By Emma Camp (University of Leeds)
[Published in Leeds African Studies Bulletin 77 (Winter 2015/16), pp. 84-108]
A defining feature of the new South African democracy has been the devastating impact of HIV and AIDS. With an estimated 6,300,000 HIV positive people, the country is considered the epicentre of the AIDS epidemic (UNAIDS, 2013). Despite being one of the richest countries in Sub-Saharan Africa, as well as being the regions only truly industrial economy, South Africa has been viewed as failing to address the crisis. A key period in the development of HIV/AIDS policy was the Mbeki presidency, during which the president of South Africa championed dissident views of HIV/AIDS science culminating in the questioning of causal links between HIV and AIDS as well as suggestions that life-saving antiretroviral drugs (ARVs) were poisonous. It seems that a lack of clear leadership on issues of HIV/AIDS has exacerbated the crisis in South Africa and may account for the levels of infection.
As Johnson (2005) writes, an emphasis on denialism reveals little about the motivation for the president’s position and so this essay aims to uncover why the president of the world’s largest HIV positive population adopted such an unorthodox opinion. Rather than assuming that acceptance of dissident science shows ignorance, there is an argument that the impacts of a neoliberal world order on the South African state shaped the opinions of the president and contributed to the controversial stance on HIV/AIDS. This essay therefore focuses on the impacts that neoliberalism had on the South African state arguing that it is this which helps to account for the denialism adopted by Mbeki and shows how Mbeki used AIDS as a political tool to confront global forces which obstruct social transformation (Johnson, 2005:329).
Section one assesses the ways in which a neoliberal world system disadvantages developing states through market discipline, international organisations and oligopolistic neoliberalism. To understand fully the issues surrounding neoliberalism and neoliberal policies, Gill’s work of Globalisation, Market Civilisation and Disciplinary Neoliberalism (1995) is used to evaluate the systems of the neoliberal world order. This links the concepts of disciplinary neoliberalism to developing states showing this to maintain global hierarchies while significantly reducing the development capacity of states. The following section focuses on the causes of Mbeki’s denialism, questioning claims that his opinions resulted solely from an immersion in dissident HIV/AIDS literature. Rather I suggest that Mbeki used HIV/AIDS as a direct response to neoliberalism, a political tool that would allow him to fight for an increased significance on the world stage.
Finally it is important to understand how change within South African society was achieved in the context of government denialism. Section three therefore discusses the impacts of neoliberalism and AIDS denialism on civil society agency, assessing the impact of the Treatment Action Campaign and addressing the extent to which their agency increased as a direct result of neoliberal policies (Habib, 2003).
I conclude that to assume Mbeki adopted a position of denialism purely because of dissident science is to fail to acknowledge the broader political and ideological struggle, which South Africa was involved in. In a bid to overcome the neoliberal hierarchies of the international order and to improve African standing on the world stage, Mbeki championed AIDS denialism and adapted state policy accordingly.
The impact of the neoliberal global order on South Africa’s state capacity and response to HIV/AIDS
Issues of HIV/AIDS and neoliberalism are inextricably linked. Johnson (2005) highlights how HIV has exposed the contradictions and inequality of a neoliberal world system. Neoliberalism is a theory of political economic practice proposing that human wellbeing can best be advanced within an institutional framework, characterised by free markets and minimal state involvement (Harvey 2005:2). South Africa has adopted conservative macroeconomic policies very much in line with neoliberalism, suggesting a willingness or even desire to conform to the global order (Johnson, 2005; Harvey, 2005) stemming from suggestions that these policies present the most effective way to address poverty. However, the greatest successes in reducing poverty have occurred in Asian countries which did not adopt principles of neoliberalism proposed by the World Bank and IMF (Rowden 2009:84). While these countries flourished, the neoliberal policies of post-apartheid South Africa resulted in a reduction of average life expectancy from 62 in 1955 to 46 in 2002 which Rowden (2009:153) believes to be due, in part, to policy reform based on neoliberal principles which exacerbate global inequalities. This section builds on the consensus that neoliberalism has negatively impacted the fight against HIV/AIDS in developing countries (Rowden, 2009; Harvey, 2005; Johnson, 2004; Gill, 1995; Mindry, 2008) suggesting that AIDS remains fatal in Africa, despite having been downgraded to chronic in the West, because of a neoliberal global order which favours western nations and corporations at the expense of developing countries. As Jones (2001:16) writes, the wealth that the world has at its disposal to challenge HIV/AIDS is unimaginable but the unwillingness to deploy these resources in any convincing way is inconceivable.
Broadly neoliberal reforms limit how health and HIV/AIDS policy develops, defining what is and is not possible (Johnson, 2004:124). Rowden (2009) agrees, arguing that neoliberal development policies reduce the ability of a state to respond to HIV/AIDS. Firstly, the discipline of capital ensures states are market focused and present a positive environment to investment, ahead of a positive development paradigm. Developing states are also disciplined by international organisations, including the World Bank and IMF, which impose neoliberal policies while ensuring the continuation of crippling debt repayments. Finally the role of international pharmaceutical companies is discussed as well as the extent to which oligopolistic neoliberalism favours their successes over that of developing nations. This section concludes that the discipline of capital and of international organisations restricts a state’s capacity to respond to an HIV/AIDS crisis which may account for the prevalence of this epidemic in sub Saharan Africa.
