When the foreign funded HIV programs pull out

For those who were not fans of the former President George W. Bush's tenure, The President's Emergency Plan for AIDS Relief or PEPFAR was his only positive contribution to global affairs, a successful utilization of 'soft power' if there ever was one. When access to antiretroviral therapy was almost impossible for your average person in the developing world, PEPFAR provided entree to HIV drugs and services, at least in the selected PEPFAR countries. The program by now can boast of many achievements, particularly the sharply increased access to AIDS drugs even in the most disadvantaged settings. Millions of lives have been saved. But as I mentioned in an earlier post a couple of years ago, this is a fragile, dubious, and non-sustainable relationship in the long term. HIV requires lifelong treatment, and it is not healthy to have your existence depend on the decisions of a foreign government, especially an economically sputtering and lurching superpower.

Now it seems that the chickens are coming to roost. PEPFAR has announced that it will no longer be funding health NGOs in South Africa that provide HIV/AIDS services. HIV positive patients are stranded and scrambling to find alternative sources of care. This generally means joining the long lines in the highly challenged public health care sector. The potential for treatment interruptions abounds. This unwelcome development has not gathered much attention in the international press, although the AIDS Healthcare Foundation has weighed in, launching a press release stating that President Obama's cutting of Global AIDS Funding is 'shameful.' Well, yes and no. The shame should at least be shared by the South African government, in particular the Department of Health, whose ultimate responsibility it is to provide reasonable access to HIV/AIDS services for citizens who need them. It is not the sort of responsibility you can outsource to foreigners in perpetuity.

Ethics, Zuma and the shield of culture

The controversy regarding President Zuma and his extramarital (and unprotected) sexual capers heated up significantly today. I was greeted this morning with the Cape Times headline: ZUMA DEFENDS LOVE CHILD. The growing media coverage, some speculative, provoked the President to react in the form of a press release. In the press release, the President decries the invasion of his privacy while admitting that he fathered a baby with Ms. Sonomo Khoza. Then he says something very strange:

I said during World AIDS Day that we must all take personal responsibility for our actions. I have done the necessary cultural imperatives in a situation of this nature, for example the formal acknowledgment of paternity and responsibility, including the payment of inhlawulo to the family.

That is certainly a new twist on the concept of personal responsibility. Translated into a new HIV prevention message, it runs something like this: when you have unprotected extramarital sex, and your sexual partner then has your child, do remember to pay compensation to the family. It's the right thing to do! This slogan should be all the rage on the international AIDS conference scene this year. Though perhaps a catchier version would be: clean up your fuck up. In a culturally appropriate way, of course.

Then the press release goes in an even murkier direction:

The media is also in essence questioning the right of the child to exist and fundamentally, her right to life. It is unfortunate that the matter has been handled in this way. I sincerely hope that the media will protect the rights of children.

When I read this, I couldn't get the image out of my mind of Arnold Schwarzenegger in Total Recall, in the scene where he picks up people and uses them as shields to protect himself from gunfire. In Zuma's case, he picks up a child (and its associated rights) in an attempt to shield himself from criticism: don't shoot the baby! In any case, the media has not focused on the right of the child to exist, if only because that boring issue does not sell papers. How the child came to exist is far more interesting.

The press release includes a statement about the possible impact of this revelation to HIV prevention efforts. The President assures us that intensified efforts in prevention, treatment and research will continue. The idea that his personal behavior could act as a template of rationalization for sexual waywardness in local communities ... that does not come into play. Nor his obvious personal dislike of condoms that he and his government promotes. Now you could argue that President Clinton had his affairs, so why shouldn't Zuma be allowed his Presidential flings? One answer is: that Clinton was not allowed, he was nearly impeached, besides being roasted in the press. But the better answer is: Clinton's actions did not take place during a heterosexually-driven HIV epidemic responsible for hundreds of lives every single day.

South African presidents and HIV prevention: the madness never stops

Former South African president Thabo Mbeki famously denied that HIV causes AIDS, and affirmed that the HIV/AIDS epidemic was really just a ploy by pharmaceutical companies to squeeze money out of African countries. He supported 'rogue scientists' who tried to support this unorthodox view with scientific evidence, though the larger scientific community was profoundly unimpressed. When it became obvious that his position on the subject was untenable, he kept hush on the whole epidemic, while sending out his minions to discretely and not-so-discretely enact his viewpoint in health policy. It led to lukewarm HIV prevention efforts, right when a real show of force and determination was needed to save lives. There are still calls, in some quarters of South African society, for Mbeki to stand trial for this episode.

