Milestone Breakthroughs in the Fight Against AIDS in South Africa, Iowa City, Iowa, April 19, 2016

- [Sue Dulek] I'll acknowledge our university and community supporters, the University of Iowa's International programs, and the University of Iowa's Honors programs. They contribute vital time, talent and logistics to our organization. I also want to thank, as always, The Stanley-UI Foundation Support Organization for their financial support. And today's special financial sponsor is John Menninger and US Bank. Our programs are made possible with these institutions and personal contributions by our sponsors. Dr. Powers is an assistant Professor of the University of Iowa Department of Anthropology and Research Associate at the University of Pretoria. His research focuses on the politics of HIV/AIDS epidemic in Post-apartheid South Africa. The aim of this work is to better understand the relationship between pathogens and social change in the contemporary phase of global introduction. Or integration. Now please join me in welcoming Dr. Ted Powers. - [Thedore Powers] Good afternoon. I'd like to start just by thanking some of the folks that invited me to come and speak here. Professor Bill Reisinger, thank you. Ed Zastrow and Sue, of course, thank you for the introduction. So in terms of how we're moving forward today. One of the things that I want to do is to situate the South African epidemic. Both within the global HIV/AIDS epidemic, even with South Africa's history so that you, as a group, can better understand, how some of the key milestones and challenges ahead had deep historical roots and also differentiate themselves from perhaps HIV epidemics in other parts of the world. So, to begin with, one of the things that we need to appreciate is that the HIV/AIDS epidemic comes out of Arica. So, recent research in phylogenetic analysis has pointed that the HIV/AIDS epidemic moved from Central Africa, the Democratic Republic of Congo, to Haiti, and later to the United States. And it then spread from these sources to other parts of the world. Now, one of the things that I want to focus on first, are the ways in which the epidemic originates in the context of Central Africa. And this is a bit of a kind of a bit of phylogenetic analysis that was published in nature, that kind of sources the origins of the epidemic based upon analyses of early HIV samples. And what they project is that, what their hypotheses is, is that the HIV/AIDS epidemic seems to originate in the city of Kinshasa in the 1920s. And what's really important to keep in mind here is that the HIV/AIDS epidemic in the African context is a heterosexual epidemic. Ie, transfer is between men and women. All right, and when we think about this period of time, I want to give a little bit of history about the Congo during this period of time. Of course, the 1920s comes in the aftermath of the Congo Free State. Over a period of time between 1885 and 1908 when 10 million Congolese people died. This period of time, during which about 20% of the population passed away, was one of forced labor, internal migration, and high levels of colonial violence. So when we think about some of the factors that precipitate large scale epidemics, when we look at this period of time leading up to the 1920s in the Congo, we can see that, kind of the dynamics of movement of compromised immune systems that come with movement of this kind, with displacement, with violence. That when we look at these dynamics, the contemporary period, we often see that various practices are associated with it. One is survival sex or the exchange of sexual access in order to access resources to survive. This often comes with conflict and displacement. Another is rape associated with conflict and war. So when we think about this period of time and the colonial period, this is the origins of movement of interchange that we see around the period of time when HIV becomes generalized. And keep in mind that Kinshasa is a port. Also keep in mind that as you look and see, the epidemic traveled down to Lubumbashi by the 1960s. That the Southern corner of the Democratic Republic of Congo, all right, is where the Conga Mines exists. All right, now where you have compromise and where you have mines in general, you'll have miners. Now it just might happen that all those miners not be from that particular area. They may actually come from outlying areas. And of course, these lines on that piece of paper in front of you, don't necessarily record and limit human movement in this period of time. So when a mine is established, both in Lubumbashi and in the Copper Belt and kind of countries that are contiguous to this area, Zambia specifically, what we see is that HIV then moves via miners, all right. Out of this area and to other parts of Central Africa. And one might ask, well why are miners coming from other parts of the African continent. Well, they're paying hut taxes. Right, mechanisms for cost recovery for Colonial administrations, so when we think about the infrastructure that's developed in the Colonial period, it's important to keep in mind, this was often paid for, by the cash wages that were earned by miners going to places like the Copper Belt. Now, this is a kind of a time series graph that looks at the expansion of the African epidemic from the late 1980s to the early 2000s. And I want to point out a couple of things here and the first is that you can see the spread of HIV across Central Africa by the late 1980s. You can see it moving into West Africa by the early 1990s. And by the late 1990s, early 2000s, you see the epidemic becoming centered on Southern Africa. All right so, I want to talk about some of the broad historical dynamics that drove the extension of the epidemic across the continent. And keep in mind that the DRC is the size, geographically, of Western Europe. All right, so when we think about this period of time, what's important to keep in mind that from the 60s to the 80s, we see intermittent conflict and civil war across Central Africa. There's a war in Uganda with Tanzania. There's a civil war in Uganda. This is one of the areas where we see an early HIV/AIDS epidemic. We also have Africa's first world war in the late 1990s in Central Africa. So when we see what's expanding and driving the expanse of the epidemic, it's similar dynamics of conflict, displacement, and mechanisms for survival that are ongoing across Central Africa during these two decades. Of course, there were intermittent programs and conflicts in Rwanda starting in the 1960s. So we need to kind of incorporate that into an understanding of the movement of people and pathogens. Now, in terms of the expansion southward. It's important to keep in mind, historically, that the cold war was a proxy war in the African continent. So if we're talking about the DRC in Mobutu, also Africa and the U.S. aligned against countries like Angola, Mozambique, and other of the kind of third