Discipline of Capital
According to the Washington Consensus, governments subscribing to neoliberalism must maintain a minimalist state that strives to achieve ten economic policies, including privatisation of state owed assets and deregulation of markets (Rowden 2009:67). While the Washington Consensus cannot directly dictate policy, Gill (1995) maintains that states are regulated by capital through the process of disciplinary neoliberalism. The mobility of capital has created a system in which transnational capital has panoptic surveillance power over states allowing investors to discipline them to fall in line with the neoliberal system, under threat of an investment strike. States respond to capital in a positive way, even if at the expense of its citizens, in order to attract foreign direct investment assuming a ‘trickle down’ effect will occur and that in securing free markets and trade a decline in poverty will follow (Harvey 2005:65). However, there is agreement that in reality, neoliberal policies and the discipline of capital negatively impact development and reduce the capacity of the state, especially in relation to health (Rowden, 2009; Johnson, 2005). Harvey (2005:3) even suggests that the process of neoliberalism has entailed ‘creative destruction’ of social relations and welfare provisions. It is therefore necessary to assess how this destruction impacts a state’s response to HIV/AIDS.
Neoliberalism asserts that the key to a successful, decentralised healthcare system is for it to be run as though part of the markets (Rowden 2009:149), including privatisation of key services and reduced state funding for the public sector. However, this immediately placing more direct costs onto individual citizens who are transformed into paying customers in accordance with the neoliberal vision. Increasing costs for public health care services result in the poorest of the population, who are also the most vulnerable to HIV, being unable to afford basic treatments and so exacerbating the AIDS epidemic. In addition, neoliberal policies require reduced state spending on remaining public health services resulting in the quality of health care declining, again frustrating an effective response to an HIV/AIDS crisis. In South Africa the discipline of capital and subsequent adoption of neoliberal policies has not alleviated poverty, but has resulted in widening the gap between the ‘health haves and have nots’ (Lee & Zwi, 1996:361) in an already deeply unequal society.
A further impact of neoliberal policies and market discipline on health services is evident in the ‘brain drain issue’ (Rowden 2009:29) which has been the Achilles heel in addressing HIV/AIDS in South Africa. From 1989 to 1997, 80,000 health care staff emigrated and there has been a steady drift from the public to private services as investment moved to the private sector (Butler 2005:598). The World Health Organisation suggested that for a successful AIDS response in South Africa, 4 million more health workers were required (Rowden 2009:29), and while the National AIDS Treatment Plan promised 12,000 new jobs, there was already a shortfall of 30,000 health care workers in the public sector. These figures offer support to the argument that the South African government had been restricted from deploying a successful AIDS programme as neoliberal policies and the movement of capital from public to private spheres reduced the effectiveness and capacity of the public health sector. This effectively created parallel health systems which favoured the wealthy at the expense of the poor and put HIV/AIDS treatments beyond reach for many South Africans.
Johnson (2005:112) believes that the ANC took office at a time when neoliberal policies restricted the capacity of a developing country’s government. The ANC had to try and maintain transformative momentum while reducing spending on social services, privatising key social industries and decreasing state intervention. Johnson believes that initially the post-apartheid government had excellent AIDS policies but were unable to implement them due to restrictions resulting from integration into global markets and therefore HIV/AIDS efforts were undermined.
Discipline of International Organisations
The pressure to adopt neoliberal policies also emanated from international organisations, including the World Bank and IMF. The doctrine of these organisations is indistinguishable from that of neoliberalism (Rowden, 2009) and Johnson (2005:111) suggests that in pushing neoliberal reforms, these organisations have made a strategic effort to reduce the capacity of African states. In doing so, they have severely reduced the ability of states to respond effectively to HIV/AIDS epidemics through hollowing out the health care services. One tool used to achieve this is Structural Adjustment Programmes (SAPs), which maintain the global power hierarchy with the implementation of neoliberal policies in return for international aid (Rowden 2009:74-75). Therefore, the national development objectives of democratically elected governments are restricted as the World Bank and IMF insist on neoliberal policies through the use of conditional aid.
Harvey (2005:116) believes the situation in South Africa to be particularly troubling. Emerging in the midst of the hopes created after the collapse of the apartheid and desperate to reintegrate into the global economy, South Africa was party persuaded and partly coerced by the IMF and World Bank to embrace the neoliberal line, with the predictable result that the economic apartheid now broadly confirms the racial apartheid which preceded it. The ANC was pressured into adopting neoliberal policies by economists from the World Bank and IMF and experts from the business community which resulted in a step back from any focus on social spending. Rowden (2009:156) furthers these arguments and suggests that adjustment policies may have inadvertently produced conditions which facilitate the exposure to HIV as well as reducing the ability of the state to respond to the disease.
Further, the public health infrastructure of many African nations was being reduced to a skeleton as a result of SAPs, at precisely the time when AIDS was taking hold. Harman (2009:3) argues that state capacity in health care provision has been weakened by the IMF and World Bank, thus undermining the capacity of African governments in dealing with HIV/AIDS. In the case of South Africa, the political and economic reforms required by the IMF and World Bank for reintegration into the global economy resulted in a loss of autonomy for the South African government in the definition of development policies. The state was still obliged to address the AIDS crisis but had to do so within the constraints of SAPs, and so could not stop the progression of an AIDS epidemic (Rowden, 2009).
However, the most significant way that international organisations have impacted the ability of a state in responding to HIV/AIDS is through debt servicing, an obligation created by structural adjustment. According to Harvey (2005:75) debt repayments were the ‘poison pill of neoliberal institutional reforms’ and it is evident that these repayments have undermined efforts to combat social issues, including HIV/AIDS.
