On January 6, a frail and grief-stricken Nelson Mandela announced that his son, Makgatho Mandela, had died of AIDS. Makgatho, 54, was Mandela’s only surviving son. His first son, Madiba Thembekile, died in a vehicle accident in 1969 while Mandela was still in prison.

In a statement to the media, the former South African president said, “Let us give publicity to HIV/AIDS and not hide it, because the only way to make it appear like a normal illness like TB, like cancer, is always to come out and to say somebody has died because of HIV/AIDS. And people will stop regarding it as something extraordinary.”

The HIV/AIDS pandemic affects at least 5 million South Africans.

The first news about a sudden worsening in Makgatho’s condition appeared in December 2004, when it was reported that Mandela had rushed to the bedside of his gravely ill son. At that time, the nature of Makgatho’s illness had not yet been made public.

Nelson Mandela joins the ranks of prominent South Africans whose lives have been directly affected by the AIDS epidemic. Last year in May, the leader of the Inkatha Freedom Party, Mangosuthu Buthelezi, disclosed that he had lost two children to AIDS.

In 2003, Peter Mokaba, a prominent ANC politician and AIDS “denialist,” died amidst widespread speculation that he had succumbed to the disease. In 2000, South African President Thabo Mbeki’s director of communications, Parks Mankahlana, suddenly passed away, giving rise to speculation he had been infected by HIV, although spokespersons for the presidency maintained he had died of anemia.

While in the US in 2003, Mbeki claimed he did not personally know anyone who had died of AIDS.

Makgatho Mandela, an attorney, was able to afford private medical treatment at Johannesburg’s Linksfield Clinic, but millions of HIV-infected South Africans are entirely dependent on services provided by the state.

Much hope was invested in the Department of Health’s Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for SA (the so-called Operational Plan), published after lengthy delays in November 2003. Amongst other things, the plan entailed the rollout of anti-retroviral drugs to those whose infection had progressed to a certain point.

The Operational Plan

The initial goal of the Operational Plan was to extend care and treatment to 50,000 people by March 2004. However, by October 2004, fewer than 15,000 people had received treatment. While the Treatment Action Campaign (TAC), a non-governmental organisation that campaigns for the government to fund AIDS treatment, supported the Operational Plan, they pointed out that approximately 400,000 people needed immediate treatment if their lives were to be saved.

When the Operational Plan was released in November 2003, the main document referred to two annexures, or appendixes, which were respectively “a week-by-week schedule for the pre-implementation period with deliverables for each of the main focus areas” and “The Detailed Implementation Plan.” These two annexures, which contained vital information for holding the government accountable, were not included in the main document.

On February 20, 2004, the TAC requested the annexures from the minister of health, but received no response. On March 2, the TAC filed a formal request under the Access to Information Act, for access to these documents. This request was simply ignored by the Department of Health. An internal appeal under the terms of the Act was then lodged by the TAC’s attorneys. This too was ignored.

On September 29, some seven weeks late, the minister of health filed an answering affidavit. In her response, the minister stated that the references to the annexures in the Operational Plan had been an error, and that no approved annexures existed. The annexures to which the Operational Plan had referred were, in fact, time-lines prepared by experts from the Clinton Foundation. These had never been approved by the Cabinet.

The minister further maintained that there was no obligation to make the time-line annexures, which she referred to as “drafts” or “working guidelines,” publicly available.

As soon as the TAC was informed of the status of the documents, they addressed a letter to the minister of health, demanding costs “by virtue of its [the Department of Health’s] gross negligence and unconstitutional conduct in creating the confusion that gave rise to the applicant’s request for access to the annexures in the first place, and then failing to clarify the true state of affairs for some ten months in the face of repeated requests.”

On November 4, the case went to the Pretoria High Court. A judgment was handed down in favour of the TAC, and the minister was ordered to pay their legal costs.

Shortly thereafter, the Department of Health released a statement blaming the TAC for litigation costs of some R5 million since 2001: “It is regrettable that the limited resources earmarked for improving the health of all South Africans, including people living with HIV and AIDS, have to be spent in resolving legal disputes lodged by the TAC.”

The TAC responded, stating, “It is indeed regrettable that the TAC had to litigate against the Minister of Health to compel her to implement her Constitutional obligations.”

What this episode clearly illustrates is that, in all probability, there never was any detailed roll-out plan. The Operational Plan released in November 2003 was intended for public consumption just ahead of the 2004 general elections. With the elections over, the political motivation to implement even the limited provisions of the Operational Plan evaporated.

ANC attacks the Treatment Action Campaign

In the aftermath of the TAC’s court case against the minister of health, the ANC led a concerted assault against the TAC and its allies.

An article attacking the University of the Witwatersrand’s AIDS Law Project and the TAC was published on the ANC’s web site on November 5, elaborating on the Department of Health’s initial statement and again accusing the TAC of obstructing government efforts to deal with the pandemic.