world movement. That there's conflict and displacement also within Southern Africa. Of course, the ANC's armed branch and exile, Umkhonto we Sizwe is also being attacked, by various cities and in areas across Southern Africa. And so, when we think about this period of time, the dynamics that have described from the early 20th century and the DRC, this can be extended across the Southern and Central part of the continent over the course of the 20th century. I also want to point out another very important factor, which is starting in the early 1980s to late 1980s, we see a series of structural adjustment programs implemented across the African continent. A structured adjustment programs. Were implemented by the IMF and the World Bank, and what they did was, they restructured domestic finances in order to pay external debts. Now, what this really did in practice was impose austerity and cuts in health, social services, food and farming subsidies, as well. So with a company structure adjustment, where cuts to the health programs and cut up incipient primary care programs that were developed in the post-colonial period, as well as mechanisms like vector control. So when we talk about a kind of particular mechanism that enabled a spread of pathogens. In Madagascar between 1986-1988, we see, in the Highlands, a Malaria outbreak that occurs because vector control is cut in order to kind of produce cost recovery to pay external debts. So that leads to the death of 60,000 people, but it was entirely predictable. We think about the AIDS epidemic and conflict, the primary care mechanisms that would have served as the first step of testing and defense for public health, were also cut back during this period of time. Now why were these countries unable to pay their debts, well, commodity prices, like today, went into a downward cycle in the 1970s. There were the oil price shocks as well, due to conflicts in the Middle East. Also there were the local policy shocks where interest rates on variable loan debt, kind of the US interest rate was raised up to almost 20%. Variable rate loans also skyrocketed. These were not denominated in local currency, therefore these debts became unsustainable. Hence, structure adjustment and external intervention. So when we think about the pathogens that were enabled during this period of time, think about the big three. Malaria, HIV/AIDS, and Tuberculosis. During this period of time we see the mechanisms that were put in place to control the expansion of these, we really started in the 1960s with independence, not prior to that. Actually, kind of disassembled and actually these pathogens begin to kind of flourish across the continent. So, let's look at this picture within, situate the African epidemic within the global epidemic. So this is 1990s and you can see the epidemic being kind of focused in the Central African region. This is 2000, and actually Africa declined to participate and report their statistics during this period. Due to internal debate, I can tell you that the country would have been dark right at this point then it should be prevalent, the adult population of over 23%. And here you can see in 2010, that South Africa has firmly emerged as the epicenter of the global epidemic, and Southern Africa generally. So how do we make sense of this picture? Why Southern Africa? Why does HIV take hold in such a stern way in this society? And what I want to talk about now is the particular historical dynamics within South African society that precipitated this epidemic. So, one of the things that we need to think about is that South African is one of the most unequal societies in the world today. The kind of mechanisms that use, at the level of the UN is the Gini coefficient. And one of the ways in which we see inequality expressed in South African context is lack of access to healthcare. A lack of development of health infrastructure in particular in parts of the country, for particular populations within the country. Politically produced socio-economic inequality. And this grows out of the history of segregation and apartheid. So, let's talk a little bit real quickly here about the Colonial period in South Africa. As many of you may or may not know, it was the Dutch that first settled, what's known as Cape Town and kind of then known as the Cape Colony. And this just kind of focused on mechanism of production that was based upon slave labor and agricultural production to fuel actually, the mercantile period of trade where they kind of ran into the cape of good hope, on their way actually over to Southeast Asia to kind of carry out trade. Now when South Africa transitioned to kind of the British Colonial period in the early 19th century, we see a shift in the way in which the colonies administered in later 19th century, a shift in the political and economic dynamics of the colony itself. And the shift moves from a focus on agricultural production to the one of mineral extraction. All right, this is driven by the discovery of diamonds in Kimberley in 1871 and of gold in Witwatersrand area in 1886. So when we think about this period of time, it's a transition to slave-based production to mineral extraction and a broader kind of economic adaptation that leads to particular changes in the way in which populations move within the country and the way in which they're segregated and divided. Particularly what we're talking about it the creation of a labor migration system. Of circular migration between urban areas, the urban areas that go up around the mines, particularly in present day Johannesburg. In rural areas that back then known as labor reserves, and now come to be known as, then known as Bantustan's are now known as customary areas. And you have, of course, a mix existing form of native reserves in this country today. So one can use that as a rough model for what we're speaking about here. So, the native reserves are created in 1912 as a mechanism for consolidating, kind of, white Colonial control of urban areas. So land is expropriated from black populations in rural areas. Folks are pushed onto reserves. And this is to kind of create demand for labor or demand for cash income to supplement domestic production and subsistent agriculture production and to kind of facilitate circular migration of the mines, by men. So three six-month contracts, men leave home, earn wages, come home. Now, in urban areas, what we also see is the development of forms of segregation. Now interestingly, it's often public health that utilizes a mechanism for putting these measures into place. So, a kind of outbreak of Bubonic Plague in Cape Town at the turn of the 19th century leads to the implementation of urban segregation for the first time in South Africa. And it actually originated in Hong Kong, made its way up to Ghana and it stopped there. But when we think about this period of time, it's one of interconnection. We need to understand the stuff, part