As UNAIDS call on countries to restructure spending to allocate increased budgets for HIV/AIDS and while the Abuja Declaration resulted in African governments committing to allocating 15 per cent of national budgets to the health sector (Piot et al., 2001:79-80), foreign debt remains crippling. In 2000 Africa was spending four times as much on debt servicing as on health and education combined (Jones 2001:15). Given that a medical response, alongside education, is vital in combating AIDS, reduced spending in these areas in favour of debt repayments will negatively impact the fight against HIV/AIDS. For South Africa, when interest is combined with inflation, twenty cents from every Rand goes to servicing debt, therefore reducing the funding for public health and education (Magubane 2002:97). The irony in this case, as Magubane highlights, is that this debt was a result of the apartheid government so the population is now paying for the regime which previously oppressed them.
Debt servicing allows the continuation of global power hierarchies and prevents the progression of developing countries. The West promotes hand-outs while refusing to remove structural barriers that continue to inhibit African nations. In 2004 at the G8 Summit, rich counties declined to forgive African debt, instead promising to fund western scientists in developing an AIDS vaccine (Johnson 2005:320). This not only narrows the response to medical science and ignores social factors of HIV/AIDS, but also promotes an unsustainable model for health care in developing countries that perpetuates dependence. In refusing to address the issues of debt, international organisations are maintaining global conditions which promote AIDS epidemics and are preventing developing states from reacting effectively, representing a shocking disregard from the international community where AIDS is concerned.
Therefore, the neoliberal global order has reduced the ability of the South African state, as well as other developing nations, to respond effectively to HIV/AIDS through the control and discipline of international organisations, namely the World Bank and IMF.
The final way in which neoliberalism affects a state’s ability to respond to HIV/AIDS is evident in how the system favours international corporations. Gill (1995) describes this as ‘oligopolistic neoliberalism’, which maintains that neoliberalism provides oligopoly and protection for the strong, and market discipline for the weak and is prominent within the AIDS paradigm.
Lee and Zwi (1996) argue that through favouring large pharmaceutical companies, the neoliberal order pushes market prices beyond the reach of many South Africans. Lee and Zwi believe pharmaceutical companies have identified their key markets to be high income countries where governments and individuals can afford to pay the expected prices, therefore ensuring the greatest profits. However, in developing countries, where more than 80 per cent of HIV positive people live, the market price is unrealistic. Persistently high ARV prices continue to slow the scaling up of HIV treatments and reduce their impact on an AIDS epidemic. With global markets encouraging high prices, the neoliberal order causes lifesaving drugs to be kept from large numbers of the world’s HIV positive population and so governments are prevented from comprehensively addressing the issue of HIV and AIDS.
Not only are poor populations denied affordable drugs by western companies, but pressure is applied by international companies and western states to prevent the purchase of generic drugs at a reduced price. With the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) stipulating that in a time of health emergencies, poor countries may circumvent normally strict regulations and buy generic drugs, the South African government argued correctly that buying generic drugs was legal. However, the resistance to this was huge, with the Clinton administration threatening sanctions if South Africa went ahead (Gumede 2007:194). Despite the advantages of the generic drugs, South Africa was forced to succumb to the pressures of the West and opt for drugs provided by Western pharmaceutical companies. The neoliberal policies which govern the global order place precedence on market success and the advance of international corporations and in doing so developing states are disadvantaged and are further restricted from responding effectively to HIV/AIDS.
It is evident that policies of privatisation, budget cutting and debt repayments ultimately aggravate poverty in developing countries. Being integrated into global markets comes at a price and requires reduced state intervention, a decrease in spending on public services and restructuring of budgets to meet global expectations, all of which limit the ability of a developing country to respond effectively to AIDS. The global neoliberal order favours rich western nations at the expense of those on the periphery who are forced to adopting neoliberal policies, even at the cost of the health of their populations. Further, debt repayments put a huge strain on resources already limited by requirements of SAPs and the discipline or markets, and exacerbate the issues created by neoliberal policies. Without autonomy over development priorities and state budgets, developing governments are restricted in their responses to health crises like HIV/AIDS and it may be that an epidemic in South Africa was facilitated by the neoliberal order within which it was situated. However, as section two demonstrates, this alone cannot fully explain South African response to HIV/AIDS. The response of leadership is also significant and therefore the role of Thabo Mbeki must be examined.
Mbeki’s ‘denialism’ of HIV/AIDS, poor leadership or a response to the neoliberal world order?
In an interview with Time Magazine in 2000, Mbeki stated ‘the notion that immune deficiency is only acquired from a single virus cannot be sustained’ (Time, 2000). Throughout his presidency, Mbeki appeared to deny the connection between HIV and AIDS while questioning medical science supporting the causal link. Some scholars, including Mbali (2004 & 2005) and Gumede (2007) have suggested that Mbeki’s opinion on AIDS was heavily shaped by dissident scientific opinion which the former President accepted as fact. However, AIDS denialists are, for the main, a minor group and if not for Mbeki, a state leader who presides over the largest population of HIV positive people, they would have long been assigned to obscurity (Nattrass, 2007). While Gumede appears to be correct in arguing that Mbeki fully believed dissident HIV/AIDS science, it is important to ask why the leader of a country so deeply impacted by AIDS would adopt such an unorthodox position. This section therefore focuses on Johnson’s (2005) explanation which suggests that Mbeki was responding to the neoliberal world order, trying to advance South Africa’s global position and attempting to address issues of African dependence.
