The following is the text of the exchange between Democratic Party/Democratic Alliance leader, Tony Leon, and South African/African National Congress President Thabo Mbeki in mid-2000 on the matter of provision of AZT to rape victims as a post-exposure prophylaxis against the transmission of HIV. This debate took place at the height of Mbeki's public challenge to the scientific orthodoxy of HIV/AIDS, but at a time when few were willing to directly criticise an ANC leadership at the height of its political and moral power.
Extract from the speech by Tony Leon, Democratic Party (Democratic Alliance) leader of the opposition, Debate on the President's Budget Speech, National Assembly, Parliament, June 13 2000:
DEBATE ON THE PRESIDENT'S BUDGET SPEECH
13 JUNE 2000
THE LEADER OF THE OPPOSITION:
We move to the second paradox of this Government, to which the President drew close attention this morning, and that is that it represents poor people globally, but neglects them locally. The President has taken on, as he told us this morning, the mantle of representing poorer nations on the world state. For that, he deserves our acclamation and congratulations, and we are not stinting in giving them to him.
But, paradoxically, and that for the Presidency deserves the widest condemnation, the poorest people here at home have seen and heard little of their President this year. [Interjections.] Those without jobs, those in dire poverty, and those living with HIV/AIDS, have been left wondering what the future holds for them under this Government. The President's questions about the causes of HIV/AIDS have failed to reach their ears. And let me say, if that is the case, then perhaps they are less confused, and, in one real sense, better off than if they had heard the mixed messages emanating from him and his office on this crucial issue.
I think the AIDS debate is an acute one. I quote the words uttered on 10 May this year by Charlene Smith, who herself survived a horrific rape ordeal. Let us listen to what she said about the Government's and the President's stance:
If, instead of spending vast amounts of money on recreating the wheel, President Mbeki had taken up the Glaxo Wellcome offer-the lowest in the world at R200 for 28 days supply of AZT-and made it available to rape survivors to prevent HIV, 10 000 rape survivors in South Africa would have got the drug. Eighty percent of them would not have sero-converted and become HIV positive if raped by an HIV positive person.
As the Americans would say, whom he met recently: Case closed.
Extract from the reply by President Thabo Mbeki in the Debate on the President's Budget Speech, National Assembly, Parliament, June 13 2000:
THE PRESIDENT OF THE REPUBLIC
I have complained in the past about the quality of some of our discussion here. The matter keeps coming up. I do not know how we should address it. I think that there are certain things that, perhaps, we should not do.
The hon Tony Leon raises the matter of the use of AZT in the instances where women have been raped. It is illogical. I do not know if the manufacturing company here, that manufactures AZT, is in fact selling AZT for that particular indication or giving it out to patients who are in those circumstances, because if they are doing that, I am not sure it [would] be legal. The reason for that is that AZT is not licensed in this country for that particular purpose. Indeed, it is not licensed in any country in the world for that particular purpose. The reason for it is that the manufacturing company says that AZT is not a vaccine. Therefore, one cannot use it in this instance where somebody gets raped, possibly by somebody who is HIV-positive, and if one gives that person AZT, it will stop an infection. The manufacturing company itself says that AZT is not a vaccine and therefore it cannot work in the circumstances, which is why they have never applied for the licensing of AZT for that purpose in any country.
AN HON MEMBER: What about the offer that they made you?
The PRESIDENT OF THE REPUBLIC: Glaxo Wellcome would not have made an offer to the Government for AZT to be used in this way. [Interjections.]
Mr A J LEON: But they made an offer!
The PRESIDENT OF THE REPUBLIC: No, Tony, they did not. You should give me the evidence of the offer. We have discussed this matter with them. We have discussed this matter with them and have said that there is this demand which is funny, because they have not applied to the MCC for this purpose. There is not a single clinical study anywhere in the world which deals with this. The manufacturing company said that, of course, they would not apply for this particular indication because it is illogical. It is absurd, because if it worked, then there would be no need to work further on a vaccine because this would be a vaccine.
It is very easy to check this one. We just need to phone Glaxo Wellcome tomorrow. [Laughter.] It is quite easy to check that out. That member should try to speak to them again and tell them what I said about this. I say that it is not licensed anywhere in the world for this purpose, because that company has not applied, for the reasons that I have indicated.
Letter from Tony Leon to Thabo Mbeki June 19 2000:
LETTER FROM LEON TO MBEKI:
19 June 2000
Mr T M Mbeki
Republic of South Africa
Private Bag X1000
Dear President Mbeki
I enjoyed participating in the debate on your Budget Vote and look forward to future encounters of this or a similar kind. Perhaps we could take the discussion further in a less adversarial forum.
I would, however, like to answer your challenge on the issue of HIV/AIDS and the proposals concerning AZT and your response thereto. My statement to Parliament was along the following lines:-
"I think the AIDS issue is an acute case. To quote the words uttered on the 10th May this year by Charlene Smith who, herself, survived a horrific rape ordeal, she said of the President and this government's stance:
‘If instead of spending vast amounts of money recreating the wheel - President Mbeki had taken up the Glaxo Wellcome offer - the lowest in the world at R200 for 28 days' supply of AZT and made it available to rape survivors to prevent HIV - 10 000 rape survivors in South Africa would have got the drug...80% of them would not have sero-converted and become HIV positive if raped by an HIV positive person.'"
Obviously what I said is generally the view of rape and anti-AIDS victim Charlene Smith. Of necessity my remarks were somewhat elliptical because of the wide number of topics I had to cover in the very limited time available to me in your debate.
However, with respect to your response, I believe that my central contention is valid. You, of course, are correct to indicate that AZT is not a vaccine, which I did not suggest it was. It is, however, an anti-retro viral medication which will prevent sero-conversion in rape victims who are raped by an HIV positive person.
I accept the accuracy of your statement that AZT is not registered with the relevant authority. But surely this is irrelevant? After all, Misoprostal, used in clinics by the government's own Department of Health to induce abortions, is also not registered by the MCC for that specific purpose.
As I understand it, a 28 day course of AZT will boost the immunity of a woman raped by an HIV positive person, thereby allowing her to fight the virus and increase her chances of not converting positive.
A J LEON MP
Leader of the Opposition
Letter from Tony Leon to Thabo Mbeki, June 27 2000:
Mr T M Mbeki
Republic of South Africa
Private Bag X1000
Fax: 012 342 1938
Dear President Mbeki
Further to my letter to you of 19 June 2000 on the issue you raised in Parliament in response to my remarks about the so-called Aids vaccine, may I draw to your attention the enclosed response I received from the Chief Executive of GlaxoWellcome.
A J LEON MP
Leader of the Opposition
Letter from Thabo Mbeki to Tony Leon, July 1 2000
PRESIDENT REPUBLIC OF SOUTH AFRICA
July 1, 2000
Thank you for your letters of June 19 and 27, 2000 relating to the AIDS issue. Thank you also for the copy of the letter of the South Africa CEO of Glaxo Wellcome, Mr J.P. Kearney.
As you are aware, during the last few months, I have tried to familiarise myself with all elements relating to the HIV-AIDS matter.
Necessarily, this has also meant studying as much literature as possible on the question of anti-HIV retroviral drugs.
What I said in parliament was based on the information I had managed to garner on the issue you raised. As you correctly indicate, this related to the efficacy of AZT in stopping HIV infection in cases of rape.
Your statement, that 80% of women raped by HIV-positive men would not become HIV-positive if they are given AZT, has no scientific basis whatsoever.
In this regard, I suggest that, among others, you obtain a copy of the publication of the US CDC, MMWR September 25, 1998/47 (RR 17).
Among other things, the CDC says:
"no data exist regarding the efficacy of (antiretroviral drugs) for persons with nonoccupational HIV exposure..." (As you must be aware, ‘non occupational exposure' includes rape.)
"Some physicians believe that antiretroviral agents are indicated for persons with possible sexual, injecting-drug-use, or other nonoccupational HIV exposure. However PHS (the US Public Health Service) cannot definitely recommend for or against antiretroviral agents in these situations because of the lack of efficacy data on the use of antiretroviral agents in preventing HIV transmission after possible nonoccupational exposure. Efficacy and effectiveness data and additional epidemiologic information is needed..." and,
"Research is needed to establish if and under what circumstances antiretroviral therapy following nonoccupational HIV exposure is effective."
The CDC makes this equally important statement:
"Postexposure antiretroviral therapy should never be administered routinely or solely at the request of a patient. It is a complicated medical therapy, not a form of primary HIV prevention. It is not a ‘morning-after pill'..." (My emphasis).
In the same report, the CDC says that:
"The risk for HIV transmission... per episode of receptive vaginal exposure is estimated at 0.1%-0.2%."
In this regard, you might care to consider what it is that distinguishes Africa from the United States, as a consequence of which millions in sub-Saharan Africa allegedly become HIV positive as a result of heterosexual sexual intercourse, while, to all intents and purposes, there is a zero possibility of this happening in the US.
In your letter to me of June 19, you make the extraordinary statement that AZT boosts the immune system.
Not even the manufacturer of this drug makes this profoundly unscientific claim. The reality is the precise opposite of what you say, this being that AZT is immuno-suppressive.
Contrary to the claims you make in promotion of AZT, all responsible medical authorities repeatedly issue serious warnings about the toxicity of antiretroviral drugs, which include AZT.
For example, in its Report, MMWR May 15, 1998/ Vol. 47./No. RR-7. the CDC says:
"The selection of a drug regimen for HIV PEP (post-exposure prophylaxis) must strive to balance the risk for infection against the potential toxicity of the agent(s) used. Because PEP is potentially toxic, its use is not justified for exposures that pose a negligible risk of transmission."
In this context, please bear in mind the 0.1%-0.2% risk of transmission indicated by the CDC with regard to receptive vaginal exposure.
The matter is not in dispute between as that AZT is not licensed by the South African MCC for use in rape cases. Further to this, Glaxo Wellcome has not applied to the MCC for such a licence.
Indeed, the approved package insert for AZT makes no claim about the efficacy of AZT with regard to rape cases.
I would presume that the reason that Glaxo Wellcome has not applied for a licence is precisely because it knows that there is no scientific evidence it could produce to justify this application.
It is very strange that you have proven scientific information which Glaxo Wellcome, the CDC, the MCC and every responsible medical-authority does not have, that 80% of rape victims in our country would not have become HIV positive if they had been given AZT.
It may be that I underestimate the scientific expertise of which your Party disposes.
Accordingly, I am ready to change my views on this matter, to pay due tribute to such expertise, if it is demonstrated that you do, indeed, have such expertise.
If it is necessary, I can present the argument about the logical absurdity of the claim that viral infection can be stopped by the use of drugs, provided that the virus was communicated in circumstances of forced heterosexual sexual intercourse.
It is in this context, apart from extant scientific information, that the issue I raised in the National Assembly about AZT not being a vaccine assumes its relevance. The PEP argument about AZT (and other anti-retrovirals) cannot be sustained unless vaccine-like efficacy is attributed to these anti-retroviral drugs.
Accordingly, the statement you make in your 19 June letter that I am "correct to indicate that AZT is not a vaccine, which I (you) did not suggest it was", is inconsistent with your argument that AZT should be used as though it were a vaccine.
I am very disturbed at Mr Kearney's statement that your incorrect statements about AZT and rape are "essentially accurate on the scientific aspects of using AZT as post-exposure prophylaxis in individuals who have been raped."
I imagine that all manufacturers of anti-retroviral drugs pay great attention to the very false figures about the incidence of rape in our country, that are regularly peddled by those who seem so determined to project a negative image of our country.
What makes this matter especially problematic is that there is a considerable number of people in our country who believe and are convinced that most black (African) men carry the HI virus.
In addition to this, reflecting a view among these about rape in our country, Charlene Smith was sufficiently brave, or blinded by racist rage, publicly to make the deeply offensive statement that rape is an endemic feature of African society.
This is what she wrote recently in the US Washington Post:
"Here, (in South Africa), HIV is spread primarily by heterosexual sex-spurred by men's attitude towards women. We won't end this epidemic until we understand the role of tradition and religion-and of a culture in which rape is endemic and has become a prime means of transmitting the disease, to young women as well as children."
The hysterical estimates of the incidence of HIV in our country and sub-Saharan Africa made by some international organisations, coupled with the earlier wild and insulting claims about the African and Haitian origins of HIV, powerfully reinforce these dangerous and firmly-entrenched prejudices.
None of this bodes well for a rational discussion of HIV-AIDS and an effective response to this matter, including the use of anti-retroviral drugs.
Whatever his obligations as the Chief Executive of the company that manufactures AZT, I think it is grossly unethical that Mr Kearney should seek to increase the sales of AZT, and therefore Glaxo Wellcome's profits, by exploiting the justified health concerns of our people.
I consider it deeply offensive and contemptuous of our people, our country and its laws that, as you and Charlene Smith say, Glaxo Wellcome should promote the sales of AZT by selling ‘cut-price' AZT in our country for use by rape victims, knowing well that this is in violation of the law and that no scientific evidence exists proving the efficacy of this drug in cases of rape.
