In the magnitude of their demographic and socio-economic impact, the Spanish ’flu and HIV/AIDS also have much in common. For reasons still not adequately explained in the case of Spanish ’flu, like AIDS, it was particularly lethal to young adults, claiming perhaps 300,000 such lives in its six-week rampage through South Africa in October-November 1918. At a stroke, therefore, South Africa’s population lost some 9% of its prime workforce, its parents and its potential child-bearers38.
The consequences of this were both immediate and long-lasting, and continued to echo through South Africa’s subsequent demographic and social history for two generations. The almost overnight creation of over half a million orphans pushed the state, parastatal bodies like the Post Office, the Police and the Railways, and organized religion into a massive orphanage-building programme, primarily for those orphans who were white, which the government supplemented by introducing special grants for ’flu widows with children. For the majority of black orphans it did very little, however, leaving them to be indentured, incorporated into extended families or to fend for themselves as best they could39. The social, psychological and emotional costs of this massive social disruption in the lives of upwards of 500,000 South African children born between 1900 and 1918 have barely been noticed in South African history. One anecdote will have to suffice to hint at this poorly-documented dimension of the country’s twentieth century history. In March 1919, a Cape Town court heard that the coloured pre-teenager before it on a charge of theft was ‘one of dozens of boys of his age who roam the city and sleep anywhere... He is a “’flu remnant”. He has no home, and does not know what has become of his parents. He does not know his age or his proper name, and has no surname, so far as he knows. He and others sleep under the Pier, in the old boxes, and in railway compartments, first-class preferred, when the opportunity offers. He looks half-starved and eats garbage, or whatever he can get hold of, and says he has never been to school.’ Having found him guilty, the presiding magistrate sent him to a reformatory for four years40. Mutatis mutandis, this report could easily have been written yesterday about the plight of AIDS orphans in South Africa.
The loss of young mothers in 1918 – and with this all their babies as yet unborn – also left a permanent nick in the country’s demographic profile, which finally worked its way through the life-cycle only recently. Consequently, its impact was felt at every social stage over the last 83 years. Evidence of this process under way is best documented among white South Africans, but its all-pervasive effects would have been a common national experience. For instance, in 1925 (which was the first year of school for children born in 1919), the Cape Education Department reported that enrolments in sub-A were down by ‘several hundred’, while by 1929 it was observed that there had been a marked ‘slackening of growth’ in school enrolments in the 1920s as ‘children of school-going age have not been increasing in number at the same rate as the total population’41. It is likely that there will be many similar reports in South Africa in the second decade of the 21st century.
As for the sudden excision of a segment of the workforce by the Spanish ’flu, it is clear that agriculture was most sharply affected, with seed left unsown in hard-hit areas like the Transkei and mature crops unharvested. Famine was a widespread consequence. Also because of a loss of labour, output on the country’s mines fell sharply for a few months in 1918-19, until the labour recruitment agencies could fill these gaps. ‘The influenza has indeed played havoc with the profits and makes one very anxious about the future’, wrote the worried chairman of Central Mining to the president of the Chamber of Mines42. Eighty-three years later, with the full economic impact of HIV/AIDS still developing, such evidence of how a serious epidemic can throttle key sectors of the country’s economy are ominous.
Casting an eye over all these parallels between HIV/AIDS and earlier epidemics in South Africa’s history, it is clear that in many of its central features – its mode of arrival, transmission and dispersion, the nature of the responses it evoked and its demographic and socio-economic impact – HIV/AIDS fits squarely into deeply-rooted epidemic patterns and precedents in South Africa. That it does so suggests that, in some measure at least, such similarities arise from the very structure, composition and mode of operation of South African society. What HIV/AIDS does is to illuminate this fact very clearly, provided one does not allow its magnitude and our historical amnesia to block out what it has in common with prior epidemics. Viewed with the benefit of such historical perspectives, HIV/AIDS appears as anything but sui generis.
Yet, it would be misleading and one-sided to see HIV/AIDS solely in terms of its similarities with previous epidemics. As Charles Rosenberg reminds us, to comprehend a particular epidemic, ‘we must distinguish between the unique and the seemingly universal, between this epidemic at this time and place, and the way in which communities have responded to other episodic outbreaks of fulminating infectious disease in the past’43.
If HIV/AIDS in South Africa is to be fully apprehended, therefore, its distinctive aspects have to be highlighted too and incorporated into any rounded assessment of it. That is what the next section of this article will do.
Distinctive features of HIV/AIDS in South Africa
Broadly, these distinctive features can be put into four categories.
Foremost among these is its biology, in particular the fact that, unlike South Africa’s other epidemics like smallpox, bubonic plague, influenza, typhus, cholera and polio, its onset is slow and its progress relatively leisurely. On average, the period between being infected with the HI virus and death from AIDS or an opportunistic infection is 8-10 years. In this respect it resembles TB and syphilis more than a fulminating epidemic disease, though, unlike TB and syphilis, its course is not reversible or even cheaply retardable.
