GOEDGEDACHT FORUM FOR SOCIAL REFLECTION

The potential destructive impact of AIDS is enormous. It can successively destroy individuals, families, communities and villages and is certain to affect both the national and household economies. (NAP; 7)

It is remarkable how often people visiting South Africa express their amazement that the country now has what is regarded as the fastest growing epidemic in the world. This amazement comes from the fact that there is no visible attempt to address this epidemic. No public awareness posters, no pamphlets, billboards, warning to travellers, no sense of urgency. People they meet will agree that it’s’ dreadful’ and a disaster, but those feelings of horror seldom translate into any real action.

It is really rather difficult to think why this should be so. Although this is a ‘hidden epidemic’ in terms of visible cases – the figures and these come from the reliable antenatal surveys show that the epidemic is indeed spinning out of control and setting up a disaster of unimaginable proportions. This disaster will not only be in terms of human suffering but also in terms of the effect on the country. Uganda’s experience both in terms of the pain of the epidemic and in terms of their alleged turn around has been well documented, and we see what is happening in Zimbabwe and we hear all the talk about declaring AIDS a national disaster. And yet the most committed we seem to be as a nation is to wear red ribbons and salute world AIDS day.

In answer to the question what has happened to the National AIDS Plan and what has been achieved since 1994, it is easy to ask – What AIDS Plan? But in fact South Africa has a very good AIDS Plan – often cited as the best in the world, both in terms of its process and its content.

NACOSA

The AIDS Plan was developed through the structures and work of NACOSA – the National AIDS Committee of South Africa, formed at a great meeting in 1992 – SOUTH AFRICA UNITED AGAINST AIDS – addressed by Nelson Mandela. Over 400 people attended it from the government, NGOs, the ANC and other political parties, religious groups, business and unions and youth. From this gathering six working groups were established to develop the six key strategies.

It is worth considering these again:

· Education and prevention

· Counselling

· Care

· Welfare

· Legal reform and Human rights

· Research

Each of these key strategies had two or three priorities for immediate attention and a detailed description of the key components so that anyone, who wished to, could set up a good comprehensive HIV/AIDS programme.

This was a plan that was developed from experience and expertise rather than a plan imposed from either the WHO or from the State – it was if you like a peoples’ plan for the people. The Plan was ratified by the Government of National Unity in 1994 and supported by every Minister.{quote1}

There was a great deal of hope pinned on the plan – but it faltered at the very moment it should have been strong – and that was in the implementation design. Here it was thought appropriate to call in the experts from the GPA and instead of the six strategic areas flowing into an plan of action they were reduced to three with their own objectives, strategy and time frame

· Prevent HIV transmission

· Reduce the personal and social impact of HIV infection

· Mobilise and unify national, provincial, international and local resources.

This killed the plan because in the first place the GPA had a notion of ‘AFRICA’ and a notion of an AIDS plan suitable for Africa. But worse it called for such a complement of staff and such a budget that even the most adventurous civil servant was daunted. Even as it was being drafted it was acknowledged that it would be impossible to implement and that aspects would need to be prioritised. But the expertise of the plan was negated by the expertise of the GPA and there was no real attempt to mutually discuss how the plan should look. 1.

Essentially the plan was shelved. The various Directors of the National HIV/AIDS and STD programme have in one way or another looked at the Plan – either through the five key strategies – or the more precise business plans around strategic areas, or ignored most of it. But THE PLAN has never been seriously taken for consideration or implementation. At the very least had the priorities in each strategic component been addressed we would have had a very good response to HIV.

And so South Africa has six wasted years. The amount of expertise that went into the plan was extraordinary. People talked about what worked and how it worked. But the plan became the worst of tokens – held up as an example when needed and ignored and ridiculed when not needed.

NACOSA whose existence after the plan was to act as a watch dog on the government and to call it to account found that it could not do this as there was no plan, and instead it could merely comment on the lack of action, which ultimately led to a tense stand off and the quite deliberate sabotaging of NACOSA by the department of health. NACOSA has an excellent record in advocacy and lobbying and became one of the first ‘AIDS victims’ in the sense of being attacked and undermined by the other AIDS organisations and attacked by Minister Zuma.

What has been achieved?

This brings us to the question of what has been achieved. It is tempting to say nothing, but of course that is not true. The plan asked that AIDS be regarded as a high level position in the department of health. It was placed at Director level a position that has little clout This Directorate has a small staff, a huge task, a reasonable budget and no autonomy or ability to act creatively or with flair. Every decision has to be passed up and down the ranks and this delays process and decisions and is an impossible way to run a programme. Each province has duplicated this in one or other way, with a person responsible for AIDS and often a range of other things as well.

The previous government paradoxically had done quite a lot in terms of dealing with AIDS. They had established 19 ATICS (2), had created an AIDS Advisory group and had introduced strict blood control measures, and held a number of important national workshops. While there were legitimate criticisms of their approach, the location of the ATICS and their assumptions about ‘at risk groups’, their track record on AIDS is by comparison to the present not all that bad.

