response to HIV/AIDS came from Justice Edwin Cameron, a South African High Court judge living with AIDS. He argued that "in my own country, a government that in its commitment to human rights and democracy has been a shining example to Africa and the world, has at almost every conceivable turn mismanaged the epidemic".
Cameron spoke of "governmental ineptitude", the "piteously little" progress it had made, and Mbeki's "intractably puzzling" association with AIDS dissidents. "I cannot believe that my President's speech has done enough to counter these concerns", he added. The South African Minister of Health Manto Tshabalala-Msimang rejected Cameron's argument. And she denounced the use of antiretroviral drug treatment as a litmus test for a strong HIV/AIDS strategy.
In a review of what does constitute an appropriate global HIV/AIDS strategy, Roy Anderson (Oxford, UK) concluded that "rigor is not the issue of the day, reality is". Policy makers need to implement fewer measures but be more effective in what they do, and on a larger scale. "Resource allocation does not in any way match the scale of the problem", he added. Although noting that the burden of HIV-AIDS will continue to increase, Anderson saw "the beginnings of a recovery" in Uganda as "a glimmer of hope".
Irrespective of measures to provide antiretroviral drugs, control sexually transmissible disease, distribute condoms, and educate young people about risk, Anderson believes that a vaccine remains "the only hope for the longer term". However, "the paradigm [of vaccine development] must be changed". Low efficacy vaccines--as little as 20% in some low prevalence areas--could have dramatically beneficial effects. The success of any strategy depends on "strong political leadership". With that remark, Anderson added his voice to those who were "disappointed" by Mbeki's speech. ____ -- Richard Horton, Lancet
OPENING CEREMONY HOOPLA
International AIDS Conference, Durban, South Africa, Sunday, July 9, 2000
The opening ceremony at the Durban World AIDS Conference was held in a football stadium two blocks from the convention center and was literally a made-for-television "Wonderful World of Color does AIDS" telecast. The audience was "warmed-up" by a television producer asking people to raise signs reading ACT UP (distributed as they entered the stadium) and pleading to everyone to shout out "ACT UP" followed by a minute of silence. Then the telecast extravaganza began "live" with music, dancing and drummers in traditional costumes on stage and suspended in the air in front of a huge chorus with a backdrop of projected images of children with AIDS. There were fireworks and fog machines and the opening address by the President of South Africa. Mbeki said we are overestimating what the AIDS Conference can do for South Africa's suffering people. He starts talking about how poverty is the lead cause for sickness and disease. "We cannot blame everything on a single virus. We have to guarantee our people good health. So I began to ask the questions to learn about AIDS." He waits to hear from his panel of experts and looks forward to their conclusions by the end of the year. In the meantime he will focus on nutrition, poverty, etc. In other words--NO SUPPORT FOR TREATMENT ACCESS, NO ADMISSION THAT HIV CAUSE AIDS, NO SUPPORT FOR AZT & NEVIRAPINE OFFERED FOR SOUTH AFRICA.
SPEECH OF THABO MBEKI, PRESIDENT OF SOUTH AFRICA
AT THE OPENING CEREMONY OF THE 13TH INTERNATIONAL AIDS CONFERENCE, DURBAN, JULY 9, 2000
On behalf of our government and the people of South Africa, I am happy to welcome you to Durban and to our country. You are in Africa for the first time in the history of the International AIDS Conferences.
We are pleased that you are here because we count you as a critical component part of the global forces mobilised to engage in struggle against the AIDS epidemic confronting our Continent.
The peoples of our Continent will therefore be closely interested in your work. They expect that out of this extraordinary gathering will come a message and a programme of action that will assist them to disperse the menacing and frightening clouds that hang over all of us as a result of the AIDS epidemic. You meet in a country to whose citizens freedom and democracy are but very new gifts. For us, freedom and democracy are only six years old.
The certainty that we will achieve a better life for all our people, whatever the difficulties, is only half-a-dozen years old.
Because the possibility to determine our own future together, both black and white, is such a fresh and vibrant reality, perhaps we often overestimate what can be achieved within each passing day.
Perhaps, in thinking that your Conference will help us to overcome our problems as Africans, we overestimate what the 13th International AIDS Conference can do. Nevertheless, that over estimation must also convey a message to you. That message is that we are a country and a Continent driven by hope, and not despair and resignation to a cruel fate.
Those who have nothing would perish if the forces that govern our universe deprived them of the capacity to hope for a better tomorrow.
