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An analysis of dissident representations of the „problem of AIDS‟ in South
Africa (1999-2008)
Monash University This paper presents an analysis of AIDS dissidence in South Africa during the period of Thabo Mbeki‟s presidency (1999-2008). In contradistinction to existing analyses it does not seek to uncover the underlying motivations for government-led AIDS dissidence. Instead, it sees this account of AIDS as a discursive configuration, which bears the impress of antecedent colonial discourses and geopolitical relations between Western powers and Africa. I suggest that the Mbeki executive constructed AIDS as bound up with the „disease of racism‟ and with Africa‟s history of dependence on Western scientific interventions. As a result, they framed the „problem of AIDS‟ as a battle to combat not a virus, but what they saw as the pervasive racism and imperialism of orthodox science on AIDS. Drawing on the Foucauldian insight that knowledge is constituted through struggles for power (Foucault 1972), I suggest that the politically supported AIDS dissident movement can partly be read as a quest to advance uniquely African knowledge on the AIDS epidemic. I argue that Mbeki mobilised HIV/AIDS as part of a Pan-Africanist agenda of pursuing Africa‟s self-determination and autonomy from the West. The paper considers what aspects of the epidemic are subordinated by this nationalist rhetoric, including the issue of HIV treatment, the feminisation of the South African epidemic and its material effects. Competing representations of the „problem of AIDS‟
In 2009, there were an estimated 5.7 million people living with HIV/AIDS in South Africa, more than any other country globally (Joint United Nations Programme on AIDS 2009). Adult mortality data predict that, in the decade 2000-2010, 7 million South Africans would die of HIV/AIDS, making it the largest single cause of death (Dorrington, et al. 2001). Given the scale of the South African epidemic, one would expect HIV/AIDS to have been a national priority from the first wave of the epidemic. Yet successive government responses have been marked by ambivalence, lethargy and, under the leadership of former President Mbeki, AIDS dissidence (Fourie & Meyer 2010). This paper focuses on the nine-year period of Thabo Mbeki‟s presidency, often described by scholars and media commentators as the era of AIDS denialism (see for example, Boseley 2008, Butler 2007, Geffen & Cameron 2009, Mbali 2004, Nattrass 2007). Mbeki questioned orthodox science on AIDS, including the viral causation of AIDS and the efficacy of anti-retroviral (ARV) drugs. While Mbeki was not the architect of the national HIV/AIDS policy, his dissident position won the support of a number of ANC executive members. It also influenced the Health Ministry‟s HIV/AIDS intervention strategies, particularly their decision to delay the roll-out of programmes for the prevention-of-mother-to-child transmission (PMTCT) and ARV therapy (ART). In this paper I address the question: how is the ‘problem of AIDS' presented in the Mbeki government's dissident rhetoric and what historical factors shaped this stance? My empirical data consist of a selection of public statements made by Mbeki and his executive, excerpts from parliamentary debates and articles written by Mbeki in the party newsletter ANC Today. I draw on Bacchi‟s (1999, 2009) post-structuralist approach to policy analysis to examine the problem representations produced in the government‟s AIDS dissident rhetoric. This approach aims to expose the taken-for- granted assumptions that underpin policy interventions, showing how policy helps to produce social problems. It is particularly appropriate for an analysis of the problematisation of AIDS in South Africa as the Mbeki government identified (created) and then addressed at least four distinct problems under the rubric „AIDS 1) AIDS as a site of scientific contention: the causation, treatment and epidemiology of AIDS is poorly understood; 2) AIDS as a disease of poverty; 3) orthodox science on AIDS as enmeshed with the "disease of racism" (Ramatlhodi, et al. 2000); 4) the scale of the AIDS epidemic as a consequence of Africa‟s dependence on Western solutions to its problems. The first problematisation concerns the Mbeki executive‟s rejection of the orthodoxy of biomedicine. By challenging established science on the causation, treatment and epidemiology of AIDS in Africa, they constructed AIDS as a site of ongoing scientific debate. The second account of the „problem of AIDS‟ presents a socioeconomic account of disease as thriving in conditions of poverty where poor sanitation, limited access to nutrition, the unaffordability of medicines and food insecurity increase vulnerability to HIV-infection (Cameron 2005, Mbali 2004). In the third and fourth problematisations, the Mbeki government situated the problem of AIDS within the context of global geopolitical relations, specifically the history of Western imperialism and racial oppression in Africa. This next section examines the last two dissident representations of the problem of AIDS, i.e. how the Mbeki government constructed AIDS as enmeshed with the political problems of racism, Western imperialism and Africa‟s dependence on Western powers. To trace the possible antecedents of this problematisation, the analysis references the historical legacies of colonial-era public health policies in South Africa and iconography of the African body in the first-wave of the AIDS epidemic. I then consider the effects of this problematisation on the national response to HIV/AIDS. 4.2. AIDS, Western imperialism and the "disease of racism"