This section first looks at the plausibility of the argument that Mbeki blindly accepted dissident views on AIDS and demonstrated poor leadership in the face of a health crisis, before examining claims that he was in fact responding to the neoliberal world order. Therefore, this section explores the impact of an ‘African Renaissance’, with South Africa at the head, showing that Mbeki used AIDS as a tool in the broader political arena which accounts for his nonconformist position (Parkhurst and Lush 2004). Further, a mistrust of the West and rejection of its neoliberal philosophy intensified Mbeki’s position on HIV/AIDS. It therefore seems clear that while Mbeki did genuinely adopt dissident views on HIV/AIDS, it was due to his overarching ideas about achieving an African Renaissance where he attempted to use HIV/AIDS to address global inequalities created and sustained by neoliberalism. The broader political issues of global inequality are fundamental in understanding Mbeki’s response to HIV/AIDS, which became part of this struggle, rather than being addressed as an issue in its own right.
Immersion in Dissident Science
Mbeki’s acceptance of denialist views on HIV and AIDS have undoubtedly exacerbated a health crisis in South Africa. Gumede (2007:215) believes Mbeki to have ‘wandered off on a deadly diversion that has helped place an entire nation in denial and needlessly taken the lives of millions of its citizens’. It is necessary to assess the reasons that Mbeki turned to such a fatal view of AIDS as the importance of senior political leadership in promoting and sustaining an HIV/AIDS intervention is significant (Parkhurst & Lush, 2004:1916).
AIDS denialism believes AIDS deaths to be caused by malnutrition, narcotics and even ARV drugs themselves (Nattrass, 2007) with HIV acting as a benign passenger virus. Mbeki adopted these opinions following regular correspondence with dissident scientists including American biochemist David Rasnick, Professor of Molecular and Cell Biology Peter Duesberg and advocate Anthony Brink who gave Mbeki a copy of his book, Debating AZT (Gumede 2007:197). This book argued that the life-saving ARV was highly toxic and Mbeki proceeded with his own investigations on the internet. Using websites such as virusmyth.net Mbeki questioned the causal links between HIV and AIDS as well as whether the virus was transmitted sexually (Gumede, 2007:197). Thornton (2008) believes that the papers and research of these men convinced Mbeki that AIDS was a lifestyle disease and led him to the conclusion seen in Time magazine. Gumede (2007:199) supports Thornton and considers Mbeki to be sincere in challenging mainstream science as well as genuinely believing poverty to be the cause of AIDS and not just an exacerbator of it.
It has been argued that dissident science appealed to Mbeki as it offered an alternative to complicated prevention policies and removed the daunting planning challenges which would otherwise face the government (Mbali 2004:106-107). The desire to promote dissident science in order to remove the issue of HIV/AIDS is evident in the Presidential AIDS Advisory Panel of 2001 which included dissident scientists and met at a cost of R2 million (Jones 2001:26-28). Jones believes that the inclusion of the denialist opinions represented an attempt to prove that AIDS did not exist as a syndrome. If this was shown to be the case, the government would have the ‘ultimate alibi’ for failing to address the crisis. As Jones concludes, it was ‘crazy, dangerous logic’ which was used as a convenient clause to avoid increasing public spending.
However, there is not universal support for the idea that Mbeki got carried away by dissident science. Rather it has been argued that the adoption of dissident views on AIDS represented an ideological move against neoliberalism. As Johnson (2005) highlights, from a biomedical perspective Mbeki’s position does not make sense, but it is possible that he was responding to a different reality. It wasn’t an immersion in literature that compounded Mbeki’s denialism, but a fixation on a broader political struggle. Therefore, the rest of this section looks at the impact of neoliberalism on Mbeki and how this may have shaped his dissident beliefs about HIV and AIDS.
An African Solution to an African Problem
The alternative reality that Johnson (2005) presents is one where the South African government believed itself to be engaged in an ideological struggle, within which AIDS offered an avenue to address issues of structural poverty created by a neoliberal world framework. These issues included weakened health care systems due to privatisation and reduced state spending as well as a global hierarchy of power maintaining African weakness. This links closely to Mbeki’s rhetoric of an African Renaissance which creates an agenda for African self-renewal and self-reliance as well as the promotion of African responses to the issues facing the continent (Johnson 2005:317). While Thornton (2008) acknowledges that the drive for African solidarity has led to unprecedented economic and political development in South Africa, he also concludes that it helps explain the governments denialism and policy decisions regarding AIDS.
In striving for an African solution to AIDS, Mbeki argued that the African epidemic was different to AIDS in the west, with the majority of cases being heterosexual transmissions, rather than homosexual. He believed that as an African problem, a uniquely African solution was necessary (Patterson, 2005) and therefore looked for alternatives to western medical responses, finding them in dissident science. Jones (2001:36-37) agrees with Patterson, writing that Mbeki believed an African solution to the AIDS crisis would demonstrate independence and the capacity for self-help. He suggests that commitment to the African Renaissance in the face of AIDS offers the most ‘graphic expression in Africa of postcoloniality’ (Jones 2001:36) and shows a government struggling against the dominance of the West.
Moreover, South Africa, as a middle income country, was under pressure to assume the position of the continent’s leader and to set the standard for African nations in moving away from western dependence (Parkhurst & Lush 2004:1916). Initially Mbeki championed Virodene hoping this would present a home grown, biological solution to AIDS. However, the ARV was not tested correctly and it was eventually established that this ‘miracle cure’ may activate HIV and prompt a more efficient replication of the virus (Mbali 2004:315). Nattrass (2007) suggests that Mbeki turned to dissident AIDS opinions following this failure and therefore focused on the relationship between poverty and AIDS. While there is nothing intrinsically controversial in linking AIDS to poverty, Mbeki went beyond this and suggested it to be one of the causes of the syndrome. Johnson (2005:322) believes that the motivation behind redefining AIDS as a disease of poverty was to expose the way that Africa’s underdevelopment, created and maintained by the interests of western countries, companies and organisations, weakens the health of its populations. Redefining AIDS as a disease of poverty highlighted the racist interests of the West and the profit motives of the pharmaceutical companies. Mbeki was attempting to alter the cause of AIDS from a virus to the inequalities of a neoliberal world order and the western powers which championed this global structure.
