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South African AIDS policy lurches into new crisis
World Report
South African AIDS policy lurches into new crisis Even by the tempestuous standards of South African health policy, the past few weeks, which have seen the dismissal of the deputy health minister and the publication of shocking allegations about the health minister, have been nothing short of extraordinary. Clare Kapp reports.
www.thelancet.com Vol 370 September 1, 2007
Zille said delays and bureaucracy meant that South Africa now took four times longer than the international average to approve new medicines and that it was still awaiting regulations allowing nurses to prescribe medications, including antiretrovirals (ARVs). The TAC published a copy of a letter it sent to President Mbeki last September with detailed grounds for dismissal of the health minister. It said it had received no reply and threatened possible court action if the president did not provide, by a Sept 7 deadline, his reasons for retaining Tshabalala-Msimang . South Africa’s Sunday Times newspaper alleged that she was dismissed from her post as medical superintendent at a Botswana clinic in 1976 for theft. It went on to state that under Botswana law she was declared a prohibited immigrant for the next 10 years. Tshabalala-Msimang’s spokesman denied the allegations, dismissing the report as ‘’false, speculative, and bizarre’’. The Sunday Times also alleged that Tshabalala-Msimang had a liver
transplant in April because of years of excessive drinking. It went on to claim that doctors were pressurised into agreeing to the transplant even though she did not fulfil the criteria. However, her physician stated that the reason for the transplant was because Tshabalala-Msimang had been diagnosed with autoimmune hepatitis. In addition, Johannesburg’s Donald Gordon Medical Centre denied that the 66-year-old minister jumped the queue and said it acted according to the internationally accepted Model for EndStage Liver Disease system, whereby the sickest person gets priority. The minister, who returned to work in June, sued the Sunday Times to recover medical records pertaining to her 2005 stay in a Cape Town clinic for shoulder surgery. The newspaper reported that during her stay she consumed alcohol and was abusive toward staff. The minister responded that the report was “false” and “malicious” and that “many allegations and insinuations are so bizarre, scandalous, speculative, and incredible that [she] does not wish to dignify them with a response”.
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President Thabo Mbeki’s dismissal of the respected deputy health minister Nozizwe Madlala-Routledge—one of the driving forces behind the country’s new 5-year HIV/AIDS strategy—and newspaper allegations of theft and alcoholism against Health Minister Manto Tshabalala-Msimang have produced a crisis of confidence in a ministry long dogged by controversy. It has also led to fears for the HIV/AIDS National Strategic Plan (NSP), which was launched in April with the goal of extending treatment and care to 80% of those in need by 2011 and halving the number of HIV infections. The Treatment Action Campaign (TAC) says that there has been little concrete action and the targets for this year are unlikely to be met. ‘’We are seeing alarming signs of a return to the rhetoric and confrontation of the past over HIV’’, warned the Southern African HIV Clinicians Society. Faced with a tidal wave of international and national criticism, the government closed ranks to protect Tshabalala-Msimang, instead turning its ire on journalists for ‘’the distasteful media coverage”. ‘’I’m not stepping down because I don’t understand why I should step down unless, as the president has said, you give him reasons for what it is that I have done”, a defiant TshabalalaMsimang said at an Aug 23 media conference. “Have I neglected the duties assigned to me?” Helen Zille, leader of the Democratic Alliance opposition party, quickly sent Mbeki a long list of reasons, including the minister’s controversial stance on HIV/AIDS, the failure to tackle the country’s tuberculosis epidemic, the department’s poor financial management record, and the staff crisis in public sector hospitals.