of a broader Colonial adaptation, politically and economically and it's operating within that context. Now, part of that context in the movement of people over the world is, of course, the missionaries. And what we see in the kind of urban areas with segregation, it manifests differently in rural areas where we see missions setup, like you see here, Lovedale Mission, which served both as a mechanism for the education of African populations, as well as the proper mechanism for accessing public health. So when we look at the missions and how they're founded, Lovedale hospital and mission actually serve as a mechanism for educating some of the early leaders of the African National Congress. So, Steve Biko, C.K. Mathews, Govan Mbeki. And these areas often served in, you know, the missionary is often also served as intermediaries between the Colonial state and indigenous populations. So these are incredibly important institutions in rural areas that set into motion like dynamics of Education and ideas of equality that we see influencing later political dynamics. Now, when we think about what's put into motion during the Colonial period, its segregation inequality and these the dynamics that are put into place, that apartheid intensifies and expands upon. So I want to be clear with you all that those dynamics were already underway before apartheid or the kind of logic of separateness is implemented as a political philosophy in South Africa. Uh oh, what did I do? So, the apartheid period in South Africa begins in 1948. All right, it's an intensification of the system of urban segregation, forced removals, and the kind of, separate development of the Bantustan's. When we think about this period of time, there's several kind of key developments, the extension to pass laws to women, forced removals in urban areas, and the dislocation this creates in black urban social formations. so it's also a period of pioneering developments in primary care. Sidney Kark who is a kind of the developer of community-oriented primary care actually develops these ideas in the 1930s, in the rural parts of what's today known as KwaZulu-Natal province and known as Zululand And the idea of Kark doing social epidemiology, of developing clinics that are also working with doctors or with community members was pioneered and developed and piloted during this period of time very successfully in these areas and by '48, the apartheid state shut these things down. Right, so these moments where possibilities emerged of a different political trajectory with rural health, and with African social formations that to a certain degree are closed down. During this period of time we also see the closure of rural missions by the apartheid state. You can't have them educating the political opposition can you? So along with closing this kind of mechanism for education, access to health is also closed with these missions, right? So, what we see is a closure of access to health in rural areas, right? And in the development of what we call white elephant projects and the capitals of the Bantustan's and in kind of the urban township.j So, an example of this is Chris Hani Baragwanath Hospital in Soweto, which is by all counts, the third largest hospital in the world. So that sounds very impressive, until you understand that the hospital, since its kind of first days, has been understaffed, staff has been under trained, the institution has been under funded. and it's barely operated in a functional fashion since that period of time, and that's sort of the dynamics of a meeting kind of the... Burden of disease in South Africa are exacerbated by the fact that building this infrastructure in urban areas meant that you had that same dynamic of circular migration of the minds now developed with access to health resources. So of course these facilities can become overburden because they're centralized in urban areas. So what emerges during this time in terms of dynamics of health? Syphilis, from the mines to the rural areas becomes the generalized epidemic. Tuberculosis, as well, we also see kind of from the mines to rural areas and amongst the miners themselves we see an epidemic of silicosis. So when we think about how HIV spreads, one of the key questions is, you know how strong is your immune system? Mow what I want to emphasize here is that the period leading up to late apartheid when HIV kind of is introduced to South African societym the immune systems of miners and people in rural areas are deeply compromised. So when we think about the late apartheid period we're talking about the anti-apartheid movement and that what begins to be a focus on public health, So the 1976 way to uprising, is the kind of a key moment of change into the African history, where the youth take to the streets, after they, kind of the language of education is changed without notice from Afrikaans or from English to Afrikaans. so they showed up for their senior year of high school and the textbooks in a different language. And of course the Black Consciousness Movement in the work of Steve Biko and others played an important role in facilitating the rise of the youth movement. And so there's a resurgence in the anti-apartheid movement following '76. And of course, you know, if those who have not seen pictures of the '76 youth uprising, youth take to the streets and they're shot and killed by, you know, security services of the apartheid state. So u... When we think about this period of time, it's not just a rise of the youth and of the urban townships, there's also the rise of solidarity movements that kind of emerged to become a part of the broad-based mass democratic movement in South Africa these are the mechanisms that serve also as the base for the first wave of HIV/AIDS activism in South Africa. So we think about these solidarity-based political activities, it's inhuman rights-based lawyer mechanisms that are created so the legal resources center is developed to protect the rights of people who are being tortured by the apartheid state in prison. That served as a mechanism for support, the HIV movement later on. The primary care movement, kind of following on the, kind of heels of the Alma-Ata Declaration and of the youth uprising. Folks who work in academic hospitals like the University of Iowa Hospital Center kind of drive on the weekends, establish clinics and the townships, all right? And treat people who are being tortured and injured by the apartheid state. The Democratic Trade Union Movement begins in the 1980s and the Urban Civic Associations begin as a mechanism for self-organization in urban areas, of the street committees, of area development committees, of township committees, where self-governance emerges as a principle. So when we think about this period of time, of increased intensification of the internal anti-apartheid movement, of the intensification of violence. This is the situation into which HIV/AIDS is