I have noted the fact that Mr Kearny seeks to achieve his commercial purposes "together with you and your Party."
It is amazing and completely unacceptable that you, the Leader of the Official Opposition, should consider all of this, including blatant disrespect for the rule of law, as "irrelevant", the word you use in your letter to me.
You will remember that during the debate around the legislation we introduced enabling the parallel import of drugs and medicines, to make these affordable for our population that is deeply mired in poverty, your party was correctly and needlessly very vocal about the necessity to ensure that all pharmaceutical products available to our people should be subject to approval by the MCC.
Why is a double standard now being applied with regard to AZT, making the need for certification of drugs by the MCC "irrelevant"?
Only recently, your party has been very strident in demanding respect for the rule of law in Zimbabwe.
Why is a double standard now being applied with regard to AZT, making the requirement for observance of the rule of law "irrelevant"?
In his letter to you, Mr Kearney says his company is committed "to improve access to drugs for HIV-positive individuals."
In more direct and plain language, this means that, consistent with its normal and understandable commercial objectives, Glaxo Wellcome is committed to increase the sales of AZT in our country, in competition with anti-retroviral drugs manufactures by other companies.
If Mr Kearney did not pursue this objective as vigorously as possible, his company would be entitled to terminate his contract.
You and I, as public representatives of our people, pursue, or should pursue, a different objective. With regard to the matter under discussion, our objective must surely be to improve the health of all our people.
I think that it is dangerous that any of our public representatives and political parties should allow themselves to be used as marketing agents of particular products and companies, including drugs, medicines and pharmaceutical companies.
I accept that it is perfectly within their right for private individuals, such as Charlene Smith, to play this role, as it would be for you, in your private capacity.
In the controversy that has attended the questions our government has raised about various matters relating to HIV-AIDS, much has been said about us, in a sustained effort to force us uncritically to accept a so-called orthodox view.
We have resisted this pressure and will continue to do so, because of the decisive importance of an accurate understanding of AIDS and its specifics in our own country.
I trust that our discussion about AZT and rape will convince you that despite the fervent reiteration of various assertions, supported by many scientists, medical people and NGO's, about the existence of some unchangeable and immutable truths about HIV-AIDS, as public representatives we have no right to be proponents and blind defenders of dogma.
Whatever the intensity of the campaign to oblige us to think and act differently on the HIV-AIDS issue, the instinctive human desire in the face of such a barrage, to obtain social approval by succumbing to massive and orchestrated pressure, will not lead us to become proponents and blind defenders of dogma.
The cost of AIDS in human lives is too high to allow that we become blind defenders of the faith.
Unless you have evidence to demonstrate that what I have said about AZT and rape is wrong, I would expect that you make a public statement distancing yourself from the false claims so regularly propagated in this country, concerning the efficacy of AZT as post-exposure prophylaxis in cases of rape, propaganda in which you joined.
Not only is this the only honourable thing to do, but, as a high-level public representative, I believe you have an obligation to correct the misleading impression on the matter we are discussing that you and your Party have conveyed on more that one occasion, in parliament and elsewhere.
Needless to say, to uphold the rule of law and to fulfil the government's obligations with regard to the health of our people, we will follow up on the matters you have brought to our attention, concerning the disturbing behaviour of Glaxo Wellcome.
Given that the matters about which you have written to me were discussed openly in the National Assembly, during which debate I suggested that you convey my views to Glaxo Wellcome, I believe that it would be correct that we make the correspondence between us available both to the National Assembly and the general public.
Once again, I would like to suggest that you inform yourself as extensively as possible about the AIDS epidemic. Again, for this purpose, I would like to recommend that you access the Internet.
On the various websites, you will find an enormous volume of literature, including CDC, WHO and UNAIDS documents, editions of various highly respected science journals as well as "dissident" articles.
As you know, many frightening statements are made with great regularity about the incidence of HIV-AIDS in our country and continent and the threat this poses to our very survival as a country, a continent and as Africans.
I believe that it is imperative that all our public representatives should base whatever they say and do on the HIV-AIDS matter, on the truth and not necessarily on the comfort of fitting themselves into the framework of whatever might be considered to be ‘established majority scientific opinion.'
Letter from Tony Leon to Thabo Mbeki, July 7 2000:
7 July 2000
Mr T M Mbeki
Republic of South Africa
Private Bag X1000
Fax: 012 342 1938
Dear President Mbeki
Thank you for your letter of the 1st of July. I appreciate the great time and effort that you have obviously put into your response, although I find much of the tone and content unhelpful in promoting rational debate on this important matter.
If I understand your letter correctly, you argue against the provision of AZT to rape victims on two grounds:
Firstly, you argue that there is "no scientific evidence" to support the argument that the provision of AZT could prevent the transmission of the HIV virus to rape victims.
Secondly, you claim that the risks of potential transmission are so low that they do not warrant the use of AZT, which as you correctly point out can have severe side effects.
You base your argument on numerous quotes from the publication of the Centre for Disease Control in America, Morbidity and Mortality Weekly Report, September 25, 1998/ Vol 47/ No. RR-17. I do not believe that when read as a whole, the document supports your arguments. I will deal with each argument in turn.
The evidence from the CDC report which you provide to support your first argument is a quote from the CDC which says "no data exist regarding the efficacy of (antiretroviral drugs) for persons with nonoccupational HIV exposure..."; the fact that the US Public Health Service "cannot definitely recommend for or against antiretroviral agents in these situations because of the lack of efficacy data"; and that further research is needed "to establish if and under what circumstances" such therapy would be effective.
The CDC report is extremely even handed. It scrupulously weighs up the evidence both for and against the provision of anti-retroviral drugs following non-occupational HIV exposure. You have unfortunately only quoted the arguments against. A point that must be made at the beginning is that the CDC does allow the provision of anti-retroviral drugs by physicians to rape victims. The document is an attempt to highlight the "potential benefits and risks" and so provide a guide to physicians on whether or not to pursue such a course of treatment. The CDC has published formal guidelines for physicians should they choose to use AZT.[i]
The reason for the lack of "efficacy data" is that there have been no prospective trials conducted to measure the effectiveness of AZT for non-occupational exposure. It is simply impossible to conduct such trials because one would need to establish beyond doubt the HIV status of both the rape suspect and the rape survivor before and after the rape. While this in itself is almost impossible, the fact that it is illegal to test for HIV against a person's will makes such research harder still. The best that can be done is to conduct a retrospective case control study. One is currently being conducted by the CDC.
It is for this reason that the CDC is unable to recommend either for or against antiretroviral drugs for rape victims. This does not mean that there is "no scientific basis whatsoever" for my statement that the provision of AZT would reduce HIV transmission to rape survivors.
In fact, the CDC report evaluates data from various trials, which could have a bearing on the potential efficacy of anti-retroviral PEPs. It makes reference to various trials conducted on animals, but I will deal only with its references to studies on humans. Two are of significance: Firstly, the CDC quotes the study (which I referred to in my letter) from a 1995 survey where investigators used "case control surveillance data from health care workers" in Europe and America to document that AZT use "was associated with an 81% decrease in the risk for HIV infection after percutaneous exposure to HIV-infected blood." According to the CDC this study "demonstrated antiretroviral effectiveness" following needle stick injuries.
The CDC also refers to the study where there was a 67% reduction in transmission of HIV from mother to child when AZT was administered during pregnancy, labour, and for six weeks after birth. The CDC states that there was evidence that a "prophylactic effect" on the foetus before, during or after birth "could account for some reduction in perinatal transmission."
Although the CDC report acknowledges that these studies "might not be directly relevant to non-occupational exposure" they do "suggest that antiretroviral agents are potentially valuable for treating HIV exposures in these settings."
These trials are obviously not conclusive for they have to be extrapolated to non-occupational settings. However, they do suggest that antiretroviral agents can act as a postexposure prophylaxis and reduce a person's risk of acquiring HIV infection after exposure. The CDC report states "it can take several days for infection to become established in the lymphoid and other tissues. During this time, interventions to interrupt viral replication could represent an opportunity to prevent an exposure from becoming an established infection."
Thus, if providing AZT to rape victims can prevent an exposure to HIV from becoming an established infection (and there is substantial evidence to suggest it can) the benefit is massive, if not priceless. The victim is literally saved from a death sentence.
Which brings me to your second argument, which is that the chances of HIV transmission from rape are so small, and the side-effects of AZT are so large, that providing such treatment to rape victims is not really worth the candle.
You quote the CDC as saying that in selecting a drug regimen for post-exposure prophylaxis the physician should "balance the risk for infection against the potential toxicity of the agent(s) used. Because PEP is potentially toxic, its use is not justified for exposures that pose a negligible risk of transmission." You then state, "in this context, please bear in mind the 0.1% - 0.2% risk of transmission indicated by the CDC with regard to receptive vaginal exposure." You seem to be implying that "receptive vaginal exposure" constitutes a "negligible risk of transmission" and that consequently it is not worth providing rape survivors with AZT with potentially toxic side effects.
This is disingenuous for two reasons: Firstly, the risk of HIV transmission following rape (particularly in South Africa) is not "negligible" at all. Rape does not constitute "receptive" sex and as such is likely to lead to trauma and consequently a far greater risk of HIV transmission. The risk is compounded in South Africa by the high levels of HIV in the population as well as the prevalence of Sexually Transmitted Diseases, which greatly increase the possibility of HIV transmission.[ii] Secondly, the CDC is not referring to rape or consensual sex when it states that PEPs are not "justified for exposures that pose a negligible risk of transmission." Rather, it is referring to contact between infected body fluid and intact skin. This would be clear had you quoted the whole sentence from the CDC report, which reads, "Because PEP is potentially toxic, its use is not justified for exposures that pose a negligible risk of transmission (e.g. potentially infected body fluid on intact skin.)" (My emphasis.)
This is just one example of where you have pruned quotes to make them fit your argument. Elsewhere you quote the CDC report as saying "Postexposure antiretroviral therapy should never by administered routinely or solely at the request of a patient. It is a complicated medical therapy, not a form of primary HIV prevention. It is not a ‘morning-after pill...(your emphasis)" Yet you omit to mention that the report continues (from precisely the point where you left off) "but, if proven effective, can constitute a last effort to prevent HIV infection in patients for whom primary prevention has failed to protect them from possible exposure." (My emphasis)
Reading through your letter I had the strong feeling that you have reached your conclusions already. You then selectively choose quotes to support your argument, and ignored others that didn't. If the quotes do not quite fit your purposes you lop off the awkward parts.
What is most disturbing about your letter is the way you impute sinister motivations on the bona fide actions of others. You seem to believe that the request by my Party, Charlene Smith and others for the government to provide AZT to rape victims, and the offer by Glaxo Wellcome to provide it at greatly reduced prices, is all part of a giant conspiracy. You imply that this conspiracy is the result of some unholy alliance between a civil society motivated by racism and an international pharmaceutical industry driven by greed.
It seems that underlying your letter is a belief that civil society is once again being driven by an overriding desire to reaffirm "its belief that its racist stereotype of Africans [is] correct." (ANC statement to HRC on racism in media)
Out of a "determination" to project a "negative image" of South Africa unnamed forces peddle what you describe as "very false figures"[iii] on the incidence of rape in this country. You claim that the AIDS debate in South Africa is being driven (and distorted) by people "who are convinced that most black (African) men carry the HIV virus." Among their number you name Charlene Smith who you claim was "blinded by racist rage" when she wrote that rape was endemic in South African society.
You proceed to complain that by publishing "hysterical estimates" (your emphasis) and by making "wild and insulting claims" about the African origins of HIV, the international community is (whether out of accident or design) acting to "reinforce these dangerous and firmly-entrenched prejudices."
You then claim that the international pharmaceutical companies are driven by even more sinister motivations. You suggest that the sole and overriding desire of the pharmaceutical companies is to maximise their profits by exploiting every available opportunity to flog their drugs to South Africa, regardless of their efficacy or toxicity thereof. You claim that having had their interest pricked by the high incidence of rape in this country, Glaxo Wellcome set out to cynically exploit the "justified health concerns of our people" in order to (once again) "increase the sales of AZT." To top this giant-racial-capitalist-conspiracy off you accuse Charlene Smith and I of being "marketing agents" of the pharmaceutical companies.
(For the record: Neither I nor the Democratic Party have received any financial assistance of any nature from Glaxo Wellcome.)
What concerns me about your letter is the tendency to turn questions of fact into questions of motive. This method of propaganda may be useful means of silencing (or isolating) your critics without responding to their arguments, but is not particularly conducive to rational debate.
It is somewhat hypocritical to accuse overseas opinion of intolerance and then to try to shut down dissent domestically by labelling people "racists" or "pawns of the pharmaceutical industry." Your statement that the government will take steps against the "disturbing behaviour of Glaxo Wellcome" is frankly sinister.
Your determination to resist the imposition of what you call the "dogma" of scientific opinion seems to be matched only by a desire to impose your own.
