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Didier Fassin, Helen Schneider

https://www.bmj.com/content/326/7387/495.full

Centre for Health Policy, School of Public Health, University of Witwatersrand,
PO Box 1038, Johannesburg 2000, South Africa

Helen Schneider

director

Correspondence to: D Fassin dfassin@ehess.fr

BMJ 2003;326:495–

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Discussion of AIDS in South Africa needs to move beyond a simplistic “for or against” stance on President Mbeki’s denial of a connection between HIV and AIDS. The authors propose ways to widen the debate and hence to increase understanding of the epidemic

At the beginning of 2000 Thabo Mbeki sent a letter to world leaders expressing his doubt that HIV was the exclusive cause of AIDS and arguing for a consideration of socioeconomic causes. He subsequently invited scien- tists who shared his view to sit with orthodox experts on AIDS on a presidential panel to advise him on appropriate responses to the epidemic in South Africa. Until April 2002, when Mbeki formally distanced himself from the AIDS “dissidents,” the international sci- entific community’s interest in South African policies on AIDS was almost exclusively focused on the polemic raised by the president. His statements questioning the AIDS statistics, on poverty as a cause of immune deficiency, and on the dangers of antiretrovirals, together with government stalling on the roll out of nevirapine to prevent transmission of HIV from preg- nant mothers to their babies, dominated the debate.1–3

However, the July 2002 Constitutional Court judgment ordering the government to make nevirapine universally available to pregnant women infected with HIV, followed in October by a cabinet statement supporting wider access to antiretrovirals, may have finally ushered in a new era. It should now be possible to discuss the reality of AIDS in South Africa without reducing the argument to simple dualisms (such as being for or against a viral cause of AIDS, for or against the president). We propose an approach to discussing AIDS in South Africa that is rooted in political economy and political anthropology. Such an approach will shed light not only on the objective determinants of the epidemic, especially social inequalities, but also on subjective responses, such as those of Mbeki.

Causes and processes: the political economy of AIDS

With an estimated five million people infected, South Africa has the highest number of people with HIV in the world. The most striking epidemiological fact is the extremely rapid growth in HIV seroprevalence, for example from 0.7% in pregnant women in 1990 to 24.5% in 2000, reaching 36.2 % in KwaZulu Natal.4 The impact on adult mortality has been dramatic. In 2000 AIDS accounted for 25% of all deaths, and mortality was 3.5 times higher than in 1985 among 25-29 year old women and two times higher among 30-39 year old men.5 This rapid evolution, unprecedented even on the African continent, is often seen as yet another symptom of South African “exceptionalism,” a phenomenon often referred to in the social sciences.6

Yet one need not look far—whether historically or in other countries—to appreciate that social conditions are important in determining exposure to disease.7 8 Had a coherent social epidemiology of HIV been more promi- nent in the scientific arena, rather than the dominant biomedical and behavioural approach, Mbeki might have found interesting alternatives to the explanations of the epidemic given on the dissidents’ websites.

Three social factors seem to place South Africa at a higher risk of HIV. Firstly, social inequalities in income and employment status are powerful predictors of HIV infection—although, interestingly, the correlation is neither linear nor unequivocal. Several factors are involved in the association. A low income or level of employment is associated with9:
x A greater exposure to risky sexual experiences
x Diminished access to health information and to prevention
x Higher frequency of sexually transmitted infections generally
x Absent or delayed diagnosis and treatment, and