How South Africa’s action on Covid-19 contrasts sharply with its response to Aids

Twenty years ago Nelson Mandela made an impassioned plea for international cooperation on “one of the greatest threats humankind has faced”.

Aids was ravaging lives and overwhelming health systems, at its peak killing up to 1,000 people a day in South Africa.

Mandela’s successor as president, Thabo Mbeki, was in obstinate denial. On the sidelines of the conference where Mandela made his appeal, Mbeki’s controversial health minister, Manto Tshabalala-Msimang, scolded scientists for daring to oppose the government’s stance.

One of those scientists, Salim Abdool Karim, now leads South Africa’s Covid-19 advisory team, earning this government plaudits from the World Health Organization for its response to the pandemic. Tshabalala-Msimang succumbed to liver problems in 2009 and left a legacy of 300,000 preventable deaths.

In early April, two weeks into South Africa’s coronavirus lockdown, Abdool Karim led a live two-hour briefing explaining the reasoning behind the strict measures, which confine people to their homes and prohibit public exercise and the sale of alcohol and tobacco.

It is in sharp contrast with the Aids response two decades ago.

“I’m impressed that the powers that be took this seriously,” he said. “They didn’t need to be convinced, they didn’t waffle around, they didn’t procrastinate.”

The 59-year-old last year joined the world’s most respected scientists to become a fellow of the Royal Society. He has shared several of his many professional awards with his wife, Quarraisha Abdool Karim, also a widely acclaimed Aids researcher.

Despite his groundbreaking scientific contributions in HIV prevention and treatment, Abdool Karim knows enough to know that little is understood about Covid-19.

“I don’t claim that we’re not making mistakes,” he said in the briefing. “If you make no mistakes when tackling a disease of this nature that means you’re not being sufficiently proactive.”

One of Abdool Karim’s medical school classmates at the then University of Natal was Zweli Mkhize, now health minister. It was him who called Abdool Karim to head the Covid-19 team.

If Mkhize’s sure-footed response to the Covid-19 pandemic has earned him praise, his handling of Aids was more chequered. As the KwaZulu-Natal executive council member responsible for health from 1994 to 2004, he opposed a court application to force government to roll out medicine to pregnant women to prevent HIV transmission to their babies, because he wanted the trials to finish first. But he also permitted government clinics in his province to roll out Aids medicines at a time when the national government had not yet allowed such a move.

Just before his 2017 presidential campaign, Mkhize unsuccessfully called on Mbeki to apologise for his view that HIV did not lead to Aids. “He led the country astray with a wrong view, which he was made to believe was true,” Mkhize said.

Mkhize’s cabinet colleague responsible for promulgating the fierce lockdown regulations, local government minister Nkosazana Dlamini-Zuma, was also in the team leading South Africa’s early Aids response. As Mandela’s health minister from 1994 to 1999, she was tasked with reforming the public health system while trying to come to grips with the new pandemic.

Some of her early ideas around Aids prevention were considered pioneering, but her later support for the toxic industrial solvent, Virodene, as an Aids cure, and the misspending of taxpayers’ money on an Aids prevention musical, tarnished her reputation.

Later she became Africa Union Commission chair and pushed for the founding of the Africa Centres for Disease Control and Prevention after the 2014 Ebola outbreak in parts of the continent. It now plays an important role in supporting African countries on Covid-19.

She has earned praise for the clear and simple way she explained the government’s plans to gradually ease the lockdown in her mother tongue, Zulu, the biggest first language in South Africa.

Also prominent in South Africa’s Covid-19 crisis are activists like Mark Heywood, who edits a news site focusing on human rights and social justice civil society organisations called Maverick Citizen. He was among those who led the fight to make Aids medication affordable and widely available. Of late, he’s also provided advice to the local C19 People’s Coalition, one of the biggest civil society Covid-19 responses in the world.

As an Aids activist he learned how important it is to build alliances between those living with the disease, the health sector, trade unions, the media, and government. “Covid-19 is a social ill as much as it affects individuals,” he says. “We have to address it socially, not just through individual behavioural interventions.”

Heywood foresees the looming possibility of a big battle around access to Covid-19 treatment and vaccines, similar to the battles for Aids medicines. “Billions of people are going to need the vaccine when it arrives. How do you make sure it hasn’t been patented and doesn’t become some company’s private intellectual property?” he says. “How do you ensure that developing countries are not last in the queue to receive it?”

Thus far the government’s prompt and scientific response to Covid-19 means the battle hasn’t been as intense as when Aids was “turned into a political fight” and activists “were pushing against power to try and get something done”, says Heywood.

During the most difficult days of the Aids pandemic, activists witnessed death on a big scale and attended multiple funerals every weekend. “When you looked at the graves, you would see the ages were all young,” he says. “It’s a strange inversion, because this time it’s older people.” So far South Africa’s confirmed Covid-19 death toll is more than 480.

Mia Malan, editor-in-chief of the Bhekisisa Centre for Health Journalism, who reported extensively on Aids as a health reporter for the South African Broadcasting Corporation, says leaders are doing things better this time around. But the government’s past failures to provide an effective and early HIV response has left South Africa with millions of HIV infections that could have been prevented. As a result people with weaker immune systems (four out of 10 HIV-positive South Africans are untreated) could be more vulnerable to developing Covid-19, she says.

“The most obvious lesson is the difference an early response can make. With HIV, the government started an evidence-based response much too late.” South Africa only had 550 coronavirus cases when it closed borders and decided on a strict lockdown that lasted at least five weeks.

Communicating a clear and unambiguous message from government was another lesson, and partnerships have been struck with the media to make this possible – and to fight disinformation. “Activists and the media were the complete enemy during that time [of Aids], but now the minister of health at his briefing would thank the media for being partners,” she says. “It’s not that we don’t criticise them, but we are on the same side.”

Putting science above politics is also crucial, she says. “Abdool Karim was world-renowned at that time [during the Aids pandemic] already, and he was rejected. Now he is chair of the [government’s Covid-19 advisory] committee.”

Compassion is vital. When child activist Nkosi Johnson died of Aids-related complications aged 12 in 2001, Mbeki was silent. Now, Malan says, Mkhize offers deep condolences in every statement announcing new Covid-19 deaths. “Mkhize and [president Cyril] Ramaphosa will come out of this and it will possibly define their legacy – very much the opposite to Mbeki and Manto.”