During a National Assembly1 (NA) Question and Replies session in October 2004, a member of the opposition posed a question about the role of rape and sexual violence in the spread of AIDS. The question was prompted by a recent letter in the ANC newsletter in which Mbeki rejected the claim that rape is pervasive in Africa because of its implication that "African traditions, indigenous religions and culture prescribe and institutionalise rape" making "every African man a potential rapist" (Mbeki 2004). Two representations of the problem of AIDS dominated debates that followed: one in which AIDS is bound up with a related social problem of gender- based violence and the other in which AIDS is subordinate to the problem of racism. The Mbeki executive helped to produce the latter representation by refusing to address the relationship between the prevalence of rape and AIDS and instead segueing into a denunciation of racism: Whatever the circumstances and regardless of the regularity of Catholic incantations about playing the race card, I for my part will not keep quiet while others whose minds have been corrupted by the disease of racism accuse us, the black people of South Africa, of Africa and the world, as being, by virtue of our Africanness and skin colour, lazy, liars, foul-smelling, diseased, corrupt, violent, amoral, sexually depraved, animalistic, savage and rapist (Republic of South Africa National Assembly 2004). This quote reveals Mbeki‟s concern to refute racist stereotypes about African sexuality. It fits in with his argument that estimates of high HIV/AIDS rates in sub- Saharan Africa reflect the underlying racism and moralism of Western scientific 1 The South African Parliament is bicameral: it is composed of two Houses who have joint legislative power, namely the National Assembly (NA) and the National Council of Provinces (NCOP) (Republic of South Africa Parliamentary website n.d.). The debates of the National Assembly offer insight into the democratic process by which elected representatives of the people decide on matters of public importance and review legislation (ibid). research, which "entails…a damning judgement on African sexual behavior" (Cameron 2005: 97). As Mbeki puts it, "[t]he hysterical estimates of the incidence of HIV in our country and sub-Saharan Africa made by some international organisations, coupled with the earlier wild and insulting claims about the African and Haitian origins of HIV, powerfully reinforce these dangerous and firmly-entrenched prejudices" (Mbeki 2000a). In the NA debate, Mbeki appears increasingly frustrated by attempts to divert the discussion from the issue of race, insisting "I have said before, and I want to repeat it, that I was discussing the question of racism and I am not going to be diverted to other issues simply because some members believe that the issue of racism is a minor question. It isn‟t a minor question, and we‟ll continue to discuss it" (Republic of South Africa National Assembly 2004: para 45). This response helps to produce the problems of HIV/AIDS and gender-based violence as subordinate to that of racism, which Mbeki contends is "not a minor question" but rather a persistent problem in South Africa. His refusal to engage the relationship between gender-based violence and HIV prevalence is particularly concerning given the feminisation of the South African epidemic and the established epidemiological evidence for the "nexus between violence, risky behaviour and reproductive health" (Abdool Karim & Abdool Karim 2005: 258). It seems to me that Mbeki‟s dismissal of the problem of rape (as a manifestation of certain violent masculinities) is bound up with a general subordination of gender in his nation-building rhetoric. As feminist scholars have amply demonstrated, gender is frequently subordinated in nationalist projects (Yuval-Davis 1997; Wilford & Miller 1998). Nation-building efforts in post- apartheid South Africa appear to be no different in this respect, as Mangaliso observes: "Thus far in South Africa, one has not heard any statement of serious concern about gender inequality from any leader. The prevailing sentiment is that issues of race still dominate and deserve top priority" (1997: 141). As we have seen, the problem of AIDS was subsumed by the so-called "disease of racism" in Mbeki‟s African nationalist rhetoric (Republic of South Africa National Assembly 2004). The use of the metaphor of disease bears consideration. As the NA debate shows, the problem of AIDS was subsumed by that of the "disease of racism" in Mbeki‟s rhetoric (Ramatlhodi, et al. 2000). To construct racism as a disease is to mobilise an assemblage of disease associations, such as contagion, infection, pathogens and quarantine. One could argue that producing racism in these terms makes its threat more tangible and immediate. Indeed, in Mbeki‟s rhetoric the "disease of racism" assumes the proportions of a public health crisis, deflecting attention away from the health crisis of