A further assault was launched against the Medicines Control Council and the TAC by Matthias Rath, the owner of Matthias Rath Inc., a pharmaceutical company that manufactures and sells expensive vitamin products. Rath promotes himself as a provider of natural, as opposed to synthetic, medicines, and accuses pharmaceutical companies of unethical behaviour. Amongst other things, he claims his products can cure cancer. Rath has also said that he supports South African Health Minister Manto Tshabalala-Msimang, and has allied himself with the Traditional Healers Association.

Rath ran a series of advertisements in the Mail & Guardian newspaper accusing the Medicines Control Council of being in the pockets of drug companies: “...all of its [the MCC’s] decision-making members are directly or indirectly on the payroll of the pharmaceutical industry.” He also maintained that the TAC “has been financially groomed by the Rockefeller Foundation” and is attempting “to silence all critics of the devastating side effects and ineffectiveness of AIDS drugs.” Rath also demands the disbandment of the TAC.

When the MCC sought to litigate against Rath for his advertisements, on the grounds that they were defamatory, the minister of health intervened and blocked the Council from taking this course of action.

Amongst the government’s allies in its refusal to deal decisively with the AIDS epidemic is the National Association of People Living with HIV/AIDS (NAPWA), a body funded by the Department of Health. An article by Lucky Mazibuko of the Sowetan put the spotlight on NAPWA and its insidious role. According to Mazibuko, “NAPWA became a perfect and convenient restorer of credibility in the government’s continued legitimisation and justification of the Department of Health’s outright refusal to provide anti-retroviral treatment to millions of people living with HIV and AIDS.” Mazibuko reported that NAPWA was acting as “an unofficial spin-doctoring cover...to polish the dented image of the Department of Health....”

On December 17, a further assault against the TAC was published on the ANC web site, entitled, “Nevirapine, Drugs & African Guinea Pigs,” which attacked the safety and efficacy of Nevirapine, the main drug used in the program to prevent mother-to-child transmission in South Africa, and accused the TAC of being a tool of the multinational drug conglomerates.

The TAC issued a rebuttal to the article, pointing out that what it called new concerns about the development of resistance to AIDS drugs in those who receive Nevirapine have actually been known for some time. However, in terms of mother-to-child transmission prevention, “its [resistance to AIDS drugs] weight is small in comparison with the potential benefit of providing a single tablet of Nevirapine to the mother and a few drops to the baby.....”

The TAC added that its long history of fighting drug companies to provide cheap, safe and effective medicines was hardly the profile of an organisation in league with multinational pharmaceutical interests.

The ANC’s attack on the provision of Nevirapine to HIV/AIDS patients, and especially to HIV-infected pregnant mothers and newborn infants, is particularly worrisome. Although government policy currently entails the provision of single-dose Nevirapine to pregnant mothers and newborn infants, the opposition to this program that has emerged indicates that something else is afoot.

In the absence of a detailed implementation plan, this program remains, along with condom distribution, the cornerstone of the government’s response to the epidemic. While it is accepted that, wherever possible, a multi-drug regimen should be implemented, should Nevirapine be removed as an option, even the small number of people currently receiving treatment will be further reduced. The consequences of this will be certain death for thousands of people.

The attacks against the TAC by Tshabalala-Msimang-supporter Matthias Rath, the Department of Health and the ANC point to a concerted effort not only to smear and discredit the TAC, but also to sow confusion amongst the general population about the need to roll out universal anti-retroviral treatment for HIV/AIDS sufferers.

The pattern of events over the past year indicates that despite the publication of an Operational Plan, the government’s position on the treatment of AIDS has not shifted since the 2002 Constitutional Court ruling that ordered them to roll out Nevirapine as part of a mother-to-child transmission prevention program. The Operational Plan appears to have been little more than an electoral ploy.

Mandela’s announcement that his son had died of AIDS is consistent with his approach to the epidemic. Mandela, unlike Mbeki, has never placed himself in the camp of the denialists. His public statements regarding the epidemic, and his association with various AIDS fund-raising events and charities, indicate his views diverge widely from those held by certain elements in the ANC and government.

Despite Mandela’s opposing views, he has not been subject to public criticism from the ANC. Nor has Mandela publicly criticised Mbeki or Health Minister Tshabalala-Msimang. However, he cannot fail to recognise the recklessness and unpopularity of the government’s approach to the pandemic, and the danger that it poses to South Africa and the political future of the ANC.

Mandela, through his various actions and utterances, is articulating the concern within the South African establishment about the impact of the AIDS pandemic on the stability of social and economic relations in South Africa. The next general elections in South Africa are due in 2009. By then, according to the Actuarial Society of South Africa, an estimated 1.4 million South Africans will require anti-retroviral therapy.