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The news has exacerbated the long-standing conflict between the South African government and frontline AIDS doctors, scientists, and activists, who accuse the government of shirking its duty to combat the raging epidemic. And it raises profound questions about Mbeki's leadership on the most pressing health issue facing southern Africa.
Mbeki has not said publicly whether he believes HIV causes AIDS, and presidential spokesperson Parks Mankahlana insisted that Mbeki is "not an advocate of the dissidents." Still, Mankahlana told the Voice that Mbeki has ordered his health minister to assemble an international panel to look into "everything about AIDS," from the merits of various treatments such as AZT to "whether there's this thing called AIDS, what it is, whether HIV leads to AIDS, whether there is something called HIV, for an example. All these questions."
It was news of this international panel, first reported by the South African Press Association two weeks ago, that brought the matter into public view and sparked immediate protest. The Treatment Action Campaign, a local activist group modeled on ACT UP, took the lead, charging that giving any credibility to the "inaccurate and harmful medical ideas" of the AIDS dissidents would "cause tremendous confusion among people at risk and undermine prevention efforts."
The health ministry hastily issued a response, downplayingbut not denyingthe possibility that the panel would address the views of AIDS dissidents such as California virologist Peter Duesberg. The statement, which acknowledged that AIDS is "the most serious health challenge facing South Africa," said that the panel's primary objective would be "developing prevention and treatment strategies that are appropriate to the African reality." Given the apparent split between the health department and the president's office, it remains unclear what kind of public airing the dissident views will receive.
Meanwhile, the government insists it is going ahead with its current AIDS programs, including research into an HIV vaccine, and it is putting the best face on Mbeki's musings. The president, an Internet enthusiast, "has read much literature on the issue of AIDS, including the literature of those who might not hold the conventional view," said Joel Netshitenzhe, chief of government communications. "And the question he has posed from time to time is whether there has been sufficient interrogation of the issue. He merely says, 'Instead of believing, be sure you have established the facts.' And I thought that would be a measure of a good president."
But Mbeki may have gone beyond mere academic questioning. There is evidence that the dissident arguments influenced one of his most controversial acts: the decision to delay making AZT available to pregnant women in order to reduce the number of babies born with the virusthought to be as many as 60,000 infants a year. Moreover, critics say, the fact that Mbeki would give serious credence to views that have long been discredited indicates a desperate urge to deny the epidemic rather than grapple with it head-on.
"It's irresponsibility that borders on criminalityand I know those are harsh words," said Mamphela Ramphele, vice chancellor of the University of Capetown and a physician who is famous for her anti-apartheid activism. She said that if the government gives credibility to "this voodoo science, there's a real danger that people might say, 'I don't have to worry about condoms.' "
Scientists in other African countries also reacted with shock and dismay. "I can't believe it," said Peter Mugyenyi, a veteran Ugandan doctor and researcher. "This would be a highly dangerous and retrogressive step with very serious public health consequences. It could cost lives." His colleague David Serwadda added that Duesberg's ideas were considered in Uganda, "but we realized his theories would not help us. If he finds fertile ground in South Africa, it would be very unfortunate."
Just how seriously is Mbeki taking the AIDS dissidents' views? One of South Africa's most senior scientists, who spoke on condition of anonymity, told the Voice that Mbeki asked four top South African researchers to review large dossiers of literature written by the AIDS dissidents. Some of those handpicked scientists presented their case that HIV does cause AIDS to the president this February, and yet last week Mbeki's spokesperson was still saying that the president wanted an international panel to review the issue. "I think we may have a president who doesn't believe HIV causes AIDS," said this source.
In addition, David Rasnick, a prominent dissident who has long argued that AIDS is not infectious, told the Voice that Mbeki's office asked him to answer faxed questions about AIDS and to comment on answers to those same questions provided by the health minister. Rasnick, a chemist and colleague of Duesberg, also said that Mbeki had personally telephoned him this January, telling Rasnick that he was planning "a public airing" of issues such as whether AIDS is sexually transmitted and whether HIV causes AIDS. Mbeki's spokesperson refused to confirm or deny whether he has asked researchers to review dissident literature and whether he has had contact with Rasnick.
Well-connected South African scientists and activists have known for months that Mbeki was flirting with the dissident theories, and their e-mails, some of which have been obtained by the Voice, show an ever increasing concern. The first tip-off came last October, when Mbeki ordered his health minister to review the safety of AZT, saying that "a large volume of scientific literature" alleges that the drug is so toxic that "it is in fact a danger to health." That effectively put on hold plans to make the drug available to pregnant women. "That's when I started feeling a very strange plot was afoot," said Ashraf Grimwood, a physician who chairs the National AIDS Convention of South Africa.
Mbeki's statement sharply contradicted the international medical consensus that the benefits of AZT outweigh its risks, and it also ran contrary to a South African study of AZT used in combination with another drug, 3TC. That large study found no more side effects among women and infants taking the drugs than among those taking a placebo.
Mbeki's office has consistently refused to divulge what scientific literature prompted the president to remand AZT for a new medical review. Health Minister Manto Tshabalala-Msimang said there is "lots of literature," but cited only the package insert that comes with the drug, adding, "I don't keep authors in my head." She added that no study had followed patients for more than five years.
