End of Aids denial era a chance to move forward

Manto Tshabalala-Msimang, photo credits: Mail and Guardian

Much has been written in the press recently about the death of South Africa’s former health minister, Manto Tshabalala-Msimang. Some of these reports pull no punches in highlighting the devastating role of the former health minister in buttressing former President Mbeki’s AIDS denialism. A recent Harvard University study found that the former President’s AIDS denialism was responsible for 350 000 deaths. In addition to this tragic loss of life, there were other less visible casualties. In particular, the polarised character of the politics of AIDS science during the Mbeki-era stymied open and constructive debate about how to tackle the pandemic.

The story of AIDS treatment in South Africa has been widely portrayed as a heroic David and Goliath struggle in which activists were pitted against the might of the state and the global pharmaceutical industry. But of course this is not the only way in which the AID treatment story in South Africa has been, or can be, narrated. Over the past decade, AIDS debates became highly polarised resulting in the emergence of sharply divided camps. During the height of these contestations over AIDS science it was very difficult to debate the merits of a range of issues including traditional healing, nutrition, diet, HIV prevention, ARV side-effects, and drug resistance, without risking being slotted into the pro-Mbeki AIDS dissident camp. Mere discussions of the relationship between HIV, nutrition and poverty provoked suspicion in some AIDS activist quarters. Even support for the government’s promotion of HIV prevention programmes was at times questioned by activists for diverting attention away from grassroots struggles for ARVs. In this highly charged political environment, there was little room for open debate and difference. Mark Gevisser’s empathetic biography of former President Mbeki, for example, was read by some AIDS activists as veering dangerously towards becoming an apologia for Mbeki’s brand of AIDS denialism. Didier Fassin’s (2008) even more empathetic reading of Mbeki’s “AIDS talk” in When Bodies Remember received a particularly hostile response from South African AIDS activists, health practitioners and academics.

The radical polarisation of AIDS positions and rhetorics was to be expected given the devastating reality of the AIDS crisis and the former President’s stubborn refusal to acknowledge the desperate need for antiretroviral therapy within the public health system. It was therefore perhaps hardly surprising that very clear lines were drawn and policed between various positions in AIDS debates during the Mbeki era. Of course similar polarising processes have surfaced in the course of contentious public debates on issues such as global climate change and nuclear energy.

Much has been written about the twists and turns in the politics of AIDS treatment in South Africa. Yet, most of these accounts have conformed to a David and Goliath narrative in terms of which heroic AIDS activists successfully fought against the might of the South African State and the global pharmaceutical industry. These accounts generally assume that activists were absolutely correct in claiming that ART is a financially viable, ethically principled, and scientifically proven biomedical technology whose successful implementation simply needed a cheaper drug pricing structure and the political will from donors and governments. There is very little ambiguity and contextual specificity in these accounts.

Sceptics and opponents of ART are described in these accounts as advocates of irrational arguments and pseudo-science. Some AIDS dissidents and denialists such as former President Mbeki and Manto Tshabalala-Msimang are even accused of complicity in genocide by activists and politicians. Borrowing liberally from anti-imperialist and anti-capitalist rhetoric, the dissidents argued that the profiteering pharmaceutical industry in the West was promoting AIDS drugs in order to exploit Third World markets. TAC activists featured in these dissident accounts as unscrupulous salespersons for the pharmaceutical industry. The dissidents also questioned the efficacy and safety of antiretrovirals, and instead promoted the efficacy of traditional medicines, nutrition, special diets (e.g., olive oil, garlic, African potatoes) and vitamins.

One of the costs of the “dissident debate” was that any questioning of AIDS orthodoxy of any sort was deemed to be complicit with AIDS denialism and dissident science. These highly polemical and politically charged contestations between activists and “dissidents” dominated the headlines, and contributed towards the radical hardening of the boundaries between positions on HIV. This resulted in the production of a stark divide between what was considered “proper science” and “pseudoscience.”

Even questions raised about cultural, logistical, financial and human resource obstacles to ARV rollout were labeled by some militant activists as examples of pro-Mbeki denialist thinking. Within the framework of these “epistemic wars” there was not much room to examine the complexities and nuances of health system realities and constraints.

