AIDS, South Africa, and the Politics of Knowledge

Jeremy R. Youde

• Publisher: Routledge
• Year: 2016
• Print ISBN:
  9780754670032
• eBook ISBN:
  9781317183457
• Topic: Law
• Subtopic: International Law
• Index: Law

Through an in-depth examination of the interactions between the South African government and the international AIDS control regime, Jeremy Youde examines not only the emergence of an epistemic community but also the development of a counter-epistemic community offering fundamentally different understandings of AIDS and radically different policy prescriptions. In addition, individuals have become influential in the crafting of the South African government's AIDS policies, despite universal condemnation from the international scientific community. This study highlights the relevance and importance of Africa to international affairs. The actions of African states call into question many of our basic assumptions and challenge us to refine our analytical framework. It is ideally suited to scholars interested in African studies, international organizations, global governance and infectious diseases.

Chapter 1

Introduction

When histories assess the democratic credentials of Thabo Mbeki’s government in the future, it is likely that their most critical attentions will focus on its responses to the HIV/AIDS pandemic, surely the most formidable developmental challenge (Lodge 2002, 255).

South Africa’s HIV/AIDS pandemic would overwhelm any government. With approximately 20 percent of its adult population HIV-positive, any state would face enormous challenges marshaling the human, social, and financial resources necessary to combat this scourge. Add to this the tremendous upheavals associated with dismantling a racist regime, and one can easily understand the scope the challenge South Africa faces.

South Africa has faced an additional challenge, one of its own (or at least, of members of its government’s) making. Jacobs and Calland describe it bluntly: “Whenever one [from South Africa] traveled, the same – or similar – questions were put: ‘Why has he [Mbeki] got such funny views on HIV/AIDS?’ There has been no easy answer to this question” (Jacobs and Calland 2002, 3).

The country with the highest number of HIV-positive adults in the world, and one of the highest HIV prevalence rates, has seemingly embraced a policy one could describe as denialism. Instead of emphasizing the provision of HAART (highly active anti-retroviral therapy) and working with the mainstream international AIDS control regime, South African President Thabo Mbeki has openly questioned whether HIV actually causes AIDS. He and members of his Cabinet have called on AIDS dissidents, largely shunned by the international community and who deny the connection between HIV and AIDS, to serve as policy advisors. Dr. Manto Tshabalala-Msimang, the Minister of Health during Mbeki’s second term, has called AIDS drugs toxic and encouraged the use of garlic, lemon juice, and olive oil to treat AIDS. Instead of working with the international AIDS control regime, the South African government has expressed reluctance, if not outright hostility, towards its fundamental beliefs. AIDS dissidents have managed to gain a foothold in South Africa and influence policy while nearly every other government has shunned them. Why is this the case?

The Paradox of AIDS Policies in South Africa

UNAIDS estimates that, as of the end of 2005, approximately 5.5 million South Africans are HIV-positive. The vast majority of that number is between the ages of 15 and 49, in the midst of what should be the most economically productive years of life (UNAIDS 2006a). The South African economy stands to lose billions of dollars, and the potential consequences for the political system are enormous. Even if South Africa managed to stop the spread of AIDS today, the country essentially faces the loss of an entire generation. Given such a grim scenario, we would expect the South African government to take the lead on treating those infected with the disease and preventing further infection. We would expect the South African government to take advantage of the resources offered by the international AIDS control regime to stem the tide of the epidemic. We would expect a group of international recognized experts on the disease to play a prominent role in formulating South Africa’s AIDS policies. We would expect the South African government to be a leader in the fight against AIDS.

At best, one could describe South Africa’s AIDS policies as schizophrenic. While President Mbeki and Health Minister Tshabalala-Mismang publicly express doubt about the efficacy of treating AIDS, other Cabinet members express support for the international mainstream consensus for addressing the disease. Members of the government advocate for nutritional interventions as the best way to treat AIDS, but the Department of Health continues to purchase millions of condoms and an increasing number of state-sponsored sites offer HAART, albeit on a limited scale. The national government’s stance has often been at odds with individual provincial governments, especially those controlled by opposition political parties. Government officials express doubt about the epistemological bases of the AIDS policies that other parts of the national government have produced. In the post-apartheid era, it has been difficult for anyone to say with certainty what South Africa’s national AIDS policies are. Leading policymakers have repeatedly challenged the mainstream scientific consensus on the cause of and treatment for AIDS. This in turn has undermined the effectiveness of AIDS prevention and treatment programs in South Africa. All the while, HIV infection rates and annual deaths due to AIDS continue to increase.