Yet what is most worrying for South Africa is that it seems your party has actually started to believe its own propaganda. Instead of identifying, confronting, and then dealing with the immense problems facing our country, the ANC is perpetually chasing shadows. You seem more concerned with the possibility that high rape and AIDS figures might confirm the prejudices of some, than with the massive human tragedy in our country which those figures are merely an indication of. In consequence, your obsession with the motives of others has begun to harm the interests of the very people you claim to represent.
As the earlier part of my letter has indicated, there are strong scientific grounds for providing post-exposure prophylaxis to victims of rape. I cannot see how the offer by Glaxo Wellcome to provide AZT to rape survivors at reduced prices can be described as "grossly unethical."
Similarly, I cannot see how you can you can equate the provision of AZT to rape survivors with the state sponsored campaign of terror and intimidation in Zimbabwe. It is a nonsensical comparison.
I, like you, are a layman on these matters. You are entitled to your personal opinion on whether AZT is effective in reducing HIV transmission, and indeed, whether HIV even causes AIDS. However, it wrong for you to use your current position (which was gained on the basis of political rather than medical talent) to block the provision by your government of such treatment.
It is perfectly consistent with the CDC report (which you quote!) for our government to make available AZT for prescription to rape victims. Obviously, our doctors must weigh up the risks and benefits of prescribing such treatment. They must act both with the informed consent of the patient, and according to proper guidelines such as the CDC provides. The point is that the physician and the patient must be left to make that decision. By denying rape victims AZT you are denying them the choice. With all due respect, you lack both the moral right and the medical expertise to make such a life and death decision.
I agree that this correspondence should be made available to the National Assembly and the general public.
A J Leon MP
Leader of the Opposition
(Signed in Mr Leon's absence.)
[The two letters above were passed on to the Sunday Times by the Democratic Party which published them in full on July 9 2000]
Letter from Thabo Mbeki to Tony Leon July 17 2000:
PRESIDENT REPUBLIC OF SOUTH AFRICA
July 17, 2000.
Thank you for your letter of 7 July 2000, which discusses various matters, related to HIV-AIDS. Unfortunately, because of pressing engagements inside and outside the country, I could not reply to your letter earlier.
As you will remember, the exchange between us in the National Assembly related to the issue of the provision of AZT to rape victims. Accordingly, your own letters to me dated June 19 and 27 also discuss this particular matter.
Your latest letter goes beyond this. For instance, you refer to such matters as needle stick injuries and mother to child transmission, neither of which was under discussion between us.
Let me therefore return to the matter of AZT and rape and the matter of statements made by representatives of Glaxo Wellcome.
As you know, in his letter to you, the CEO of Glaxo Wellcome South Africa, Mr Kearny, said that your incorrect statements about AZT as rape were "essentially accurate on the scientific aspects of using AZT as post-exposure prophylaxis in individuals who have been raped."
Yet, Dr Moore, Medical Director of Glaxo Wellcome South Africa, had said on the television programme, Carte Blanche, on 7 November 1999:
"I have to state emphatically that AZT is not registered and we do not recommend it for use after rape." (My emphases.)
A rule of simple logic states that two diametrically opposed statements about the same thing cannot both be correct.
It was not possible that both Mr Kearny and Dr Moore, both of Glaxo Wellcome South Africa, could both be correct.
I am pleased to see that the CEO of Glaxo Wellcome has now repudiated what he said about your comments being "essentially accurate on the scientific aspects...etc."
As you will have seen in the Sunday Times edition of July 16, 2000, this is what Mr Kearny now says:
"The company has not engaged in any price or supply negotiations to provide AZT for use in rape survivors, nor does the company promote the product for that indication, Mr Leon has therefore misinterpreted the company's offer.
"President Mbeki is correct in pointing out that Glaxo Wellcome's package inset for AZT does not mention the medicine's use in rape situations. For the reasons spelled out in Mr Leon's letter, it has not thus far been possible to carry out clinical studies relating to the use of anti-retrovirals in rape survivors."
I trust you will also note that whereas Mr Kearny says his company does not promote AZT for use by rape survivors, Dr Moore says they do not recommend it for use after rape.
Given the gravity of the matter under discussion, this is not simply a matter of semantics. Perhaps Glaxo Wellcome will have an opportunity to clarify this matter in future.
As I said to you and the rest of the National Assembly, AZT is not registered in this country for use by rape victims. Neither has its efficacy for such situations been demonstrated scientifically.
Obviously, you did not believe what I said then and continued to communicate things I am convinced were clearly wrong.
You sought to convince us that there was proven efficacy of AZT in cases of rape and that Glaxo Wellcome had offered this drug at reduced prices for use in such circumstances.
You even went so far as to suggest that the fact that AZT was not registered or suggested for this indication was "irrelevant".
I remain firmly of the view that had AZT been promoted and offered at reduced prices for rape cases, this would have constituted very disturbing behaviour on the part of Glaxo Wellcome, driven by nothing else except profit, with no regard for ethics and the health of our people.
It would require that the government take the necessary action to stop what would have been illegal behaviour.
I find very interesting indeed that you consider the enforcement of the law in this regard, as you say in your letter, as "frankly sinister".
At the National Assembly and subsequently, you communicated wrong things as fact, Glaxo Wellcome has now also stated that what you conveyed was incorrect.
This may come as a surprise to you, but given this reality, all normal human beings will naturally ask what you motives are in doing this.
Throughout our communication on the matter under discussion I have not resorted to any "propaganda" as you allege. Neither have I sought to silence you.
What we are about is gaining as accurate and factual an understanding as possible with regard to the matter under discussion. As I am doing in this letter, I am quite ready to respond to all your arguments and hope that you are as ready to respond to mine without rancour.
You and Mr Kearny argue, as you say in your letter, that "the CDC does allow the provision of anti-retroviral drugs by physicians to rape victims".
I can only interpret this as being nothing more, or less, than a determined attempt to ensure that rape victim use AZT and other anti-retroviral drugs.
Let me go back to the CDC documents I cited in my letter to you.
The CDC document MMWR September 25, 1998 / 47 (RR17) - hereafter RR17 - says:
"Because no data exist regarding the efficacy of this therapy for persons with non-occupational HIV exposure, it should be considered an unproven clinical intervention." (My emphasis).
"Although healthcare providers and other have proposed offering anti-retroviral drugs to persons with unanticipated sexual or injecting-drug-use HIV exposures, no data exist regarding the effectiveness of such therapy for these types of exposures." (RR17). (My emphasis).
"Many insurers will not cover the cost of this unproven therapy, so any possible benefit will be limited, based on the patient's ability to pay." (RR17).
"The risk for HIV transmission per episode of receptive penile-anal-sexual exposure is estimated at 0.1% - 3%; the risk per episode of receptive vaginal exposure is estimated at 0.1% - 0.2%. No published estimates of the risk for transmission from receptive oral exposure exist, but instances of transmission have been reported." (RR17).
Commenting on studies of anti-retroviral agent use to prevent HIV infection in animals, the same document says:
"Treatment initiated within 24 hours of exposure and continued for 28 days appeared to have a greater effect than treatment initiated 72 hours after exposure. However, ZDV (AZT) might not be the optimal agent to demonstrate proof-of-concept because it has no demonstrated potent inhibitory activity against SIV infection in macaques, even when treatment is initiated before viral exposure." (RR17). (My emphasis).
Presumably this is where you and MS Smith found your figures about the need to dispense AZT within 24 hours of rape and sustain this for 28 days.
Yet the same document concludes:
"Extrapolating these results to humans is problematic because of several factors...Animal studies offer proof-of-concept and demonstrate the challenges to understanding the requirements for effective use of anti-retrovirals to prevent HIV transmission in humans." (RR17).
In your letter you draw attention to comments made in this document to the entirely different issues categorised in the document as:
· "percutaneous exposure to HIV-infected blood" among health workers; and,
· "perinatal transmission" of HIV to their child by HIV-infected mother.
The CDC goes on to say:
"Despite the apparent usefulness of anti-retroviral agents in perinatal and occupations settings, it is unclear whether these findings can be extrapolated to other settings. Further studies are needed before one can conclude whether using anti-retroviral agents to prevent HIV infection after non-occupational exposures is effective." (RR17).
Whereas the CDC warns against the extrapolation of these findings to other; and specifically non-occupational, settings, you proceed to do precisely this.
"Thus, if providing AZT to rape victims can prevent an exposure to HIV from becoming an established infection (and there is substantial evidence to suggest it can) the benefit is massive..."
Nowhere is it suggested in the CDC documents that thus the provision of AZT to rape victims can prevent exposure to HIV!
Where is the substantial evidence to which you refer, when in your own letter you also say: "The reason for the lack of ‘efficacy data' is that there have been no prospective trials conducted to measure the effectiveness of AZT for non-occupational exposure"!
The allowance you assert the CDC gives for the provision of anti-retroviral drugs to rape victims is nothing more than a statement that the US Government has not banned the use of these drugs in cases of rape.
Any open-minded reading of its documents can only lead to one conclusion.
As stated by the CDC, that conclusion is that:
"Because of the lack of efficacy data for the use of anti-retroviral agents to reduce HIV transmission after a possible non-occupational exposure, PHS is unable to recommend for or against therapeutic approach... Research is needed to establish if and under what circumstances anti-retroviral therapy following non-occupational HIV exposure is effective." (RR17).
I therefore find it extremely puzzling and very strange indeed that you can describe this CDC document merely as "an attempt to highlight the ‘potential benefits and risks' and so provide a guide to physicians on whether or not to pursue such a course of treatment."
Repeatedly, the CDC says no data exist to demonstrate or disprove such benefit. Yet you say that the document, among other things, seeks to highlight potential benefits!
What the document does highlight are the risks of toxicity associated with the use of anti-retroviral drugs. Balanced against this, it gives the estimate for the risk of HIV transmission in the case of one episode of receptive vaginal intercourse as being almost zero.
What the CDC says is that if any physician should nevertheless decide to prescribe anti-retroviral drugs, despite everything it says, then such a physician should do a whole range of things, spelt out under 9 bullet points, including obtaining the informed consent of the patient.
So serious is this matter that the CDC says that such informed consent should be "recorded in the medical charts of all persons prescribed anti-retroviral agents following non-occupational exposure."
The CDC says:
"The patient should be told that physicians have diverse opinions about the use of anti-retroviral medications to treat possible non-occupational HIV exposure and that PHS cannot make definitive recommendations because of limited knowledge."
Beyond all this, because of the problems of toxicity, the CDC says any physician who decides to use these medications should do so "in consultation with an expert in the use of anti-retroviral agents" and "if physicians decided to use anti-retroviral agents, they should consult with an HIV-care provider experienced with their use." (My emphasis).
Your letter contains this extraordinary sentence:
"Rape does not constitute ‘receptive' sex and as such is likely to lead to trauma and consequently a far greater risk of HIV transmission."
All the literature I have seen, the words "receptive" and "insertive" are used to distinguish the passive from the active partner, as during male homosexual intercourse.
Where the CDC referred to receptive vaginal exposure, this is to differentiate this exposure from receptive anal exposure and receptive oral exposure for women.
Clearly, in the event that no receptive exposure would have occurred, then no rape would have occurred. It therefore makes no sense to say, as you do, "rape does not constitute ‘receptive' sex ..."
You also make the extraordinary statement that:
"The CDC is not referring to rape or consensual sex when it states that PEPs are not ‘justified for exposure that pose a negligible risk of transmission'."
It this letter and, to some extent, the previous one I wrote to you, I quoted estimates the CDC made about the risk of HIV transmission in situations of homosexual and heterosexual sexual intercourse.
I trust that the planets you and I inhabit are not so foreign to each other, as seems to be the case, that we failed to agree that the receptive vaginal exposure to which the CDC refers, constitutes "sex" in the colloquial meaning of this word.
I also trust that we will also agree that by any standard, a 0.1% - 0.2% risk of transmission in instances of receptive vaginal exposure constitutes a negligible risk of transmission.
Indeed, the particular paragraph of the CDC document in which these figures are mentioned is headed - Probability of Transmission From One HIV Exposure!
The only conclusion ‘a reasonable man' can reach from the CDC document is that the CDC is saying that the Probability of Transmission From One HIV Exposure in the event of receptive vaginal exposure is negligible, whatever the national levels of HIV infection, which you describe in our country as high.
Any other conclusion would obviously be illogical or constitute a wilful attempt to disregard facts, for whatever reasons.
I do not understand how you came to the conclusion that ‘negligible risk of transmission' refers to "contact between infected body fluid and intact skin." Nowhere does the CDC say this.
It says that "a estimated 95% of recipients become infected from transfusion of a single unit of infected whole blood."
Obviously, this represents an almost certain risk of transmission.
In the same paragraph, the CDC says "the risk for HIV transmission per episode of intravenous needle or syringe exposure is estimated at 0.67%. The risk per episode of percutaneous exposure (e.g. a needlestick) to HIV-infected blood is estimated at 0.4% ..."
The figures relating to anal, vaginal and oral sexual exposure are, again, cited in this same paragraph which, as we have said, is headed Probability of Transmission From One HIV Exposure.
You say that, deliberately to mislead, I did not quote the words that appear in the CDC report, viz, ‘e.g. potentially infected body fluid on intact skin."
