African Affairs Advance Access originally published online on September 8, 2005
African Affairs 2005 104(417):591-614; doi:10.1093/afraf/adi036
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South Africa’s HIV/AIDS policy, 1994–2004: How can it be explained?
Anthony Butler is Associate Professor of Political Studies at the University of Cape Town.
This article aims to explain South Africa’s controversial post-1994 HIV/AIDS policy. It isolates two competing sets of policy prescriptions: a ‘mobilization/biomedical’ paradigm that emphasized societal mobilization, political leadership and anti-retroviral treatments; and a ‘nationalist/ameliorative’ paradigm that focused on poverty, palliative care, traditional medicine, and appropriate nutrition. It explains the ascendancy of the ameliorative paradigm in terms of its administrative and political viability in South African conditions. It explores how public sector institutions circumscribed the viability of biomedical interventions, while political institutions and state-society relations reduced knowledge transfer and policy learning. It then investigates the intellectual context that shaped the political viability of each paradigm. Finally it argues that the ANC accommodated proponents of each policy paradigm, and that instrumental calculation of the dangers of an inequitable and unsustainable anti-retroviral programme best explains the government’s continued adherence to a cautious prevention and treatment policy.
1. See E. Cameron ‘The dead hand of denial’, Weekly Mail and Guardian, (Johannesburg), 17 April 2002; A. Butler, Contemporary South Africa (Palgrave Macmillan, New York, 2004), pp. 128-9, 144-6; M. Crewe, ‘How do we make sense of Mbeki?’, AIDS Analysis Africa 11, 1 (2000), pp. 10-11; K. Cullinan, ‘Infected by toxic ideas’, Financial Mail, (Johannesburg), 7 May 2004.
2. N. Nattrass, The Moral Economy of AIDS in South Africa (Cambridge University Press, Cambridge, 2004), p. 41.
3. I draw heavily on the path-breaking framework advanced by P.A. Hall, ‘The politics of Keynesian ideas’, in P.A. Hall (ed.), The Political Power of Economic Ideas: Keynesianism across nations (Princeton University Press, Princeton, NJ, 1989), pp. 361-91.
4. Nattrass, Moral Economy, pp. 41-2.
5. African National Congress, A National Health Plan for South Africa, May 1994. Available at <www.sas.upenn.edu/African_Studies/Govern_Political/ANC_Health.html> [22 June 2004]. Compare the 2003 out-turn of 5.3 million people living with HIV/AIDS and 1.69 million cumulative deaths. O. Shisana, ‘Taking a closer look at the national response to HIV/AIDS in South Africa’. Paper presented at the Next Decade of Democracy seminar series, August 2004. Human Sciences Research Council, Pretoria, 5 August 2004.
6. A. Whiteside and C. Sunter, AIDS: The challenge for South Africa (Tafelberg and Rousseau, Cape Town, 2000), p. 120.
7. J. Parkhurst and L. Lush, ‘The political environment of HIV: lessons from a comparison of Uganda and South Africa’, Social Science and Medicine 59 (2004), pp. 1913-24.
8. Whiteside and Sunter, AIDS, p. 121; Nattrass, Moral Economy, p. 43.
9. Department of Health, National STD/HIV/AIDS Review Report (Department of Health, Directorate HIV/AIDS and STDs, Pretoria, 1997).
10. Parkhurst and Lush, ‘Political environment’, pp. 1914, 1921.
12. National Department of Health, HIV/AIDS/STD Strategic Plan for South Africa, 2000-2005 ( Department of Health, Pretoria, 2000).
13. M. Tshabalala-Msimang, ‘The state has an Aids [sic] plan’, Weekly Mail and Guardian, (Johannesburg), 28 February 2003.
15. UNAIDS, Guide to the Strategic Planning Process for a National Response to HIV/AIDS (Joint United Nations Programme on HIV/AIDS, Geneva, 1998).
16. Tshabalala-Msimang, ‘The state’.
17. On Plato’s malign attack on rhetoric, see B. Vickers, In Defence of Rhetoric (Clarendon Press, Oxford, 1988), pp. 83-147.
18. J.S. McClelland, A History of Western Political Thought (Routledge, London, 1995), pp. 659-82.
19. A.M. Butler, ‘Unpopular leaders: the British case’, Political Studies 43, 1 (1995), pp.48-65.
20. Parkhurst and Lush, ‘Political environment’, p. 1914.
21. A. de Waal, ‘AIDS: Africa’s greatest leadership challenge’, Justice Africa, October (2000), available at <www.justiceafrica.org/aidspaper.htm> (6 June 2003).
23. Cameron, ‘Dead hand of denial’.
24. J. Dunn, ‘Practising history and social science on "realist" assumptions’, in C. Hookway and P. Pettit (eds), Action and Interpretation: Studies in the philosophy of the social sciences (Cambridge University Press, Cambridge, 1978), p.174.