We find ourselves confronted by a paradox. Given the scope of South Africa’s pandemic, we would rationally expect the South African government to actively collaborate with the international AIDS control regime and work with the recognized experts in the field to create the best possible policies. Instead, it has produced a jumbled mess of policies that reflect the influence of AIDS dissidents and challenge the fundamental bases of the international AIDS control regime and its epistemic community. Why would the country that seemingly has the most to gain from working with the international AIDS control regime and its epistemic community shun those experts and turn to a discredited group of AIDS dissidents? Some, including members of the South African government, argue that the cost of providing HAART is simply too expensive. While a national HAART program is indeed costly, it does not logically follow that an inability to afford the program would lead to a wholesale rejection by some prominent government officials of the fundamental tenets of AIDS science.

I posit that this situation has arisen because of the influence of a counter-epistemic community of experts who provide advice and policy recommendations from a fundamentally different basis than that of the mainstream international AIDS control regime. South Africa cannot incorporate the regime’s messages without contradicting its own commitments. The mainstream epistemic community’s messages, from South Africa’s perspective, are inconsistent with, if not hostile to, the country’s historical experiences with public health interventions and its identity commitments. This aversion to the mainstream epistemic community’s messages comes from South Africa’s negative experiences with outside public health campaigns and its expressed desire for an autonomous voice in international affairs as symbolized by the African Renaissance. The South African government’s identity, especially in this post-apartheid era, is intertwined with avoiding the post-colonial paternalism that has often accompanied international policy toward Africa, while simultaneously promoting the need for African states to take an active role in African affairs. If we fail to understand the fundamental role that this clash of identities plays, we are left with simplistic, underdeveloped and unsatisfying answers.

Why would the South African government open itself up to international criticism by actively questioning the international consensus? The answer comes through an examination of the country’s history with public health interventions and the state’s identity commitments. Throughout South African history, government officials have invoked public health rationales to justify discriminatory, racist policies. For some current leaders, the international attention paid to South Africa’s AIDS policies reek of an attempt to reassert control and domination over Africa. At the same time, the government actively promotes a post-apartheid national identity based on African Renaissance-inspired ideals. Finding African solutions for African problems is key to this identity, and proponents frequently reject the notion that Western experiences and suggestions can be superimposed on the African experience. (Curiously, though, nearly all of the AIDS dissidents are from Western countries, an odd juxtaposition to which I will return in Chapter 5.) President Mbeki and other members of his government have explicitly linked this African Renaissance-inspired identity commitment to the state’s AIDS policies. This book will explore both of these factors in great detail.

Instead, it turned to a counter-epistemic community of AIDS dissidents. The counter-epistemic community of AIDS dissidents translates South Africa’s history with public health interventions and its identity commitments translate into actual governmental policy. This counter-epistemic community of scientists and experts has an international membership and shapes the AIDS discourse in South Africa by offering advice and policy suggestions to the South African government. It serves as a counterweight to the epistemic community embraced by the international AIDS control regime. Just as any epistemic community does, the counter-epistemic community translates the amorphous notions of history and self-identity into policy outcomes, giving them real-world weight.

Peter Haas introduced international relations scholars to the idea of the epistemic community. An epistemic community is a network of scientists and experts to whom policymakers turn for guidance and unbiased information when a new issue emerges. Policymakers, in turn, take this information to craft appropriate governmental responses. Members of an epistemic community possess a significant amount power, as they frame the problem for the government and, often, the public. This power, according to Haas and other scholars, derives from the seemingly impartial nature of the information provided by members of the epistemic community. Because these scientists and experts are regarded as apolitical, policymakers are more willing to defer to them. Numerous scholars have adopted the epistemic communities framework to analyze issues like ozone depletion, Mediterranean Sea pollution, and the regulation of space satellites. The literature on epistemic communities and international regimes plays an increasingly important role in both academic and policy debates.