When Jacob Zuma came to power, there were misgivings. Here was a man who was accused (and eventually acquitted) of rape, and who during the trial affirmed that he had unprotected extramarital sex with a HIV-positive woman, and in addition, believed that a post-coital shower was sufficient to protect himself from the virus. It was not looking good. However, President Zuma did seem to take a more progressive stance on HIV/AIDS than his predecessor in the first year of office. There seemed to be more committment in regard to provision of anti-retroviral treatment and HIV prevention campaigns.

And now this. The news this week is that President Zuma has recently fathered a 'love child' with the daughter of the owner of the Orlando Pirates, a local professional soccer team. From which one can reasonably gather, another case of unprotected extramarital sex -- from a man with three wives, one fiance and 20 children already.

I was listening on the radio today to various condemnations and defenses of the president. The condemnations were predictable, and so were some of the defenses (especially opportunistic appeals to cultural relativism). But one defense struck me: that the sexual behavior of the president will not have an effect on HIV prevention in the country, because studies have shown that a person's sexual behavior is more likely to be influenced by his or her own peers than by his or her president. No need to worry.

Perhaps that is true, though more research is needed. What seems true is that South Africa is back to failed leadership again, in the most personal way: the president apparently cannot restrict himself to only five sexual partners, and when he breaks out, he can't locate a condom dispenser. And when he is sitting there at the next World Aids conference, with his red ribbon on, promoting the use of condoms, what are we supposed to think?

National Health Insurance in South Africa put on hold

South African president Jacob Zuma and American president Barack Obama do not seem to have much in common. Obama went to college, and not just any college: Yale University. Whereas Zuma only attended school until Standard 3 (or Grade 5). Zuma has been tried in court on charges of rape and corruption, and during questioning stated that risk of HIV transmission could be minimized by taking a shower after sex. Whereas Obama used to smoke. Zuma has 4 wives, Obama has Michelle. Despite these and other differences, the two presidents have one thing in common: they are both currently involved in controversial national health care reforms. In the case of Zuma, it is the proposed National Health Insurance (NHI), which has been planned since the African National Congress first took office in 1994.

Social, political and economic inequality, as many studies have indicated, are bad for your health. It would seem to follow that decades of Apartheid would be generally bad for the health of those at the lower end of the ladder in South Africa. And it is. I spent the early part of this week marking medical ethics exams from budding doctors at Groote Schuur Hospital in Cape Town, and some of the case studies they presented were positively hair-raising. So it makes ethical sense, in principle, to increase access to health care for South African citizens.

While everyone seems to agree on the basic principle, the details of the NHI are vexing, and the discussions bring out the old social tensions and wounds. One large question is where the massive amount of money in support of the scheme is to be drawn from. If it is through taxation, this causes concern among those better off in South Africa, who are already been taxed to support the existing public health care system -- though many of them go to private health services when they are sick themselves. There is also a worry that private health institutions would be 'de-skilled' and overwhelmed if subjected to government demands to focus on primary care services. Requiring well-off South Africans to use public health care might also, it is feared, lead to people leaving the country: both patients who fear a drop in their standard of care as well as doctors who do not want to work in sub-standard conditions for less pay. There seems to be a general feeling that if the NHI might lead to the generalization of the health care standards currently provided in the public sector. It depends who you ask, and where you ask, but generally speaking opinions about the health care on offer in public hospitals and clinics are not positive. This is an understatement. The problems the government has had in doing just one thing -- providing antiretroviral therapy for those who need it -- draws serious doubt on its ability to provide a broad spectrum of services at an adequate and affordable standard. For the poorest of the poor, on the other hand, the promise of some (perhaps not great) services may look better than none.

Olive Shisana, head of the Human Sciences Research Council (which is responsible for drafting versions of the NHI) likes to say that opposition to the NHI is based on myths. But this week the Health Minister put the NHI on hold, perhaps for as long as five years. Reason? The public health sector is said to be in shocking shape, so shocking that bringing in the NHI wouldn't help matters. So back to the drawing board.

