Europe Solidaire Sans Frontières
If you were a South African health journalist during the late 1990s and early 2000s, you were mostly an Aids reporter. Eight out of 10 stories you produced were about the epidemic. It was a time of unprecedented Aids-related deaths, government policy based on politics rather than science, and activism that, in many respects, was as fierce as the fight against apartheid.
I was a cub reporter, with limited insight, for the public broadcaster.Following HIV during a controversial time when the government refused to provide antiretroviral drugs to people infected with the virus, quickly taught me an important thing – a pandemic isn’t simply a disease gone viral. It’s a political, social, economic and human rights crisis, because the germ that causes the outbreak travels through a society ravaged by inequality.
There’s nothing like a pandemic to expose what works and what doesn’t. Like a magnifying glass, disease outbreaks amplify everything.
HIV and more recently Covid-19, laid bare that inequality doesn’t just appear. It’s human-made. As the head of UNAids, Winnie Byanyima, put it recently: “Inequalities are a policy choice. They are choices our governments make.”
Campaigners in Pretoria in November 2021 urge reform to intellectual property laws to improve access to medicines for Covid, cancer, mental health, TB and other illnesses. Photograph: Phill Magakoe/AFP/Getty Images
Inequality, research shows, iswhy we still see Aids-related deaths in an era when we have all the antiretrovirals, HIV prevention pills, vaginal rings, injections and harm-reduction plans needed to end the pandemic.
Sex workers and drug users feel they’re not human enough to be served at clinics
It was also one of the chief causes of unnecessary Covid deaths. Because we’ve normalised inequalities – women having less power than men; prejudice against gay and transgender people; and sex workers and drug users feeling they’re not human enough to be served at clinics – making it impossible to get lifesaving medicine to those who need it most.
Getting scientists to develop medicine that cures or prevents or improves outcomes is a relatively small part of the solution. The difficult thing is to get the pills, injections, vaccines, to people who need them – and to ensure they then use them.
HIV and Covid have shown that, just because science can save lives doesn’t mean people will necessarily take up the pills on offer. People’s views on life – and trust in the providers of medication – influence their decisions.
During Covid, whether someone got vaccinated or masked up had a lot to do with their ideologies. A 2021 study by the Economist revealed the biggest indicator of whether Americans would get vaccinated was who they voted for in 2020: supporters of Donald Trump were 18 percentage points more likely to shun Covid vaccines than those who voted for Joe Biden.
South Africa is home to an estimated 7.9 million people with HIV – 94% of infected people have been diagnosed – but of those who know that they have contracted the virus, only 77% are on treatment, says the health minister, Joe Phaahla.
So, despite studies that show antiretroviral treatment (ART), if started in time, can dramatically increase an HIV-positive person’s life expectancy, 23% of our diagnosed people choose not to be on treatment.
For many South Africans society or their living conditions made the choice for them.
Francois Venter, head of the health organisation Ezintsha, points out: “We have testing available, and I think most people understand treatment is free and readily available, and safe and effective. But things like denial, stigma, unfriendly services and simply the hassle factor for people with busy and full lives may all be contributing.”
Take stigma. When researchers from Ritshidze, a group of organisations representing people with HIV, asked transgender people, men who have sex with men, sex workers and injecting drug users in South Africa about how they’re treated at government clinics, less than half, and in some cases not even a quarter, of the near 10,000 respondents reported being greeted by a friendly face. In some of these groups, about one in five people said they had been blocked from services.
People from these key populations have a higher chance of getting HIV than the general population. But, knowing they will be discriminated against, they stop going to clinics, James Oladipo, one of the Ritshidze report’s authors, told the health media group Bhekisisa in May.
To address this, the health department is providing training to help workers better understand transgender people, sex workers and men who have sex with men.
The department’s acting head of HIV, Thato Chidarikire, says they use video clips where people share their experiences. “What we’re trying to say is, ‘Be sensitive, be competent.’”
Solving inequality, says Byanyima at UNAids, requires agreed-upon rules, in the form of policies – because we can’t control people or governments’ day-to-day decisions without it.
The answer to putting a stop to epidemics that thrive in the midst of inequality lies in policies to get society’s sectors to work together, rather than merely making medication available at clinics.
An estimated 7.7 million people in South Africa are HIV positive, but only 62% take the drugs that suppress the virus and prevent transmission. Photograph: Bram Janssen/AP<
The late US medical anthropologist Paul Farmer, who spent much of his career bringing high-quality services to poorer countries such as Haiti , explained it in an interview with the Boston Globe in 2008: “Medicine should be viewed as social-justice work in a world that is so sick and riven by inequities.”
So what do solutions to inequality look like?
We can learn a lot from the partnership organisations in South Africa formed during our fight for access to HIV treatment, says Byanyima. To get the government to change its policy of not providing antiretroviral treatment in the late 1990s and early 2000s, lawyers, scientists, doctors, economists, journalists and communities of people living with HIV joined hands to stand up to the state.
As a result in 2002, about four years into the battle, the constitutional court ordered the then minister of health, Manto Tshabalala-Msimang, to provide HIV-positive pregnant women with ART to protect babies. In 2004, HIV treatment was expanded to the public.
As a direct consequence of that decision, and the pressure it put on the government to make free HIV treatment widely available, the annual death rate among black Africans, who make up the largest proportion of South Africa’s HIV cases, has decreased by 31% between 2006 and 2016. And the likelihood of someone reporting bad health is down by almost half. In this case too, inequality navigated the virus’s spread.
But the fight against inequality should cross borders, says Steve Letsike, at the South African National Aids Control Council. “Why are we bystanders when countries such as Uganda, Ghana, Kenya, Tanzania and Namibia introduce anti-homosexuality laws that seek to erase LGBTIQ+ people?” Letsike asked in June at the South African Aids conference. “It undermines the health agenda. Injustice there means injustice where we are.”
In May, Uganda’s president, Yoweri Museveni, signed the country’s anti-homosexuality bill into law, extending punishment for certain types of gay sex from life imprisonment to the death penalty, and creating new crimes such as the “promotion of homosexuality”.
“Truly draconian” says Letsike, and will lead to “even more hate crimes and human rights violations”.
This legislation will, undoubtedly, lead to fewer LGBTIQ+ people accessing HIV services, and many new infections.
Men who have sex with men in countries that criminalise same-sex activities are twice as likely to be infected with HIV. In Uganda that rises to eight times
Research in 10 sub-Saharan African countries found that men who have sex with men who lived in countries that criminalised same-sex sexual activities were twice as likely to have HIV compared with men in countries where it was legal. This increased to eight times more likely in countries with “severely criminalised” environments.
Anti-gay laws make it difficult for people with same-sex relations to visit health facilities to get tested or treated for HIV, as they fear their sexuality being discovered.
Byanyima, who is Ugandan, says the missing ingredient to fight inequality is the political will to make “tough choices to invest in people to end Aids”.
Sadly, a tendency to allow prejudice trumps science. Prevention pills can
A Durban township … Aids remains a leading cause of death for women in South Africa despite medical advances. Photograph: Chris Bloom/Alamy
Laws intended to stop teenagers from having sex, frequently achieve the opposite. Research shows that in countries where the age of consent for HIV testing is 15 or lower, teenagers are 74% more likely to have been tested in the past year than where the age of consent is 16 or higher.
The policy choices governments make, and the values they use, will determine how fast – or slowly – we end inequality and the pandemics inequality fuels.
How inclusive we’re prepared to be will frame our future.
We need to constantly remember the question Farmer asked: “If access to healthcare is a human right, who is human enough to receive it?”
Mia Malan
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