The Oxford English Dictionary explains the expression e.g. as follows:
"Exempli gratia - for the sake of example."
Because of the strange twists of logic that litter your letter, you have transformed what was stated by the CDC for the sake of example into the totality of what the CDC sought to convey.
I am puzzled about why you find it necessary to do this.
You also complain that I omitted to mention certain CDC words that occur after its statement that anti-retroviral therapy "is not a morning-after pill..."
I note that, of course, you make no comment about this very firm CDC statement, given that you seen so keen that AZT should be given to rape survivors, despite the absence of any data to justify this, and despite the comments of Glaxo Wellcome.
Again, I do not understand why you think the particular fragment I did not quote helps your argument.
This fragment starts, "if proven effective ..." (My emphasis.)
Here, the CDC is making the same point it makes throughout the document from which we have quoted, that the efficacy of anti-retroviral drugs with regard to non-occupational exposure has not been proved.
Accordingly, it says that if such efficacy is proved in future, "post-exposure antiretroviral therapy (which is not a form of primary HIV prevention) can constitute a last effort to prevent HIV infection in patients for whom primary prevention has failed to protect them from possible exposure."
I fail to see why you think this fragment which I "pruned" from what I quoted, to use your word, helps your very curious determined defence of the scientifically indefensible.
In your letter, you also state that sexually transmitted diseases "greatly increase the possibility of HIV transmission."
On this matter; the CDC says:
"Sexual activities associated with a risk of HIV transmission also are associated with risk for unintended pregnancy and STDs (e.g. syphilis, gonorrhoea, chlamydia, or hepatitis B virus.)"(RR17).
As you will notice, this is very different from what you say about greatly increased possibilities of HIV transmission.
You may have noticed that in my speech at the Opening Session of the XIII International AIDS Conference earlier this month, I mentioned the incidence of STDs as one of the conditions that contribute to Africa's health crisis and referred to teenage pregnancies.
I believe that STDs are very relevant to the collapse of immune systems among many Africans, including our own people, and therefore the acquired immune deficiency syndrome.
There are many scientists who have been conducting research into this matter for some time.
One of these, John B. Scythes of Canada has written to the WHO as follows:
"Latent syphilis is chronic active syphilis from the immunological standpoint, and is both more dangerous for immune system genetics and harder to treat than exanthematous late syphilis. Judging from the word of Poland's Jadwiga Podwinska and the late Tom Fitzgerald from Minnesota, a Th2 cytokine pattern begins to predominate in most persons with latent syphilis, and standard treatment does not reverse this phenomenon.
Subsequent re-exposure without TH1-driven immunologic anamnesis would lead to the silent re-dissemination of treponemes."
I hope that the international scientific panel on AIDS that we have convened will address the important issue of STD's.
However, whatever the impact of STDs on the immune system, the correct medical response to infection with these is to treat them using established therapies. None of these include the use of AZT or any of the other anti-retrovirals.
The suggestion that because STDs impact negatively on the immune system, as does TD, they should therefore be treated with AZT would constitute very serious medical malpractice.
I hope this is not what you are suggesting.
I also note that you make no comment whatsoever against the gravely insulting statement made by Charlene Smith about rape being "endemic" in African culture.
Rather, you attach footnotes to your letter which, by trying to talk the rape figures upwards, seek to imply that she may, after all, be right.
My attention has also been drawn to Ms Smith's denial, in a recent publication, of ever having written the passage I quoted in my letter to you.
In the event that you did not understand its true import, let me cite it once again.
‘Here, (in South Africa), (AIDS) is spread primarily by heterosexual sex - spurred by men's attitude towards women. We won't end this epidemic until we understand the role of tradition and religion - and of a culture in which rape is endemic and has become a prime means of transmitting the disease, to young women as well as children."
The article in which this appears is subtitled - "Their Deaths, His Doubts, My Fears".
It appears in the Washington Post edition of June 4, 2000. Datelined Johannesburg, the newspaper says it is "By Charlene Smith", described by the newspaper as "a South African journalist who writes about HIV, (who) will speak at the International AIDS Conference in Durban in July."
Since she denies having made this nakedly racist statement, which you seek to justify in your footnotes, time will tell who between her and the Washington Post is prone to the shameless propagation of unembellished untruths.
The racist stereotype of Africans that many South African carry in their heads has nothing to do with "civil society". The subterfuge of seeking to hide behind the skirts of "civil society" will not pass.
Your comments suggest that you are not aware of the fact that the figures published about the incidence of HIV in our country and the rest of our Continent are estimates.
Mathematicians and statisticians have questioned the reliability of these estimates and the correctness of making extrapolations, in our country, from information gathered among pregnant black (African) women at antenatal clinics, using highly questionable mathematical models.
To understand the extraordinary distortion this creates, please try to get figures about the incidence of HIV-AIDS among the white population of our country!
I am certain you will find the search very frustrating and the result very illuminating! But, of course, I am likely to be quite wrong in assuming that a person as well informed as you are about HIV-AIDS does not already have this information.
You may also be unaware of the desperate attempt made by some scientists in the past to blame HIV-AIDS on Africans, even at the time when the USA was the epicenter of reported deaths from AIDS.
To me as an African, it is both interesting and disturbing that the signatories of the so-called "Durban Declaration" return to the thesis about the alleged original transmission of HIV "from (African) animals to humans", given what science has said about AIDS during the last two decades.
I accept that it may be that you do not understand the significance of this and the message it communicates to Africans, hence your queer observation that I seek to silence our critics, without responding to their arguments.
In my letter of July 1, 2000, I took issue with you about the matter of double standards. In one instance this related to the matter of the rule of law, about which you campaigned with regard to the land question in Zimbabwe.
In this regard, you accuse me of making "a nonsensical comparison."
Since the issue of the rule of law is a matter of principle, I believe that it is fundamentally incorrect to argue, as you did, that AZT should be prescribed for rape, despite the fact that the existing legal procedures had not been followed enabling this drug to be registered and legally dispensed for this purpose.
Strangely, you, the Leader of the Official Opposition, argue that my insistence on the observance of the rule of law is nonsensical.
Whereas you would not accept what I said in the National Assembly about the fact that Glaxo Wellcome neither asserted the anti-HIV efficacy of situation, I trust you now accept the truthfulness of these statements, since they have been confirmed by representatives of the company.
After all, relative to them, you do not occupy the position of "an effective opposition."
Whatever your personal views, I trust that, as Leader of the Official Opposition, you will understand and accept the proposition that it is incorrect to argue for the observance of the rule of law in Zimbabwe and to categorise its observance as "irrelevant" and "nonsensical" in South Africa, when AZT is affected.
What I have said in this and the previous letter about the efficacy of AZT in rape cases does not constitute a "personal opinion", as you assert.
Unless they indicate otherwise, I would also assume that the manufacturers of AZT, Glaxo Wellcome, do not consider what I have said about what the CDC says about AZT and AIDS as constituting a "personal opinion."
If there were any dispute about this, I would be very willing to ask the CDC whether it has changed its mind since 1998.
On this matter, our government will therefore continue to act in a manner that is consistent with available scientific evidence. I have a political obligation to ensure that this happens, regardless of your own personal opinions.
I am certain that, as government, we are perfectly aware of the interests of the people we represent. We will continue to do everything we van to ensure that these interests are addressed, naturally within the context of the constraints imposed on us by the stubborn legacy of colonialism and apartheid.
That legacy includes the persistence of racist ideas in the minds and the psychology of many of our people and others elsewhere in the world.
I spend the amount of time and effort I do on the issue of AIDS because as a government we have to do everything necessary to deal with this syndrome and the destructive health crisis in our country and the rest of Africa.
None of this constitutes "shadows', as you allege, which allegation might be informed by the fact that throughout their lives the majority of those you represent have had the "good fortune" of being perhaps unwilling beneficiaries of racist practice and recipients of supremacist racist prejudice and ideology.
I must also make the point that the formulation of correct policies and programmes makes it imperative that, as government, we proceed from the most accurate information we can access.
We will therefore always seek to obtain the most accurate figures about such matters as rape and AIDS so that we adopt correct policies with regard to these important challenges.
We do not have the luxury to play political games with information, merely to advance party-political objectives.
As a government, we will not abdicate our responsibility to work for the health of all our people, leaving this matter exclusively to "the physician and the patient as you suggest.
I may have no medical expertise, but I have grave doubts that the fact of being the largest opposition party means that you are best placed to advise our government about the medical decisions it should take.
All of us have a moral obligation not to do anything we believe to be fundamentally wrong. This applies as much to Presidents as it does to Ministers who might feel that decisions of the President or the Cabinet are wrong.
No amount of pressure, however virulent, strident and sustained, will persuade me to betray this principle.
If nothing else, this is what many of us have learnt from a very long history of struggle by our people from liberation form oppression, contempt and lies.
I believe that common courtesy required that you inform me that you intended to release our correspondence to the media, as I would if I were handling this letter to that media.
The only thing we had agreed was the principle that the National Assembly and the general public should have access to the communications between us.
But, again, possibly we do originate from different planets with radically different value systems.
Extract from Business Day report, July 26 2000:
CAPE TOWN - Tony Leon, leader of the newly formed Democratic Alliance (DA) lambasted President Thabo Mbeki yesterday for flouting proven scientific methods to fight HIV/AIDS.
IN what appeared to the the start of the DA's campaign for the November local government elections, Leon said at a gathering at Stanger city hall in KwaZulu-Natal that Mbeki had damaged government's reputation by mishandling the Zimbabwean election and the HIV/AIDS crisis.
He accused Mbeki of suffering from a ‘near obsession' with finding African solutions to every problem, even if this meant flouting scientific facts about AIDS in favour of ‘snake-oil cures and quackery'."
Letter from Tony Leon to Thabo Mbeki, July 28 2000:
28 July 2000
His Excellency Mr T M Mbeki
President of the Republic of South Africa
Private Bag X1000
Thank you for your letter of 17 July 2000.
Let me begin my response by stating something which I should have made more strongly in my previous letter: I do not think it appropriate that politicians should decide upon technical and scientific issues. South Africa has world-class scientists, and they should be allowed to render judgement on such matters. Nonetheless, in your previous letter you chose to debate this issue on the technical scientific merits of prescribing AZT, obliging me to respond to your arguments as best I could.
In your letter of 17 July you claim that John Kearney of Glaxo Wellcome has repudiated "what he said about your comments being ‘essentially accurate on the scientific aspects... etc." The basis of this assertion is Mr Kearney's letter in the Sunday Times where he states that you are correct "in pointing out that Glaxo Wellcome's package insert does not mention the medicine's use in rape cases."
You appear to be making two assumptions: The first is that if a drug is not registered for a particular indication then there is "no scientific evidence" to support its prescription for that particular indication; and, secondly, if it was prescribed for a unlisted indication this would be a violation of the law.
I have been advised that in order for a drug to be registered for a particular indication, a double-blind prospective trial needs to be conducted. In cases like AZT for rape victims (as I pointed out in my previous letter) it is simply impossible to conduct such a trial. There are also various other (non-scientific) reasons why a pharmaceutical company may not seek approval for a particular indication. Thus because a (registered) drug is not registered for one or other specific indication does not mean there is "no scientific evidence" to support its prescription for that indication.
I have been advised, further, that your assumption that providing AZT to rape survivors would constitute a violation of the law is equally invalid.
In your letter you state that if Glaxo Wellcome had offered AZT for rape victims this "would have constituted very disturbing behaviour" and the government would have to "take the necessary action to stop what would have been illegal behaviour."
Further on in your letter you state:
"Since the issue of the rule of law is a matter of principle, I believe that it is fundamentally incorrect to argue, as you did, that AZT should be prescribed for rape, despite the fact that the existing legal procedures had not been followed enabling this drug to be registered and legally dispensed for this purpose."
You argue that it is illegal to provide a (registered) drug for a specific indication if the drug regulatory authority has not registered it for that indication. This is simply not the case. There appears to be a confusion on two issues:
As the law stands no one may prescribe an unregistered medicine (such as Virodene) for any indication. But AZT is registered with the MCC and (as the law stands) doctors are free to use registered drugs for non-indicated purposes if, in their better judgement, they believe the scientific evidence supports it.
My research indicates that in the United States the law is similar: The fact that a drug is not listed for a particular indication, does not mean that it would be either illegal or medically inappropriate to do so.
For example, the American Food and Drug Administration (FDA) states that:
The Food, Drug and Cosmetic Act does not limit the manner in which a physician may use an approved drug. Once a product has been approved for marketing, a physician may prescribe it for uses or in treatment regimens or patient populations that are not included in approval labelling. Such "unapproved" or, more precisely, "unlabeled" uses may be appropriate and rational in certain circumstances, and may, in fact, reflect approaches to drug therapy that have been extensively reported in medical literature. (Source: American Medical Association - correspondence - Chicago, Ill. 21.700).