Therefore, Mbeki’s acceptance of denialist views on AIDS may be more complex than Gumede (2007) and Mbali (2004) suggest. Rather than being swayed by unconventional scientific opinions, Mbeki saw an opportunity to strengthen South Africa’s global standing and to challenge power balances which promote African dependence. It is through the lens of a pan-Africanist ideology and with a desire to see an African Renaissance that Mbeki’s challenge to the dominant orthodoxy on AIDS makes sense (Nattrass, 2007), although this resulted in a dangerous response which put a political struggle before the health of citizens. In searching for an African solution to AIDS, the president hoped to provide an alternative solution to HIV/AIDS and reduce dependence on the West, resulting in him accepting arguments that AIDS was strictly poverty driven and not a biomedical issue.
Addressing a Racist Agenda
While Robins (2004) agrees that neoliberalism impacted Mbeki and his turn to dissident science, he suggests that the reason for this lies not with an African Renaissance but with issues of race and African stereotypes, used by both apartheid oppressors and western countries to degrade Africans. It is imperative to include the issue of race when addressing AIDS in South Africa as the apartheid created such deep racial segregation, the legacy of which remains evident in all areas of contemporary society, including health. Within the literature there is consensus that the denialist view championed by Mbeki was influenced by issues of race and stereotypes of black South Africans (Butler, 2005; Nattrass, 2007). Indeed Diethelm and McKee (2009) believe that denialism exploited genuine concern regarding the racist agenda seen within AIDS which may explain why Mbeki was able to bring this minority view to the forefront of South African politics.
Under the apartheid regime, medical science was used to enforce segregation and subsequently everything is now read through the colour coded lens of a colonial history of discrimination (Robins 2010:654). Robins suggests that for Mbeki, AIDS denialism was not the product of neutral, rational and universal scientific enquiry but was understood as the product of a history entrenched in colonialism, apartheid and capitalism. The African AIDS crisis was therefore attributed to poverty which was a direct result of western racism and capitalism and so required dissident science to be accepted. Patterson (2005) supports Robins’ argument suggesting that this demonstrates Mbeki’s mistrust of the western world and believes that Mbeki hoped to distance himself from those who championed apartheid by approaching AIDS in an alternative way. Patterson believes Mbeki was showing the world that Africans are entitled to hold different views and Nattrass (2007) suggests that in doing so he acted as a political projection of many Africans distrust of medical science. Further, Mbeki believed that the AIDS science supported by western nations was inherently racist and branded all Africans as ‘promiscuous germ carriers devoted to the sin of lust’ (Mbeki cited in Mbali 2004:111). These negative perceptions were insulting and blamed African sexuality for the rapid spread of HIV across the continent as well as placing South Africa in the demeaning position of reliance on western medicine (Nattrass, 2007). Therefore denialism offered a way of addressing AIDS which did not champion derogatory stereotypes and gave South Africa global independence, thus challenging the neoliberal world order which created and sustained dependence.
Furthermore, the acceptance of a denialist agenda in relation to AIDS not only reflected a mistrust of western perceptions but also a rejection of western companies who were seen to benefit financially from the disease. As Nattrass (2007:25-26) explains, denialists believe that AIDS science has been co-opted by an industrial revolution of financial interest which has clouded the truth about AIDS and allows international pharmaceutical companies to benefit at the expense of African populations. They therefore maintain that the tens of thousands of doctors and scientists who work on HIV/AIDS are part of a vast conspiracy to justify a billion dollar market in anti-AIDS drugs (Epstein 2007:106). As Parks Mankahalana, Mbeki’s spokesman, put it ‘shareholders would be delighted to hear that South Africa had decided to supply AZT to pregnant women, their joy would not be from concern for people’s health but about profits and shareholder value’ (Cited in Epstein 2007:108). While the major flaw in this argument is that if ARVs were just a profit making scam, companies would keep people alive as long as possible on chronic therapies, it highlights Mbeki’s belief that South Africans were fighting against the West and demonstrates his distrust of the neoliberal world order. Mbeki believed it to be his duty to protect his people from exploitation by western corporations which represented the new oppressors in a long colonial history of black oppression in South Africa (Robins 2004:654) and in doing so he turned to dissident AIDS science.
In conclusion, it is apparent that Mbali (2004) and Gumede (2007) have failed to see the wider political struggle facing South Africa at the time of Mbeki’s government. While Mbeki did accept opinions of Duesberg and Rasnick as fact and openly argued that poverty was the cause of AIDS, an immersion in dissident literature does not offer sufficient explanation for his unorthodox stance which can only be fully understood when examined through the lens of a desire for greater South African influence on a global scale. Mbeki was heavily influenced by the pursuit of an African Renaissance which resulted in AIDS being used as a tool to promote South Africa and address the power imbalances within the world. This caused Mbeki to turn to dissident AIDS science which closely fitted with his political agenda. Further, Gumede and Mbali fail to see the significance of race in Mbeki’s position on AIDS. A dissident approach allowed an overturning of western stereotypes of African sexuality which further influenced the president’s adoption of these opinions on AIDS. Rather than accepting denialist views as a result of literature and research, Mbeki found dissident AIDS science in a search for opinions that bolstered his views of an African Renaissance and the promotion of South Africa as a world power. Mbeki showed dangerous leadership and undoubtedly increased the AIDS crisis in South Africa with funds diverted from ARVs. However, the denialism surrounding AIDS does not represent a political whim but a poor use of health to achieve victory in a broader political struggle against neoliberalism.