AIDS. This construction extends military metaphors of disease (evident in terms like combat, battle, crusade, weapon) to the domain of racism, allowing a kind of metaphorical slippage where Mbeki‟s Pan- Africanist movement is constructed as a battle against the imposition of a (racist) Western model of science on Africans: "People who otherwise would fight very hard to defend the critically important rights of freedom of thought and speech occupy, with regard to the HIV-AIDS issue, the frontline in the campaign of intellectual intimidation and terrorism which argues that the only freedom we have is to agree with what they decree to be established scientific truths" (Mbeki 2000b: 3, my emphasis). The use of military metaphors sets up a field of combat between two opposing sides and so reinforces the polarisation of the AIDS debate along orthodox/dissident lines. The Mbeki government‟s account also constructs AIDS as entangled with Western imperialism in Africa: it resists Africa‟s perceived "slavish dependence" on Western scientific solutions by emphasising the African incidence of HIV/AIDS and promoting African interventions (Ramatlhodi, et al. 2000). I suggest that the repeated calls for an African solution to "this uniquely African catastrophe" are part of Mbeki‟s Renaissance vision for achieving Africa‟s self-determination and independence from Western world powers (Mbeki 2000b). The connection between the fight against AIDS and the spirit of African Renaissance is made quite explicitly in Mbeki‟s letter to World Leaders of the G8, where he enjoins African states to resist the hegemony of the Western scientific model of HIV/AIDS: It is obvious that whatever lessons we have to and may draw from the West about the grave issue of HIV-AIDS, a simple superimposition of Western experience on African reality would be absurd and illogical. […] I am convinced that our urgent task is to respond to the specific threat that faces us as Africans. We will not eschew this obligation in favour of the comfort of the recitation of a catechism that may very well be a correct response to the specific manifestation of AIDS in the West (Mbeki 2000b). The letter concludes with an appeal for leaders of the G8 to support "all of us, as Africans. in the common fight to save our continent and its peoples from death from AIDS" (Mbeki 2000b). The rhetoric of AIDS dissidence is coupled here with a pan- Africanist discourse which constructs "the epidemic as part of the ANC‟s anti-colonial struggle" against the imperialism of Western world powers (Fourie & Meyer 2010: 161). The Mbeki government argued that AIDS in Africa can only be overcome if the larger „war‟ against the post-colonial relics of racism, Africa‟s underdevelopment and Western imperialism is „won‟. Here the „fight against AIDS‟ is seen as inseparable from the larger political battles facing post-apartheid South Africa. Tracing the antecedents of the „disease of racism‟
The government‟s construction of racism as a disease has a pertinent historic link. It reverberates with colonial health policies when racism coalesced with public health concerns. For example, in the 1900s when the Bubonic Plague reached Cape Town, quarantine measures in the form of the forcible relocation of black Africans into Native Reserves ostensibly protected people from the risk of contagion, but also served the more insidious goal of racial segregation (Swanson 1977). The racial motivation for these Native Reserves is evidenced by the fact that more White and Coloured people were infected with the plague than Black Africans and yet Whites and Coloureds were not confined to separate reserves (ibid). Significantly, this was the first time in South Africa‟s history that segregation had been enforced in the form of Native locations, which were to become a pillar of the apartheid state (Youdé While narratives of „African AIDS‟ have shifted since AIDS was first named in the 1980s, these racialised constructions of AIDS were not uncommon in epidemiological research in the first-wave of the epidemic (Treichler 1999). This first- wave research purported that Africans practise sex in different ways and with more sexual partners than their Western counterparts making them more vulnerable to HIV-transmission (ibid). As Cameron puts it, "[r]ace and the epidemiology of AIDS collided in Africa in the 1980s. A rank colonial legacy of racial thinking and bigotry has plagued our understanding of AIDS in Africa" (2005: 78). In 1985, Africa became the focus of scientific research because of the emerging evidence that AIDS originated in West-Central Africa. This occasioned a media frenzy in late 1986 in which the spread of AIDS was represented as a crisis decimating Africa (Treichler 1999, Youdé 2007). These scientific and media explanations proposed that „African AIDS‟ was caused by the deviant sexual practices of indigenous Africans which allowed the HI-virus to be transmitted from African monkeys to human beings. They tended to exaggerate or even invent cultural practices which attribute racial-cultural differences to African people, reinforcing the belief that AIDS is a disease of the „exotic other‟ (Treichler 1999). Consequently, in the first-wave of the epidemic, Western epidemiologists and scientists representing the "international AIDS control regime" tended to assign