Now is not the time for inaction on AIDS

Democracy is both irritating and rewarding. This is brought into sharp focus when one talks about democracy in the context of a pandemic like HIV/AIDS. On the one hand, the norms of deliberative democracy require that all stakeholders be consulted in the policy formation processes. On the other, such consultation processes, if not managed properly, deliver us democracy at the expense of necessary action.

That, in a nutshell, is the state of the South African National Aids Council (SANAC), the most important body that is meant to help President Zuma in his visible and justified quest to depart from years of Mbeki denialism. But in order to succeed he must think through how to avoid a democratic deficit that will haunt him at the polls (should he not consult widely) while, nonetheless, showcasing decisive leadership by making sure policy decisions get taken and implemented (by learning when to stop consulting).

The problem is this. Many policies get debated at a forum like SANAC. The body, comprising various stakeholders including both government and civil society, is supposed to make recommendations that could eventually become policy. Unfortunately, SANAC's efficacy is increasingly being hampered. The bottleneck is a tough one to complain about - deliberative democracy. Or so it would seem.

First, it is important that all voices be heard in processes that can lead to policy outcomes. Civil society organisations have fought in our courts to reverse policy processes undertaken by government that failed to do so. It would be bizarre to suddenly moan that citizens are getting too much attention from government.

Second, input from various organisations have substantive merit in designing policies. As a citizen of a country you have a legal and political entitlement to influencing policy to reflect your wishes. If that means lobbying government to prevent the legalisation of sex work then so be it.

Furthermore, policy processes are not perfect. It is only through having tough, open debate and disagreement that we can maximise the chances of decisions being taken that are based both in fact and which reflects the ideological convictions of the population. A process that does not have these elements does not have full legitimacy.

These qualifications about the need for deliberation are important to avert any misinterpretation of this article's contention that too much of a good thing can be bad. The fact of the matter is that public deliberation is not an end in itself. It is a means to the various ends outlined. If, for example, deliberation results in policy inertia, then deliberation has become a pointless exercise. So it is important that we gauge deliberation's success relative to practical standards such as whether or not, in the case of an outfit like SANAC, practical goals and legal mandates are achieved. This, unfortunately, does not seem to be the case.

Two examples are illustrative. Male circumcision can reduce a man's chances of contracting HIV by about 60%. It also slightly reduces the chances of infecting another person. These are established medical facts. They are the basis for why other countries in the region such as Botswana, Zimbabwe and Swaziland are promoting circumcision.

In SA, no policy on circumcisions exists. One objection is located within initiatives to fight the pandemic. It is the fear that more irresponsible behaviour, such as abandoning condom use, will follow. Another objection is delivered through a wider socio-cultural prism: traditional circumcision is important on the cultural landscape of SA and publically promoted medical circumcision will simply subvert rights to cultural practise. If, for example, a Xhosa boy were circumcised when very young, in the name of fighting the AIDS pandemic, that would make it impossible for him to also undergo traditional circumcision later in life.

The objections to publically promoting medical circumcisions are not sound. However, it is less interesting to rehearse the weaknesses of these objections than it is to ask the question at the heart of this analysis. How much deliberation should a leader preside over? The answer, as challenging as it might be for someone who enjoys coming across as ‘giving a hearing' to all who want to listen to him or her, is that in the context of a pandemic, your context practically demands of you to take urgent action - any action.

This means that an organisation like SANAC, and its ultimate political head, president Zuma, must get on with deciding whether or not it will go with a fact-based intervention to help reduce the HIV transmissions rate or whether it will consider the surrounding socio-cultural sensitivities as overriding. Whatever the decision, inaction is symptomatic of crippling leadership.

The second example is that of sex work. The SA law reform commission has long ago made available a very comprehensive report into different possible responses to sex work ranging from retaining the status quo to having controlled areas within which sex work can legally take place.

In terms of the AIDS pandemic, there is unquestionable evidence that the criminalisation of sex work exacerbates the AIDS pandemic. This logically implies that one of the many tools needed to reduce the transmission of HIV is to bring sex workers into the legal fold so that the state can empower them and their industry to be better equipped to practise their work while taking the best possible precautions to minimise the contraction and spreading of the virus.

Obviously it is not politically easy to endorse this policy. If the success criterion is only the reduction of HIV transmission then it would be a no-brainer. Politicians are right, however, to take into account moral and social sensitivities. The debate on sex work is as much about HIV/AIDS as it is about whether or not sex work is morally acceptable and whether or not the SA government should take account of the views of the majority.