In a neoliberal South Africa, does the Treatment Action Campaign, as a civil society organisation, have a greater agency than the government in issues of HIV/AIDS?
On 10 December 1998, International Human Rights Day, a group of fifteen people in Cape Town collected over a thousand signatures calling for the government to reduce ARV prices and increase access to HIV treatments (Robins & Lieres, 2013:663) which subsequently led to the formation of the Treatment Action Campaign (TAC). By 2003, TAC had won cases against international pharmaceutical companies as well as the South African government and were offering an alternative to the unorthodox government agency in addressing AIDS in a neoliberal world. Like the government, TAC recognised inequality to be an inherent consequence of neoliberalism but unlike the government they operated from the conviction that significant resources for social reform are available and that progressive policy reform can be achieved within the current framework, if fought for (Heywood, 2009:23). Indeed some scholars (Grebe, 2011; Mindry, 2008) argue that it was precisely the neoliberal order which offered an increased agency to civil society organisations, allowing activists to become the driving force behind change.
While the power of policy making ultimately lies with the government, the agency of civil society organisations was significant in the fight for greater access to treatment. This section first addresses how the impacts of a neoliberal world order and the South African government’s policies on HIV/AIDS allowed TAC, now widely considered the most important AIDS activist organisation in the world, to gain momentum (Grebe, 2011:849). The organisation campaigns against the view that AIDS is a death sentence and promotes affordable treatment for all people (Friedman & Mottiar, 2005:513). This section therefore focuses specifically on the victories of TAC, over both the pharmaceutical companies and the South African government, arguing that a neoliberal world order allowed for increased agency and therefore enabled greater prominence in the fight for access to HIV treatment. It concludes that the South African victory over the Pharmaceutical Manufacturers Association (PMA) was reliant on TAC to overcome international pressures and that ultimately a human rights based approach to treatment and access triumphed over the neoliberal framework of the government. Further, in addressing HIV/AIDS from outside the global neoliberal hierarchy, TAC, alongside other civil society organisations, was able to successfully challenge both the international pharmaceutical industry and the neoliberal South African state and achieve greater access to treatment.
The Growing Agency of Civil Society
South Africa has a history of an influential civil society but following the democratic transition, civil society organisations emerged as a response to neoliberalism (Habib, 2003:237), offering an effective opposition to the ANC government. South Africa’s transformation was characterised by economic liberalisation and an increased leverage of multinational corporations and the international community resulted in the ANC adopting neoliberal economic policies. While this led to the realisation of the state’s deficit targets, it came at the expense of poverty and inequality (Habib, 2003:235-236). It is within this environment that civil society organisations have emerged, responding to the social impacts of neoliberal policies and these organisations have been at the forefront of promoting prevention, care and treatment of HIV/AIDS. The government failure to fully address HIV/AIDS opened the door to civil society activism.
While the main focus is TAC, one of the factors leading to greater agency within the country was the collaboration of civil society organisations. As HIV/AIDS is such a far reaching issue in South Africa, TAC was able to create links with other civil society organisations, thereby increasing its agency. TAC formed alliances with Anglican and Catholic church leaders, the AIDS Consortium and various NGOs (Grebe, 2011:860). However, the most significant ally was the Congress of South African Trade Unions (COSATU). Members of COSATU are a demographic heavily affected by AIDS, as well as being supporters of the ANC and Gaffen (2010:58) believes their support to have been important in establishing legitimacy among ANC supporters as well as being crucial in isolating Mbeki. These alliances allowed for greater influence and increased the pressure on both pharmaceutical companies and the South African government.
Together these actors were able to challenge the limited access to ARVs as well as contest the high prices of patented drugs which prevent poorer populations from accessing lifesaving medication. The neoliberal order has decreased the agency of the government and therefore opened up space for civil society activism, allowing organisations like TAC to not only assist the governments of developing countries in fighting neoliberal constraints but also to challenge them.
Agency at an International Level
In 2001 the South African government achieved a legal victory over international pharmaceutical companies when the Pharmaceutical Manufacturers Association, comprised of over 40 companies took the government to court over theft of intellectual property (Grebe, 2011:860-861). This followed the parliamentary passage of the Medicines Act in 1999 which would allow the South African government to seek cheaper drugs, including ARVs, through parallel importing and compulsory drug licensing, reducing the price of some ARVs by 70 to 90 per cent (Bond, 1999:768). The government faced legal pressure from pharmaceutical companies and international pressure from Western governments who were not only concerned with the loss of money but also the challenge to western power (Bond, 1999). TAC initially viewed these pharmaceutical companies as the greatest barrier to treatment due to inflated prices under patent monopolies (Heywood, 2009; Gaffen, 2010) and their involvement in the case, as a ‘friend of the court’ to the South African government was invaluable in achieving the victory, with the PMA dropping the case after just weeks of TAC campaigning.