This view is supported by the American Medical Association (AMA) which states:
The AMA reaffirms its policy that a physician may lawfully use an FDA approved drug product or medical device for an unlabeled indication when such use is based upon sound scientific evidence and sound medical opinion; and affirms the position that, when the prescription of a drug or use of a device represents safe and effective therapy, third party payors should consider the intervention as reasonable and necessary medical care, irrespective of labelling, and should fulfil their obligation to their beneficiaries by covering such therapy. (AMA policy number H-120.988)
AMA policy definitively supports the unlabeled use of drugs as long as such use is based upon sound scientific evidence and sound medical opinion.
Thus, your claim that prescribing a registered drug for a non-indicated purpose would constitute a violation of the rule of law is, with respect, baseless.
The question then is, would the provision of anti-retrovirals to rape victims be based upon sound scientific evidence? A related question is do politicians have the right to decide what constitutes "sound scientific evidence" and "sound medical opinion" or should this be left to medical professionals?
In your letter you restate your arguments that there is no scientific evidence to support the provision of AZT to rape survivors and further, that the CDC regards the risk of transmission through heterosexual sex (as well as rape) as "negligible."
You claim that my description of the CDC document as "an attempt to highlight the ‘potential benefits and risks' and so provide a guide to physicians on whether or not to pursue such a course of treatment" is "extremely puzzling and very strange indeed."
I do not quite understand your reasoning here, for the document itself says:
"Health-care providers and their patients may opt to consider using antiretroviral drugs after nonoccupational HIV exposures that carry a high risk for infection, but only after careful consideration of the potential risks and benefits and with a full awareness of the gaps in current knowledge." (Summary)
The document then proceeds to discuss these potential benefits and risks, as well as the gaps in the current knowledge.
As the CDC study points out (and you repeatedly highlight) there is no direct data on the efficacy of anti-retrovirals as PEPs following non-occupational exposure. For this reason the CDC has had to resort to evaluating indirect evidence from animal trials; as well from studies of the efficacy of AZT in reducing transmission of HIV both from mother to child, and in occupational settings.
You chastise me for mentioning these aspects of the CDC report (which you assert is an unacceptable widening of the scope of our correspondence) and claim that these are "entirely different issues" not relevant to the matter under discussion. In fact, these studies are directly relevant for they show the efficacy of anti-retrovirals in preventing sero-conversion following HIV exposure.
In May 1998 the CDC released fairly prescriptive guidelines on the management of occupational exposures to HIV (MMWR 47 (RR-7) 15 May 1998) The decision to make these recommendations was based on the French case control study, which associated the provision of anti-retrovirals with an 80% decrease in the risk of HIV seroconversion following needlestick injuries, "along with data on ZDV efficacy in preventing perinatal transmission" and "evidence that post exposure prophylaxis prevented or ameliorated retroviral infection in some studies of animals." (My emphases)
Thus, just as animal data and perinatal data were relevant in drawing up recommendations for occupational exposure, so is such data relevant (although not conclusive) in evaluating the efficacy of PEPs for rape survivors.
What these various studies, cited by the CDC, show is that anti-retroviral drugs can prevent sero-conversion following HIV exposure. As the CDC states, "Information about primary HIV infection indicates that systemic infection does not occur immediately, leaving a brief ‘window of opportunity' during which post exposure anti-retroviral intervention may modify viral replication." (RR-7)
In your letter you state that the CDC document "gives the estimate for the risk of HIV transmission in the case of one episode of receptive vaginal intercourse as being almost zero." You then proceed to repeat your argument that when the CDC states "anti-retroviral agents should not be used for persons with HIV exposures that have a low risk of transmission" they are referring to heterosexual intercourse. You state:
"The only conclusion ‘a reasonable man' can reach from the CDC document is that the CDC is saying that the Probability of Transmission From One HIV Exposure in the event of receptive vaginal exposure is negligible, whatever the national levels of HIV infection, which you describe in our country as high."
It is simply not true to assert that the CDC regards rape (or consensual sex for that matter) as constituting a "negligible risk of transmission." When the CDC use the term "negligible" they are referring to risks in the order of potentially infected body fluid on intact skin. (Shaking hands and blowing kisses across a park would also constitute "negligible" risks of transmission.) Quite obviously, there is a far greater risk of acquiring AIDS from receptive vaginal exposure than from body fluid on intact skin.
The CDC does regard risks in the order of 0.1% to 0.2% as constituting a sufficient risk of transmission to justify the provision of anti-retroviral drugs. This can be seen by referring back to the CDC report on the management of occupational exposure to HIV (RR 7). That document estimates that the "average risk for HIV transmission after a percutaneous exposure to HIV-infected blood is approximately 0.3% and after a mucous membrane exposure is 0.09%." The CDC regards such levels of exposure as constituting sufficient risk to warrant a "basic 4-week regimen of two (anti-retroviral) drugs for most HIV exposures."
Furthermore, forced sexual intercourse is likely to constitute a far higher risk of transmission than consensual sex (which is what the 0.1 to 0.2% figure is referring to.) Forced sexual intercourse can lead to trauma, which (as I said before) will lead to an increase in the risk of transmission. In the case of child or gang rape the risk of transmission (for obvious reasons) is even higher still.
In my previous letter I stated that the risks of transmission were increased by the high levels of STDs in South Africa. You then proceed down a side track, which ends up at this particular dead end:
"Whatever the impact of STDs on the immune system, the correct medical response to infection with these is to treat them using established therapies. None of these include the use of AZT or any of the other anti-retrovirals.
The suggestion that because STDs impact negatively on the immune system, as does TB, they should therefore be treated with AZT, would constitute very serious malpractice.
I hope this is not what you are suggesting."
I was not suggesting that AZT should be prescribed for STDs. My point was that if one person has an STD there is a substantial increase in the chance of HIV transmission. The CDC states that an STD increases the chance of transmission of HIV by three to five times. In a case of heterosexual sex this could increase the risk of transmission from 2 in a 1000 to 1 in a 100. The CDC report (RR 17) states that vaginal tears or bleeding, visible genital ulcers or other evidence of an active STD would all increase the risks of HIV transmission.
Although the CDC does not make a binding recommendation for or against the provision of anti-retrovirals following non-occupational exposure, it does regard such treatment as a perfectly acceptable clinical intervention by individual doctors. However, the lack of direct clinical data was not the only reason for the lack of a firm recommendation; there were two other considerations:
Firstly, the CDC document was not concerned solely (or even primarily) with possible HIV exposure caused by sexual assault. A major concern of the CDC was that if the general public thought that anti-retrovirals could be used as a ‘morning after pill' there would be an increase in risky behaviour and a decrease in adherence to preventative measures. Since no woman chooses to be raped this consideration is not applicable in cases of sexual assault.
Secondly, America has a far lower rate of both HIV infection and sexual assault than in South Africa. This means both that in America rape is not a major means of HIV transmission, and that in a case of sexual assault there is far less likelihood that the rapist would be HIV positive. There is consequently a far lower risk of HIV transmission following sexual assault in America than in South Africa. Thus, it is not the important concern of public health policy in America that it is (or should be) in South Africa.
What I argued in my previous letter was that anti-retrovirals should be made available in the public health system for doctors to prescribe (according to proper guidelines) to rape victims. Such a course of action would be both legal and medically acceptable.
Indeed, as Mr Kearney notes in his letter to the Sunday Times "the medical profession's discretion to administer AZT to rape survivors is supported by the recommendation of the Centre for Disease Control in Atlanta, US, the worldwide authority on communicable diseases."
By refusing to make AZT or other anti-retrovirals available within the public health system you are preventing doctors from exercising that discretion.
This brings me to the issue I raised earlier: Do politicians, whatever their enthusiasm for scientific research, have the right to decide what constitutes "sound scientific evidence"?
In your various statements on the many aspects of the AIDS debate (Virodene, anti-retrovirals, the provision of AZT to pregnant mothers and rape victims etc.) you have chosen to act as effective final arbiter on technical scientific questions.
I have tried to answer your assertions as completely as possible. But I do not believe there should be a "Mbeki theory of AIDS" or a "Leon AIDS theory" for that matter. All of us have a simple duty, as public figures, to consult the most scientifically informed - and best supported - medical view and to go on that. It seems clear - and it was made clear again at the AIDS Conference in Durban - that the overwhelming weight of world scientific opinion is on the crisis before us. I think we must all have the humility to accept that, and not to second-guess the experts.
But I do not think that politicians are under any "moral obligation" (in fact quite the opposite) to claim the right to deliver final judgement on questions of scientific fact. It is a totalitarian principle that political leadership is somehow on a higher plane to technical expertise, and is thus entitled to override the autonomy of all institutions in society.
There are, however, one or two other issues I must raise. First, I have no brief to defend or attack Charlene Smith. She is her own person.
But I think it is a fundamental mistake and profoundly misguided to associate matters of race with the AIDS crisis. This matter is just too serious for any of us to play politics, racial or otherwise, with the figures. Since in our society allegations, or repeated assertions of racism are appropriately very serious matters. Therefore, in my view, there needs to be a very clear basis in fact before one pronounces persons guilty of racism. There does not, with respect, appear to be such a basis in your gratuitous assault on Charlene Smith.
In your letter you dismiss Charlene Smith's defence of herself in the Mail & Guardian and once again re-quote her as saying in the Washington Post (4 June):
"Here, (in South Africa), (AIDS) is spread primarily by heterosexual sex-spurred by men's attitudes towards women. We won't end this epidemic until we understand the role of tradition and religion-and of a culture in which rape is endemic and has become a prime means of transmitting the disease to young women as well as children."
You claim that this is a "nakedly racist statement." Yet nowhere in this quote does Charlene Smith make a racial distinction between Black, coloured, Indian or White South Africans. You are reading into the statement a racial intention that is by no means evident.
In fact what she actually wrote was this:
"In Africa, even if we develop a vaccine or distribute billions of condoms, and the continent is already awash in latex, unless we begin working on male attitudes toward women - and that requires looking at the role of culture, tradition and religion; we will get nowhere. In doing this there is a need to reflect on how modernisation has warped cultural attitudes." (Mail & Guardian 14 July 2000)
As you can see, in the article Charlene Smith sent to the Washington Post, she did not say (or imply) that rape was endemic in South African culture. What happened was that the Washington Post sub-editors cut down the article (by about a third); the question is, was there a dark and sinister racial motivation behind their action, or were they just trying to fit the article onto the page?
I actually think that of Ms Smith as a rape victim and that she has been publicly brave about her awful experience. She deserves your understanding, not your vilification.
The ANC's Statement to the HRC Inquiry on Racism in the Media made the claim that all whites carry around a racist stereotype in their heads all the time. This claim was made on the basis of no factual evidence whatsoever and paid no regard to the deep changes this country has experienced over the last twenty years. Nonetheless, it seems to be a belief shared by your spokesman, and it is implicit in your statement that "many South Africans carry in their heads" a "racist stereotype of Africans."
I would suggest that you take a moment to consider how deeply racist (in the true sense of the word) and offensive is this assertion. Just because a group of racially prejudiced ANC members sit around a table and agree with each other on how morally reprehensible a particular minority is, does not transform those prejudices into fact.
By labelling your critics (even those who mildly disagree with government policy) as "racist", you cut your party off from new ideas. Since, you could so easily dismiss your critics (both publicly and to yourself) you did not test your ideas against those of your opponents in reasoned and rational debate. It was far easier to dismiss a person as "racist" than to argue issues on the merits, or even acknowledge that your opponents might just be right, every now and then. As a result the thinking of your party has stiffened into orthodoxy:
You will find that on the AIDS issue, South African and International opinion will simply not be bludgeoned into silence by tactics of moral blackmail or demonisation. I can understand your deep sense of frustration at this turn of events.
Lastly, you state that "I believe that common courtesy required that you informed me that you intended to release our correspondence to the media."
As a matter of fact I observed all the courtesies which you suggest I did not. Although I dictated the letter from overseas our Executive Director, Ryan Coetzee informed your Mr Mankahlana, by telefax of our intention to publish (as we understood with your concurrence) the correspondence. Since we received no response from either fax number, we assumed that our proposal met with no disagreement from your office. In fact it was you, not I, who specifically suggested we publish the correspondence in the first place.
But since you raise the issue of "common courtesy" in our dealings perhaps you will allow me to comment on this issue more broadly. I have always treated you, and your office, with the courtesy and the decorum, your position and you personally are entitled to expect. However, I believe that as elected Head of State you have treated me, as elected Leader of the Opposition, with basic discourtesy since June 1999. I think you will find if you consult your opposite numbers in other constitutional democracies that the relationship between head of government and the leadership of the opposition in other countries, ranging from Botswana to Britain, is somewhat different from how you have chosen to conduct this relationship. Your immediate predecessor chose the path of consultation and will confirm that not once, or ever, was any confidential briefing in which he engaged the opposition, breached by the opposition.
Be that as it may, you are obviously entitled to adopt any style of behaviour that you deem appropriate. But you might wish to reflect on the fact that you have never once issued an invitation to the opposition to discuss matters of common concern to the country. It is only when the opposition has sought a meeting with government that same has been acceded to. In respect of projects which should unify the country, whether they be the Presidential Inauguration, the Millennium celebrations, the new Coat of Arms and national symbols, or even the latest "South Africa Unlimited" project, such were either never discussed with the opposition, or we were slighted at the event concerned, or our participation in them was never sought.