Tshabalala-Msimang has said that she is not stepping down from her post
727
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World Report
Madlala-Routledge dances with HIV/AIDS activists after a press conference
Amid outrage over the breach of patient-doctor confidentiality, the Cape Town Medi-Clinic joined in the legal action against the theft of the records, which disappeared from the clinic. Tshabalala-Msimang also sought to ensure in the court hearing that all records and any references to her hospitalisation, treatment, and medical status was deleted from reporters’ notebooks and personal laptop computers. As The Lancet went to press, no ruling had been made by the court. The newspaper denied theft. It said its reports were a legitimate part of a debate on whether the minister was fit to hold office and did not breach confidentiality. President Mbeki’s office said there was no immediate reason to investigate the allegations of alcohol abuse or a theft conviction. Mbeki’s close ties with the minister date back decades when the two were in exile from the apartheid regime. Critics say the fact that her husband is treasurer of the ruling African National Congress has also helped shield her, as well as the fact that Mbeki harbours denialist tendencies on HIV/AIDS. Tshabalala-Msimang is widely dubbed Dr Beetroot or Dr Garlic because of her promotion of certain foods for people with AIDS and her open mistrust of ARVs (she went out of her way at a recent news conference to warn that the price of next generation drugs may soar by 500%). 728
Her theories, long ridiculed by the international medical establishment, were also refuted in a 300-page report by the Academy of Science of South Africa. “The panel has concluded that no food, no component made from food, and no food supplement has been identified in any credible study as an effective alternative to appropriate medication”, said professor Barry Mendelow, one of the authors. Madlala-Routledge was nearly dismissed 2 years ago when she spoke out in favour of ARVs rather than nutrition in parliament. Mbeki sacked the deputy minister after she took her son and an adviser on an unauthorised trip to an International AIDS Vaccine Initiative meeting in Spain. She said she was unaware that Mbeki had refused his approval and returned home as soon as she found out. Mbeki also accused her of not acting as part of a team. In addition to her differences with her boss over HIV/AIDS, MadlalaRoutledge also infuriated the country’s leadership by declaring that infant mortality at some public sector hospitals was a ‘’national emergency’’. Nokuzola Ntshona, a senior doctor at the Frere hospital at the centre of the scandal, was suspended for a breach of conduct after she also went public with her concerns. The dismissal prompted shock and anger. The South African Medical Association, Rural Doctors Association of Southern Africa, and the former UN special envoy on HIV/AIDS in Africa, Stephen Lewis, were among those who voiced their unequivocal support. The HIV Clinicians Society said Madlala-Routledge played a ‘’fundamental role in bringing civil society and professionals together’’. ‘’Our country desperately needs trusted and brave leadership in the area of HIV. The deputy minister gave us hope that this was possible’’, it said. The Society and TAC asked for urgent clarification why the mother-to-child HIV prevention programme (PMTCT)
was still at only 30% coverage after 5 years, and questioned the delay in upgrading single-dose nevirapine for PMTCT to the dual therapy recommended by WHO. It said that fewer than 20% of adults requiring antiretrovirals were receiving them, after more than 3 years of publicly available antiretroviral therapy (ART). An estimated 250 000–280 000 people are receiving ART in the public sector, although reliable figures are hard to come by because of lack of monitoring and evaluation. TAC said if the government was serious about achieving the NSP targets, it would mean bringing an additional 120 000 adults and 17 000 children on treatment by the end of the year. It said 70% of all pregnant women should—according to the targets—be tested for HIV, and 25 000 pregnant women should receive a comprehensive package of AIDS care including ART. Fatima Hassan of the AIDS Law Project told The Lancet there was no way the government would reach its target of 1·6 million people on treatment by 2011 at the current rate. Specifically, she said that the health department was slowing the accreditation of new ART dispensing facilities by insisting on central control rather than giving responsibility to individual provinces. Nor had there been any moves to allow nurses to administer ART as provided for in the plan, Hassan said. Mark Heywood, a civil society activist nominated to be vice-chairman of the revitalised South African National AIDS Council, said the mood was one of uncertainty over the future direction of the council. ‘’There is frustration because people are thinking that things are not happening at the speed at which they are meant to be. The government keeps saying there is no threat to the NSP. But it’s not just a case of saying it, it’s all about demonstrating it.’’