Gender, sport and race in South Africa

The case of Caster Semenya is fascinating from what you might want to call a 'purely bioethics' point of view. Semenya blew away the field in the women's 800 meters at the world athletics championship in Berlin. In fact, the margin of victory was so great, and the improvements in her recent race times have been so radical, that it makes you suspect some kind of artificial enhancement. But that is not it. Along with these achievements, Semenya's outward appearance (body shape, facial hair, deep voice) have raised the possibility that Semenya is not an enhanced woman, but simply a man. No, that is not right: 'simply' is the wrong choice of words. She may be biologically too much like a man to fairly compete against other women. Which leaves us (as well as the International Association of Athletics Federations or IAAF) with the unsimple question: where do you draw the line for biologically 'man-ish' women in competitive sport?

In South Africa, the question is even more fascinating, or more depressing, depending on your perspective. Caster, after all, is South African, and the debate here, reflecting local realities, turned instanteously to questions of race. The whole sticky biological question was sidelined in favor of another question: is the questioning of Caster's gender racist? A number of prominent government officials were ready to answer in the affirmative, and ventilate their righteous indignation in front of press and cameras. The idea was that Caster's gender would not be in question if she were white; she is being unfairly discriminated against. When it was pointed out that gender tests were applied also to white athletes in the past, some took a new line of argument: that the South African media did not rally sufficiently behind Caster, too easily giving in to suspicions about her gender, and this proving that the media continues to be controlled by whites. According to this view, the Caster Semanya story exposed the South African media as racist, and if you don't want to deemed a racist yourself, it is best to regard Caster as a woman. (A woman, a whole woman, and nothing but a woman.) It is unfortunate that, at least in South Africa, strange new dilemmas about gender and sport have taken a backseat to posturing about race.

Forced circumcision case in South Africa

The ancient practice of circumcision never fails to stir things up. Neonatal circumcision, whose popularity has steadily declined in Europe and is on the wane in the United States, is a reliable flashpoint for ethical debate. The debate over the costs and benefits of circumcision has been stimulated by research indicating that being circumcised significantly reduces a man's chances of getting HIV via hetrosexual intercourse. In South Africa, there has been much discussion about the state of traditional circumcision rituals, given that a significant number of young men die from circumcision-related causes each year.

An ongoing case in South Africa adds some new wrinkles to ethical and legal debates about circumcision in Africa. Bonani Yamani claims that when he was 19, he was abducted from his home, taken into the bush, circumcised against his will and forced to eat his own foreskin. His father apparently arranged or otherwise had knowledge that the abduction/circumcision was to take place, and it is his father that Yamani is suing. As it turns out, Yamani had undergone a (partial?) medical circumcision some months before. So Yamani is not against circumcision per se; he is opposed to traditional (Xhosa) circumcision, which he believes is contrary to his own Christian faith. And he is naturally opposed to having had it forced upon him.

The case brings out conflicts in a number of directions. There is the conflict between the father and son. The conflict between different views of circumcision: medical, traditional and (adopted) religion. But there is also a conflict between traditional leaders (in particular, the Congress of Traditional Leaders of South Africa or Contralesa) and the South African constitution: according to traditional norms, a male Xhosa who refuses to be circumcised is to be ostracised from his community. Traditional circumcision is not a matter of informed consent. It is just simply done, as part of being a Xhosa man, and refusal is not accepted. On this view, non-traditional circumcision and community membership are mutually exclusive. Yamani's legal defense will be arguing that not being able to live as a non-traditionally circumcised Xhosa should be regarded as discrimination under the South African constitution. Members of Contralesa have publicly stated that the constitution really has no grip on this area of South African life. This should be one to watch.

This blog has moved to Cape Town

From the beginning, this blog has explored emerging bioethics, research ethics and public health ethics issues in developing world contexts. But much of it has been, unapologically, about sub-Saharan Africa. Unapologically, because these fields have been -- and continue to be -- disproportionately orientated towards what goes on in more affluent, industrialized nations of the north.

Within this sub-Saharan focus, South Africa has had a prominent place in this blog. There are probably many sources for this. South Africa is a comparatively better-off country than (some of) its sub-Saharan counterparts, and therefore there is greater exposure of bioethical issues in the press and on the web. HIV/AIDS always brings with it dilemmas for researchers, clinicians and public health policymakers, and South Africa has a devastating HIV?AIDS epidemic, coupled with standard-fare tuberculosis, multidrug-resistant tuberculosis, and as if that was not enough, extremely drug resistant tuberculosis. The country has also had a spectacularly strange Minister of Health, some of whose pronouncements and policies about HIV/AIDS could have been written by Monty Python, but of course the unfunny part was that she really meant it. And an ex-President who denied HIV causes AIDS, and a bevy of medical charlatans running about. Plus conflicts between modern medicine and traditional healers, rising up (for example) in cases where young men die by the dozen in blotched ritual circumcisions. The country also has -- a legacy from the Apartheid era, no doubt -- a strong research infrastructure capable of conducting clinical trials and therefore dredging up all the research ethics issues of doing such trials with vulnerable populations. In short, a little bit of everything.