But three well-placed sources, who requested anonymity, reported that Mbeki has privately cited well-known AIDS dissidents such as Duesberg and a group of Australian scientists as sources for his concern about AZT. In addition, the large dossiers of dissident material given to four of the country's top scientists contain a great deal of material alleging that AZT is dangerous.
If Mbeki did call for a review of AZT based in part on the dissidents' writings, it would mark the only time that their opinions have influenced a government decision to withhold life-saving medication.
Why would Mbeki take the dissidents seriously? Many observers chalk it up to denial, but Salim Abdool Karim, scientific chairperson of the World AIDS Conference that will be held this July in South Africa, isn't so sure. "The president's talk on World AIDS Day was excellentand he writes most of his own speeches," said Karim. "He clearly understands this epidemic. So I don't know. It's not denial, it's more complicated than that."
Mbeki is famously inscrutable, almost sphinxlike. What is known is that he is proud and considers himself an intellectual. When he was a little boy, according to an extensive profile that ran in South Africa's largest-circulation paper, the Sunday Times, he read letters aloud for the illiterate adults in his village, and even wrote their letters. He is accustomed, therefore, to feeling intellectually superior to people with much more experience.
He is also a contrarian. Though a member of the Communist Party, he was one of the first and fiercest ANC advocates of market reforms. And, of course, he himself was a dissident until apartheid was overthrownand may very well still consider himself one. After all, whites still control most of the wealth in South Africa, and Americans and European pharmaceutical companies have priced the life-saving AIDS drugs far out of South Africa's reach. It is often said that Mbeki, unlike Mandela, is bitter.
And so, it is entirely possible that Mbeki, in one of his frequent Internet trawling sessions, came across one of the dissident Web sites, read its contrarian arguments, and began to doubt mainstream Western science. The AIDS dissidents are "a small group of people who spend an enormous amount of time making sure their message will have an impact," noted Malegapuru William Makgoba, president of South Africa's Medical Research Council. "When you see it for the first time, and if you are not experienced, you are likely to be seduced by it."
Using scraps of truth, along with distortions and outright misstatements, the AIDS dissidents patch together a coherent, if erroneous, theory of AIDS. In the industrialized world, they believe that AIDS is caused by "lifestyle" factorsespecially the use of various recreational drugsand even by anti-HIV drugs such as AZT. Even before the drug cocktails reduced AIDS death rates throughout the industrialized world, that theory had been demolished by epidemiological studies. According to a report from the U.S. National Institute of Allergy and Infectious Diseases, "Individuals as different as homosexual men, elderly transfusion recipients, heterosexual women, drug-using hetero- sexual men, and infants have all developed AIDS with only one common denominator: infection with HIV."
Of course, the Western lifestyle theory is patently absurd for AIDS in Africa, where illicit and pharmaceutical drugs are rare, so the dissidents argue that AIDS in underdeveloped countries is simply a new name for long-standing diseases caused by malnutrition, unclean water, and the other scourges of poverty.
Thus Rasnick and fellow AIDS dissident Charles Geshekter wrote to Mbeki asking his government to consider "what evidence is there that people with antibodies to HIV live shorter, poorer lives than people in the same community who do not have antibodies to HIV? We know of no such evidence." But various studies in Africa have answered exactly this point. A study of 1400 Rwandan women, for example, found that those who tested HIV antibody positive were 20 times more likely to die than their negative counterparts, while two studies from Uganda also found stark differences in the death rates between HIV-positive and -negative adults.
Despite a decade of vociferous argument, the dissidents have failed to convince a single major medical authorityand precious few doctors. Ugandan physician Elly Katabira recalled a visit by an AIDS dissident to his clinic in Kampala years ago. He has forgotten the dissident's name, but he remembers an exchange. At the time, his clinic couldn't afford to give patients HIV tests, and so Katabira was asked, " 'How do you know these people have AIDS if you don't test them?' I said, 'What we are seeing now is not what we used to see. Do you think we are stupid?' "
For South Africa, the larger issue is leadership. It has been more than four months since the president asked the health minister to review the risks and benefits of AZT, and despite having received three official reports, she has not acted, telling the Voice that she will not act until the new advisory panel gives her its advice, which will take at least another month or two. Thus, whether the government will fund AZT for pregnant women or use that money for some other pressing priority remains undecided. Last week, it was revealed that the health ministry failed to spend a shocking 40 percent of its AIDS funds. (The government said that most of these unspent funds "are committed.") And now, the president seems to be entertaining a discredited theory.
So, protest is building. Ramphele, the University of Capetown vice chancellor, made a speech charging the government with having "no coherent management strategy" on AIDS. Last week, at a national convention of people with HIV, the health minister was booed and jeered. And at the same convention, Edwin Cameron, a judge on South Africa's Constitutional Court, the equivalent of the U.S. Supreme Court, took the highly unusual step of castigating the government's failure to lead, saying, "It simply does not seem that the government can begin to get it right on AIDS." After referring to the reports of Mbeki's flirtation with AIDS dissidents, the openly HIV-positive Cameron said, "There are too many lives, too much happiness, too much human prosperity at stake for flirtation with dangerous and wayward theories."
Research intern: Elinore Longobardi
Additional articles on AIDs by Mark Schoofs.