restricted access 6. Responding to HIV/AIDS and Tuberculosis in South Africa
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6 Responding to HIV/AIDS and Tuberculosis in South Africa Along with South Africa’s transition to democracy in 1994 and its unwavering commitments to po­ liti­ cal stability and economic growth, in the 1990s it joined the other BRICS nations in confronting the threat of health epidemics. As in Rus­ sia, HIV/AIDS and TB posed such a threat. When its poor response to the epidemics aroused international criticism and pressure, South Africa’s leaders did not use this situation to pursue a stronger policy response with an eye to bolstering the government’s international reputation in health. Instead, building on a long foreign policy tradition of state sovereignty, in­ de­ pen­ dence, and international and regional leadership, the government’s reaction to the international community reflected its negative geopo­ liti­ cal positioning. That is, po­ liti­ cal leaders ignored the international pressure, resisted international­ financial and technical assistance, and deci­ ded to respond to ­ these epidemics at their own pace and in their own way. South Africa joined Rus­ sia in responding to HIV/AIDS, though not to TB, only when the epidemic threatened national security—­ including the economy, government, and military per­ for­ mance. Though the South African government also briefly joined its BRICS counter­ parts in providing foreign aid assistance for HIV/AIDS and TB programs, as in Rus­ sia, its intent was not to increase its international reputation but rather to solidify its regional leadership. Over time, however, South Africa’s bureaucratic and policy reforms proved to be in­ effec­ tive, revealing the inability of the Department of Health (DOH) to obtain a sufficient amount of parliamentary funding for prevention and treatment programs, much needed investments in­ human resources and infrastructure for policy implementation, and financial and technical assistance for provincial health departments. Responding to HIV/AIDS and Tuberculosis in South Africa   203­ These ongoing challenges ­ were also ­ shaped by the absence of strong bureaucratic–­ civil societal partnerships. For both HIV/AIDS and TB, bureaucrats never sought to partner with NGOs to improve their ability to obtain ongoing po­ liti­ cal and financial support for their programs. This challenge reflected the historically weak relationship between the bureaucracy, activists, and ­ those afflicted by disease in the area of public health, the resulting lack of expectations and motivation for working with each other, NGOs’ subsequent inability to effectively mobilize and respond and receive the po­ liti­ cal attention needed to influence policy, and thus a lack of interest and incentive for bureaucrats to partner with them. Without a strong bureaucratic–­ civil societal partnership , the government has not been able to achieve a centrist policy response. Responding to HIV/AIDS AIDS first emerged in South Africa in the city of Johannesburg in 1982 (Ras et al., 1983). Of the 215 South Africans who died of AIDS during the mid-­to late 1980s, 26 ­ were flight attendants for South African Airways. The virus was mainly contained within the white gay community during this early period, but by 1986 had transitioned to the black heterosexual and IDU community (Wren, 1990). Figure 6.1 traces the increase in AIDS cases in the 1980s and 1990s. 0 0 2 4 8 8 34 51 98 184 1980 1996 345 549 887 1,882 3,816 4,219 Figure 6.1. HIV/AIDS cases in South Africa, 1980–96. Source: UNAIDS, 2004. 2004 Update. South Africa. Epidemiological Fact Sheets. 204   Geopolitics in Health Motivated by fear and misunderstanding, National Party members and health officials exercised a ­ great deal of discrimination ­ toward the gay and black communities (A. Butler, 2005; Marias, 2000; Wren, 1990). Homophobia hampered policy attention to the gay community’s needs, creating an excuse for the government not to respond (A. Butler, 2005; S. Karim et al., 2009; Marias, 2000; Wren, 1990). Meanwhile, racism ­ toward the black community comported with the National Party’s policy of racial segregation, resulting in ­ little healthcare assistance (A. Butler, 2005; S. Karim et al. 2009; Lieberman, 2009; Marias, 2000; Wren, 1990). Feeling increasingly threatened by the rising and prosperous black population, and fearing that whites would one day be outnumbered , some Nationalist politicians celebrated the possibility that AIDS might fi­ nally eradicate the black population (A. Butler, 2005; Maxmen, 2009).­ These sentiments dovetailed with a general disbelief and denial within the Nationalists that HIV/AIDS had, in fact, emerged in their country. As we saw in China and Rus­ sia, a deep conservative moral impulse ran through the veins of South Africa’s National Party...