However, the first most difficult issue was the tension between the National programme and the provincial programme. Power struggles that assumed a self-sustaining importance, and in turn the struggles between provinces and local authorities, hindered the AIDS response. The provinces both expected the National Directorate to give leadership and when it did they rebelled. They wanted both guidance and autonomy and instead of one vibrant national united response there are 10 AIDS programmes. At National meetings what is most significant is how these different programmes vie for power and influence.

Many of the people in positions of power in the new government had been comrades in the struggle and part of the NACOSA process. There was high expectation that this commitment would carry forward into the new response. But instead, the former friends became antagonistic and very soon criticism was regarded and ‘counter revolutionary’ and the early tensions between the NGOS and the Government began to surface, coupled with the tensions between the three tiers of government.

Even at the most basic level of delivery – the formulation of policy the Government has failed to deliver. And the media campaign is marked by a lack of imagination and failure to produce sufficient quantity. All in all the response since 1994 has been characterised by a lack of vision, by pedestrian programmes and by a lack of any kind of leadership. It is as if we have just become aware of this epidemic and are struggling to find ways to understand it. There is also a tendency to uncritically reach out for any success story – Uganda, Thailand, and to try and replicate it here, with little regard for local conditions of programmes.

The various scandals have also had their effects – both Sarafina and Virodene were of great consequence to the National AIDS response, no matter how these are dismissed. It is also interesting to note that Mbeki was prepared to defend and support Virodene, a known toxin, whilst being scrupulous about AZT. But the greatest scandal of all is just starting to unfold and that is the scandal of lack of delivery, failure to engage the society in the urgency of prevention and the lack of any planning for care and support. The minimum standards for counselling have yet to be ratified, and whilst on a visit to a country area the Minister is reported to have queried the value of confidentiality and encouraged nurses to demonstrate against it. (3)

The failure to co ordinate the response means that while there are excellent programmes and policies, and these are largely run by NGOs and CBOs, there is no linking of these programmes, no shared learning and no shared vision.

It is clear that we do not know what we are doing. The failure of leadership means that there is no critique or debate about key issues affecting transmission such as sexual patterning of behaviour or culture. There is no theoretical understanding of either the epidemic or the society in which we are dealing with it. This is because in the main there has been an uncritical populist approach, decidedly anti intellectual and uninformed by either social or political theory. There are many calls that ‘the people’ understand their world, and they will tell us what they need. The issue is that it is not enough to understand the world – the crucial thing is to change it. Also we have no mechanism to understand or to cope with ‘the people’ when they tell us things that we do not like to hear. We complain that the interventions are not working, but there is no serious attempt to find out why they are failing. We see things in overly simplistic categories of poverty, gender, apartheid, migration etc as if these in and of themselves can act as an explanation and a justification. We have made no attempt to look critically at how our society and the individuals within it are constructed, how they understand power, relationships, education and how they understand either the epidemic or the attempts to address it. And so we throw out more of the same, ask for more money to do more of the same and seek endlessly for external factors for blame and for the massive social and political denial with which we are faced. And so we have the paradox of a society which is well informed about HIV and AIDS and in which vast sums of donor money have been poured into HIV/AIDS work, but with the result that we have a society in which there is little understanding of how to take this awareness and use it to create new meanings and patterns of community behaviour.

We have dealt with this, the most fascinating and irrational of epidemics, in a rational, predictable, pedestrian way. We ask status quo questions, we get status quo answers and despite billing AIDS as the new struggle we have no conceptual of understanding and no realisation that this could be the most powerful agent we have for social, political, economic and personal transformation.

Factors associated with refusal to treat

HIV-infected patients: the results of a national survey of dentists in

Canada

Public Health Association

GM McCarthy, JJ Koval and JK MacDonald

School of Dentistry, University of Western Ontario, London. gmccarth@julian.uwo.ca

OBJECTIVES: This study investigated dentists refusal to treat patients who have HIV. METHODS: A survey was mailed to a random sample of all licensed dentists in Canada, with 3 follow-up attempts (n = 6444). Data were weighted to allow for probability of selection and nonresponse and analyzed with Pearson's chi 2 and multiple logistic regression. RESULTS: The response rate was 66%. Of the respondents, 32% had knowingly treated HIV-infected patients in the last year; 16% would refuse to treat HIV-infected patients. Respondents reported willingness to treat HIV-infected patients (81%), injection drug users (86%), hepatitis B virus-infected patients (87%), homosexual and bisexual persons (94%), individuals with sexually transmitted disease(s) (94%), and recipients of blood and blood products (97%). The best predictors of refusal to treat patients with HIV were lack of ethical responsibility (odds ratio = 9.0) and items related to fear of cross-infection or lack of knowledge of HIV. CONCLUSIONS: One in 6 dentists reported refusal to treat HIV-infected patients, which was associated primarily with respondents' lack of belief in an ethical responsibility to treat patients with HIV and fears related to cross-infection. These results have implications for undergraduate, postgraduate, and continuing education.

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