During the height of these AIDS science wars, a small group of public health practitioners and health systems researchers argued that although the Khayelitsha pilot may have been located in a resource-poor urban community, the actual ART programme was very “resource-intensive.” They pointed out that the Khayelitsha programme benefited from massive donor funding and was supported by the well-resourced city and provincial departments of health. In addition, the MSF programme was driven by committed and highly skilled MSF clinicians, nurses, and activists. Due to its location, the Khayelitsha pilot was also able to attract clinicians and researchers from Cape Town’s academic hospitals and schools of medicine and public health. In other words, these public health pragmatists argued that, notwithstanding the successful treatment outcomes at Khayelitsha, the MSF model was exceptional, and was not easily replicable in typical rural African settings. These health systems practitioners were criticised by activists for claiming that it would be extremely difficult to replicate the MSF model in provinces that were less well resourced and burdened with dysfunctional health systems.

Cultural arguments were also deployed by some sceptics to highlight numerous barriers to testing and treatment. One of the most sophisticated of these arguments appears in Jonny Steinberg’s much acclaimed book on the reasons why a young man Steinberg got to know persistently refused to test for HIV even though he was very familiar with issues relating to HIV and treatment, and he lived close to the MSF treatment site in Lusikisiki. Steinberg’s book offers numerous cultural, social and psychological reasons for the man’s reluctance to test. For some activists, however, studies that emphasised cultural obstacles to treatment were regarded as providing an alibi for not fighting AIDS and providing treatment. As one of the TAC veteran activists told me, the aim of the TAC was to instil scientific ways of seeing the world and to rid South Africans of backward superstitions.
While the AIDS dissident arguments of Mbeki and Rath could be discounted by the activists on the basis of credible scientific studies, it was not so easy to dismiss the observations of Steinberg and others regarding the cultural, social and psychological obstacles to HIV testing and treatment in many parts of South Africa. It was even more difficult to dismiss the claims of public health experts on the extensive challenges of ART provision in the public health systems in South Africa’s poorer provinces.
The response from MSF, together with its TAC partners, was to start up a treatment programme in Lusikisiki, an impoverished rural area in the Eastern Cape Province. This programme sought to prove to sceptics that it was indeed possible to replicate the successful Khayelitsha programme in resource-poor rural settings. As in Khayelitsha, MSF developed a decentralized, people-centred, and nurse-driven approach to ART that was based on primary health care principles and practices, rather than relying on doctors and vertical, hospital-based treatment programmes. Studies of treatment outcomes at Lusikisiki demonstrated that it was indeed possible to have successful ART programmes in resource-poor rural settings.

Whereas the MSF programme in Khayelitsha was well-resourced and had a vibrant AIDS activist movement at its disposal, in Lusikisiki it was much more difficult to mobilize and there were countless social, economic and cultural obstacles to the promotion of HIV prevention, testing and treatment literacy. Activists in the rural villages of Lusikisiki District encountered numerous barriers to their biomedical messages, and alternative conceptions of illness, beliefs in witchcraft, and AIDS stigma and denial seemed much more entrenched in these rural settings. The health systems skeptics were clearly not far off the mark when they identified a litany of constraints and challenges for ARV rollout in the more resource-poor rural provinces.

Throughout the Mbeki period, and up until the present, a number of public health practitioners and academics managed to straddle the scientific and ideological divides that separated activist and health systems approaches. These practitioners and researchers provided pragmatically oriented health policy studies that identified the challenges of scaling-up treatment in South Africa and elsewhere in Africa. These studies highlighted health systems concerns that tended to be bracketed out of the activist frame during the “AIDS science wars”. These challenges to ARV rollout included the growing caseload of people to be maintained on long-term ART; problems of shortage and skewed distribution in the health workforce; and the heavy workload of ART delivery models. Similarly, researchers have called for a strengthening of health systems in order to address the challenges of scaling up access to treatment in contexts characterised by ineffective health systems. They also identified human resource challenges that included inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers. Clearly, ART is much more complicated than activists implied during the Mbeki-era contestations over AIDS science. At the same time, the fact that 700 000 South Africans are now on ARVs in the public health system, suggests that the activists were not entirely unrealistic in their expectations.

In the post-Mbeki period activists have reinvented their agenda by moving from protests and litigation to an active involvement with health policy and health systems. TAC has added to its repertoire of strategies, the production of policy briefs on various topics including the disability grant for people living with HIV, male circumcision, and the National Strategic Plan for HIV treatment. The organisation has also become directly involved in HIV prevention programmes and the rollout of condoms, the training of community health advocates, and campaigns against gender-based violence. Clearly, the Zuma Administration’s orthodox position on HIV has allowed for a shift away from the polarisation and discursive policing of the Mbeki and Tshabalala-Msimang period. What it also offers is the possibility of critical reflection on the ways in which contestations over scientific truth unfold under particular historical conditions.