I accepted a sort of one-year visiting professor position in Cape Town awhile ago, and arrived here last week. It is not the first time I've been in the Cape: I completed my philosophy Ph.D. while living in nearby Stellenbosch some years ago, and left the country in 2001. Some things have changed, much has stayed the same. It remains to be seen whether this blog changes, now that it is being written out of Africa.

Unhealthy health policies

Do we believe that good health policies can reduce mortality and morbidity at a population level? The answer is yes: scientific research, meetings, consultations, reports and all the other magical ingredients that go into health policy formation are driven by the idea that if our policies are well-constructed and implemented, they will have a beneficial effect on public health. The whole process assumes that policies can have real and widespread effects. Conversely, it seems to follow that if the process of health policy formation goes awry, and we end up with wonky policies, needless death and disease can be produced in substantial numbers. Normally, the production of human death and suffering on an industrial scale raises strong ethical objections. Especially when guns are involved, we have strong words to describe this sort of thing: massacre, slaughter, carnage, genocide. Oddly, when errant health policies produce similar 'end points', in similar numbers, the ethical (and legal) responses are quite different. Ministers of health do not normally get hauled off to The Hague. And there really are some unhealthy health policies: there is an interesting book of case studies describing a selected few of them.

I was led to these thoughts by a recent case in South Africa of a physician who was suspended for giving HIV-positive pregant women a more effective drug combination to prevent them from transmitting the virus to their infants. You read that sentence correctly. A doctor in KwaZulu Natal, Dr. Colin Pfaff, gave dual therapy (nevirapine and AZT) to HIV positive mothers, rather than the 'nevirapine only' regime that is currently government health policy. But the government policy is behind the times. Dual therapy has already been recommended by the World Health Organization for a year, and has been shown elsewhere in South Africa to reduce the chance of mother-to-child HIV transmission down to 8%, while monotherapy with nevirapine has only reduced chances of transmission down to 22% in KwaZulu-Natal. The Southern African HIV Clinicians Society have condemned the decision to threaten Dr. Pfaff with discipinary action, and petitions have been written. It is a strange world when a physician is threatened with punishment for providing a superior standard of care, and when doing so cost the local health department nothing, because the AZT had been donated by a British NGO.

There has been pressure for sometime for the South Africa health ministry to alter their mother-to-child HIV transmission policy (last revised in 2001) to keep up with scientific advances and international recommendations, but its responses have been ambiguous, hesitant and sometimes openly hostile. This is part of a larger and deeply entrenched pattern in the country. From the beginning of the epidemic in South Africa, president Thabo Mbeki made no secret of his embrace with 'HIV dissidents' -- who believe that HIV does not cause AIDS or that HIV does not exist at all -- or his suspicion that drugs like AZT are harmful and promoted in Africa only to make money for corporations. By appointing health ministers sympathetic to his views, Mbeki has guaranteed that national responses to the epidemic will be marked by foot-dragging and denial. For almost ten years now, health minister Manto Tshabalala-Msimang has been responsible for a kind of 'Alice in Wonderland' approach to health policy leadership, carefully cherry-picking whatever scientific research seems to support her own beliefs about HIV in Africa, sidelining the rest, while touting the benefits of herbal concoctions and aligning herself with quacks. She was, for example, very quick to abandon provision of nevirapine when some studies indicated its use led to drug resistance among HIV positive mothers. Now, when it comes to providing dual therapy, Minister Tshabalala-Msimang wants to stick with nevirapine. Or she did, until the story with Dr. Pfaff hit the newspapers.

In South Africa, the struggle against HIV/AIDS is especially hard, because it partly a struggle against a government whose commitment has never been more than lukewarm. True, in the beginning of the HIV epidemic in the United States, there was strong government reluctance to engage in the control of a 'gay disease.' But that changed after a few years. In South Africa, that kind of obstructionism in high places endures, with deadly effect. In the future, perhaps it will be possible to estimate how many people in South Africa became infected by HIV or died of HIV-related causes due to the country's delinquent style of HIV policy-making. Will anyone be held responsible? Very unlikely.