Business Day (Johannesburg)

12 March 2007

South Africa: How Minister Throws a Spanner Into the Works of Her Personnel

opinion

Johannesburg — IT HAS been said over and again that the messages Health Minister Manto Tshabalala-Msimang transmits about AIDS treatment are confusing and destructive.

But little has been written on how, or indeed, whether at all, the minister's utterances affect specific AIDS treatment programmes on the ground. I have a story in this regard worth telling.

Some time last year, an interview with Tshabalala-Msimang was broadcast on national radio. I was in Lusikisiki, in the old Transkei, at the time, and the interview enjoyed a large audience there. Tshabalala-Msimang said what she usually says about AIDS treatment: that antiretroviral (ARV) medicine is available at health institutions accredited to prescribe it, but that those who feel uncomfortable about the drugs should consult one of the many traditional healers the government has accredited. They, too, the minister said, can treat AIDS.

I spent the following morning with a health-care worker employed at a government clinic in Lusikisiki, one that had been dispensing ARV medicine for three years. As we walked through her village towards the taxi rank, person after person stopped her to talk about the broadcast. Some joked that she and the health minister should fight it out in public. Others remonstrated with her. That woman is both a doctor and the minister of health, they said, and you are neither. So what is your story when you tell people they will die if they go to the healers instead of taking ARVs? Some of those who remonstrated were genuinely angry; by the time we got to the taxi rank, my companion was rattled.

Making sense of these interactions requires some background. Three years ago, there was no AIDS treatment in Lusikisiki, and ordinary people's definitions of AIDS were very narrow indeed. It was accepted that a person had died of AIDS if she suffered from chronic diarrhoea, got very thin, and then died. But a person who contracted cryptococcal meningitis or AIDS dementia was said to have had a demon sent to him by an enemy. A person suffering from shingles -- a common opportunistic infection triggered by immunodeficiency -- was said to have had a witch's snake crawl over her skin while she slept. As with all witchcraft illnesses, people sought cures from diviners and herbalists.

When antiretroviral medicine arrived in the Lusikisiki clinics, nurses began treating these illnesses as opportunist infections associated with AIDS. People reeled in shock. What they had thought was a surge in witchcraft they were now told was AIDS. Across the villages, ill people were watched with intense scrutiny. If a person began suffering from shingles, her treatment choices were monitored. Did she go to the clinic or a traditional healer? Did she get better, or did she die? Often, the evidence was inconclusive. One person would visit both and live. Another would visit both and die. But enough people had gone to the clinics and recovered their health for the old explanation to have been thrown into serious doubt.

Whether brain and skin infections were caused by witchcraft or AIDS had become a subject of debate.

There are healers in Lusikisiki who insist that their patients have HIV tests and encourage them to use ARVs. But in my experience, they are a minority. Most I have spoken to say that dementia, nervous disorders and chronic skin diseases are the work of demons. They attract clientele because for many people it is more comforting to believe that one has been bewitched than that one has AIDS. The shame lies with someone else, not with oneself. And the illness is not chronic and life-long; it can be cured by ritual and treatment. In the minds of many villagers, healers and clinics represent two rival accounts of the causes of illness and its treatment.

The people who stopped my companion on the way to the taxi rank that morning last year had interpreted the health minister to be saying that the matter was still open to question. Experiment, they believed she had said. Sometimes these infections are caused by this, sometimes by that.

To an outsider this may seem a puzzling interpretation. But in context it is not. For three years, government health-care workers had been broadcasting their message over and over again: these skin diseases could be opportunistic infections, they said. You must test for HIV. If you are positive, we will treat you with drugs, and if your immunity is low you will go on to ARVs. If you hide from these realities you will die.

The health minister appeared to be broadcasting a contradictory message, one that threw the wisdom of her own personnel into doubt. Some of Lusikisiki's health-care workers were angry with her that morning; they felt she was undermining their authority and setting back their work.

--Steinberg is a freelance journalist.

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