In summary, AIDS activists undoubtedly played a highly constructive role in the fight against AIDS. By contrast, the AIDS denialism and dissident positions of former President Mbeki and his health minister were extremely destructive and contributed towards much suffering and loss of life. Another less obvious consequence of the AIDS science battles elicited by Mbeki and Tshabalala-Msimang was the polarization of debate around HIV, which in turn obscured the complexity of treatment provision and adversely impacted upon efforts to address such issues as HIV prevention, drug resistance and the numerous other challenges of the pandemic. Fortunately, the end of Mbeki era of AIDS denialism has created the conditions for responses that do take these challenges and complexities seriously.

Steven Robins,
First published in the Cape Times, 24th December, 2009

Re-Negotiating the Terms of Contemporary African Art: a reply to Professor Achille Mbembe

In his stimulating discussion “African contemporary art: Negotiating the terms of recognition,” posted to the JWTC Blog on September 8, Professor Mbembe is especially critical of the pernicious influence that Western-funded ‘development’ projects have had on the arts of the African continent. Although acutely aware of the equally baneful influence of the commercialization and privatization of all forms of civic life in the global economy, he singles out development as the primary threat to the continued growth of a vital African culture. I would like to critique his admittedly powerful argument with reference to a recent University of the Witswatersrand doctoral thesis, “Agency, Imagination and Resilience: Facilitating Social Change through the Visual Arts in South Africa” (2009), by artist and activist, Kim Berman.

In his lively conversation with consultant Vivian Paulissen, Mbembe refers to an ongoing collusion between African governments and Western funding agencies in promoting an anachronistic idea of development that lines the pockets of the functionaries while making very little dent in the very real problems of poverty. The so-called ‘humanitarian impulse’ in these (unnamed) development projects is in his view a “vicious ideology that promotes a view of Africa as a… doomed and hopeless continent waiting to be rescued and ‘saved’ by the new army of Western good Samaritans.” According to his argument, these powerful agencies conceive ‘development’ in narrowly materialistic terms, and so are blind to “cultural and artistic critique as a public good in and of itself.” The deplorable result “…is a tendency to conflate African art, culture and aesthetics with ethnicity or community or communalism; to deny the power of individuality in the work of art creation.” And he concludes, “…the function of art in Africa is precisely to free us from the shackles of development both as an ideology and as a practice.” [his italics]. I worry about prescribing any function for artistic practice, but also cannot agree with the basis of this assertion.

In my own view, the commercialism of the international art system of dealers and museums is far more of a threat to the future of the creative arts in Africa, and “the power of individuality in the work of art creation,” than the ideology of development. Despite the supposed success of the Africa Remix exhibition, which only came to Africa (Johannesburg) as the result of a last-minute effort, the work selected for that exhibit fit neatly into the well-established parameters of contemporary avant-garde practice. Although much contemporary art commands respect, all too many artists use technologically-based media to formulate a few sly references to their ethnicities or cultures, without presenting any real challenge to the viewers’ preconceptions or expanding their limited understanding. Whether from the BRIC countries or the Middle East or Africa, the individual creative artist makes work that can be ‘knowingly’ selected for exhibition, and accepted/purchased by a Western viewer. And, despite the very real differences in the contexts from which the artists make work, the art presents a homogenous facade, as a glance through catalogues of non-Western contemporary art will confirm. The discouraging visual uniformity of international avant-garde art production is a direct result of commercialism is therefore a direct refutation of the capitalist-based idea of art as individual expression. If they wish to be regularly included in international exhibitions, contemporary artists must make works that can sell. I suspect that work that truly challenges Western assumptions about a given non-Western region never makes the scene.

