Johannesburg — On Friday the South African government instructed the ministry of health to develop a plan for the distribution of HIV/Aids drugs by the end of September. Although Aids activists said they would await the plan before declaring their campaign for treatment over, the decision was widely hailed as a major policy advance.
The announcement is one that Stephen Lewis, the United Nations Special Envoy on HIV/Aids in Africa, has been increasingly vocal in pursuing. Lewis has been in the job for the past two years, criss-crossing the continent and talking to presidents, ministers and other government officials, religious leaders, civil society representatives and, most importantly, Africans living with HIV/Aids.
Last weekend, Lewis, who is Canadian, gave a keynote speech at the conference of the Centre for the Aids Programme of Research in South Africa, on the eve of the first National South African Aids Conference, both held in the port city of Durban this week. In that speech, his language was strong, and he was unequivocal about the urgency of more effective action by the South African government, among others.
He cited the position of the World Health Organization - a s specialized agency within the United Nations system - that all people deserve "the highest attainable standard of treatment". And he argued that several UN human rights covenants give such standards the force of international law.
The UN envoy arrived in South Africa from Uganda, and then travelled to Zambia, accompanied by Graca Machel, the former first lady of Mozambique. He described her as a passionate advocate and a continental ambassador for the rights of African children. Together they visited HIV/Aids community development and home-based care projects in Zambia and Uganda.
"This is how I've been spending my life" for the past two years, Lewis told AllAfrica in a telephone interview from the Zambian capital, Lusaka. He invited Machel to take part in this trip," because I thought she could give a very powerful profile, especially for women and orphans. And it is fair to say that she has taken both countries by storm. She was totally alive, and she has been extraordinary. I've never seen anything like it before".
Machel's husband of the past five years is former South African president, Nelson Mandela, who has been outspoken in his relentless campaign on HIV/Aids and his determination to see the distribution of antiretroviral medication in his country, as well as treatment programmes to help prolong the lives of people living with the pandemic.
The issue of treatment and prevention of mother-to-child transmission (PMTCT) - and use of the drug Nevirapine, which is widely used in Africa for PMTCT - dominated the national Aids conference. South Africa's pharmaceutical regulatory body, the Medicines Control Council (MCC), announced last week that it was considering the deregistration of the use of Nevirapine for PMTCT, querying its efficacy in an important clinical study carried out first in Uganda and then a major clinical trial here in South Africa. The MCC has given the drug's German manufacturers three months to present fresh evidence to support the continued use of Nevirapine in South Africa.
The announcement caused an emotional uproar amongst HIV/Aids activists and campaigners in South Africa, including the influential Treatment Action Campaign (TAC). Testimony from Aids' doctors and health care workers insisted that Nevirapine was both safe and efficient in the prevention of mother to child transmission of the Aids' virus.
At the South African national conference, the government of President Thabo Mbeki again came under pressure to stop sending out conflicting signals about its policy on HIV/Aids and the use of antiretrovirals (ARVs). Campaigners continue to urge South African authorities to roll out an ARV treatment programme in the public sector as a matter of urgency.
In his pre-conference speech to the research centre's gathering, Stephen Lewis called on the Pretoria government to act. "When people are dying" he said, "a signal is seldom sufficient. Speed and action become the sine qua non. And when the action finally happens, there will be an outpouring of relief and exhilaration throughout Africa akin - for many - to the emotional catharsis which accompanied the end of apartheid. South Africa is one of the leaders on this continent. If there is a breakthrough here, every country will feel similarly encouraged The world, overwhelmingly, wants South Africa to defeat the pandemic."
By his own admission, relations between Lewis and the South African government are not cordial. It was for this reason that he declined an invitation to join a panel at the opening of the national HIV/Aids conference, which included senior South African cabinet officials.
Speaking to AllAfrica's Ofeibea Quist-Arcton in a telephone interview from Lusaka, Zambia, shortly before the South African government announced that it was developing a treatment plan, Lewis said the time for diplomatic niceties had long past and that South Africa - and all other countries on the continent - must act decisively to halt the ravages of the epidemic. She began the interview with a quote from Nelson Mandela that Lewis cited in his Durban speech:
"The world must do more, much more on every front in the fight against Aids. Of course, it means dramatically expanding our prevention efforts, but the most striking inequity is our failure to provide the lifesaving treatment to the millions of people who need it most ... the single most important step we must now take is to provide access to treatment throughout the developing world. There is no excuse for delay. We must start now.... If we discard the people who are dying from Aids, we can no longer call ourselves decent people. (Treatment) is an elemental matter of human decency - and history will judge where decency was wanting".
What were you trying to say by quoting Mr Mandela?
I mean that governments generally, whether in the developed or developing world, that have failed to give treatment to keep people alive, will be judged by history and will not be judged kindly by history. And I'm talking as much about donor countries that have not given resources as I am about countries that have been unnecessarily slow about providing treatment.
And among those countries dragging their feet, I suppose you're talking particularly about South Africa?
Yes, I don't want to pretend otherwise. I was talking directly and indirectly about South Africa as well [as about other issues].