Again, however, the critical issue is not what position is ultimately taken on these substantive areas of disagreement. Some of us would lobby for a liberal attitude based in part on medical fact and in part on liberal ideologies. Others are entitled to lobby for more conservative decisions. As with circumcision, however, leadership inertia with respect to taking a position - any position - is unacceptable.

A body such as SANAC needs a political head that can pull together the strands of different viewpoints that have been debated, lay them on the table, and propose a solid policy position that can then be developed. Failure to do will reduce SANAC to a high school debate chamber: fun, but with no impact.

Deliberative processes are crucial for developing our democracy. We should continue to hear all views on major policy issues. But when facing a pandemic, sensible political leadership requires someone - call him Jacob Zuma or Kgalema Mothlanthe? - to demonstrate an understanding of the need to balance deliberation with urgent action. Time is not on our side.

Eusebius McKaiser is an associate at the Centre for the Study of Demoracy. He is also a contributing editor at Business Day. He blogs at www.safferpolitics.co.za/

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responses to this article

ABC, not circumcision Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are more likely to be HIV if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is . .more 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw. ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them. . .less by Mark Lyndon on December 01 2009, 03:12 Find this comment inappropriate? Report it

Distortion I could not continue reading this after the comment about Mbeki denialism. Distortion of facts in the first line and the credibility of the rest of the post must be questioned. by Mokoni on December 01 2009, 08:53 Find this comment inappropriate? Report it

SA Behaviour and culture In a country where 80% of the population believe in such things as the Tokolosh and muti, concocted by witchdoctors, muti so powerful it can ward off evil spirits, disease, pestilence and even bullets fired at point blank range, HIV aids is bound to . .more flourish. See; http://letterdash.com/g.annandale/the-problem-with-aids-and-south-africa . .less by Geanann on December 01 2009, 10:43 Find this comment inappropriate? Report it

Zuma HIV ? If a president has unprotected sex with an HIV prostitute, claims that a shower afterwards will protect him and support claims that vegetables cure AIDS and then also don't take a public HIV test on World Aids Day like other political leaders, then you . .more know that there is an HIV problem that won't be dealt with anytime soon.... . .less by RSmith on December 01 2009, 11:18 Find this comment inappropriate? Report it

Aids protection The best cure for aids is dont sleep around and have your partner tested before you have sex.The goverment cant take responsibility for the peoples SEX actions. Why must the goverment pay for this? Treatment of aids must be done by . .more dedicated and compasioned staff.Not staff that are only there for the money.Because they realy DONT CARE. You can put as much money in aids treatments as you wish.But if the people dont want to look after themselfs..AIDS is going to KILL them and there partners. !!!!!!!!! BELIEVE IT !!!!! . .less by alkie on December 01 2009, 12:51 Find this comment inappropriate? Report it

r.i.p May Nkosi Johnson who died on World Children's day rest in peace. May all other people who are suffering from the AIDS pandemic find strength and live until they meet with their destiny. May they worry not about things of the flesh which come to pass- . .more materialism. Those who have passed on after dedicating their lives to upholding basic human rights, may they also receive the mercy of God. The grace of God shall be upon them all infinitely, eternally and indefinitely. Rest in Peace . .less by King Zwakala on December 01 2009, 14:12 Find this comment inappropriate? Report it

Not just ANY action... "your context practically demands of you to take urgent action - any action." If you spend money and resources on something that is at best futile and at worst increases the spread of HIV, it would be better to sit on your hands, and let someone else . .more spend the money and resources on something that works. It is just not true that "It also slightly reduces the chances of infecting another person." A study in Uganda (an arm of the circumcision-to-prevent-HIV-infection in men trial there) was called off "for futility" before it could reach statistical significance, but 18% of the women whose HIV partners were circumcised had HIV, compared with only 12% of the women whose HIV partners were not. Researchrs were quick to blame the vicitms for resuming sex too soon, but there are physiological reasons suggesting the hardened circumcised P**** itself and the desensitised man using it may be the reason. Why do you discount "risk compensation" (men saying "I don't need to wear a condom, I'm circumcised") when men are reported as saying just that? Telling men "circumcision reduces the risk but you must continue to use condoms" is a hopelessly mixed message, especially with circumcision being so dramatic and visible. And this assumes that the three non-blinded, non-placebo controlled studies are sound... . .less by Hugh7 on December 03 2009, 02:34 Find this comment inappropriate? Report it

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