The Ministry of Magic School of Falsification

There’s a fantastic moment towards the end of The Crying Game when Jaye Davidson’s character recounts the story of a scorpion hitching a ride across a river on the back of a frog. Half way across, the scorpion stings the frog. When asked why, she simply replies: “It’s in my nature!”

Earlier, when reading through the Minister of Magic’s foreword to the recently revised guidelines on the prevention of mother-to-child transmission of HIV (PMTCT), the scorpion came to mind as I realised that the honourable doctor just couldn’t help herself. Instead of simply publishing the overdue guidelines, she couldn’t resist the temptation to airbrush history.

I could give a line-by-line critique of the foreword, pointing out all the lies, inconsistencies and misrepresentations. But I won’t. It’s not worth it. No one really cares anymore. We’ve resigned ourselves to the strong likelihood of the minister being allowed to serve out a full decade of mismanagement and unlawful conduct.

Instead, I’ll restrict myself to two examples of her transparent attempt to rewrite history: her characterisation of the Constitutional Court’s landmark PMTCT decision in 2002; and her implicit recognition of the president (of the country) as the champion of “the comprehensive HIV and AIDS programme”. Yes, I know, it really is quite laughable.

Let’s start with the court.

In her foreword, the minister writes the following: “After much discussion between policy makers and scientists, the Department of Health introduced the prevention of mother-to-child transmission of HIV (PMTCT) programme in 2001. The programme was first piloted to explore the impact of the use of nevirapine both with respect to its side effects as well as the operational requirements of the programme. The department had concerns about the use of monotherapy and the possibility of resistance to a single drug as well as the lack of clarity on infant feeding options. The presentations by the scientific community also suggested that the use of monotherapy needed further research. But whilst these discussions were taking place, the Constitutional Court ordered otherwise, in 2002 — the implication of which resulted in the expansion of the Niverapine [sic] use without adequate requisite preparations.”

Where does one even start? I guess at the beginning.

The PMTCT “pilot sites” were introduced in 2001 in response to civil society demands for the intervention. At its launch in December 1998, for example, the Treatment Action Campaign (TAC) publicly called for the provision of PMTCT services in the public sector. My organization, which played a key role in TAC’s birth, had been making this call for some time.

At some point, the government agreed to set up pilot sites (using zidovudine, also known as AZT) in Gauteng. They never materialised — the high cost of AZT being cited as the official reason for not implementing a programme. Just before the 1999 election, the minister’s predecessor met with the TAC and agreed on the need for joint action to reduce the price of AZT.

TAC kept its side of the bargain. The state did not. Instead, the president began his public questioning of the link between HIV and AIDS and the alleged toxicity of AZT. For more on this shameful legacy of his Presidency, it’s worth reading the transcripts of his 1999 speeches at Fort Hare and in the National Council of Provinces.

This history is simply blocked out when the minister notes that: “the comprehensive HIV and AIDS programme had its genesis in the Partnership Against AIDS that was launched in 1998 by then deputy president Mbeki as well as in the work done by the South African National AIDS Council (SANAC) which was established in 2000, first under the chairpersonship of the then deputy president of the country, Mr Jacob Zuma and most recently the current Deputy President Mrs Phumzile Mlambo-Ngcuka.”

The president’s “partnership” delivered little more than the schizophrenic report of his International Advisory Panel and the truly crazy Castro Hlongwane missive. And until it’s restructuring in 2006, which took place during the spirit of glasnost that followed the government’s extreme embarrassment at the Toronto International AIDS Conference, SANAC was largely dysfunctional.

But back to the minister and her mischaracterisation of the Constitutional Court’s order.

That she has always insisted that she was forced to provide nevirapine is disgraceful. It’s a blatant lie. She didn’t simply oppose nevirapine — she opposed PMTCT in any form. And when she had no choice in 2001 but to develop and implement a PMTCT programme of sorts, it was she who chose nevirapine as the antiretroviral of choice.

In contrast, the TAC has always insisted on a programme in accordance with World Health organisation guidelines. It never championed nevirapine.

Similarly, the court did not insist on nevirapine. But given government’s choice of nevirapine, the court held that the drug’s provision could not be limited to the 18 pilot sites that had been set up in 2001.

Importantly, the court expressly stated that its orders “do not preclude government from adapting its policy in a manner consistent with the Constitution if equally appropriate or better methods become available to it for the prevention of mother-to-child transmission of HIV”.

The minister also charges that the court order “resulted in the expansion of … [nevirapine] use without adequate requisite preparations.”

If that is indeed what happened, the blame should not be placed on the court. If she had read the judgement herself (her conduct suggests that she has never done so), or if her exceptionally well-paid (overpaid?) lawyers had correctly advised her (as they appear not to have done), she would know that the court expressly required the expansion of the PMTCT programme to be effected in a systematic and phased manner.

Consider, for example, paragraph three of the order, which required government to do the following: (a) Remove the restrictions that prevent nevirapine from being made available for the purpose of reducing the risk of mother-to-child transmission of HIV at public hospitals and clinics that are not research and training sites.
(b) Permit and facilitate the use of nevirapine for the purpose of reducing the risk of mother-to-child transmission of HIV and to make it available for this purpose at hospitals and clinics when in the judgement of the attending medical practitioner acting in consultation with the medical superintendent of the facility concerned this is medically indicated, which shall if necessary include that the mother concerned has been appropriately tested and counselled.
(c) Make provision if necessary for counsellors based at public hospitals and clinics other than the research and training sites to be trained for the counselling necessary for the use of nevirapine to reduce the risk of mother-to-child transmission of HIV.
(d) Take reasonable measures to extend the testing and counselling facilities at hospitals and clinics throughout the public-health sector to facilitate and expedite the use of nevirapine for the purpose of reducing the risk of mother-to-child transmission of HIV.

One last point deserves mention.

The minister makes much noise about nevirapine resistance. While a concern (although, as is clear from the court’s judgement, not sufficiently problematic to justify the non-provision of nevirapine monotherapy when nothing else is feasible), the inescapable conclusion one must reach about her obsession with the issue is that she has no real interest in finding a solution.

In the past few years, researchers have found ways to limit the risk of resistance significantly. None of these has found its way into the new PMTCT protocol, despite the evidence and express calls for inclusion. If she were truly concerned, as she claims she is, she would give up on trying to score political points and would take the experts seriously. Maybe she would even use her last year in office to undo some of her past mistakes.

Or maybe that’s just not in her nature.

With special thanks to Mark Heywood, who coined the title to this rant!