blame to Africa for the origins and spread of HIV/AIDS (Youdé 2007: 47). In response, the governments of several developed countries enacted strict disease control measures to stop HIV-positive people from African states from spreading AIDS to the developed world, including "a host of discriminatory visa requirements, special blood tests" and other medical examinations (Youdé 2007: 49). Given that HIV/AIDS is sexually transmitted, these surveillance measures could be seen to impute moralistic judgements on African sexual behavior as deviant and promiscuous (Cameron 2005). Tracking how the concept of race was deployed in some colonial and post-colonial discourses reveals that Mbeki‟s sensitivity to racist slurs in AIDS discourses has a basis in negative, racial stereotypes which represent black Africans as sexually prodigious vectors of disease (Cameron 2005). When Mbeki took office in 1999, only five years after South Africa made the transition from an apartheid state to a democracy, post-colonial and post-apartheid racial pathologies were major political challenges to reconciliation and democratic restructuring. This recent political transition, South Africa‟s history of racist public health policies and "the politics of race, sex and death" that surrounds AIDS in Africa, are some of the conditions which facilitated reading the problem of AIDS through the pervasive lens of race (Cameron 2005: 75). In contradistinction to some of the existing literature2, I am not suggesting that Mbeki‟s dissident stance was motivated by a history of colonial powers using medical science to oppress indigenous Africans or by racist stereotyping in first-wave epidemiological research on HIV/AIDS. Or rather I do not see this problematisation as "the inevitable product of „natural‟ evolution over time", as a predictable outcome of oppressive, racist policies in South Africa‟s history (Bacchi 2009: 10). Instead from a genealogical perspective, this dissident representation can be interpreted as an assemblage of historical and contemporary discourses that associate „Africanness‟ with disease, sexual deviance and racial inferiority. Reading AIDS dissidence against this historical backdrop can help to explain the currency that AIDS dissidence held within a politics of African nationalism. Effects of AIDS dissidence on the national response
Examining how the problem of AIDS was represented under Mbeki is important because representations of social problems shape policy responses. In this section, I probe the impact of the Mbeki government‟s problematisation on national policy and on the people who are the targets of social change, e.g. HIV-positive people and poor communities who are reliant on the public healthcare system. As we have seen, the government represented the problem of AIDS as entangled with (and subordinate to) the twin problems of racism and Western imperialism in Africa. While this problematisation does sometimes incorporate aspects of the Western biomedical model of AIDS causation3, it prioritises a political explanation of AIDS causation over a biomedical one. As such, it shifts the problem orientation from the individual body (or the carrier of the virus) to the legacy of racial thought that links high AIDS rates in Africa to the sexual promiscuity of black African people. Perhaps the most notable consequence of this dissident position on AIDS is that it called into question the established findings on the causation and treatment of AIDS, e.g. HIV causes AIDS 2 For example, Fassin (2007), Mbali (2004) and Wang (2004) 3 It views the HI-virus as one possible cause of AIDS, though it constructs the viral causation of AIDS as a matter of ongoing scientific debate. Moreover, while the Mbeki government‟s account challenged some scientific findings on AIDS, it operated from the scientific premise that HIV is sexually transmitted: placing safe sex campaigns at the centre of their prevention policy assumes that HIV is sexually transmitted. and ARVs are the best-known form of treatment. I suggest that the government‟s ambivalent position on AIDS causation and treatment compromised the efficacy of their policy interventions. In terms of what is subordinated or marginalised in the Mbeki government‟s problematisation, I argue that it deflects attention away from the practical response to AIDS: the urgent material implications of the rising HIV prevalence rates in South Africa are far-removed from esoteric, political discussions of the „disease of racism‟ that allegedly permeates orthodox science on AIDS. For example, conspicuously absent in the debates on AIDS is serious consideration of the AIDS-related problems of increased illness and mortality, pressure on health services, the disease burden on young women who are disproportionately infected with HIV/AIDS, rising numbers of orphans and child-headed households. As we saw in the extract of the NA debate, when the relationship between prevalence of rape and AIDS was raised, Mbeki dismissed both issues in favour of addressing what he saw as the more pressing national priority of combating racism. Furthermore, it seems to me that the contestation around HIV/AIDS directed the ANC leadership‟s energy and resources away from mitigating the severe impact of AIDS on vulnerable, poor communities. Notably, the Health Ministry delayed implementing