Once more I welcome you all, delegates at the 13th International AIDS Conference, to Durban, to South Africa and to Africa, convinced that you would not have come here, unless you were to us, messengers of hope, deployed against the spectre of the death of millions from disease. You will spend a few days among a people that has a deep understanding of human and international solidarity.
I am certain that there are many among you who joined in the international struggle for the destruction of the anti-human apartheid system. You are therefore as much midwives of the new, democratic, non-racial and non-sexist South Africa as are the millions of our people who fought for the emancipation of all humanity from the racist yoke of the apartheid crime against humanity. We welcome you warmly to South Africa also for this reason.
Let me tell you a story that the World Health Organisation told the world in 1995. I will tell this story in the words used by the World Health Organisation. This is the story: "The world's biggest killer and the greatest cause of ill-health and suffering across the globe is listed almost at the end of the International Classification of Diseases. It is given the code Z59.5 : extreme poverty.
"Poverty is the main reason why babies are not vaccinated, why clean water and sanitation are not provided, why curative drugs and other treatments are unavailable and why mothers die in childbirth. It is the underlying cause of reduced life expectancy, handicap, disability and starvation. Poverty is a major contributor to mental illness, stress, suicide, family disintegration and substance abuse. Every year in the developing world 12,2 million children under 5 years die, most of them from causes which could be prevented for just a few US cents per child. They die largely because of world indifference, but most of all they are poor .
"Beneath the heartening facts about decreased mortality and increasing life expectancy, and many other undoubted health advances, lie unacceptable disparities in wealth. The gaps between rich and poor, between one population group and another, between ages and between sexes, are widening. For most people in the world today every step of life, from infancy to old age, is taken under the twin shadows of poverty and inequity, and under the double burden of suffering and disease.
"For many, the prospect of longer life may seem more like a punishment than a gift. Yet by the end the century we could be living in a world without poliomyelitis, a world without new cases of leprosy, a world without deaths from neonatal tetanus and measles. But today the money that some developing countries have to spend per person on health care over an entire year is just US $4 less than the amount of small change carries in the pockets and purses of many people in the developed countries.
"A person in one of the least developed countries in the world has a life expectancy of 43 years according to 1993 calculations. A person in one of the most developed countries has a life expectancy of 78 a difference of more than a third of a century. This means a rich, healthy man can live twice as long as a poor, sick man.
"That inequity alone should stir the conscience of the world but in some of the poorest countries the life expectancy picture is getting worse. In five countries life expectancy at birth is expected to decrease by the year 2000, whereas everywhere else it is increasing. In the richest countries life expectancy in the year 2000 will reach 79 years. In some of the poorest it will go backwards to 42 years. Thus the gap continues to widen between rich and poor, and by the year 2000 at least 45 countries are expected to have a life expectancy at birth of under 60 years.
"In the space of a day passengers flying from Japan to Uganda leave the country with the world's highest life expectancy almost 79 years and land in one with the world's lowest barely 42 years. A day away by plane, but half a lifetime's difference on the ground. A flight between France and Cote d'lvoire takes only a few hours, but it spans almost 26 years of life expectancy. A short air trip between Florida in the USA and Haiti represents a life expectancy gap of over 19 years.
"HIV and AIDS are having a devastating effect on young people. In many countries in the developing world, up to two-thirds of all new infections are among people aged 15-24. Overall it is estimated that half the global HIV infections have been in people under 25 years with 60% of infections of females occurring by the age of 20. Thus the hopes and lives of a generation, the breadwinners, providers and parents of the future, are in jeopardy. Many of the most talented and industrious citizen, who could build a better world and shape the destinies of the countries they live in, face tragically early death as a result of HIV infection." (World Health Report 1995: Executive Summary WHO.) This is part of the story that the World Health Organisation told in its World Health Report in 1995.
Five years later, the essential elements of this story have not changed. In some cases, the situation will have become worse.
You will have noticed that when the WHO used air travel to illustrate the import of the message of the story it told, it spoke of a journey from Japan to Uganda, another from France to the Cote d'lvoire and yet from the United States to Haiti. From developed Asia, Europe and North America, two of these journeys were to Africa and the third to the African Diaspora.
Once again, I welcome you to Africa, recognising the fact that the majority of the delegates to the 13th International AIDS Conference come from outside our Continent. Because of your heavy programme and the limited time you will spend with us, what you will see of this city, and therefore of our country, is the more developed world of which the WHO spoke when it told the story of world health in 1995. You will not see the South African and African world of the poverty of which the WHO spoke, in which AIDS thrives a partner with poverty, suffering, social disadvantage and inequity.