25. Parkhurst and Lush, ‘Political environment’.
26. See A. Padarath, C. Chamberlain, D. McCoy, A. Ntuli, M. Rowson, and R. Loewenson, Health Personnel in Southern Africa: Confronting maldistribution and brain drain. Equinet Discussion Paper Series 3 (Health Systems Trust, Durban, 2003); South African Department of Health, Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa (Department of Health, Pretoria, 19 November 2003).
27. T. Lodge, ‘The ANC and the development of party politics in modern South Africa’, Journal of Modern African Studies 42, 2 (2004), pp. 189-219; J. Cronin, Interview with Helena Sheehan in Cape Town on 24 January, 2002, available at <http://www.comms.dcu.ie/sheehanh/za/cronin02.htm>(17 August 2004).
28. Cronin, Interview; R. Suttner, ‘Culture(s) of the African National Congress of South Africa: imprint of exile experiences’, in H. Melber (ed)., Limits to Liberation in Southern Africa ( Human Sciences Research Council, Pretoria, 2003), pp. 178-99.
29. R. Southall, ‘Post-colonial legitimacy in Lesotho’, in Melber, Limits to Liberation, p. 129.
30. Republic of South Africa, Constitution of the Republic of South Africa, Act 108 of 1996 (Government Printer, Pretoria, 1996), S85(2).
32. Hall, ‘Politics of Keynesian ideas’, pp. 378-80.
33. K. Owen, ‘Quality education the only hope’, Business Day, 27 May 2002.
34. P. Bond, ‘Corporate cost-benefit analysis and culpable homicide’, ZNet, 25 June 2002. Available at http://www.zmag.org/content/showarticle.cfm?SectionID=2&ItemID=2023 (6 September 2004)
35. A. Butler, ‘The negative and positive impacts of HIV/AIDS on democracy in South Africa’, Journal of Contemporary African Studies 23, 1 (2005), pp. 1-24.
36. Hall, ‘Politics of Keynesian ideas’, p. 383.
38. See, for example, Nattrass, Moral Economy, pp. 49-50; P. Sidley, ‘Clouding the AIDS issue’, British Medical Journal 320 (2000), p. 1016; M. Makgoba, ‘HIV/AIDS: the perils of pseudoscience’, Science 288 (2000), p. 1171; H. Schneider, ‘On the fault-line: the politics of AIDS policy in contemporary South Africa’, African Studies 61 (2002), pp. 45-67; D. Forrest and B. Streek, ‘Mbeki in bizarre Aids [sic] outburst’, Weekly Mail and Guardian (Johannesburg), 26 October 2001.
39. N. Sheon and M. Crosby, ‘Ambivalent tales of HIV disclosure in San Francisco’, Social Science and Medicine 58, 11 (2004), pp. 2105-18; R.J. Wolitski, R. Valdiserri, P. Denning and W. Levine, ‘Are we heading for a resurgence of the HIV epidemic among men who have sex with men?’, American Journal of Public Health 91 (2001), pp. 883-6.
40. S. Cohen, States of Denial: Knowing about atrocities and suffering (Polity Press, Cambridge, 2001), pp. 56-7; E. Lowy and M. Ross, ‘"It’ll never happen to me": gay men’s beliefs, perception and folk constructions of sexual risk’, AIDS Education and Prevention 6, 6 (1994), pp. 467-82.
41. Sheon and Crosby, ‘Ambivalent tales’; R.S. Gold, ‘AIDS education for gay men: towards a more cognitive approach’, AIDS Care 12, 3 (2000), pp. 267-72.
42. C. Campbell, Letting Them Die: How HIV/AIDS programmes often fail (Double Storey, Cape Town, 2003), pp. 188-95.
43. Cohen, States of Denial, p. 56.
44. M. Swanson, ‘The sanitation syndrome: bubonic plague and urban native policy in the Cape Colony: 1900-1909’, Journal of African History 18, 3 (1977), pp. 387-410.
45. C. Kaufman, Reproductive Control in South Africa (The Population Council, New York, 1977); O. Chimere-Dan, ‘Population policy in South Africa’, Studies in Family Planning 24, 1 (1993), pp. 31-9.
46. D. Fassin and H. Schneider, ‘The politics of AIDS in South Africa: beyond the controversies’, British Medical Journal 326 (2003), pp. 495-8. This section draws heavily on this illuminating article.
47. Forrest and Streek, ‘Mbeki’.
48. P. Mokaba and anonymous others, ‘Castro Hlongwane, caravans, cats, geese, foot and mouth and statistics: HIV/AIDS and the struggle for the humanisation of the African’, 2002, p. 5. Available at <www.chico.mweb.co.za/doc/aid.Castro.Hlongwane.doc> (8 September 2004).