a public sector anti-retroviral treatment (ART) programme until they had completed a pilot study of the efficacy of ARVs (Geffen 2010). Since ARVs were already available in the private sector, the Health Department‟s phased approach to the implementation of ART created a socioeconomic barrier between private and public sector HIV-positive patients: "To the extent that government limits the supply of nevirapine4 (sic) to its research sites, it is the poor outside the catchment areas of these sites who will suffer. There is a difference in the positions of those who can afford to pay for services and those who cannot. State policy must take account of these differences (Constitutional Court Judges 2002: para 70). Considering that 80% of South Africans rely on the public healthcare system because they cannot afford 4 Nevirapine is an ARV drug used to reduce the risk of intra-partum transmission in HIV-positive pregnant women. private sector treatment (SAinfo Reporter n.d.), it is the poor, HIV-positive majority who suffered deleterious effects under the government‟s approach. This is cruelly ironic given Mbeki‟s professed concern to alleviate poverty as a social determinant of the epidemic in South Africa. The tragic consequences of the delay in implementing a national treatment programme is underscored by estimates that, between 2000 and 2005, 330 000 people died without access to life-prolonging ART (Chigwedere, et al. 2008). Conclusion
The Mbeki government‟s dissident account suggests that AIDS in Africa cannot be separated from the politics of race and colonialism. An account that produces AIDS as enmeshed with the „disease of racism‟ creates the problem as the product of colonial and apartheid relics. Teasing out the "nesting" of problems (Bacchi 2009) under the „disease of racism‟ rubric, we can understand the racial thread of AIDS dissidence as bound up with "a political effort to argue that the reality of racism and apartheid are still too fresh to be consigned to the past" and play themselves out in the contours of the AIDS epidemic (Marais 2005 cited in Fourie & Meyer 2010: 187). Metaphorising racism as a disease helped construct AIDS as political problem, rather than a strictly biomedical one. As such, this formulation challenges the neat delineation between science (in the form of biomedicine) and politics. I am not suggesting that the Mbeki government consciously set out to challenge the boundaries that set science apart from politics. Rather, I see the partial interruption of the science/politics binary as a constitutive effect of the government‟s critique of orthodox science on AIDS. The genealogical thread in the analysis described some of the historical conditions through which AIDS came to be a proxy for the Mbeki administration‟s overriding concern with the problems of racism and Western imperialism in Africa. This genealogical reading is not an attempt to condone the government‟s manifestly insufficient response to AIDS; rather it seeks to show how South Africa‟s colonial and apartheid history of racial oppression and its relatively recent democratic transition has shaped contemporary politics, including the national response to the AIDS epidemic. In challenging dominant discourses of AIDS, the Mbeki executive refused the scripts offered by Western biomedicine to explain the epidemic in Africa. They sought to expose hegemonic Western narratives of AIDS as imperialist and replace them with an Afro-centric narrative, sensitive to the unique socio-historical context which allowed AIDS to explode in Africa. Framing the problem of AIDS this way situates it within the projects of post-apartheid restructuring and the African Renaissance. It also produces AIDS as a vehicle for nation-building rather than strictly as an affliction affecting individuals or even the population in public health terms. This unusual formulation of AIDS is encapsulated in Mbeki‟s quest to find an „African solution‟ to the epidemic as part of his vision for achieving Africa‟s autonomy from the West. In this regard, Africa‟s reliance on international aid funds and Western pharmaceutical drugs to address AIDS is constructed as "deeply symbolic of Africa‟s continued dependence on its former oppressors" (Fourie & Meyer 2010: 187). It is with these neo-colonial relations in mind and the African Renaissance movement that I argue that the Mbeki government constructed the battle against the AIDS epidemic as part of a larger post-colonial, Pan-Africanist struggle for African unity and socio-economic development across the continent. References
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Genome Transplantation in Bacteria: Changing OneSpecies to Another DOI: 10.1126/science.1144622 The following resources related to this article are available online atwww.sciencemag.org (this information is current as of August 3, 2007 ): including high-resolution figures, can be found in the online Updated information and services,version of this article at:

11b-r_burnett.indd

PRACTICE REPORTS Omeprazole Stability and viscosity of a fl avored omeprazole oral suspension for pediatric use JANE E. BURNETT AND ETHAN R. BALKIN Purpose. The stability and viscosity of tration dependent. After one week, the Proton-pump inhibitors (PPIs) are substituted pyridylmeth- preparations of a commercially available,