The Constitution obviously requires of us robust debate and in this regard I have always accepted your original commitment in Parliament on 23 September 1994 when you stated:-
"With regard to the matters that the Hon member Mr Tony Leon raised, I would like to agree with him about the role of the opposition and the need for openness and candour, the need for good and robust debate, and the need for us to accept the bona fides of our interlocutors."
In the event, you appear to have changed your mind, fairly fundamentally, since then.
In conclusion, let me revert to the AIDS pandemic: I would far rather, Mr President, that you and I should work together on this supreme crisis facing our country. I agree entirely, for example, with what you say about other sexually transmitted diseases. I would be only too happy to stand on the same platform with you to back a campaign for the eradication of STDs whose prevalence does so much to help spread HIV/AIDS. I am not interested in whether my supporters or yours suffer more from STDs: this is not a matter of, as you put it, "political obligation" or of whom one represents. You and I are both patriotic South Africans. We both want the best for our country and for all our countrymen and women. I will be only too happy to meet you at your earliest convenience to discuss how we may work together to dramatise that this is a crisis for all of us, that death and disease know no distinction of politics, creed or race. I believe that the sight of the President and the Leader of the Opposition working together in such a way would have a very great public impact and would show just how serious we are and how great the crisis is. This in itself could save lives. I beg you, let us make that our sole priority.
Letter from Thabo Mbeki to Tony Leon, August 5 2000:
PRESIDENT REPUBLIC OF SOUTH AFRICA
August 5, 2000
Thank you for your letter dated 28 July, 2000
The positions you have taken with regard to the matter we have been discussing, the use of AZT in cases of rape, have been consistently wrong from the day this matter came up in the National Assembly in June.
The problem is that you seem to find it extremely difficult to admit this obvious fact.
The result of this is that the harder you try to advance indefensible propositions, the greater the difficulties you get yourself into.
It seems clear that you are determined that neither established fact, nor anything else whatsoever, will deter you from pursuing your set goal of ensuring that rape victims use AZT.
In your letter of June 19, you claimed that AZT "will prevent sero-conversion in rape victims who are raped by an HIV positive person."
As you must surely know by now, this statement has no substance in fact, since no trials have been carried out anywhere that would enable anybody to come to such a conclusion.
In the same letter you said, "a 28 day course of AZT will boost the immunity of a woman raped by an HIV positive person."
Again. as you must surely know by now, this statement has no substance in fact, since no trials have been carried out anywhere that would enable anybody to come to such a conclusion.
You will also remember that in his 21 June letter to you, the CEO of Glaxo Wellcome South Africa, Mr Kearney, said "your reply to the President is essentially accurate on the scientific aspects of using AZT as post-exposure prophylaxis in individuals who have been raped."
In my letter to you of July 17, I quoted Mr Kearney and Dr Moore, Medical Director of Glaxo Wellcome South Africa, as essentially repudiating this statement.
As you will remember Mr Kearney said his company does not "promote (AZT) for (rape survivors)." Dr Moore said that "emphatically, (the company does not recommend AZT) for use after rape."
In your response of 28 July, you carefully avoid reference to these straightforward statements by the manufacturers of AZT, which address the very heart of the matter we have been discussing.
Despite this evasive action, you must surely know by now that not even the manufacturers of AZT support you in your campaign to sell AZT to rape victims.
In your letter of 19 June you said that it was "irrelevant" that AZT was not licensed in this country for use by rape survivors. To prove your point, you cited the use of a particular drug to induce abortions, even though it was not licensed for these purposes.
Again, you advanced these arguments to promote the use of AZT by rape victims.
To assist you in your campaign and as you correctly point out, once more, Mr Kearney of Glaxo Wellcome came to your aid.
Indeed, he wrote in his Sunday Times letter that "the medical profession's discretion to administer AZT to rape survivors is supported by the recommendation of the Centres for Disease Control..."
In your letter of 28 July you expend a lot of effort to defend this position, to promote the administration of AZT to rape survivors.
The FDA and AMA statements you cite in this letter make the points that the use of approved drugs for indications for which they are not registered would be permissible "in certain circumstances." (FDA)
In the text you have cited, the FDA says such use "may, in fact, reflect approaches to drug therapy that have been extensively reported in medical literature."
In the text you have cited, the AMA says such use should be "based upon sound scientific evidence and sound medical opinion..."
Surely, you must know by now that the use of AZT in cases of rape meets neither of these FDA and AMA conditions.
Apart from anything else, you restate the point that "in cases like AZT for rape victims... it is simply impossible to conduct such a trial", (that would provide sound scientific evidence proving the efficacy of AZT in cases of rape.)
In my letter of July 1, I told you that "if it is necessary, I can present the argument about the obvious logical absurdity of the claim that viral infection can be stopped by the use of drugs, provided that the virus was communicated in circumstances of forced heterosexual sexual intercourse."
Immanent within this logical absurdity, is the equally absurd notion that drug trials can be conducted to test the efficacy of AZT in cases of rape.
I am glad that you have now understood that "it is simply impossible to conduct such a trial."
I am still puzzled about where you and Ms Charlene Smith found the evidence you presented to the National Assembly that, if given AZT, "80% of (women) would not have sero converted and become HIV positive if raped by an HIV positive person."
Given what you, yourself, quote from the FDA and AMA, I am deeply concerned that Mr Kearney of Glaxo Wellcome still finds it possible publicly to state, in support of your campaign, that "the medical profession's discretion to administer AZT to rape survivors is supported..."
Glaxo Wellcome is a major and long-established pharmaceutical company. I do not believe that its representatives are not familiar with the rules and guidelines laid down by such bodies as the FDA and AMA.
Neither do I believe that its senior representatives would no know that there is no basis whatsoever for the claim that "the medial profession's discretion to administer AZT to rape victims is supported..."
Taking the totality of Mr Kearney's public comments together, I find it difficult to avoid the conclusion that he is determined to say things here that no Glaxo Wellcome representative would say, for instance, in the US or the UK.
When I have said that we should act to enforce the spirit and the letter of the law with regard to the use of medicaments, you have sought to express your horror at this idea.
Nevertheless, I must remind you that our oath of office enjoins us to defend the laws and the Constitution of the Republic.
In your letter of July 28, you say that you have been advised that my "assumption that providing AZT to rape victims would constitute a violation of the law is equally invalid."
I trust that you now understand that you have no basis of any kind to substantiate the arguments that the positions I have taken are invalid on scientific/medical grounds.
However passionate your commitment to AZT, I also hope that now you understand that your FDA and AMA quotations provide no basis to assert the legal invalidity of my arguments.
You are a lawyer and I am not. Nevertheless, I must disagree with your interpretation of South African law, as it applies to the matter we are discussing.
In your June 19 letter you refer specifically to a medicament used to induce abortions, despite the fact that it is not licensed for this purpose. You identify this product as "Misoprostal".
In a legal opinion to the Director General of Health dated 1997-01-04, relating to this specific matter of what they all "misprostol", the State Law Advisers say:
"With Regard to the Department's view that medical practitioners can use a medicine for an unapproved indication in a professional situation where it is deemed in the interest of the patient, Steyn Die Uitleg van Wette, (5th ed.) on page 228-229, remarks that where the authorised person or body uses his statutory powers in the public interest but for an unauthorised purpose, the act will be ultra vires."
Further, the State Law Advisers say:
"We are... of the opinion that the Council (MCC) cannot in terms of section 21 of the (Medicines and Related Substances Control) Act, authorise the use of the medicine (misoprostol) for a purpose not previously provided for..."
On this same matter, Professor S.A. Strauss, Professor Emeritus of Law at the University of South Africa has written:
"Off-label use can legally take place only if the conditions of registration have been duly amended... Application may in terms of section 15A of the Act be made for amendment of entries in the medicine register. But the section makes provision for such amendment only ‘on application by the holder of the certificate of registration', which will normally be the manufacturer or its authorised distributor of the medicine involved."
Later, Professor Strauss says"
"A practitioner who uses a medicine for the treatment of an indication not approved of by the MCC when registering a medicine, may expose himself to a civil action under common law for damages if the patient were to suffer harm in consequence of off-label use... The mere fact that off-label use might constitute a "technical" criminal offence in terms of the Act, would not lead to an inference of negligence. But in the event of a criminal conviction, the Medical Council might take disciplinary action against the practitioner for unethical conduct. Unjustified and potentially harmful off-label use would in any event decidedly be regarded as unethical."
I accept that the above are, merely, ‘legal opinions'.
You write that you have been advised that the view of government, that it is illegal for medical practitioners to use drugs for purposes other than those for which they have been licensed, is invalid.
That, too, is merely, a legal opinion.
I hope that any medical practitioner who acts on your advice, and dispenses AZT to rape victims, will do so knowing the possible legal consequences indicated in the medial opinions I have cited.
Relying on these opinions, our Department of Health is of the view that medicines should be used for the specific indications for which they are registered, in compliance with the requirements of the Medicines and Related Substances Control Act of 1965.
I do not agree that "providing AZT to rape survivors" would not "constitute a violation of the law."
Accordingly, I will continue to insist that respect for the rule of law requires that all of us must demand that AZT should not be used for a purpose for which it is not registered, for which no registration application has been made and for which no efficacy data exist.
I still find it completely unacceptable that the Leader of the Official Opposition should, in a democracy, blatantly urge defiance of the law.
Given that you seem to agree with Glaxo Wellcome on a number of issues, it might help that you talk to them to overcome their reticence and try to have AZT registered for use in cases of rape.
If, for some reason, the MCC agreed to this, that would end the prospect of possible civil and criminal action against medical practitioners who prescribe AZT in rape cases, which you fervently urge.
Such an MCC decision would be taken despite the fact that the manufacturer does not approve of this and despite the fact that no scientific evidence exists to justify such use.
Given the extant literature on non-occupational PEP, some of which I have cited in the previous letters, I do not believe that there is any need for me to comment on the outlandish remarks you make in your last (28 July) letter.
In this letter you say: "if one person has an STD there is a substantial increase in the chance of HIV transmission." (My emphasis.)
There is no evidence anywhere to support this bold assertion.
The ‘orthodox' position, as I understand it, would be stated thus:
any person suffering from an STD stands a greater possibility of HIV infection.
According to this proposition, whatever its merit, the transmitter of the HIV may very well be free of any STD. If, however, the ‘receptive' person suffers from an STD, his or her risk of being infected by HIV increases.
Your bold and wrong assertion is based on the assumption that there is a strong relationship between affliction with an STD and being an HIV carrier.
To clarify this matter, in my last letter I drew your attention to the association between STD's and acquired immune deficiency.
It is most odd that, even as the CDC is working to improve its focus on STD's precisely because of this, you consider my comments "a side track" and a "dead end."
With regard to the issue of comments that appeared under Ms Charlene Smith's name in the Washington Post of June 4, 2000, clearly, in terms of your July 28 letter, you have access to the sub-editors of this newspaper that I do not have.
Because of this, you even know by how much her article was cut down by these sub-editors.
You must also maintain particular relations with her to state so unequivocally, (in your July 28 letter), that "in fact what she actually wrote was..." (My emphases.)
For our present purposes, let us accept that in her unedited article (and her convictions,) Ms Smith was referring to Africa, rather than South African specifically.
Perhaps wrongly, I wonder what Ms Smith knows about Africa. I would be very interested to hear from you how, in her view, "modernisation has warped cultural attitudes" in Egypt and Morocco, Mali and Nigeria, Cameroon and Rwanda, Ethiopia and Tanzania, Namibia and Mozambique, Cap Verde, Madagascar and Reunion.
I would be very interested to hear from you what she says about "the role of culture, religion and tradition" in these countries, which leads her to conclude that vaccines or condoms will prove useless in the fight against AIDS in these countries.
For example, how have the Hausa-Fulani, Yoruba and Ibo traditions and cultures of Nigeria been warped by modernisation, such that the accepted anti-AIDS interventions will not work?
How do the African, Moslem and Christian religions of Nigeria relate to this matter, such that they make it impossible for these interventions to achieve results?
In what ways do the traditions, cultures and religions of Nigeria make Nigerian women and Nigerian society as a whole, prone to HIV/AIDS, unless warped Nigerian cultural attitudes are ‘reflected' upon, by whosoever?
You say that what I read in the Washington Post was not what Ms Smith intended to say.
Clearly, you are best placed to pose the question to the Washington Post, whether its sub-editors were promoting a racial objective, or were merely trying "to fit the article onto the page", when they reduced (and rewrote?) Ms Smith's article.
Unlike you, like the normal readers of the Washington Post, I had to proceed from what I read, and not what had been written originally, which, allegedly, was subsequently edited in a particular way.
The article I read, attributed to a South African journalist, has a paragraph I quoted, which begins with the word "here". Accordingly, I read "here" to mean South Africa.
In my letter to you, I said the statement I read was racist, a view I have not abandoned, but which you contest.
In the main, white South Africans are, in their religions, Christian and Jewish. They have cultures and traditions that are somewhat different from those in your letter you describe as "Black."