Clare Kapp www.thelancet.com Vol 370 September 1, 2007
South African AIDS policy lurches into new crisis Even by the tempestuous standards of South African health policy, the past few weeks, which have seen the dismissal of the deputy health minister and the publication of shocking allegations about the health minister, have been nothing short of extraordinary. Clare Kapp reports.
www.thelancet.com Vol 370 September 1, 2007
Zille said delays and bureaucracy meant that South Africa now took four times longer than the international average to approve new medicines and that it was still awaiting regulations allowing nurses to prescribe medications, including antiretrovirals (ARVs). The TAC published a copy of a letter it sent to President Mbeki last September with detailed grounds for dismissal of the health minister. It said it had received no reply and threatened possible court action if the president did not provide, by a Sept 7 deadline, his reasons for retaining Tshabalala-Msimang . South Africa’s Sunday Times newspaper alleged that she was dismissed from her post as medical superintendent at a Botswana clinic in 1976 for theft. It went on to state that under Botswana law she was declared a prohibited immigrant for the next 10 years. Tshabalala-Msimang’s spokesman denied the allegations, dismissing the report as ‘’false, speculative, and bizarre’’. The Sunday Times also alleged that Tshabalala-Msimang had a liver
transplant in April because of years of excessive drinking. It went on to claim that doctors were pressurised into agreeing to the transplant even though she did not fulfil the criteria. However, her physician stated that the reason for the transplant was because Tshabalala-Msimang had been diagnosed with autoimmune hepatitis. In addition, Johannesburg’s Donald Gordon Medical Centre denied that the 66-year-old minister jumped the queue and said it acted according to the internationally accepted Model for EndStage Liver Disease system, whereby the sickest person gets priority. The minister, who returned to work in June, sued the Sunday Times to recover medical records pertaining to her 2005 stay in a Cape Town clinic for shoulder surgery. The newspaper reported that during her stay she consumed alcohol and was abusive toward staff. The minister responded that the report was “false” and “malicious” and that “many allegations and insinuations are so bizarre, scandalous, speculative, and incredible that [she] does not wish to dignify them with a response”.
Getty Images
President Thabo Mbeki’s dismissal of the respected deputy health minister Nozizwe Madlala-Routledge—one of the driving forces behind the country’s new 5-year HIV/AIDS strategy—and newspaper allegations of theft and alcoholism against Health Minister Manto Tshabalala-Msimang have produced a crisis of confidence in a ministry long dogged by controversy. It has also led to fears for the HIV/AIDS National Strategic Plan (NSP), which was launched in April with the goal of extending treatment and care to 80% of those in need by 2011 and halving the number of HIV infections. The Treatment Action Campaign (TAC) says that there has been little concrete action and the targets for this year are unlikely to be met. ‘’We are seeing alarming signs of a return to the rhetoric and confrontation of the past over HIV’’, warned the Southern African HIV Clinicians Society. Faced with a tidal wave of international and national criticism, the government closed ranks to protect Tshabalala-Msimang, instead turning its ire on journalists for ‘’the distasteful media coverage”. ‘’I’m not stepping down because I don’t understand why I should step down unless, as the president has said, you give him reasons for what it is that I have done”, a defiant TshabalalaMsimang said at an Aug 23 media conference. “Have I neglected the duties assigned to me?” Helen Zille, leader of the Democratic Alliance opposition party, quickly sent Mbeki a long list of reasons, including the minister’s controversial stance on HIV/AIDS, the failure to tackle the country’s tuberculosis epidemic, the department’s poor financial management record, and the staff crisis in public sector hospitals.