While the epistemic communities framework certainly represents an advance in our understanding of the role of scientific knowledge in international policymaking, it has one significant limitation: it assumes that only one epistemic community will emerge on any given issue. This is puzzling. First, claims of the impartiality of scientific knowledge are false. Scholars working within the sociology of scientific knowledge have demonstrated repeatedly that scientific knowledge often reflects a particular social, political, and historical context. That does not mean that this science is manipulated; rather, what counts as scientific fact reflects broader societal contexts. By the same token, they have demonstrated how policymakers have repeatedly cited the impartiality of science to justify policy action (or inaction) that accord with their own preferences. Second, it is epistemologically contradictory to argue on the one hand that policymakers will turn to a group of experts for policy advice when a new issue emerges, yet assert on the other that all these policymakers will turn to the same group of experts. The epistemic communities literature builds on knowledge-based theories of international regimes. These theories argue that normative and causal beliefs can have a direct impact on policy outcomes, and that changes in beliefs can lead to changes in policy. However, given its understanding of the power of normative beliefs on policy, it makes little sense to assert that only one causal belief will emerge. Haas notes that members of the epistemic community may disagree with one another on policy suggestions. He does not mention, though, what happens when competing groups of experts not only offer differing policy suggestions but also understand a given issue in fundamentally different ways. It is true that one explanation may eventually fall by the wayside as more information becomes available, but there is no a priori reason to assume this will always happens. How do these competing groups of experts impact international policymaking?

Through an in-depth, qualitative examination of the interactions between members of the South African government and the international AIDS control regime and its associated epistemic community, I examine not only the emergence of an epistemic community but also the development of a counter-epistemic community. Members of this counter-epistemic community are not simply crackpots; many of them have advanced degrees from prestigious universities and hold important positions in academia and industry. In essence, we find one group of highly-credentialed experts competing with another group of highly-credentialed experts, offering fundamentally divergent understandings of AIDS and radically different policy prescriptions. This is an important advance in understanding how and when epistemic communities operate which addresses both policy and academic concerns. It resolves the epistemological contradiction noted above, while also clearly demonstrating how differing causal and normative beliefs can have an important impact on policy outcomes.

This book is certainly more than the story of one man (Thabo Mbeki) and one woman (Manto Tshabalala-Msimang). These two people are highly prominent in the South African government who have empowered a group of dissident advisors and help direct national AIDS policies. It is also the story of how scientific knowledge plays a role in the policymaking process, how governments empower different groups of actors, and how science can be a political tool and reflect a state’s social, historical, and political contexts.

International relations theories traditionally assume that the state is a single unitary actor, speaking with one voice. Individuals exist within a government and may disagree with one another, but state actions ultimately present a single perspective. Within the neorealist vein, Waltz notes that, even as personalities and behaviors change within a state, the structures of that state endure. What’s more, these structures place limitations on the actions of those personalities and channel state actions through the top leaders (Waltz 1979, 80–87). By this logic, then, we should rightfully understand that the state speaks with only one voice. Different voices may exist within the state, but policies eventually come from a single point with a single voice. Keohane, working within a neoliberal framework, agrees, as this assumption allows for more parsimonious theories and focuses attention on how structures constrain actors (Keohane 1984, 29).

If we start from this assumption, then it makes little sense to investigate the beliefs of Mbeki, Tshabalala-Msimang, and the AIDS dissidents. South African AIDS policies do not uniformly reflect a dissident stance. Even if Mbeki, Tshabalala-Msimang, and the AIDS dissidents wanted to unilaterally impose their ideas, they could not. They are simply parts of a much larger government, and the legislative process requires the assent of a wide variety of actors to make any idea policy.

However, the confusion and incoherence of the government’s AIDS policies demonstrate the importance of disaggregating the state and investigating the beliefs of different groups. Milner notes: “When domestic actors share power over decision making and their policy preferences differ, treating the state as a unitary actor risks distorting our understanding of international relations” (Milner 1997, 33).

This is the situation that prevails in South Africa for its national AIDS policies. Mbeki and Tshabalala-Msimang’s beliefs about AIDS may not be policy, but their doubts about the wisdom of conventional AIDS policies introduces a degree of doubt that undermines the effectiveness of those policies. AIDS dissidents may not make policy on their own, but they influence those policies, their implementation, and the public reception of those policies. The South African government is not speaking with one voice when it comes to national AIDS policies or communicating these policies to the outside world. Not every South African, or even every South African government official, values and supports the AIDS dissident position, but some highly-placed South Africans with a major impact on national policy (and the public reception of those policies) do.