TAC were successful in aiding the South African government in overcoming international pressure as they approached the case from outside of the neoliberal hierarchy of states and therefore did not face the same restraints as a developing country. For example, as Bond (1999:772) shows, the South African government was concerned with international pressure, particularly from America with the administration threatening trade restrictions if South Africa pursued the case. The South African government had to consider economic interests and trade relations as well as the health concerns of the population which, in some cases, resulted in South Africa succumbing to the pressure of the West. However, TAC, as a civil society organisation, was not subject to international pressure in this way. In joining the case TAC strengthened the voice of the South African government and enabled it to stand up to the international pressure directed at the Medicines Act.
TAC was further influential as the organisation used the fluidity of capital inbuilt into neoliberal systems to its advantage. TAC focused on international public opinion in the hope of ‘shaming the companies into dropping the case’ (Gaffen, 2010:49). This proved successful as neoliberalism had not only created an environment in which international corporations thrive but also one where a company can be faced with immediate unfavourable publicity in America or Europe because of actions in Africa which Friedman and Mottiar (2005:546) believe offers considerable scope for activism. TAC were able to create negative publicity and show the extent to which the neoliberal system favours international companies over developing countries, in a way that the South African government could not. One way that TAC highlighted these inequalities was through Zakie Achmat, a co-founder of TAC, smuggling generic Fluconazole, used for treating AIDS related illnesses, from Thailand to South Africa. He bought 3,000 capsules for the same price as 60 Pfizer capsules exposing the grossly inflated prices of patented drugs (Gaffen, 2010:51). When Achmat announced what he had done, international public outcry against Pfizer meant that no charges were brought and the imported drugs were successfully prescribed to South African patients (Robins, 2004:664).
TAC had the ability to take on, and beat, international pharmaceutical companies as they fought for access from outside of the neoliberal world order and could harness public opinion against pharmaceutical giants. Here TAC seems to have shown a greater agency than the South African government who only challenged international companies as a way of confronting global hierarchies and were unable to effectively do so alone. Access was not the most significant motivation for the government, which became apparent when, flowing the victory over the PMA, the Health Minister Tsabalala-Msimang equivocated on the roll out of ARVs citing price as a barrier (Gaffen, 2010:56). While TAC had helped achieve a significant victory for the government, it became clear that they had been wrong to assume that the greatest challenge to HIV treatment access would come from pharmaceutical companies and TAC now turned its attentions to domestic challenges against the government.
Taking on the Government
Acting as a friend of the court, TAC was able to offer vital support to the South African government against PMA. However, as a civil society organisation, TAC also had the ability to challenge the government and this took the form of legal battles surrounding the human right to access ARV medicine which they believed to be enshrined in the South African constitution (Grebe, 2011). It is argued that human rights as a collective frame have been significant in addressing issues of HIV/AIDS and contributed to the successes of TAC (Jacobs & Johnson, 2007:132) showing the powerful role of civil society and how activists can successfully challenge national governments. One result of government denialism of HIV/AIDS science was the claim that affordability prevented a country-wide rollout of ARVs (Gaffen, 2010) which presented TAC with a challenge from an unexpected source. In 2001 TAC filed legal proceedings against the government to require a rollout of the trial Mother-to-child HIV Transmission Prevention Programme (MTCTP) and were rewarded when the government policy on MTCTP was declared unconstitutional (Friedman & Mottiar, 2005). TAC were successful for two reasons: firstly they challenged the government on a human rights basis, again outside the neoliberal framework within which AIDS is usually located; and secondly they established connections which allowed them to undermine government reasoning and show that HIV prevention would be more cost effective that the burden on the health care system of treating people with HIV/AIDS.
TAC argued that constitutionally the South African government was obliged to offer ARVs to all who needed them as the new constitution promised rights to equality, life and dignity as well as specifically mentioning the right to health care services (Heywood, 2009:14-15). While the government claimed that the obligation to realise these rights is conditioned by available resources, TAC demanded that the government honour its constitutional duty to fulfil these socioeconomic rights (Johnson, 2004). Johnson (2005) believes that a neoliberal framing of HIV/AIDS removes the space for public discourse and demands that HIV/AIDS is understood solely as a health issue. However, through the court case, TAC successfully established a human rights response to the epidemic where HIV is understood as a developmental issue necessitating a government response. Johnson believes that in demanding AIDS to be viewed in a broader socioeconomic sense, TAC increased their agency in the struggle for increased treatment. Grebe (2011:867) supports Johnson and suggests that a legal challenge based on human rights allowed TAC to be successful as the human rights framework within the constitution represented the victory over apartheid. Framing the fight for access in this way enabled TAC to legitimise their struggle by highlighting the ideological similarities between the fight for treatment access and the fight for democracy (Jacobs & Johnson, 2007:134) therefore placing HIV/AIDS within the legacy of the anti-apartheid movement.
Further, TAC’s challenge was effective as the organisation worked closely alongside other groups and organisations to achieve their goals. In challenging the government this was significant as TAC could draw on expertise from outside the organisation. For example, lawyers were required to fight the legal battle and economists were used to show that government costs would be reduced if MTCTP was implemented, demonstrating that the cost of administering ARVs is lower than treating a child born with HIV (Robins & Lieres, 2013:578). Robins (2004:63-64) agrees and suggests that through the networks TAC formed, they were able to refute government claims about affordability and denialism which proved invaluable as evidence against the government in the court case. The government lost both the case and its appeal and was declared unconstitutional in its refusal to provide a comprehensive MTCTP programme (Friedman & Mottiar, 2005). This represented another breakthrough victory for TAC and the Health Minister was forced to develop a comprehensive national AIDS plan as a direct result of TAC’s actions. Following these successes TAC continued to bring legal cases against the government and individual ministers in the drive for improved access to HIV treatment. While access to treatment is not yet universal in South Africa, as Friedman and Mottiar (2005:528) highlight, winning victories over both the international pharmaceutical giants and the South African government enhances members beliefs that they can achieve change. This allows the strength of TACs agency as a civil society organisation to increase with each victory and has enabled TAC to become a driving force for change in South Africa.