introduced, in South Africa. The first case is identified from a Malawian miner in 1982 on the gold mines in Johannesburg. So, this is the context into which HIV/AIDS emerges. part one of intensified civil conflict within South Africa... In one of kind of mobilization of various sorts. Both of which are incredibly important for understanding why HIV spreads so quickly as well as why the HIV/AIDS movement also formed so quickly. Because the forms of civic association and of kind of social organization against a kind of political force that was, let's say, against the rights of the majority's with Africans, can then be applied against the pathogen, in this case, HIV. Now in terms of what I want you to take out of this brief history that I've tried to move through quickly, my apologies, I want you to kind of build upon something that the anthropologist, Didier Fassin, has argued is an important way to understand disease, and specifically about the HIV/AIDS epidemic in South Africa, Fassin has argued that HIV/AIDS is the embodiment of inequality. That those who are most affected by South Africa's history are the most infected. That when we think about how would we correlate the question of poverty, of history, of inequality, HIV/AIDS is almost like a proxy mechanism for understanding those who've been most discriminated against historically. So, understanding the illness then involves contextualizing disease within the particular history and mechanisms by which a society has been transformed over time. So, Now that we've got a bit of context let's talk about some of the key milestones and developments that occur with the HIV/AIDS epidemic in South Africa. Now the first thing that I'd like to focus on is the first wave of HIV/AIDS activism. And so what you see here are the pictures of two very prominent HIV/AIDS activists who represent two very different groups within South African society, so on your right is Edwin Cameron who's now the Chief Justice of the Constitutional Court in South Africa. Cameron is part of that group of solidarity-based kind of human rights lawyers who began to work with the anti-apartheid movement. And it just so happens that people like Cameron, Arthur Trask Wilson also write this African Constitution, so that period of time of sorry-based activism from the legal rights sector, right, begins to kind of also filter into a rights-based approach to HIV/AIDS, right? So we see kind of the organization of white middle-class men beginning around the professional class within both the kind of Human Rights sector, the legal sphere, as well as the primary care sphere, right? Now, when we think about the other aspects of this period of time, and this is really from 1982 to about 1990 that we're talking about, Simon Nkoli is the figure on the left and he's wearing a shirt for the Gay and Lesbian Organization of Witwatersrand. And what Nkoli does is he brings the, kind of ANC to the table with HIV/AIDS. He begins to organize in the kind of, the urban townships across the Transvaal as it was called at that time, and he begins to argue and carry debates within the ANC about the importance of HIV/AIDS as a human rights issue to be addressed as part of the anti-apartheid campaign and then later, as part of the political transition, and subsequently to that, to be included in the South African Constitution anti-discrimination mechanisms for both, kind of same sex partnerships, right? And later for rights based approach to HIV/AIDS policy. So this particular period of time we see the contradictions of South African society, begin to be addressed by the anti-apartheid movement, through the mechanism of HIV/AIDS. So when we understand these two organizations, these two kind of aspects of the HIV/AIDS movement, we also have to understand that they were strongly supported by the emergence of the Democratic trade Union Movement. So the National Union of Mineworkers strongly supported the HIV/AIDS movement. The first wave and subsequently to this, because it was their workers who are being infected by HIV, it was affecting their members. So that's an incredibly important group to have the support of for a Minerals Extraction Economy. Where these are the individuals who are developing value, right? We're producing volume in the economy through the extraction of minerals out of the ground. All right so, I think one of the next key developments in this particular period of time is The Rainbow Nation period of time. Or the ANC is unbanned, we move into the political transition, and then actually it moves into the Democratic period and I think for you know this period time between 1990 and 1999, what we really want to focus on is the fact that the first wave of the HIV/AIDS movement is incredibly influential in the political transition and constitutional negotiations. So, they formed the National AID Committee of South Africa or NACOSA, so those kind of variants, those individuals that we put in it before, become a part of the process of both developing the, kind of governing rules for a post-apartheid South Africa as well as creating the foundations for the first National AIDS Policy, which was adopted in 1994, which is like, you know, the first year of the Democratic period. So it shows that this is a high priority. Unfortunately HIV/AIDS falls to the wayside during this period of time. You know, restructuring a society is a big job, isn't it? So, creating new government, creating a new province system, restructuring kind of cities and their boundaries, writing a constitution, and restructuring the economy, these are the issues that take precedence. And as a result, from 1990, prevalence is under 1%, by 1999, it's 23%. So this is that period of time, the Rainbow Nation period, when we see a massive explosion of HIV in South Africa, and you know, I think we can look at this period in various ways, but I think one of the issues is that there simply might not have been enough capacity, right? There might not have been the health infrastructure because of the way in which South African history had unfolded there might not have been the human resources capacity in these various ways. These are some of the issues that have been discussed about this period of time, but I think we need to be critical about this, but certainly it's the case that, you know, South Africa's taking an increasingly critical look at the Mandela period in terms of the country's history. Now, following the kind of Rainbow Nation period, the Mandela period, we have the emergence of what I call the ANC's AIDS dissident faction, or a group of powerful individuals in the African National Congress find dissident positions on the link between HIV and AIDS that were produced by American scientists, and they adopt these and transform or limit the response to HIV and AIDS in South African society based upon this particular belief system. So, they question the link between HIV and AIDS, and Mbeki actually , President Thabo Mbeki who's pictured here, has recently come out and doubled down and confirmed his position on these beliefs earlier this year. And this particular position linked the emancipation of South African society, the idea of African nationalism to the idea of creating African solutions to the HIV/AIDS epidemic, to rejecting AIDS treatment as toxic and unaffordable, as a mechanism by which the profiteering of the global pharmaceutical industry unfolded, and one through which the interest of African societies were not being attended to. So there's many aspects of this where there are kind of elements where a lot of people who are critically-minded might agree, but I think really where this issue began to become quite problematic is where the link where HIV and AIDS was questionsed Now there's the establishment of kind of presidential commissions on this issue, and I, this is Dr. Manto Tshabalala-Msimang on the right, and she's the national minister of health. So, when we talk about the institutional mechanisms that were in place, the presidency and the National Department of Health, the norms generating institutions within the country for policy had individuals that kind of were in charge of these office institutions that were questioning the link between HIV and AIDS, and as a result, HIV/AIDS treatment was not adopted in South Africa, although it was scientifically proven, and the kind of epidemic was actually quite, you know, at a higher, it was expanded at a very high rate in the late 1990s. And as a result, a study estimated that 330,000 South Africans died prematurely due to delays in adoption of HIV/AIDS treatment. So, what happens as a result? Well, there's a second wave of HIV/AIDS activism that emerges. And, you know, key activists like Mark Haywood and Zackie Achmat were actually trained by members of the first wave of HIV/AIDS activists. So, when we talk about Edwin Cameron, you know, future Chief Justice of Democratic South Africa, he worked with Zackie Achmat and Mark Haywood in the AIDS Law Project, which he established through an institution that he created. So, when we talk about the connection being these two waves, it's actually quite direct, that there's actor networks that expand over time, and serve as a mechanism for uniting this late apartheid period to the second wave of HIV/AIDS activism. And quite central to the second wave is the formation of the treatment action campaign in 1998, it was actually formed at the death, at the funeral of Simon Nkoli. So, when we think about this period of time, the lack of access to treatment of first wave activists, which leads to their death is the precipitating factor for the second wave of HIV/AIDS activism, and they serve as the primary social organization that leads the charge against the ANC's a dissident faction in trying to create access to treatment. I mean, after all, they're called the treatment access campaign, or TAC. So, when we think about how this campaign unfolds for access to treatment, what's incredible important is that they're supporting by the local resources center, which emerged after '76, and leading the Supreme Court, for us, it would be a supreme court case, but for them, it would be a constitutional court case, for access to treatment within South Africa. This is before the prevention of mother and child transmission, this is carried out in 2002, and they win that court case. Unfortunately, due to the fact that public health institutions, the presidency, were staffed or controlled by the AIDS dissident faction, we see various slow movement on that. So, what occurs is, a civil disobedience campaign, a campaign of direct action, and they take to the streets, they occupy police stations, they call for the arrest of the President initial health for culpable homicide, right, they're put in jail, and eventually they negotiate behind closed doors with then Deputy President, Jacob Zuma, whose working with the Trade Union Movement for backing HIV activists and they lead to the development of the comprehensive treatment plan in 2003. Now, this is the mechanism by which treatment access should have become available in a widespread way in South Africa, but it doesn't. Because of the control of state health institutions by the AIDS dissident faction. So, although the law and the policy on paper look to be quite progressive, although they utilize the right to health to argue for widespread access to PNPCT and for AIDS treatment, those were necessary, but insufficient conditions for people to experience the full benefit of the right to health in South Africa. All right? So, when we think about this period of time, coalitions were built, legal challenges were carried out, direct action civility disobedience were employed as tactics and strategies, and these were the mechanisms by which policy was changed. But that was not, that was not sufficient, that was not adequate to enable the majority of people living with HIV/AIDS to sustain their lives, and people continued to die as a result. Now, what changes, what happens? Well,.. After the international AIDS conference 2006 in Toronto, when AIDS dissidents displayed garlic, lemon, and beetroot alongside ARVs as forms of AIDS treatment, which leads to international uproar, right? What occurs is that there's actually a breaking point reached within the ANC, and as a result, members of the ruling party begin to kind of pull the AIDS movement into the state, and they restructure the South African national AIDS council or SANAC to be a broad-based hybrid kind of government civil society institution, and the deputy chair of the institution is Mark Haywood, who is the co-founder of the treatment action campaign, a member of the AIDS law project, and one of those activists that was trained by first wave activists. So, what this does, right? And they kind of, the AIDS movement moves into this state, they occupy the state, and they kind of control the development of policy norms that then can oversee, and they are allowed to oversee and kind of monitor implementation with the national department of health. Now, this sounds like a wonderful plan, and as you can see, it actually in the end does lead to kind of large scale, you know, increases in spending on HIV/AIDS treatment, but it's not really until 2007, 2008 that this begins, because that is the period of time when the AIDS Dissident faction is pushed out of office. So, when we look at this period of time, and Mbeki, Thabo Mbeki is recalled from office as being president because he's actually running indirectly for a third term of office. He runs to be president of the ANC where he will actually control party policy, and so he won't be president, but he'll control the party that is operating within the state. Now, the ANC turns against this, and as a result, Jacob Zuma is put forward as presidential candidate, and Mbeki's recalled from office early, Manto Tshabalala-Msimang is recalled from her post as the National Minister of Health, and we see very fast movement on HIV/AIDS. So, between 2008 and 2012, we see a massive increase in the allocation in resources to the HIV/AIDS epidemic, to rolling out access to HIV/AIDS treatment. And you can see in this graph, this is the number of people on intraurethral valve therapy. So, when we look at this period of time, there were increases leading up to that period of time that we see ramping up. But post 2008, in those four years, universal treatment is reached. 