Maintaining an art-craft distinction that makes little sense in the South African context at least, Prof. Mbembe argues that “…without a major investment in critical theory, our artistic production will remain in the domain of artisanship. And it will always be left to others to dictate the intellectual, theoretical and political terms of its recognition in the international arena.” Admittedly, I am an outsider, but having taught at various South African universities over the course of the past decade, I have been consistently impressed with the uniformly high standard of academic discourse there. It seems to me that theoretically-based research is both firmly-established and well-supported, as exemplified by the Wits Institute of Social and Economic Research (WISER) and the newly-established research Centre, Visual Identities in Art and Design (VIAD) at the University of Johannesburg. In fact, I would argue that critical theory is so well articulated and taught in universities in South Africa that, as in the West since the 1980s, much of creative art production dutifully illustrates theory, to its own detriment. Critical theory is neither a panacea nor a bogeyman. It is only problematic when teamed with commercialism and used by artists as a sign for a hip product.

The question that should be asked is whether critical theory has been tested on the ground through practice-based, ‘development’ projects, and if so, whether or not it has generated new knowledge and models for rethinking notions of creativity. Again, I would cite Berman’s thesis as evidence that it has, yet neither of the recent books on contemporary African or South African art give so much as a nod to the innovative community arts projects operating throughout the continent. (see: Sue Williamson, South African Art Now [New York, Collins Design, 2009]; Okwui Enwezor and Chika Okeke-Agulu, Contemporary African Art Since 1980 [Bologna: Damiani, 2009]).

But to return once again to the nub of my argument, communalism or ‘lumpen-radicalism’ is not the problem, commercialism is. I would argue that the picture Prof. Mbembe paints of ‘development,’ which is based on his own negative experiences, fails to take into adequate account current approaches to the field. As he certainly knows, ‘development’ has changed quite radically as a result of influential theorists such as Arjun Appadurai and Amartya Sen, as well as the tireless work of artist-activists on the ground in South Africa and elsewhere. Although government policies and procedures justifiably remain open to criticism, the results of these numerous initiatives for the most part have demonstrated that community arts projects have provided its participants with the capacity to “inscribe our voice,” as Mbembe so eloquently phrases it. Unfortunately, despite the vitality of the field of development theory, relatively few community arts projects have been given sustained academic analysis. Contributing to this nascent field, Berman’s thesis places the three major ‘development’ projects she has founded over the past fifteen years—Artist Proof Studio, Paper Prayers for Aids Awareness, and the Phumani Hand-Papermaking Project—in the context of critical, educational and development theory, and demonstrates that individual and collective creativity need not be at odds, but rather can reinforce one another. Rather than attempting to paraphrase, I can do no better than to quote the first paragraph of the first chapter in its entirety:

“The argument that the visual arts can play a positive role in creating social change is based on the premise that a creative collaboration between the community arts and development fields is possible. This thesis argues for a paradigm shift in approaching development in a way that an art educator approaches the facilitation of an artist’s personal and creative growth. Dreaming and imagination facilitate self-expression. Developed further, self-expression is arguably a transforming process of self-creation. Empowerment is the ability to become an agent of one’s own life and to achieve self-actualization. When individual agency is applied as a catalyst to inspire new possibilities, social systems respond to stimulate change.”

Through her case studies, the thesis indeed demonstrates the ways in which change can occur and be sustained. Arguing that seeing beneficiaries as “inert units within a collective…is one of the primary reasons why development projects fail,” (and here she is in full agreement with Mbembe), Berman proposes that when members are seen as individuals with the creative capacity to use imagination and dreaming to envision a better future for themselves, and their voice as a tool to navigate their way out of poverty, they gain agency and their projects can succeed. One of the guiding voices for Berman’s own efforts has been Arjun Appadurai, whose notion of ‘the capacity to aspire’ she has tested with such impressive results. Also referencing Appadurai, Prof. Mbembe concludes that “In circumstances under which millions of poor people indeed struggle to make it from today to tomorrow, the work of theory and the work of art and the work of culture is to pave the way for a qualitative practice of the imagination—a practice without which we will have no name, no face and no voice in history.” (5).

Precisely. I have no problem with this passionate articulation of the function of art! However, to oppose individual creativity and ‘development’ is to sustain an anachronistic definition of ‘art.’ Community arts and individual creativity are not an either/or proposition, either for the artist-activist or for the participants on those projects. The radical paradigm shift in the development studies has opened broader roles for the artist in culture and in society. Because the contemporary museum-gallery system always follows the money, today’s studio artist is ipso facto a commercial artist. At the very least, development projects using the arts are a counterforce to its stifling power.

Pamela Allara, associate professor emerita, Brandeis University

Achille Mbembe’s piece is available at:

http://jhbwtc.blogspot.com/2009/09/african-contemporary-art-negotiating.html