Tshabalala-Msimang has said that she is not stepping down from her post
727
Getty Images
World Report
Madlala-Routledge dances with HIV/AIDS activists after a press conference
Amid outrage over the breach of patient-doctor confidentiality, the Cape Town Medi-Clinic joined in the legal action against the theft of the records, which disappeared from the clinic. Tshabalala-Msimang also sought to ensure in the court hearing that all records and any references to her hospitalisation, treatment, and medical status was deleted from reporters’ notebooks and personal laptop computers. As The Lancet went to press, no ruling had been made by the court. The newspaper denied theft. It said its reports were a legitimate part of a debate on whether the minister was fit to hold office and did not breach confidentiality. President Mbeki’s office said there was no immediate reason to investigate the allegations of alcohol abuse or a theft conviction. Mbeki’s close ties with the minister date back decades when the two were in exile from the apartheid regime. Critics say the fact that her husband is treasurer of the ruling African National Congress has also helped shield her, as well as the fact that Mbeki harbours denialist tendencies on HIV/AIDS. Tshabalala-Msimang is widely dubbed Dr Beetroot or Dr Garlic because of her promotion of certain foods for people with AIDS and her open mistrust of ARVs (she went out of her way at a recent news conference to warn that the price of next generation drugs may soar by 500%). 728
Her theories, long ridiculed by the international medical establishment, were also refuted in a 300-page report by the Academy of Science of South Africa. “The panel has concluded that no food, no component made from food, and no food supplement has been identified in any credible study as an effective alternative to appropriate medication”, said professor Barry Mendelow, one of the authors. Madlala-Routledge was nearly dismissed 2 years ago when she spoke out in favour of ARVs rather than nutrition in parliament. Mbeki sacked the deputy minister after she took her son and an adviser on an unauthorised trip to an International AIDS Vaccine Initiative meeting in Spain. She said she was unaware that Mbeki had refused his approval and returned home as soon as she found out. Mbeki also accused her of not acting as part of a team. In addition to her differences with her boss over HIV/AIDS, MadlalaRoutledge also infuriated the country’s leadership by declaring that infant mortality at some public sector hospitals was a ‘’national emergency’’. Nokuzola Ntshona, a senior doctor at the Frere hospital at the centre of the scandal, was suspended for a breach of conduct after she also went public with her concerns. The dismissal prompted shock and anger. The South African Medical Association, Rural Doctors Association of Southern Africa, and the former UN special envoy on HIV/AIDS in Africa, Stephen Lewis, were among those who voiced their unequivocal support. The HIV Clinicians Society said Madlala-Routledge played a ‘’fundamental role in bringing civil society and professionals together’’. ‘’Our country desperately needs trusted and brave leadership in the area of HIV. The deputy minister gave us hope that this was possible’’, it said. The Society and TAC asked for urgent clarification why the mother-to-child HIV prevention programme (PMTCT)
was still at only 30% coverage after 5 years, and questioned the delay in upgrading single-dose nevirapine for PMTCT to the dual therapy recommended by WHO. It said that fewer than 20% of adults requiring antiretrovirals were receiving them, after more than 3 years of publicly available antiretroviral therapy (ART). An estimated 250 000–280 000 people are receiving ART in the public sector, although reliable figures are hard to come by because of lack of monitoring and evaluation. TAC said if the government was serious about achieving the NSP targets, it would mean bringing an additional 120 000 adults and 17 000 children on treatment by the end of the year. It said 70% of all pregnant women should—according to the targets—be tested for HIV, and 25 000 pregnant women should receive a comprehensive package of AIDS care including ART. Fatima Hassan of the AIDS Law Project told The Lancet there was no way the government would reach its target of 1·6 million people on treatment by 2011 at the current rate. Specifically, she said that the health department was slowing the accreditation of new ART dispensing facilities by insisting on central control rather than giving responsibility to individual provinces. Nor had there been any moves to allow nurses to administer ART as provided for in the plan, Hassan said. Mark Heywood, a civil society activist nominated to be vice-chairman of the revitalised South African National AIDS Council, said the mood was one of uncertainty over the future direction of the council. ‘’There is frustration because people are thinking that things are not happening at the speed at which they are meant to be. The government keeps saying there is no threat to the NSP. But it’s not just a case of saying it, it’s all about demonstrating it.’’
Clare Kapp www.thelancet.com Vol 370 September 1, 2007