80% of people in need of AIDS treatment, particularly amongst women and children have that by 2012. So, this is driven by SANAC and SANAC is being pushed by the HIV/AIDS movement. So, when we talk about how universal treatment was achieved, it's important to keep in mind this kind of long duration between the late 1990s and 2012, that it took to push government policy, and eventually not just to push government policy, not just to build alliances with people in the state, but to actually move into the state, move into SANAC move into a government institution, and actually direct policy by those folks within those institutions directly. So, this is like the really big success story here, the universal treatment's been achieved. This is the largest HIV/AIDS treatment program in the world. It's also the largest HIV/AIDS epidemic in the world. But that's a massive achievement. So, now that universal treatment has been achieved, what are the challenges that lay ahead? Now, a big issue here is that HIV incidents is steady. And in English, what that means is that the infection rate is steady, it's level, it's the same. So, as more folks go in treatment, that means that there are more people living with HIV/AIDS in Africa, so we're up to almost seven million now of people living with HIV/AIDS in the country. So, one of the issues is, of course, that we're going to see rising treatment costs. As more people live longer lives, you know, HIV/AIDS is a chronic medical condition if you have access to treatment, you stay on your treatment. So, if someone is infected between the ages of 15 and 24, they may live to be in their mid 60s. So they're going to be on treatment for the rest of their lives, and they actually need to stay on treatment because if they go off treatment, the virus mutates in their body, then you move to second line treatment, which is more expensive. And of course, a lot of these debates are about access to medicines, and you know, there's a lot of pressure from civil society groups and from communities for access to HIV/AIDS treatment. It's clear that people can sustain on treatment. The argument, some of the link between HIV and AIDS, you know, while still being resuscitated by some kind of secretors of African society, largely speaking, uptake has been quiet strong of treatment. So, what we're seeing now is not a question of a link between HIV and AIDS, but questioning how long South Africans can afford to pay for treatment. About 30% of AIDS treatment is donor funded, but that still leads the largest HIV/AIDS epidemic in the world, you know, being kind of addressed by a middle income country. so when we think about where treatment is heading right one of the big developments of the last five years is pre exposure prophylaxis now again in English what that means is that people can take antiretroviral therapy prior to exposure to HIV and this serves as a mechanism for preventing infection so right now in urban areas across the United States populations at risk are on pre exposure prophylaxis or prep. Now, in the United States the epidemic is relatively concentrated amongst men who have sex with men MSM there are some kind of larger trends towards in urban areas towards other populations all right but in South Africa given the size of the epidemic one of the questions with prep is how many people have to be on pre exposure prophylaxis to prevent HIV transmission. We're talking about epidemic of over six million people in a population of nearly 60 million. is it everyone and their partners? Do they have one partner? So how do you begin to kind of cost this out? How do you begin to kind of say we want an AIDS-free world by 2030 this is City Bay and other folks at UNAIDS. And I think that one of the questions we need to ask here is, what kind of solidarity is going to be necessary to massively upscale pre-exposure prophylaxis in South Africa so that the 15 to 24 group that they're targeting, in South Africa right now, can actually grow up without being exposed to HIV. And so the current strategy right now emerging of SANAC is to target sex workers and so the sex worker strategic plan just came out about a month and a half ago. Now this is incredibly important because it builds on the most recent research. Where half of sex workers in Johannesburg were found to be HIV positive. Now that sounds very high doesn't it? Well earlier research on thewhich connects Johannesburg and Durban found that four to five sex workers had HIV. So when we think about how the kind of way in which prep is being targeted they're going to really focus on, you know, sectors of the population first where they know that there's a high concentration of HIV, tom you know, also suppresses viral load which means someone doesn'tm the possibility of transmitting HIV is a lot lower. Now one of the things that serves as an important backdrop to discussion of treatment of pre exposure prophylaxis is the fact that staff workers macroeconomic policy has generally kept allocations for health relatively steady. Now an important bit of contextual information that builds on the broader historical overview that I gave is that South Africa really has a dual epidemic, of HIV/AIDS and tuberculosis, is endemic, where one builds off the otherm you're exposed to TB, your immune system is compromised, you're more likely to get HIV. You're exposed to HIV, your immune system is compromised you're more likely to get TB. And unfortunately, it's not just straight old tuberculosis. This is multi drug-resistant tuberculosis, extensively drug-resistant tuberculosis, and now total drug-resistant tuberculosis. So we think about the burden of disease in South Africa and we think about the level of resources which should be allocated within a particular society, all right, these kind of broad normative claims towards say the Abuja Declaration and allocating 15% of your budget to health really must run up against the historical constraints of inequality in South Africa as well. You know, how does one undo 300 years of unequal development? 