From this fact have flowed several momentous social, political and economic consequences peculiar to the HIV/AIDS epidemic in South Africa. Its long, steadily draining duration has created a swelling number of AIDS invalids requiring increasing family or institutional nursing care in their dying years, and thus calling into being numerous AIDS advice, support and care groups. Parents being in this condition have produced a generation of what may be termed ‘orphans in the making’. Secondly, its relatively gradual advance in its early phase in South Africa meant that opportunities for intervention to try and prevent its further spread by education and publicity were numerous and consequently generated initiatives unprecedented in South Africa’s epidemic history, such as massive AIDS awareness campaigns, the introduction of intensive programmes of sex education into schools, free, mass distribution of condoms by the state and the official commissioning of safe sex videos (which the Publications Control Board banned in 1993!) and Sarafina 244. In this respect it transformed the terrain of sexual activity in South Africa out of all recognition.
Moreover, HIV’s relatively slow conversion into full-blown AIDS in an individual created a generation of people living with AIDS, fit, keen and able to organize around their condition, to lobby and to draw support from sympathetic individuals and institutions around key issues like discrimination against HIV-positive people, the need for AIDS-delaying drugs to be made cheaper and the unacceptability of compulsory HIV testing and notification. As a result of all of these initiatives, derived ultimately from the biology of the disease, AIDS-related NGOs proliferated in South Africa. By 1993 over 700 were in existence45, not counting the specialized units and offices set up within existing institutions like insurance companies, business and law firms, trade unions, universities, churches and private and semi-private healthcare agencies like the Red Cross and the blood transfusion services. On top of these, a veritable AIDS monitoring and projection industry was born. To this surge in AIDS-related NGOs in the early 1990s neither the South African National Tuberculosis Association, nor the Poliomyelitis Research Foundation, as examples of NGOs created by public initiative during earlier epidemics46, could hold a candle.
For the same basic reason – the extended window of opportunity for action provided by the slow-paced escalation of HIV into AIDS – pharmaceutical firms have found themselves in the unusual situation amidst an epidemic of being able to have an immediate impact on the disease with their newly-developed drugs. Many have been taken by surprise by the political, moral and financial implications of a position they had seldom met with before.
Pressures of a similar unprecedented kind on government saw, even before 1994, equally novel official administrative initiatives in the history of epidemics in South Africa: the creation of a dedicated AIDS Unit within the Department of National Health, the establishment of specialized AIDS Training and Information Centres throughout the country, a request to the Law Commission to investigate all aspects of the law with regard to AIDS, and even a bid to set up a single body involving trade unions, business, the churches, the government and even the ANC government-in-waiting, the National AIDS Convention of South Africa (NACOSA), to develop a joint national policy on AIDS47.
What the latter points to is the second distinctive feature of the HIV/AIDS epidemic in South Africa – its political context. Just as the epidemic was getting into its stride in the early 1990s, South Africa underwent an unprecedented political transition which put into place, for the first time in the country’s history, a fully democratic political dispensation. This produced a government with a wholly novel (for South Africa) commitment to the human rights of all South Africans, an outlook which introduced a sea-change in state policy in respect of HIV/AIDS. Aware of the rapid inroads by the disease into the country’s African majority in particular – a recognition which had seen it participate in NACOSA’s deliberations even before the new South Africa had been born – once in power, the ANC gave the fight against HIV/AIDs far greater priority than any of its predecessors had done when faced by an epidemic particularly prevalent among the African majority in the population.
Thus, within months of assuming office, it identified AIDS Awareness as a special Presidential Lead Project and doubled the budget for combating AIDS, with sex education programmes in schools, public information campaigns via the mass media, condom distribution and the expansion of the network of STD clinics being the chief beneficiaries48. Alongside this enormous increase in funding for prevention and care, the ANC’s promise of a compassionate approach to those with the disease, informed by a respect for human rights, began to permeate wider state interventions too. For instance, the new government overturned the policy of the Police, Correctional Services and Defence Force to carry out HIV testing on all new applicants for jobs as this ‘affronted the spirit’ of the Bill of Rights and contravened the Labour Relations Act49. Similarly, it rejected the idea of HIV/AIDS tests for all incoming hospital patients as it deemed this unacceptable, discriminatory and an infringement of human rights50, while in the country’s prisons it reversed existing policy by having condoms distributed free to all prisoners and by ending the segregation of HIV-positive inmates51.