As an African, speaking at a Conference such as this, convened to discuss a grave human problem such as the acquired human deficiency syndrome, I believe that we should speak to one another honestly and frankly, with sufficient tolerance to respect everybody's point of view, with sufficient tolerance to allow all voices to be heard. Had we, as a people, turned our backs on these basic civilised precepts, we would never have achieved the much-acclaimed South African miracle of which all humanity is justly proud.
Some in our common world consider the questions I and the rest of our government have raised around the HIV-AIDS issues, the subject of the Conference you are attending, as akin to grave criminal and genocidal misconduct.
What I hear being said repeatedly, stridently, angrily, is: do not ask any questions!
The particular twists of South African history and the will of the great majority of our people, freely expressed, have placed me in the situation in which I carry the title of President of the Republic of South Africa. As I sat in this position, I listened attentively to the story that was told by the World Health Organisation. What I heard as that story was told, was that extreme poverty is the world's biggest killer and the greatest cause of ill health and suffering across the globe. As I listened longer, I heard stories being told about malaria, tuberculosis, hepatitis B, HIV-AIDS and other diseases. I heard also about micronutrient malnutrition, iodine and vitamin A deficiency. I heard of syphilis, gonorrhoea, genital herpes and other sexually transmitted diseases as well as teenage pregnancies. I also heard of cholera, respiratory infections, anaemia, bilharzias, river blindness, guinea worms and other illnesses with complicated Latin names. As I listened even longer to this tale of human woe, I heard the name recur with frightening frequency Africa, Africa, Africa. And so, in the end, I came to the conclusion that as Africans we are confronted by a health crisis of enormous proportions.
One of the consequences of this crisis is the deeply disturbing phenomenon of the collapse of immune systems among millions of our people, such that their bodies have no natural defence against attack by many viruses and bacteria. Clearly, if we, African countries, had the level of development to enable us to gather accurate statistics about our own countries, our morbidity and mortality figures would tell a story that would truly be too frightening to contemplate. As I listened and heard the whole story told about our own country, it seemed to me that we could not blame everything on a single virus. It seemed to me also that every living African, whether in good or ill health, is prey to many enemies of health that would interact one upon the other in many ways, within one human body. And thus I came to conclude that we have a desperate and pressing need to wage a war on all front to guarantee and realise the human right of all our people to good health.
And so, being insufficiently educated, and therefore ill prepared to answer this question, I started to ask the question, expecting an answer from others what is to be done, particularly about HIV-AIDS! One of the questions I have asked is are safe sex, condoms and anti-retroviral drugs a sufficient response to the health catastrophe we face! I am pleased to inform you that some eminent scientists decided to respond to our humble request to use their expertise to provide us with answers to certain questions. Some of these have specialised on the issue of HIV-AIDS for many years and differed bitterly among themselves about various matters. Yet, they graciously agreed to join together to help us find answers to some outstanding questions. I thank them most sincerely for their positive response, inspired by a common resolve more effectively to confront the AIDS epidemic. They have agreed to report back by the end of this year having worked together, among other things, on the reliability of and the information communicated by our current HIV tests and the improvement of our disease surveillance system. We look forward to the results of this important work, which will help us to ensure that we achieve better results in terms of saving the lives of our people and improving the lives of millions.
In the meantime, we will continue to intensify our own campaign against AIDS including:
You will find all of this in our country's AIDS action plan which I hope has been or will be distributed among you. You will see from that plan, together with the work that has been going on, that there is no substance to the allegation that there is any hesitation on the part of our government to confront the challenge of HIV-AIDS. However, we remain convinced of the need for us better to understand the essence of what would constitute a comprehensive response in a context such as our which is characterised by the high levels of poverty and disease to which I have referred.
As I visit the areas of this city and country that most of you will not see because of your heavy programme and your time limitations, areas that are representative of the conditions of life of the overwhelming majority of the people of our common world, the story told by the World Health Organisation always forces itself back into my consciousness.
The world's biggest killer and the greatest cause of ill health and suffering across the globe, including South Africa, is extreme poverty. Is there more that all of us should do together, assuming that in a world driven by a value system based on financial profit and individual material reward, the notion of human solidarity remains a valid precept governing human behaviour!
On behalf of our government and people, I wish the 13th International AIDS Conference success, confident that you have come to these African shores as messengers of hope and hopeful that when you conclude your important work, we, as Africans, will be able to say that you who come to this city, which occupies a fond place in our hearts, came here because you care. Thank you for your attention.
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