I would be most interested to see the evidence you and Ms Smith have that demonstrates that, as a consequence of tradition, religion and culture among these white South Africans, "rape is endemic" and is "a prime means of transmitting (AIDS) to young women as well as children."
Could you also produce similar evidence with regard to the groups you identify as "Black, coloured (and Indian)?"
The valuable information you will supply on this matter will help us to settle the issue whether I was right or wrong to interpret Ms Smith's published comment as racist.
All rape is reprehensible. I was as distressed when I heard about Ms Smith's rape as happens whenever I hear of any incidence of rape. Accordingly and unreservedly, I sympathise with her.
In Ms Smith's case, I immediately spoke to the then Minister of Safety and Security to take all necessary measures to ensure that the culprit was apprehended and charged.
The Minister kept me informed about this matter constantly, relating even to the means the SAPS used to identify the culprit.
I know that none of this could ever undo the grave harm and damage done to Ms Smith. Over this specific incident, I have no influence. I, like other people, did what I had the power to do.
I have not sought to vilify Ms Smith.
But, neither do I accept that her terrible and unacceptable ordeal gives her the license to propagate racism, as I am convinced her published Washington Post comments do.
I also do not accept that her terrible and unacceptable ordeal entitles her to say wrong and absurd things about AZT and rape.
Comment by anybody on such matters as the efficacy of drugs and the roles of tradition, religion and culture have to be dealt with on their merits.
We have fought against racism throughout our whole lives. We have made enormous sacrifices to achieve the goal of a non-racial South Africa, which is yet to be realised. We have occupied and continue to occupy the frontline in the struggle to avoid a racial explosion in our country.
We do not need anybody to educate us about the imperatives to fight against racism and to transform South Africa into a country that belongs to all who live in it.
You would do well to listen to those who have been and continue to be victims of the most virulent racism.
Difficult as it may be, the least you might try to do is fight against the tendency to hold in contempt those whom white South Africa has held in and treated with contempt for many centuries, even if you do not quite understand everything they mean when they speak.
I do not understand how you can be a fighter against racism in our country, if you do not understand the simple, obvious and unhidden reality that "many South Africans carry in their heads a racist stereotype of Africans."
That you contest this tells me that you would not understand the racism in the classic white statement-some of my best friends are black-and its equivalent black statement-some of my best friends are white.
As a result of your determined effort to promote AZT, you make the meaningless statement in your July 28 letter that it is not "appropriate the politicians should decide upon technical and scientific matters."
The National Assembly, in which you sit as Leader of the Official Opposition, has to take decisions about many "technical and scientific matters", when it considers many of the draft statutes it has to pass into law.
In its normal work, the executive has to take many decisions on "technical and scientific matters."
For example, our legislature and executive have taken the decision to spend public funds to build a new and powerful telescope, located in the Northern Cape.
You argue that neither the legislature nor the executive should have taken this decision, as it was a "technical and scientific matter."
The US government has been discussing the highly "technical and scientific matter" of the possible development, deployment and use of anti-ballistic missiles, seemingly a version of the "star wars" of the Reagan years.
This is one of the issues on which the presidential candidates in the US are campaigning.
The development etc of ABMs, is highly "technical and scientific". You argue that, because of this, politicians should play no role with regard to the development etc of ABM's.
You need to know this that US politicians will be involved, in a decision-making capacity, at all stages of the evolution of this issue, however "technical and scientific" it may be.
They are morally obliged thus to be involved. There is absolutely nothing totalitarian about this. Neither does it constitute "overriding the autonomy of all institutions of society."
I would like you to understand this that it is deeply offensive for you to present yourself as the great defender of democracy in contrast to us, whom you are determined to project as a present and imminent threat to democracy.
You take exception to the statement I make in my letter of July 17 that "all of us have a moral obligation not to do anything we believe to be fundamentally wrong."
The position you have taken, that there is no moral obligation that attaches to our actions if we are acting on the advice of technicians and scientists, tells me that I was correct when I said, in my July 17 letter to you, that perhaps we inhabit different planets.
Let me assure you that as long as I have to occupy a decision-making position within our politics, so long will I take such decisions as may be necessary and morally defensible, whatever institution makes recommendations according to its mandate and possibilities.
The idea that, as the executive, we should not take decisions we can defend, simply because views have been expressed by scientist-economists, scientist-agriculturists, scientist-pedagogues, scientist-soldiers, scientist health workers, scientist-communicators, etc, is absurd in the extreme.
It is sad that you feel compelled to sink to such absurdity, simply to promote the sale of AZT.
Parks Mankahlana did not know that we were writing to each other on the matter we have been discussing.
When you took the unilateral decision to give your letters to the Sunday Times, you should have consulted me on the issue, rather than refer it to Parks Mankahlana.
My "office" did not write to you. I did.
Common courtesy required that you tell me, not Parks Mankahlana or my "office", that you intended to hand our correspondence to the Sunday Times.
The broader issue you raise about how the President of the Republic and the Leader of the Official Opposition should relate to each other is completely irrelevant to the matter we have been discussing.
We have to develop our own South African conventions in this regard. References to such countries as Botswana and Great Britain will not necessarily help.
It has seemed to me that you set great store by your being a vigorous and uncompromising opposition to the government.
You have argued that unless you played this role, democracy in our country would be threatened.
I am told that your party has put up posters suggesting that if you were not the vigorous opposition you pride yourselves to be, South Africa would degenerate into a "Zimbabwe".
I have also heard and seen comments made that our effort to encourage the development of a consensus around a jointly determined national agenda, amounts to an attempt at cooption and the silencing of alternative, critical points of view.
This has given cause to some to reject the call Nelson Mandela made for the development of an adherence to a new patriotism.
So vital to the survival of democracy is the existence of this consistently opposition view, that, so it has been said, various actions of the President cause concern.
Among these actions was our failure to appoint certain people as Ministers, who were thought by some to be precisely the people, who, within Cabinet, would differ with the President.
It was these, so it was said, who would guarantee the health of our democracy, rather than, again it has been said, the time serving "yes-men" who dare not speak their minds and criticise the President, if they think he is wrong.
Your Party and its supporters have been very active in promoting this overall view.
I am quite happy to restate that I will not oppose this approach "about the role of the opposition and the need for openness and candour, the need for good and robust debate, and the need for us to accept the bona fides of our interlocutors."
Contrary to what you write, I can think of nothing that would indicate that we have changed from this position.
In addition, I have said that in the National Assembly, that in any case, the DP and the ANC differ so radically in their philosophy and politics that they are, objectively and effortlessly, opposed to each other.
Given all this, it seems to me that your remarks in your letter of 28 July, prompted by my comments about ‘common courtesy', represent an attempt to have your cake and eat it.
Accordingly, you want to present yourself as an uncompromising opposition force, naturally, in the interest of democracy.
Simultaneously, you want to be seen as being of such importance that you are given the space to help determine the decisions of the executive, and therefore the evolution of our country.
In your letter, you argue that the President should assist you to evolve and present this Janus-face, in your interest. Frankly, I do not see why, in the interests of a better South Africa, I should.
I am certain that, in time, conventions will develop, governing the relations between the President and the Leader of the Official Opposition.
You have not listened to the suggestions I have made in this regard, deeming them to be inimical to democracy.
I respect your views on this matter and accept your bona fides. The future will decide the matter of what stable conventional balance our country arrives at, relative to our respective views.
In the meantime, I will continue to respect and defend your right to be a vigorous opposition, without seeking to find conventions from anywhere in the world, that seek to give the possibility to the executive to circumscribe this legal and constitutional right.
The ruling party, which constitutes the first point of the origin of the mandate the President exercises as head of government, must also discharge its popularly mandated obligation to rule.
I trust that, as the opposition, you will respect and defend the legal and constitutional right of the ruling party to govern, without seeking to circumscribe this by invoking supposed conventions in Botswana, the UK and other countries.
I would like to encourage you that, indeed, you must campaign for the elimination of STD's, as well as all the other obstacles that obstruct our people's effort to rebuild their lives.
There is no need, whatsoever, that you wait for the moment when the President and the Leader of the Official Opposition can do this together, sharing the same platform.
You state that the appearance of the President and the Leader of the Official Opposition on the same stage, campaigning on the same health issue, would make "a very great public impact."
You may very well be correct.
But I can also imagine how many people there would be, at home and abroad, who would ask a particular question.
That question would be-why does the elected President not have sufficient courage to discharge his responsibilities about the health challenge we face, without requiring that the Leader of the Official Opposition should hold his hand!
Surely, you must admit that the executive role you seek is somewhat strange in any normal democracy. It is also inconsistent with everything you say and do everyday to convince all and sundry how rotten our government and its policies are.
I do not believe that we should encourage the convention whereby the opposition is both an effective opposition and an effective player with regard to the decisions of the executive.
The most difficult problem we face as a country and people is the wiping out of the deeply entrenched and pervasive racist legacy of colonialism and apartheid. It is about this that we should share a common patriotism.
It would be obscene to reduce this to an HIV/AIDS issue, as you do. It would be a fundamental error to reduce the challenges we face to the incidence of disease in our country, as you do.
You are entirely wrong to claim, as in your 28 July letter, that "death and disease know no distinction of politics, creed or race".
Perhaps, this illustrates graphically the point that we do, indeed, occupy different planets.
Contrary to what you say, even a child, from among the black communities, knows that our own ‘burden of disease' coincides with the racial divisions in our country.
I think you made your point about your importance when, in the National Assembly, to depart from the physical position occupied by F.W. de Klerk, the first democratically elected Leader of the Official Opposition, you moved from the bench opposite the Deputy President's, to the bench opposite the President's bench.
As for the rest, I wish you success as the Leader of the Official Opposition.
In keeping with what I proposed to you in my letter of July 1, to which you agreed, I will ask my Parliamentary Counsellor, the Hon Charles Nqakula, to submit the entirety of our correspondence, to date, to the Speaker of the National Assembly and the Chairperson of the NCOP.
I do not believe that the dialogue in which we have been engaged is of any help in helping the people of our country to understand the truth about what we have been discussing.
The presentation of the truth is somewhat different from what you and I might consider to be an effective representation of whatever "macho" image we might have of ourselves.
The first common stage we have the possibility to occupy is surely this, which requires that we treat the truth as primary, above the impulse to play to the gallery.
Please consider carefully whether you have responded correctly and adequately to this requirement.
Please consider also whether, from this limited experience, you are ready to fight together with us, for the realisation of the objectives of an agenda targeted at genuine social transformation.
Necessarily, these advisory strictures apply as much to you as they apply to us.
Extract from speech by Thabo Mbeki, Second NIEP Oliver Tambo Lecture delivered by the President of the Republic of South Africa, Johannesburg, August 11 2000:
I believe that what I will try to talk about during this Second Oliver Tambo Lecture, dedicated to the memory of a noble African, should, because of its drama and pathos, evoke among all people of conscience, a Miranda-response, sufficient to cure deafness itself.
Recently, a leading white South African politician [Tony Leon] spoke his mind either honestly or, alternatively, seemingly without inhibition. As with Prospero's brother, circumstance had created the apparent necessity that he needs must be absolute Milan.
Just over a fortnight ago, one of our newspapers reported that this white politician had said that the President of our Republic had damaged the reputation of the government.
According to the newspaper, the white politician accused the President of suffering from a "near obsession" with finding African solutions to every problem, even if, for instance, this meant flouting scientific facts about AIDS, in favour of "snake-oil cures and quackery."
(Business Day: July 26, 2000.)
Our own absolute Milan, the white politician, makes bold to speak openly of his disdain and contempt for African solutions to the challenges that face the peoples of our Continent.
According to him - who is a politician who practices his craft on the African Continent - these solutions, because they are African, could not but consist of the pagan, savage, superstitious and unscientific responses typical of the African people, described by the white politician as resort to 'snake-oil cures and quackery'.
By his statements, our own absolute Milan, the white politician, demonstrates that he is willing to enunciate an entrenched white racism that is a millennium old.
This racism has defined us who are African and black as primitive, pagan, slaves to the most irrational superstitions and inherently prone to brute violence. It has left us with the legacy that compels us to fight, in a continuing and difficult struggle, for the transformation of ours into a non-racial society.
Such crimes against humanity as slavery, colonialism and apartheid would never have occurred unless those who perpetrated them, knew it as a matter of fact that their victims were not as human as they.
Our white politician would not have made the statements he reportedly made, unless he knew it as a matter of fact that African solutions amounted to no more than snake-oil cures and quackery.
Letter from Tony Leon to Thabo Mbeki, August 24 2000
24 August 2000
His Excellency Mr T M Mbeki
President of the Republic of South Africa
Private Bag X1000
Dear President Mbeki,
Thank you for your letter of the 5th of August.
I will deal first with some outstanding issues concerning the provision of anti-retrovirals to rape victims. I will then raise some of my concerns about this correspondence. I will try to be as brief as I can.
In my letter I quoted from AMA and FDA guidelines which showed that, in America at least, the use of registered drugs for off-label indications is perfectly acceptable. This use should be based upon "sound scientific evidence and sound medical opinion" and may "reflect approaches to drug therapy that have been extensively reported in medical literature."
