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S. Africa Embraces Study Critical of Health Policy

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The New York Times |

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Several organisations involved in this report are Atlantic grantees: Save the Children, University of Cape Town, University of the Witwatersrand, University of KwaZulu-Natal, University of Pretoria, and University of the Western Cape.

Funding for this publication was provided by Saving Newborn Lives/Save the Children USA through a grant from Bill & Melinda Gates Foundation. Additional funding for printing was provided by the Centre for the AIDS Programme of Research in South Africa (CAPRISA).

The Lancet South Africa Series are available online at

August 25, 2009

JOHANNESBURG — Leading South African scientists challenged the governing party on Monday to break with its deeply flawed record on AIDS and public health, spurring the country’s new health minister to say that he and his party shared their diagnosis of systemic problems and were determined to repair them.

The decision by the health minister, Dr. Aaron Motsoaledi, to embrace the often withering assessment of his party’s failings, laid out in six papers published online Monday by The Lancet, a medical journal based in London, provided a strong signal that the governing party’s new leadership intended to shake up a badly managed health system.

It was also evidence that the long often strained relationship between the government and the country’s senior medical researchers, who at times saw their cutting-edge scientific findings ignored by their political leaders, could be coming to an end.

“We do take responsibility for what has happened and responsibility for how we move forward,” said Dr. Motsoaledi, who took charge of the Health Ministry in May.

He also said, “I am feeling quite at home and comfortable with this Lancet report.”

South Africa, still struggling to overcome the legacy of the racist apartheid system, has H.I.V. and tuberculosis epidemics that are among the world’s worst. The rate at which women here are killed by intimate partners is six times the global average.

It is also one of only a dozen nations in the world where child mortality has risen since 1990 — a period when many countries, including African ones far poorer than South Africa, have seen significant declines. South Africa, which delayed carrying out dual drug therapies proved to prevent the transmission of H.I.V. from mother to baby, could save some 37,000 children’s lives a year by 2015 by broadening the provision of such therapies, the researchers estimated.

Dr. Motsoaledi vowed Monday that he was committed to eradicating such deaths. “If others can do it, why can’t South Africa?” he asked.

The team of Lancet authors — public health doctors, epidemiologists, health economists and other researchers from South Africa — said the April elections that brought the new leadership of the governing African National Congress to power offered an opportunity for change.

The party has run the country since apartheid ended 15 years ago, but the new president, Jacob Zuma, had for years been at odds with his predecessor, Thabo Mbeki, and has pledged a new direction. South Africa’s approach to AIDS and health began to shift significantly last year after Mr. Mbeki was forced out of office by his own party and Barbara Hogan was named health minister.

The current government “has the mandate and potential to address the public health emergencies facing the country,” the authors wrote, adding, “Will they do so, or will another opportunity and many more lives be lost?”

The scientists described the calamitous and now familiar consequences of what they called Mr. Mbeki’s “bizarre and seemingly unshakable belief that H.I.V. did not cause AIDS.” But they went further to detail the management failures of his health minister, Manto Tshabalala-Msimang, that too often crippled the quality of services even after good policies were adopted.

“South Africa is this great paradox of excellent policies,” said one of the main authors, Prof. Salim S. Abdool Karim, who leads the Durban-based Center for the AIDS Program of Research in South Africa. “The problem is they can’t implement them.”

In The Lancet, the authors decried what they described as “a stubborn tendency to retain incompetent senior staff and leaders, including (until recently) the former minister of health. As a result, for many years, loyalty — rather than an ability to deliver — has been rewarded in the public sector.”

The authors of the papers prescribed what they considered an affordable agenda to improve the health system, including a more strategic effort to prevent the further spread of H.I.V.

The potential to contain the AIDS epidemic “was irretrievably lost,” they wrote.

South Africa, with less than 1 percent of the world’s population, now bears 17 percent of the world’s burden of H.I.V. infection. It has more H.I.V.-infected people than any other nation.

Expanding efforts to prevent mothers from infecting their babies and to discourage people from having multiple sexual partners, as well as moving urgently to routinely offer circumcision to men — a relatively simple surgical procedure proved here in South Africa to more than halve their risk of infection — could help the government achieve its goal of halving new infections.

But doing so will be no easy task. Dr. Motsoaledi, asked when South Africa would adopt a policy to promote circumcision, said that before moving forward the country still needed to consult leaders of various ethnic groups. Some of them practice circumcision, while the Zulu, the country’s largest ethnic group, do not. The World Health Organization recommended circumcision more than two years ago as an effective H.I.V. prevention method.

Still, there is no question that the tone of the debate between the government on one side, and scientists and advocates on the other, has lost the contentious edge that often characterized it during the Mbeki era.

Dr. Motsoaledi noted Monday that he had been classmates with Dr. Karim at the University of Natal’s medical school in the early 1980s. Dr. Motsoaledi and Dr. Karim were both students of another of the report’s authors, Hoosen M. Coovadia, a pediatrician and professor of H.I.V./AIDS at the University of KwaZulu-Natal.

“I’m quite happy and excited about this gathering and the report,” Dr. Motsoaledi said.

Professor Coovadia repaid the compliment, saying, “I’m so pleased we’ve reached a moment when we’re all going to work together.”

Copyright 2009 The New York Times Company