This is an excerpt from Theodore Powers, Sustaining Life: AIDS Activism in South Africa, © University of Pennsylvania Press. Excerpted with permission.
People, pathogens, and power: situating the South African HIV/Aids epidemic
Matamela shook his head as he spoke to me, a wistful expression coming over his face. He turned and looked out of the window, pensively stroking his beard for a moment, deep in thought. Matamela was a leading activist for the Treatment Action Campaign (TAC) at the organisation’s district office in Khayelitsha, a black urban township approximately 20 miles from Cape Town’s city centre. TAC’s district office was housed in an off-white building in a shopping complex adjacent to the Nonkqubela railway station, and it was the base of operations for community-oriented activities designed to limit the spread and impact of HIV/Aids in the township. As night fell we leaned toward the cracked windows, hoping to catch the last moments of light. Matamela adopted an urgent tone as he spoke of the daily obstacles faced by those accessing HIV/Aids services in the South African public health sector.
If you go out and you say to people, “We are coming to your community to talk about VCT [voluntary counselling and testing for HIV/Aids]. Come out and go and have voluntary counselling and testing.” And people go to the clinic, and wait hours to go do VCT, and at the end of the day, they do not want to go to the VCT anymore, then there’s a problem there. That quality of service is compromised. Because no one wants to wait for two hours, three hours just for testing for HIV. No one wants to wait. Because you will wait, and at some point [you will be] be told that, ‘Come tomorrow, because we are about to close down now.’ In some instances, you are being told that there is no medication for this particular illness that you are suffering from. It creates a problem.”
Emphasising how often people waited in line for hours but were unable to see a doctor, Matamela painted a picture of under-resourced and under-staffed public health services in a community where nearly one in three pregnant women are HIV positive. In this and other conversations, Matamela attributed the continuing challenges of HIV to the socioeconomic conditions created by colonisation, segregation and apartheid. His was a sobering analysis of the world’s largest HIV/Aids epidemic.
I met Matamela during one of my first visits to TAC’s office in Khayelitsha. A tall Xhosa-speaking black South African in his mid-30s, his expression alternated between a broad smile and a searing gaze. As one of the senior activists at the district office, Matamela was often too busy to sit and discuss the broader politics of the South African HIV/Aids epidemic. That night, another activist had left with the only set of keys, and we had been locked in the office due to a power failure in the township. As was the case for many homes and offices in South Africa, the TAC office had a steel gate and a locking door that had been installed to deter would-be intruders, imagined or real. As I had realised the first time I had locked a gate of this kind, the barrier not only prevents someone from entering but also restricts the movement of those inside. Now, fortunately for me, being locked in the office enabled me to learn more about Matamela’s background and his experiences confronting the HIV/Aids epidemic.
Matamela was born and raised in the Cape Flats, a series of townships that stretch out from the Cape Town city centre across a broad floodplain. Brought up in a working-class household, he was radicalised by the Soweto student uprising in 1976 and the subsequent intensification of government violence. During the late apartheid era, Matamela was a member of the Pan African Congress, an African nationalist organisation that was part of the anti-apartheid movement. He also helped to found TAC and subsequently served as a leading member for the district office and the organisation as a whole. As we discussed the political history of the epidemic, Matamela underscored the significance of a TAC protest at the International Aids Conference held in Toronto in 2006. The South African government delegation to the conference, which included the nation’s minister of health, Dr Manto Tshabalala-Msimang, had placed garlic, lemon and beetroot alongside antiretroviral drugs (ARVs) in their display of HIV/Aids treatments. Protesters from TAC, including Matamela, confronted the delegation for suggesting equivalence between homeopathic remedies and ARVs.
The health minister was part of a powerful dissident faction within the ruling African National Congress (ANC) that questioned the underlying science linking HIV to Aids. The faction critiqued the efficacy and toxicity of ARVs, challenged the characterisation of Africans as oversexualised and unable to govern themselves and condemned the global pharmaceutical industry for profiting from African illnesses. The messages emanating from ANC members in high government positions had a tangible effect on perceptions of HIV/Aids within TAC’s district branch in Khayelitsha. Matamela recounted:
“The problem is – with Aids, which emanates from poverty – people deny completely that they are having HIV. And these people are going to deny that there is an existence of HIV, so there is no point for them to use condoms. So the rate of infection becomes high. The death rate is huge. There are people who are delaying to start treatment. There are people in TAC who have been delaying their treatment. You ask them ‘why?’ [and] they say that they are afraid. ‘Of what? Of drugs, why?’ ‘Because the minister is saying this.’ Tell me, if people in TAC, who are more informed, are having those doubts, how much more for people who aren’t informed, who are listening only on the radio, watching the television, catching those messages from the minister of health and from the president? I stand by what I said. The president and minister of health, they need to be charged for genocide. Many people have died from Aids because of their confusing messages.”
Matamela was not alone in offering a harsh assessment of the Aids dissident faction within the ruling party and its effects on South African society. Its obfuscating statements on the relationship between HIV and Aids and critiques of orthodox biomedical HIV/Aids treatments provoked a transnational response that included American and European HIV/Aids activists, scientists, academics and international organisations. Within South Africa, TAC was at the forefront of the South African HIV/Aids movement, confronting government inaction on access to HIV/Aids treatment and highlighting Aids-dissident attempts to limit the public sector response to the epidemic. But even an organisation leading the campaign for HIV/Aids treatment access was not immune to the broader social effects of Aids dissidence.
A brief window of political opportunity opened because the HIV/Aids movement’s confrontation with South African Aids dissidents in Toronto brought intensified international attention and the minister of health left office on sick leave in the aftermath of the protest. Over the next several months, HIV/Aids activists, including Matamela, worked with government officials to develop a new HIV/Aids policy and revamp national health institutions to include input from the HIV/Aids movement. Together, they made significant progress in laying the groundwork for expanding HIV/Aids treatment access.
South African activists’ participation in the transnational HIV/Aids movement and their convergence at strategic sites was decisive for HIV/Aids politics in South Africa, influencing sociopolitical dynamics and shaping the campaign for HIV/Aids treatment, often in unpredictable ways. Focusing on activists such as Matamela, this book tells the story of how the South African HIV/Aids movement transformed public health institutions and enabled access to HIV/Aids treatment, thereby sustaining the lives of people living with HIV/Aids. Based on extended participant observation and in-depth interviews with members of the movement, I trace how the political principles of the anti-apartheid struggle were leveraged to build a broad coalition that changed national policy and institutions to increase access to HIV/Aids treatment.
From the historical roots of HIV/Aids activism in the struggle for African liberation to the everyday work of community education in Khayelitsha, I show how people and organisations negotiated access to treatment in South Africa. Sustaining Life, then, offers an on-the-ground ethnographic analysis of the ways that HIV/Aids activists built alliances, developed new policy, and transformed national health institutions to increase access to HIV/Aids treatment. In analysing how encounters among activists, state health administrators and people living with HIV/Aids transformed access to treatment in South Africa, the book addresses three key questions: How were the activists of the South African HIV/Aids movement able to overcome an Aids-dissident faction that was backed by government power? How exactly were state health institutions and HIV/Aids policy transformed to increase public sector access to treatment? How should the South African campaign for treatment access inform academic debates on social movements, transnationalism and the state, and what insights does it provide for health care activism?