TAC have demonstrated that civil society organisations in South Africa can experience just as much as, and if not greater, agency than the government on issues of health in a neoliberal world. Civil society organisations benefit from sitting outside of this framework and are not constrained by neoliberal global hierarchies in the same way as governments of developing countries, but are established precisely because of the negative social and political impacts of neoliberalism. TAC could successfully challenge pharmaceutical companies as international pressures do not affect the civil society to the same extent as it affects a country entering into the global economy. Further TAC used international public opinion to create negative press for the companies involved and could therefore force concessions in a way which the government could not, as well as relying on a human rights framework to address AIDS. In South African civil society, activists can challenge both the international order and the South African government and so possess significant agency. This agency provides a platform from which to address issues of access to ARVs and thus allowed the victories seen over both the international pharmaceutical community and the government. Therefore, the agency of civil society organisations in South Africa, and especially of TAC, cannot be ignored in the fight against HIV/AIDS.
The purpose of this essay has been to assess the impact that neoliberalism and neoliberal policies had on the South African state and civil society under Mbeki’s presidency. Specifically, it aims to highlight the links between neoliberalism and the unorthodox denialist position championed by the president. While these opinions have impacted significantly on South Africa’s battle with HIV/AIDS, there have been incomplete conclusions drawn about Mbeki’s support of dissident AIDS science, which fail to account for the impacts of neoliberalism on a developing state and on Mbeki’s political ideology (Johnson, 2005).
In assessing the impacts of neoliberalism on developing countries, it becomes apparent that market discipline, international organisations and transnational corporations all operate to serve the interests of capital and in doing so promote Western standing at the expense of developing countries. Disciplinary neoliberalism results in a reduction of state spending on vital social services including health and education with the demands of capital limiting the capacity of the state (Johnson, 2005). SAPs further reduce government resources and capability as well as resulting in user fees which put access to treatments beyond the reach of many in developing countries. Developing governments are further impacted by the structural limitations of neoliberalism, with state health responses undermined by international organisations. This is clearly evident in the insistence from the World Bank and IMF that developing countries prioritise debt servicing over domestic development agendas again undermining any attempts to address an HIV/AIDS epidemic.
In the South African context, neoliberalism has not only damaged social structures and diverted vital resources from addressing HIV/AIDS, but has also led to the acceptance of AIDS denialism among key government figures, including Mbeki and Health Minister Tsabalala-Msimang. Questioning the causal links between HIV and AIDS intensified the epidemic in South Africa and resulted in a lack of clear government policies to reverse these trends. While Mbeki adopted the views of several dissident scientists, he did not do so out of ignorance. Rather, denialist views on HIV/AIDS were heavily influenced by the impacts of neoliberalism on South Africa and Africa as a whole (Johnson, 2005; Jones, 2001; Parkhurst & Lush, 2004). Mbeki believed the international order to be against the African continent and therefore used AIDS as a political tool to portray the epidemic as a result of decades of western underdevelopment, neoliberalism and global hierarchies.
Further, denialism appealed to Mbeki for practical reasons. If dissident science could prove that AIDS was the result of poverty and not of a virus, the government would be spared the huge costs of improving health care provision. AIDS denialism constituted a convenient way to avoid complex planning and expensive programmes at a time when neoliberalism was reducing the capacity of the state (Jones, 2001). It seems clear that Mbeki adopted such an unorthodox position on HIV and AIDS as it best served his political interests. Not only did it reduce the need for government intervention in a health crisis, but it also furthered Mbeki’s desire to promote South Africa as an African and world leader, and allowed him to directly challenge the status quo of the world order and hierarchies.
This was dangerous logic and resulted in the material impacts of an HIV/AIDS crisis being ignored. It therefore became necessary for change to come from outside of the government and the door was opened to civil society organisations such as the Treatment Action Campaign. Neoliberalism created a gap which neither the government nor the health services could fill, therefore affording TAC greater agency (Habib, 2003). They became the voice against the international pharmaceutical companies and successfully showed the world the extent to which neoliberal policies favoured transnational corporations through protected patent monopolies. Moreover, TACs agency was further increased when the government cited affordability as a reason not to rollout MTCTP programmes. TAC, alongside other civil society organisations, refuted government claims and, by using a human rights based approach to HIV/AIDS, were able to win a constitutional victory over the government. It seems clear that the reduced government capacity, as a direct result of neoliberalism and denialism, increased the agency of civil society and enable these victories for TAC.
AIDS in the developing world cannot be addressed without looking first at the structures within which the epidemic is situated. This essay has shown that unless the neoliberal world order recognises the limitations placed on developing countries, governments will continue to be restricted in addressing HIV/AIDS. Further, in South Africa, this resulted in an administration that questioned universally accepted science. While Mbeki showed dangerous leadership in questioning HIV/AIDS science, it was as a result of the neoliberal world order, championed by western nations, organisations and companies, which decreased the development capacity of the South African government. Without structural change in the current neoliberal order, HIV in the developing world will remain a potential death sentence rather than being downgraded to a chronic illness, as it has been in the West.
Emma Camp was the winner of the 2015 Lionel Cliffe Prize for the best undergraduate dissertation on an African topic at the University of Leeds. Her essay in this Bulletin is a revised version of her dissertation.
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