49. Campbell, Letting Them Die, p. 195.
50. Fassin and Schneider, ‘Politics of AIDS’, p.496.
52. African National Congress Youth League, ‘Statement on the order to provide Nevirapine’, issued by the League on 26 March 2002, available <www.anc.org.za/youth/docs/pr/2002/pr0326.html> (4 May 2004)
53. Mokaba, Castro Hlongwane, p. 4.
55. Thabo Mbeki, quoted in ibid., p. 107.
56. Tshabalala-Msimang, ‘The state’; see also R. Hecht, O. Adeyi and I. Semini, ‘Making AIDS part of the global development agenda’, Finance and Development 39, 1 (2002), pp. 36-9.
57. C. Ford, G. Lewis, and B. Bates, ‘The macroeconomic impact of HIV/AIDS in South Africa’, in K. Kelly, W. Parker and S. Gelb (eds.), HIV/AIDS, Economics and Governance in South Africa: Key issues in understanding response: a literature review (Centre for AIDS Development, Research, and Evaluation, Johannesburg, 2002), pp. 10-20.
58. ING Barings, Economic Impact of AIDS in South Africa (ING Barings, Johannesburg, 2000); J. Stover and L. Bollinger, Economic Impacts of AIDS in South Africa, (Futures Group International, Connecticut, 1999). Available at <http://www.iaen.org/impact/stovboll.pdf> (4 March 2004); C. Arndt and J. Lewis, ‘The macro-economic implications of HIV/AIDS in South Africa: A preliminary assessment’, Journal of South African Economics 68, 5 (2000), pp. 856-87.
59. Bureau for Economic Research, Macro-Economic Impact of HIV/AIDS in South Africa (Bureau for Economic Research, Stellenbosch, 2001).
60. Ford, etal., ‘Macroeconomic impact’.
61. J. Cohen, ‘South Africa’s new enemy’, Science 288, 5474 (2000), pp. 2168-70.
62. C. Bell, S. Devarajan, and H. Gersback, Long-run Economic Costs of AIDS: Theory and an application to South Africa, Policy Research Working Paper WPS 3152 (World Bank, Washington, DC, 2003); A. De Waal, ‘How will HIV/AIDS transform African governance?’, African Affairs 102, 406 (2003), pp. 1-23.
63. A. Butler, ‘Considerations on the promotion of Foreign Direct Investment in South Africa’, unpublished paper, 2001, Department of Political Studies, University of Cape Town, Political and Policy Uncertainty in South Africa Project.
64. Hall, ‘Politics of Keynesian ideas’, p. 391.
65. Idasa, ‘Democratic governance in South Africa: the people’s view’, Afrobarometer 11 December 2002, archived at <www.idasa.org.za> (7 February 2003)
66. United States National Intelligence Council, ‘The global infectious disease threat and its implications for the United States.’ National Intelligence Estimate 99-17D (NIC, Washington, DC, January, 2000), available on CIA website at http://www.cia.gov/cia/reports/nie/report/nie99-17d.html Bell etal, Long Range Economic Costs; De Waal, ‘How will HIV/AIDS transform African governance?’.
67. Tshabalala-Msimang, ‘The state’.
68. K. Kober and W. Van Damme, ‘Scaling up access to antiretroviral treatment in southern Africa: who will do the job?’, The Lancet 364, 9428 (2004), pp. 6-8; World Health Organization, Treating 3 Million By 2005: The WHO strategy (WHO, Geneva, 2003).
69. Kober and Van Damme, ‘Scaling up’.
71. Abt Associates, Impending Catastrophe Revisited: An update on the HIV/AIDS epidemic in South Africa, a report commissioned by Henry J. Kaiser Family Foundation and Lovelife (Lovelife, Parklands, 2001).
72. Government Communication and Information Service, ‘Special cabinet meeting statement: enhanced programme against HIV and AIDS’, 8 August 2003, Pretoria. Available <www.gcis.gov.za/media/cabinet/030808.htm> (8 September 2004).
73. Afrobarometer, ‘Public opinion and HIV/AIDS: facing up to the future?’, Afrobarometer Briefing Paper No. 12, April 2004. Available <http://www.idasa.org.za/gbOutputFiles.asp?WriteContent=Y&RID=457> (10 September 2004).
74. Whiteside and Sunter, AIDS, p. 67.
75. National Department of Health, HIV/AIDS/STD Strategic Plan for South Africa, 2000-2005 (Department of Health, Pretoria, 2000), section 1.1. This document, produced under the auspices of the department, has no attributed authors and is not acknowledged by the department as an official document.
76. Mokaba, Castro Hlongwane, p. 8.
77. Ibid, quotes respectively on pp. 107, 106, my emphasis.
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