350 years, let's be honest. Right, how does one begin to address? Right, the broad social inequalities that also manifests in the area of disease and illness, but addressing those diseases and illnesses has a cost associated with them. Many of these medicines are patent controlled, and as a result, I mean you know, there's a high cost involved with upscaling these sorts of accesses as treatment. So Universal treatment has been achieved. However, incidence is steady, the current interventions to control the spread of HIV/AIDS may, you know, be, let's say, given the scale of doing so unaffordable right now in South Africa. So one of the questions that really have to be faced is you know how will the epidemic be ended in South Africa? Right, now the technology exists. Pre-exposure prophylaxis works. What are we going to decide? The staff are going to go it alone? Who's going to work with them? How will we upscale? These are the questions that we're facing now. So thank you for your time I appreciate it. - [Sue Dulek] What did moral authority, that's in quotes, types such as Archbishop Tutu and Nelson Mandela contribute to the national dialogue about how to respond to HIV/AIDS? - [Thedore Powers] I think both Tutu and Mandela played a very positive role. Mandela actually publicly broke within MBeki during the Mbeki Presidency and this is, you know, not expected for a previous ANC President to actually publicly critique a standing ANC president you know of the country he actively went to public protests he wore the HIV-positive t-shirt he disclosed that one of his sons had died from HIV. So when we think about Mandela's role in the late 1990s, you know, clearly there could have been more done let's say, to be succinct amidst a kind of a sea of pressing priorities and current, including in current currency crises but there was a lot of kind of very strong action taken by Mandela after the previous Presidency to address stigma, to kind of publicly support access to HIV/AIDS treatment and I think that, you know, Archbishop Desmond Tutu has been very clearly on message in this the entire time, with the AIDS activists. So I think that one of the issues is that these kind of aspirational symbolic leaders of the anti-apartheid movement right were important during a particular period of time but that kind of state control of public health institutions was an impetus structural impediment that could not be overcome until there was the removal of particular individuals from office. So when we think about this period of time I think that's important to kind of think about the kind of, not only the role of an individual within society but also the way in which they occupy certain roles in institutions, be they within the AIDS movement or outside of it, but they played an important role. I think it was a universally positive one. - [Sue Dulek] We have a few questions. Going to try to combine them a little bit. And this has to do with, I think your quote was 30% comes from the South African nation itself for healthcare, maybe 70% outside, vice versa. In any event the outside is a money coming from the US such as in George Bush's programs, Bill Gates private contributions, a little of both, if you could comment on that. - [Thedore Powers] So right the world of foreign donor funding for HIV/AIDS programs is complex, as you might imagine and now you know the way in which has been defined as by people on the ground to go around townships and go to different kind of clinical sites has been a mix of either Anarchy or projectification, ie that access to health has been become a process of analyzing or let's say accessing different projects and in South Africa that's also been true and so the Presidential Emergency Plan for AIDS relief PEPFAR, you know has been important in terms of providing access to treatment and resources in South Africa. Importantly that donor program bypasses the South African state, so it goes directly to nongovernmental organizations and community-based organizations. So that one's structured in that fashion. The Global Fund, you know for HIV/AIDS, tuberculosis and malaria has also been very important donor in South Africa. Those funds go through the Ministry of Health and are kind of deployed within that particular framework, so there are also important multilateral donor, you know, programs after Mbeki was pulled out of office, the UK actually came forward with actually a strong donor support for both the National AIDS Council and for expansion of PMPCT. So it's really issue based and there are a lot of countries that are expressing solidarity through support for kind of AIDS treatment programs, you know, but what I would say is really important to think about alongside that is that governments and donor organizations can't do this alone. Really an important group to bring to the table are the producers and patent holders for intraurethral valve therapy. They hold the key to this particular issue because they control pricing. So there might be a certain amount of resources that are allocated to fight AIDS in South Africa. The question is, how people can go on treatment within that given amount? And I think that's really where the conversation needs to be shifted for us to begin to think about actually ending AIDS. - [Sue Dulek] Can you speak a little bit about HIV/AIDS among children in South Africa? - [Thedore Powers] So the impact on children has shifted over time. One of the first targets of the second weight of HIV/AIDS activism was as I mentioned the prevention of mother-to-child transmission of HIV/AIDS, and we've known since the early 1990s that AZT cuts the kind of rate of vertical transmission right across generations and called a vertical transmission by about half. Combination, kind of PMPCT with nevirapine cuts it by above 90%. So when we get to the period of time when dual therapy has been implemented in South Africa in the kind of mid-2000s, one of the goals is to keep that above 90%, right, to keep the transmission rate below 10% between mother and child when the mothers have HIV. So the number of children who are born with HIV/AIDS is decreasing. This is one of the target areas that, you know, you can kind of prevent that actually with a very inexpensive and efficient mechanism, however, we've had, you know, some of the productive generations taken out of stuff in society haven't we? So you actually have a big issue of AIDS orphans. There are children who were also born without being registered for the necessary paperwork to receive state grants, you know, it's child care and whatnot for forms of state support. So a big question is, is how can those children be supported and of course there's many donor organizations that are doing kind of, you know, AIDS orphan programs, but you know, simply housing and clothing and feeding an orphan, you know, doesn't necessarily deal with all the contradictions that they're going to face as a young person growing up in African society, social reproduction is a complex process whereby knowledge in kind of cultural practices or passed across generations. So we think about this conduct the way in which HIV/AIDS figures in the lives of children, it's one where those children are, if they're not infected, they're affected, right? Whether its family members, whether