So what is your message to the South African government about rolling out a treatment programme for HIV/Aids?
My message is that they shouldn't think there are any confused messages [from] outside. The UN system - by virtue of everything it is committed to - believes in treatment and believes in treatment now. It is a human right.
South Africa wants to put everything into place first. You hear in news reports that the government and the cabinet are concerned about cost and sustainability and are assessing this. But other countries in the region, which are so much poorer than South Africa, are putting treatment systems in place to keep their people alive - now.
Indeed, if I may be so bold, that's the message that Peter Piot (head of UNAIDS) gave in his video address. He expressed a clear exasperation and said "for heaven's sake, don't wait till everything is perfect, get going now".
So the message on the eve of the South African national conference on Aids, from the executive director of Unicef and the UN Africa Aids envoy, is that South Africa should start treatment and should start now. I don't think there is any confusion about that message. I didn't want to root the message in a sort of gratuitous criticism of South Africa. I wanted to root the message in those international covenants and in UN declarations, and I wanted to build a case that made it clear that the position that I was taking was consistent with the UN - and that position leads me to believe that the sooner South Africa starts, the better off everyone will be.
And what has been the response of the South African authorities to your uncompromising speech last Sunday?
You know, this was interesting. There wasn't a response, and I suspect that is because the speech went unnoticed, because I delivered it on eve of South Africa's first national Aids conference, and the conference was consumed with issue of Nevirapine and prevention of mother-to-child-transmission. And I suspect there was no time to concentrate on other speeches.
I had originally been invited to speak at the opening of the National Aids conference. I was invited to give a keynote speech and I imagined that there might be some introductory remarks from the chair setting out the agenda. What I didn't realise was that there would be a panel. When I realised that the Health Minister and the Deputy President were on the panel too, I suggested to the organisers that I remove myself from the opening, because I didn't want to be a red flag and a belligerent controversy at the outset.
So they agreed and then were kind enough to suggest that I could speak to the plenary on Monday morning, the following morning, but I was coming to Zambia with Madame Graca Machel.
Then they said to me, in very good conscience, that there was a conference of researchers preceding the main conference and asked why don't I come to speak to that and put myself on record as I wish to be, and I said that was fair.
But don't you think that you might have acted as a stimulus - a stimulant and a catalyst if you had given your speech at the actual Aids conference in the presence of senior South African government officials?
I think that would be naïve and that would be self-deluding. I have already been attacked by the government. The government doesn't regard me in a friendly light. They would not see me as a stimulant or a stimulus, they see me as an antagonist and would respond in kind. And I didn't think it was useful - where people of goodwill were trying to seek answers to a very difficult question. I didn't want to introduce a note of bitterness at the beginning and compromise the conference.
Then, the difference between, say, the Ministry of Health and, say, Stephen Lewis becomes the issue, rather than the very many other papers and discussions at the conference. I think it was particularly true because of the way Nevirapine emerged in the conference, and it was very important that that be dealt with and that there be no distractions.
That's a desperately important issue. There are 100,000 women in treatment or about to be in treatment or regularly coming in and that really is important; it is crucial. It is important for the [South African] government to understand that the advice of the MCC [Medicines Control Council] is flawed and no attention should be paid to it.
By the way, I'm talking from within the UN context. When the World Health Organisation (WHO) and my agency, called the United Nations, say to me, we have looked at Nevirapine several times and everything is fine, then I am guided by that and I think all other opinions are in error. Let me be more specific, I think the South African MCC opinion is in error.
I am the envoy on Aids in Africa for the secretary general. I learn whatever I can about the other countries and report back to the secretary general. I try as carefully and scrupulously and honourably as possible to identify the issues that are at the heart of the pandemic. And I spend my life in the context of people who are dying and are struggling desperately to stay alive. And it seems to me that a very important part of my job is to help to keep those people alive on the African continent.
And because of that I cannot be silenced. I cannot allow myself to be muffled by diplomatic protocols. There is too much at stake. And it is particularly true in dealing with South Africa, because South Africa is a beacon for the rest of the continent and when South Africa takes a particular position on an issue, it influences everyone else. That's inevitable, because people see South Africa as a very strong, democratic, opinionated society and I have often heard, as I've travelled, questions raised about (HIV/Aids) treatment, because people are confused about South Africa's position.
I therefore felt that, within the context of the UN itself, I should say in no uncertain terms that we have reached the point where the entire continent is consumed by the need for treatment, obsessed by the need for treatment and that is not surprising. Because of the infections that occurred in the late 80s and 90s, we are now at a point where people are reaching the stage of full blown Aids and we are on the verge of a terrible escalation of death. And it's beginning to happen. We are seeing it here in Zambia. It is beginning to happen in South Africa, and we can see it everywhere. Therefore the need to keep people alive is more dramatically felt than ever.
So I felt personally that, at this point in time, it's my responsibility to say publicly where the UN stands on treatment and effectively to say to the government of South Africa, "get going, start it. There is simply no more time for delay," and that's what I did and I offer no apologies. Peter Piot's speech, too - I think it was unusual in its force.