The AIDS Epidemic in Perspective

We should put the AIDS epidemic in perspective. In its 2006 report on the worldwide AIDS epidemic, UNAIDS estimates that approximately 39.5 million people are HIV-positive (UNAIDS 2006b, 1) – up from 34.3 million in 2000 (Population and Development Review 2000, 629). Nearly 95 percent, or 37.2 million, of these cases are in people over the age of 15. Over 4 million people contracted HIV during 2006, dwarfing the 2.9 million AIDS deaths during that same period (UNAIDS 2006b, 1). While some areas, like Zimbabwe, Tamil Nadu in India, and urban districts in Burkina Faso, have reported successes in decreasing their HIV prevalence rates, and research suggests that the worldwide HIV prevalence rate peaked in the late 1990s, the absolute number of HIV-positive persons continues to increase annually (UNAIDS 2006b, 6).

Women make up an increasing percentage of HIV infections. “Globally through 1997, women, children, and teenagers seemed to be on the periphery of the HIV/ AIDS pandemic. In 2002 however, they became the center” (Stine 2005, 332). In 2006, UNAIDS reported that women made up 44 percent of all HIV-positive persons (UNAIDS 2006b, 90). By 2005, over 50 percent of all new infections occurred among women (Stine 2005, 332). Not only are women more vulnerable to HIV infection for physiological reasons, but their lack of empowerment in many parts of the world puts them at risk. Women are also expected to care for those who get sick with AIDS, regardless of their own HIV status. UNAIDS suggests that women face greater stigma and discrimination when they reveal their HIV status than the male partners who infected them (UNAIDS 2006b, 90).

The situation is more dire in sub-Saharan Africa. UNAIDS reports that 24.7 million people in the region are living with HIV, an increase of nearly one million people since 2004. This means that nearly two out of every three HIV infections in the world in sub-Saharan Africa. While two million Africans died of AIDS during 2006, nearly three million new HIV infections occurred on the continent. The region’s adult infection rate hovers around six percent. By comparison, the Caribbean is the second most-infected region at 1.2 percent, and the worldwide adult infection rate stands at one percent (UNAIDS 2006b, 2). Women comprise an increasing percentage of HIV infections in the region. By 2006, they made accounted for 57 percent of the HIV-positive adults in sub-Saharan Africa. The situation is especially acute for women aged 15 to 24, as they are 2 to 6 times more likely to be HIV-positive than sub-Saharan African men of the same age (UNAIDS 2006b, 88).

In the worst-affected region in the world, South Africa has one of the most severe epidemics. Over 5 million South African adults, approximately 18.8 percent of the adult population, are HIV-positive (UNAIDS 2006a). This figure gives South Africa not only one of the world’s highest adult infection rates, but also one of the highest numbers of HIV-positive persons in the world.

The South African Department of Health published a comprehensive survey of HIV prevalence in 2006. It found that 30.2 percent of women attending antenatal clinics in 2005 were HIV-positive. Two years earlier, the national prevalence estimate was 27.9 percent. Infection rates were not uniformly distributed across the country, with KwaZulu-Natal (though its 2005 prevalence rate was lower than in 2004) and Mpumalanga recording the highest rates and Northern Cape and Western Cape the lowest (see Table 1.1). Women in their late 20s had the highest infection rates at 39.5 percent in 2005, followed closely by women in their early 30s at 36.4 percent (SADOH 2006, 9).

Table 1.1 South African Provincial HIV Prevalence Rates among Antenatal Clinic Attendees

The above figures only reflect pregnant women who attended antenatal clinics, not the entire population. Using mathematical models to extrapolate from these findings, the Department of Health estimates that approximately 5.54 million South Africans are HIV-positive, though they suggest this number is on the conservative end (SADOH 2006, 16). This translates to an adult HIV prevalence rate of 16.25 percent, with women comprising nearly 60 percent of this total (SADOH 2006, 17). While prevalence rates have declined for women under age 20, suggesting a decline in new cases, rates appear to be increasing for women aged 25 to 34.

A subsequent report by the Actuarial Society of South Africa, the Medical Research Council, and the University of Cape Town’s Center for Actuarial Research reports similar findings, estimating that 5.3 million South Africans are HIV-positive over over 500,000 new infections would occur during the year (Dorrington et al. 2006, 8). This puts the overall prevalence rate in South Africa at 11.2 percent, with the adult (20–64) prevalence rate at 19.2 percent. Breaking it down by gender, adult women had a prevalence rate of 20.4 perce...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Tables
• Acknowledgments
• List of Abbreviations
• 1 Introduction
• 2 Knowledge and International Policymaking
• 3 Counter-epistemic Communities
• 4 History and Public Health in South Africa
• 5 Identity, AIDS, and Public Health in South Africa
• 6 South Africa AIDS Policies and the Counter-epistemic Community
• 7 Conclusions and Implications
• Works Cited
• Index