Nor was this new climate of respect for individuals’ rights limited to government only. It is clear that even before 1994, key sectors of industry and business were adopting a line on HIV/AIDS far more enlightened than they had done in the face of previous epidemics, probably as a result of overseas influence and trade union and NGO pressure. Thus, as early as 1986, the Chamber of Mines opposed the government’s wish to repatriate all foreign miners who were HIV-positive 52 – in striking contrast to its stance on tubercular miners two generations earlier – while the comprehensive AIDS policy it developed at this time (with its emphasis on the employment rights of HIV-positive miners, on counselling those it found to be HIV-positive and on instituting education programmes to prevent HIV infection) was described by a leading AIDS academic as, for its time, ‘probably one of the most enlightened and responsible responses to AIDS of anybody anywhere in the world’53. It even went on to reach rough consensus with the National Union of Mineworkers on AIDS, concluding an industrial agreement on the disease with it in 199354. For an industry whose attitude to sick workers during earlier epidemics of phthisis, pneumonia, TB and Spanish ’flu had been hard line, this was indeed a change of heart.
The public position of business showed a similar novel degree of respect for the rights of employees. In 1988 the Association of Chambers of Commerce and Industry (ASSOCOM) came out strongly against compulsory HIV testing of workers and the dismissal of those found to be HIV-positive. The former was a breach of individuals’ privacy, while the latter would constitute unfair dismissal, it warned. Employers should instead concentrate on AIDS education for their workforce as the best means of preventing the disease55. However, the gap between this enlightened stance and the reality of testing, discrimination and dismissal in actual workplaces soon became apparent, a trend which it took decisions by the courts and the South African Law Commission to retard56.
The fact of active involvement by the latter two institutions in defence of individuals’ rights again highlights the fact that AIDS was the first epidemic in South Africa in which the rights of all infected citizens were vigorously asserted and upheld in public. It was the first epidemic to occur within a context of a burgeoning human rights culture. Whether it was prisoners insisting that their right not to be tested for HIV without their consent be respected57, an HIV-positive man suing his doctor for breach of confidentiality and invasion of privacy for revealing his HIV status58, an industrial court ruling that the automatic dismissal of an HIV-positive employee constituted an unfair labour practice59, or the Law Commission opposing mandatory HIV testing of prospective employees or warning insurance companies not to discriminate unfairly against prospective clients who were HIV-positive 60, it is clear that the second phase of the HIV/AIDS epidemic in South Africa coincided with a transformation in state and private sector public attitudes to epidemic infection. By virtue of this too then, HIV/AIDS is in a category of its own in South Africa’s epidemic history.
The third dimension of the HIV/AIDS epidemic which distinguishes it from its predecessors stems, like the second, from a changed South African context. By the time that the disease emerged in the 1980s, the extent to which biomedicine had penetrated into South African society was far greater than could have been the case during earlier epidemics. Thus, while it is true that biomedicine was not the only system of treatment to which a majority of the population turned in the face of HIV and its symptoms, it is likely that in many cases it was the first. No longer did biomedicine elicit the same level of popular circumspection and even hostility which vaccination or deverminization had during earlier epidemics. The fact that AZT is an acronym probably as familiar in Mtubatuba as in Mayfair is a product of this process of the biomedicalization of South African society, which means that, in terms of the degree of acceptance of biomedicine, the HIV/AIDS epidemic takes place against a background markedly different from that of earlier epidemics in South Africa.
Fourthly, the international setting in which HIV/AIDS has occurred in South Africa is so different from that of earlier epidemics as to constitute a wholly new environment. Certainly prior epidemics in the 20th century saw South African governments trying to draw on overseas medical expertise to help them combat both epidemics and epizootics – Robert Koch during the 1896 rinderpest and 1903-4 East Coast Fever outbreaks61, Professor W.J. Simpson during the bubonic plague in 190162, the latest British thinking on treating ’flu during the 1918 pandemic63, the World Health Organization (WHO) for eradicating malaria in the 1950s64 and the collaboration of US laboratories in the 1950s to develop a vaccine against polio65.
Yet, despite this history of a growing input from outside experts and international health authorities into South Africa’s counter-measures against epidemics during the 20th century, nothing they did can remotely compare with the scale of the huge international resources against HIV/AIDS offered to South Africa, particularly since 1994. With the WHO and UNAIDS in the lead, an extensive international anti-AIDS framework has been put into place to combat the disease around the world, with ‘best practices’ laid down by global health and philanthropic bodies, both official and unofficial.
To a degree unparalleled in South Africa’s epidemic history, this has shaped both governmental and non-governmental policies and practices in the country. This globalized and Africanized dimension of South Africa’s campaign against HIV/AIDS was epitomized by the holding of the XIII International AIDS conference in Durban in July 2000, organised by UNAIDS. ‘[W]e count on you as a critical component part of the global forces mobilized to engage in struggle against the AIDS epidemic confronting our Continent’, President Mbeki told the delegates66.
Even though the president’s own words and deeds have not borne out this apparent readiness to welcome international advice, resources and know-how, it is clear that at most other levels of the country’s fight against HIV/AIDS, international input and influence has been colossal and unprecedented67.