Why do you think the South African government is being cautious and taking its time to put a national HIV/Aids treatment programme in place?
I don't understand. The explanation given to me is that the cabinet and the president are still uncertain about how to approach it. The explanations given to me are that they want to be absolutely certain about financial sustainability before they even begin models or prototypes at all. I have been told that they fear that the infrastructure and capacity are not strong enough to handle treatment. I have been told all those things, but I don't know myself what the explanation is. I neither know it nor do I understand it. I have heard nothing that persuades me or is plausible in the face of this unbelievable situation of death and illness.
So I'm not about to point fingers and give explanation A or explanation B, but my own feeling is that the delays are unwarranted' there has to be treatment now.
You have given the examples of other African countries in and outside the region - Namibia, Mozambique, Botswana, Malawi, Rwanda, Uganda, Zambia, Nigeria - who rank lower than South Africa in the UN Human Development Index - based on social and economic indicators - and the Human Poverty Index for developing countries. They are all poorer than South Africa yet, as you said in your speech, "Nothing daunts them - even the question of sustainability in the face of acute financial distress, put quite simply, unremitting poverty" and reeling economies. But these countries have all decided that they have to afford comprehensive HIV/Aids treatment and have put programmes in place. South Africa hasn't -
- Exactly and I think that all of us, Peter Piot at UNAIDS, the secretary general, the outgoing World Health Organisation head, Gro Harlem Bruntland, me, Stephen Lewis (for what it's worth) - all of us have pointed out that, even with limited capacity, even with faulty infrastructure, it is absolutely possible to begin to save millions of lives and you don't have to have absolutely everything in place. You can build your infrastructure, you can raise your money and improve capacity while you are saving people's lives. I don't understand the need for delay. All these much, much, much poorer countries are beginning to save their people and get involved in treatment and they have made it clear that they are moving ahead, working at fever pitch, because they want their people to live. And I see that everywhere.
How much have you been able to talk about your concerns with former President Mandela, who has become a vocal HIV/Aids and ARV treatment campaigner - flying in the face of the position taken by the South African government, something he is known to be loath to do.
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Of course I follow everything he says. We haven't really talked about this issue as such, but I think we agree. I have followed and agree with everything he has said and agree with his frustration that everything is taking so long. That's why I quoted him. And I think that if I can't quote Mandela, who can I quote? If his words aren't sufficient to guide the nation, then whose words are?
So, what can act as the catalyst to get the South African government moving?
I can't answer that question. I wish I could. People with a great deal more influence than I have attempted to make the case - Clinton, Mandela. I don't know what will turn the tide. I don't understand what is taking so long when they have all the evidence they need - including all their own internal cost studies.
I wasn't kidding in that speech I gave. I was really shocked by that sobering World Bank report, stating that the prospects for South Africa are nothing less than apocalyptic. And I don't think that the World Bank study should be dismissed out of hand, as it was dismissed out of hand by cabinet officials in South Africa. I think that was one of the most unsettling alarms that has ever been rung in this pandemic - and the World Bank is given to dispassionate and sober analyses. What the World Bank was saying, as many others were saying, is that we are facing a succession of failed states in two or three generations if we continue like this and if treatment doesn't begin immediately. It is unusual for an international financial institution to take a position that is that bold - and as bald - as this.
In personal terms, I guess I made the speech because I had reached the point in my own feeling of - I don't know how to put this - after more than two incredibly intensive years of dealing with Aids on the ground, country after country, I had reached the point where it felt like a dishonourable act, a betrayal of the people I have been working with, not to say publicly what should now be done in South Africa.
Because I now understand. Maybe a year ago it would have been premature and presumptuous and, at any time, may be seen as politically risky. But I have passed that stage. That no longer influences me. If I can argue from the base of the UN, from UN covenants and decisions and make the case, then I felt the time had come to do so. To tell you the truth, I could not live with myself much longer without doing something.
What more can the very active and vocal civil society in South Africa do to push the process forward on HIV/Aids treatment?
I think they have to put the pressure on and keep clamouring for treatment. I think the TAC (the Treatment Action Campaign HIV/Aids lobby and awareness group) - as much as some of its tactics the government is deeply offended by - I think that these NGOs [non-governmental organizations] will arise.This is a case of survival in the tradition of the anti-apartheid struggle, the nuclear disarmament campaign, the civil rights movement and the anti globalisation struggle. They are fighting for their existence, fighting to live. How could it be otherwise? Some campaigns have been more defiant. I think TAC has acted with remarkable restraint, considering that people are fighting for survival. They have thought very carefully before taking action.
I think civil society has the right to take public decisions that are markedly different from the government and/or critical of government. Civil society is there to serve the people and to engage in advocacy. Otherwise why should there be civil society?
I have been a politician for 15 years, and was often attacked by civil society and I value it. That is what one pole on the outside of government should do and ultimately force politicians to take action. It is an honourable route and civil society has the right to keep the pressure on.