it's your parents, whether you live with your grandmother, these are questions that I think permeates the African society and it's really difficult to know what the long-term effects of that will be, but I think that we're going to going to have to wait and see. - [Sue Dulek] Could you further explain the rationale for the ANC AIDS dissident factions point of view and what kind of power, I think you'd mention that they still have it and why does it still hold sway with some folks? - [Thedore Powers] Right so there was a controversial clinical trial with AZT in the early 1990s caused a vigorous debate within the AIDS circles in the United States itself. Now Peter Duesberg, other American scientists were heavily critical over whether the way in which the clinical trial was carried out, simply showed high levels of toxicity or whether it actually showed remission of the virus. As a result those debates about AIDS treatment and the kind of confident link between HIV and AIDS that kind of grew out of that debate were picked up on by other groups in society, societies around the world, including South Africa. So, you know, one of the things about dissidents and dissidents of science, is that the Internet has been a wonderful mechanism for the expression and extension of those belief systems and that it appears as though that is the mechanism by which the AiDS dissidents faction was first exposed to these ideas in South Africa, they were then disseminated by the president of South Africa to other kind of key allies within the state and for a long time we weren't sure about this but Mbeki recently came on confirmed this an auger biography by Frank Chikane also confirmed that Mbeki was the key source of the information and the way which is continues to manifest, is that, you know, Manto Tshabalala-Msimang and Thabo Mbeki are no longer formally in politics. That does not mean that their acolytes have gone away. So when we think about some of the folks that were aligned within the dissident faction they still hold positions within the state and so the the question about whether you know what's the the kind of half-life of this sort of a belief system or the long term effects you know one of the questions is you know with the uptake population, you know, if one actually is ill and you eat healthy foods, your health recovers to degree doesn't it? So garlic, lemon, beetroot, sweet potatoes, these things actually will, if you're, you know, slightly it'll help to kind of, in a homeopathic fashion, heal your body. They will not curates but one has to really ask whether or not people's everyday experiences of those foods have a healing quality led to them to at least consider this hypothesis as having a degree of validity, right? And we can't discount the long-term potential impacts of this, all right. It looks like the uptick numbers override this. There's, I mean, there's a lot of research on this, there's a lot of people looking into this. We also have to ask whether or not people are somewhat circumspect of like researchers showing up with a survey. And saying, what do you think about this? Remember the belief system was about profiteering of global pharmaceutical corporations and the ways in which various actors support and extend the agenda of those corporations. Now what a research did, are doing research about AIDS but into that particular demographic for individuals in certain parts of the country perhaps. So one of the questions we have to ask is about what kind of information do we really have? When does someone really expose their belief system to you, after they've known you for five or 10 years, five minutes, right? So these are some of the questions that we have to really grapple with in this instance and I think that in terms of the way that I've been looking at it in the end, we have to look at treatment uptake. Are people going on treatment or not? Have they seen their friends live or not? And I think in the end what we see is people are going on treatment when they're sick. So it's a very kind of complex set of issues but there's been a lot of books written as a belief system. Personally I looked at it as a belief system in terms of how it was put into practice politically, through institutions, do the limitations on treatment. So that I could actually see how it worked in motion rather than an abstract set of ideals. - [Sue Dulek] Last question, we'll try to be on. Are you optimistic about the future at all? I mean... I mean do you see, with the prep and other things going on politically, that the corner has been turned, so to speak? - [Thedore Powers] I think that the developments are all this year about a sex worker strategic plan for me were an incredibly important transition point. Because it focuses on the decriminalization of sex work and this is an incredibly important vector for disease control in South Africa and particularly when you have a generalized epidemic that's sexually transmitted, criminalizing the population that might be might be the kind of key point for addressing transmission would seem to be maybe a counterproductive strategy. I've spoken with people, the National AIDS Council, I know that there are very smart, hard-working people that are based in this institution. I think that we're entering different period of time in history of HIV/AIDS because we now have tools and we have tools and we have the knowledge to understand that, we can halt transmission. We should still keep people alive but we can halt transmission. The question is about collective political will. So Africa does not have the resources to go this on their own. They do not to upscale treatment of pre-exposure prophylaxis. The question is who will come together in solidarity with South African society to produce that outcome? And I'm hopeful about the capacity of South African people to address this issue and develop tools and interventions within their own society. When it comes to the mobilization of global resources or on pre-exposure prophylaxis, I've not seen a lot of movement yet, so perhaps that will come, but I've not heard it brought up in the election cycle. I'm not necessarily expecting to hear about this. But it's certainly an issue that we, as a society, should be consider discussing about and that's why I'm very thankful for the opportunity to speak with you and bring these issues to your attention. - [Sue Dulek] On behalf of the Iowa City Foreign Relations Council. I do want to thank you Dr. Powers for your presentation. I also want to thank our sponsors once again. University of Iowa's International Programs, the U of I Honors Program, Stanley UI Foundation Organization for their generous financial support. Again, we also want to thank today's financial sponsors, John Menninger, and US Bank, and City Channel 4. And last but not least, our coveted mug, we want to present to you for taking the time to enlighten us on this topic. Thank you very much.