In your letter you claim that the "use of AZT in cases of rape meets neither of these FDA and AMA conditions." According to your argument it would be illegal and unethical to prescribe anti-retrovirals to a rape victim in the United States. This is not the case.
Such treatment has been extensively reported in medical literature (see for example American Journal of Medicine March 1999 Vol. 106.) And while the CDC has not made a binding recommendation as a matter of public health policy, it does regard the provision of anti-retrovirals for rape victims as a perfectly acceptable clinical intervention by individual doctors. Mr Kearney is absolutely right in this regard. If the provision of anti-retrovirals to rape victims
was really illegal in America then why do the CDC not say so, instead of providing long guidelines for such treatment?
You write that in this country the view of the government is that "it is illegal for medical practitioners to use drugs for purposes other than those for which they have been licensed"; that the Department of Health "is of the view that medicines should be used for the specific indications for which they are registered"; and that if doctors prescribe registered medicines for unlisted indications they are liable for "possible civil and criminal action." On this basis you continue to accuse me of "blatantly" urging "defiance of the law."
You use two legal opinions to support these claims: that of the State Law Advisors on Misoprostol and that of Professor S.A. Strauss. Unfortunately, if read carefully and in context, neither opinion actually supports your case.
What both the State Law Advisors and Professor Strauss are discussing are the statutory powers of the MCC. In terms of the law, it is only the manufacturer or authorised distributor of a particular drug, who can apply for that drug to be registered for a particular indication. Neither the Health Department, nor a doctor, nor the MCC is allowed to apply for a drug to be registered for a particular indication. This is the sole prerogative of the pharmaceutical company concerned.
What the State Law Advisors are saying is that the MCC would be acting outside its powers if it tried to register a drug for an indication not applied for by the pharmaceutical company. When they state "where the authorised person or body uses his statutory powers in the public interest but for an unauthorised purpose, the act will be ultra vires" they are referring to the MCC not individual doctors.
Thus, the advice of the State Law Advisors dealt with the authority of the MCC and its exercise of statutory powers. It was not concerned with the obligations and responsibilities of individual doctors.
Indeed, Misoprostol continues to be used for abortions within the public health system, even though it has not been listed for that indication and a current Health Department document states the following:-
"The current registration of Nevirapine could possibly enable any physician to prescribe Nevirapine for a mother to child transmission indication as "off label" usage. Until the MTCT has been registered as a specific indication, there should be some reluctance by government to promote a policy of Nevirapine use. There are, however, several examples of such "off label" use of other drugs where failure to use them would be considered bad practice, or in some circumstances malpractice. These include the use of Misoprostol for termination of pregnancy and the use of corticosteroids for preterm labour."
As far as Professor Strauss is concerned, you are guilty of extremely selective quotation. You quote Professor Strauss as saying:
"A practitioner who uses a medicine for the treatment of an indication not approved of by the MCC when registering a medicine, may expose himself to a civil action under common law for damages if the patient were to suffer harm in consequence of off-label use."
You then omit the following:
"A patient may successfully sue the practitioner if he or she can prove that off-label use in the circumstances was negligent, i.e. harm was reasonably foreseeable.
South African law does not yet recognise ‘product liability' in the sense of no-fault liability for harm caused by the mere use of the product.
Accordingly, if off-label use by practitioners has taken place regularly and ‘openly'-colleagues knowing of it and possibly doing the same-over a considerable period of time with a reasonable degree of success in the treatment of patients and without harm being caused to patients, a prospective patient would have an almost impossible burden to establish a case of reasonable foreseeability of harm. The position of the defendant-doctor would obviously be strengthened by scientific evidence to the effect that off-label use for a specific condition is quite acceptable, harmless and possibly effective."
Professor Strauss then says (and you quote) "The mere fact that off-label use might constitute a "technical" criminal offence in terms of the Act, would not lead to an inference of negligence." (SA Practice Management 1998 (1) pp 12-15)
Thus, according to Professor Strauss, a doctor will be liable for off-label use only if they have acted negligently in prescribing that drug. They are not guilty of a criminal offence and liable for civil action merely for prescribing a drug for an non-listed indication. As the law stands in South Africa, doctors are free to exercise their independent judgement in prescribing drugs for off-label purposes as long as this is done in good faith.
To deny doctors this discretion would represent a gross intrusion by the state into the autonomy of the medical profession. It would also lead to the health profession being strictly constrained within boundaries set by the pharmaceutical industry-since it is only the pharmaceutical company who can apply for their drug to be listed for a particular indication. As I noted in my previous letter, a drug company may not choose to register a drug for a specific indication for a variety of (non-medical) reasons: They may not want to pay for the necessary clinical trials; or they may not want to offend a powerful political lobby in that (or another) country.
To restate my case: Although there is a lack of direct clinical data on the efficacy of anti-retrovirals as post-exposure prophylaxis, there is sound medical evidence supporting the provision of such treatment. Furthermore, it would not be against the law to make anti-retrovirals available within the public health service for the treatment of rape victims. Currently, such treatment is available to those who use private health care and can afford it. Recently I heard an SABC report on how a Norwegian tourist had been raped but was immediately treated with AZT. The effect of your government policy is merely to deny such treatment to those dependent on the public health care system.
You have asked for a "rational discussion of HIV-AIDS" (July 1). You have also stated that we must "treat the truth as primary" (5 August). I would like to raise a couple of concerns in this regard.
During the course of this correspondence, you have made it clear that you wish to confine this debate to the issue of PEPs for rape survivors. This is a fair request and I have respected it. However, there are certain inconsistencies between the arguments you have used in this correspondence and those you have used in other public statements particularly on Virodene and the provision of anti-retrovirals to pregnant women.
In debating the provision of anti-retrovirals for rape victims you argued that there was a lack of direct clinical data; you cited (incorrectly) the recommendations of the CDC; and you claimed that it would be a contravention of the rule of law to provide a registered drug for off-label use.
On the question of providing anti-retrovirals for pregnant women you ignored the copious amounts of clinical data, the unambiguous recommendations of the CDC, and the fact that AZT is registered for that indication. Instead you refused to make AZT available in the public health service on the basis that "the toxicity of this drug is such that it is in fact a danger to health."
I find it even more difficult to reconcile the arguments in our correspondence with your statements on Virodene, which your party so aggressively promoted as a cure for AIDS.
On 8 March 1998 you defended the Virodene researchers by saying that "those who seek the good for all humanity have become the villains of our time!"
You then proceeded to attack the MCC for refusing to allow the testing of this industrial solvent on AIDS patients. You stated:
"Alas, ‘the local review board', the MCC, still refuses to accept the application, despite its knowledge of these ‘learned and highly qualified professionals' [whom you had quoted], and whose credentials it is perfectly aware of. To confirm its determined stance against Virodene, and contrary to previous practice, the MCC has, with powers to decide who shall live or die, also denied dying AIDS sufferers the possibility of ‘mercy treatment' to which they are morally entitled. I and many others will not rest until the efficacy or otherwise of Virodene is established scientifically. If nothing else, all those infected by HIV/AIDS need to know as a matter of urgency. The cruel games of those who do not care should not be allowed to set the national agenda." (Sunday Tribune 8 March 1998)
Thus, on AZT and Virodene you have taken the following contradictory positions: AZT is a "toxic danger to the public health" but Virodene is a "mercy treatment"; AIDS sufferers are "morally entitled" to Virodene but doctors should not be allowed to prescribe AZT to rape survivors; Glaxo Wellcome is driven solely by a concern "to increase the sales of AZT" but the owners of Virodene were seeking "good for all humanity"; and arguing for off-label use of AZT is a "violation of the law", but the refusal by the MCC to allow Virodene to be tested on AIDS sufferers are the "cruel games of those who do not care."
My second concern is with the way you have attempted to play the race-card in this debate. You have misrepresented your opponents, twisted their words and tried to impose your own meaning on what they said, all in an attempt to blindside your critics. I cannot judge whether this is merely a cynical attempt to silence debate, or whether you really believe that anyone who criticises you or your government is (by definition) a "racist."
You write again and at length about Charlene Smith. I will leave her to speak for herself. I can't but agree with her that we suffer from a virtual epidemic of rape in this country. The racial characterisation of this problem must be, surely, irrelevant. All rape is equally wrong, it is not the colour of the rapist which is at issue but the criminal violence of the act.
I am perfectly willing to enter into a separate correspondence on your eccentric definitions of "racism" and "non-racialism." However, I think it is important for us to debate the issues around HIV/AIDS on their merits.
South Africa is facing a massive human tragedy. HIV/AIDS will kill more South Africans than any war has. It is already leading to enormous human suffering.
There is an urgent need to put in place a preventative campaign with a clear and consistent message. As politicians we have an obligation to provide political support for such a campaign and not to muddy the waters by squabbling with international opinion.
The government has a moral obligation to urgently take steps to make anti-retrovirals available to pregnant women and rape survivors within the public health system. And where we lack the systems to provide such treatment, to put those in place.
There is an urgent need to reform and extend the welfare system so that the state assists those looking after the sick, the dying and the orphaned.
To fight the war against HIV/AIDS successfully our whole country needs to pull together. This is not the time (or the issue) to indulge in racial politics-to try and turn black against white.
We now have a non-racial constitution and franchise. We have no segregation of public facilities or services. We should now be free to confront the real problems facing our country. It would be disastrous to respond to this crisis by trying-like the old general-to fight the last war.
We live in the same country, face the same problems and share a common concern for our people. We must, on the HIV/AIDS issue at least, set aside personal differences and personal pride and work together for the good of the country.
I believe that you and I ought to follow the conventions of reasonable, regular and frank discussion that were established during the Constitutional negotiations and continued by your predecessor during the ANC's first term in office.
These are conventions that have been painfully built up. They were based upon a recognition of shared concerns, common challenges, and the acknowledgement of equal legitimacy. It is important that we should meet on occasion to discuss major problems or crises facing our country. This would not end the proper and robust debate between ruling party and opposition which is fundamental to democracy, nor would it be an intrusion on the functions of the Executive. But it would follow a path bequeathed to us by our predecessors, one which led our country away from a civil war. It would also send a message to the voters that we contest issues as opponents not enemies. We should not turn our back on that tradition now.
I agree that this correspondence should be published when Parliament reconvenes.
Letter from Thabo Mbeki to Tony Leon September 1 2000:
PRESIDENT REPUBLIC OF SOUTH AFRICA
September 1, 2000
Thank you for your letter dated 24 August 2000.
As I indicated in my last letter, it is perhaps best that we close this written exchange of views.
You will therefore understand why I will not respond to your latest letter of August 24th though I would contest many of the points you make.
I would like to assure you that the Government will continue to do everything it can to respond to the health challenges facing our people.
[This correspondence was subsequently tabled in parliament and widely reported upon in early October 2000. Later that month it was reported that President Mbeki was "withdrawing from the debate" on HIV/AIDS.]
[i] CDC, "Guidelines for treatment in cases of sexually transmitted diseases", MMRW 1998; 47: 109-110
[ii] The 1999 Health Systems Trust report reports that over half of all antenatal clinic attendees have at least one STD. More specifically, it was estimated that up to 15% of family planning and antenatal clinic attendees were seropositive for syphilis, 16% harbour chlamydial infections, 8% have gonorrhoea and as many as 20-50% have other vaginal infections. Further, Medical Research Council research suggests that one quarter of the country's sexually active population have at least one STD.
The South African Institute for Medical research has some alarming figures on the implications of the STD epidemic for AIDS infection. The likelihood of infection increases to 5% if one partner has a discharge associated with gonorrhoea, chlamydia or trichomoniasis. If both partners have such a discharge the risk increases to 25%
In the case of genital ulcer, as associated with syphillus, herpes or chancroid, the AIDS transmission rate increases to about 7% with one infected partner and 49% if both are infected. With multiple STD infections, the tranmission rate can be well over 50%.
[iii] You have on previous occasions expressed doubt about the extent of the rape crisis in South Africa. But two facts are probably undisputable. The first is that South Africa has extremely high figures of reported rapes. The second, is that it is extremely difficult to determine the precise extent of rape due to underreporting.
The number of rapes is also increasing alarmingly. Police statistics show that the number of reported rapes in the country increased from 109.8 per 100 000 people in 1994 to 119.1 in 1996. According to the SAPS, between 1994 and 1998 the number of reported incidents of rape increased by 16%. While there may be different views about the extent of under-reporting, there is no doubt that reported cases represent only the tip of the iceberg. A 1998 victims survey by Statistics South Africa found that there was a 47% underreporting of sexual offences. However, the report suggested that even this figure was debatable, as people who had reported sexual assault to the police would be more likely to acknowledge such an assault to the survey.
I also refer you to a survey carried out over three years by the Johannesburg Southern Metropolitcan Council and CIET Africa, the results of which were published in June of this year and which you have no doubt seen. The survey found that one out every four men questioned said that they had committed rape before the age of 18, while eight in ten said they believed women were responsible for sexual violence. Alarmingly, one in ten thought that gang rape was "cool".
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