m_sajhiv_n20_a2.pdf


5THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                        SEPTEMBER 2005  

H O R I Z O N S

HIV/AIDS: THE MIRROR IN SOUTH
AFRICA’S FACE

Let us open with Nkosi Johnson’s words of wisdom: 

‘I want people to understand about AIDS – to be careful and
respect AIDS – you can’t get AIDS if you touch, hug, kiss, hold
hands with someone who is infected. Care for us and accept us
– we are human beings. We are normal. We have hands. We
have feet. We can walk, we can talk, we have needs just like
everyone else – don’t be afraid of us – we are all the same!’

Why would an 11-year-old child have to make such an
impassionate plea in the South Africa of 2000? Is this not a
society that has committed itself to the fundamental human
rights enshrined in the UN Charter? Is this not a society that
prides itself in adhering to the African value system of
Ubuntu? Is this not a country with a government that has
explicitly stated that its governance principles are based on
‘Batho Pele’ (People First)? What has gone wrong?

HIV/AIDS is a mirror in the face of our society. It forces us to
examine the contours of our face as it really is, not as we
would like to see it. Like any face, ours bears the scars of the
past, the impact of the realities of today and indications of
how the future is likely to shape up for us. Let us take each in
turn.

HIV/AIDS and the past

The old adage ‘the chickens are coming home to roost’ has a
particularly cruel twist to it for South Africa as a society. There
are just too many chickens coming home to roost on our
fragile democratic edifice. We were dealt too bad a hand by
history. Just think of the legacy we have to cope with which
has contributed to our vulnerability to the HIV/AIDS pandemic.
That legacy also undermines our capacity to address the
pandemic decisively.

First, the foundations of our society are built on conquest that
undermined the structure and socioeconomic fabric of
indigenous people and constrained their ability to adapt and
evolve to meet the challenges of modernity. Adherence to
cultural and customary practices that may be in conflict with
the values of science in areas where universally accepted
practices save lives, might be seen as the only way to protect
and defend the dignity of a wounded people. We have
elements of this way of thinking in our society. 

Second, the migrant labour system and its disruptive impact
on family life over generations have undermined the dignity of
people housed in migrant labour hostels. This system is a
major contributor to the size and shape of the HIV/AIDS
pandemic in our society. Denial of the rights of migrants to
dignified lives with their families made them vulnerable to
sexually transmitted diseases. It turned men into conduits of
the infection to their families.

Third, the pressures of the struggle against apartheid and the
brutal suppression of the liberation movement forced many
into exile. Life in exile made many vulnerable to contact with
and infection by the virus, which had its early manifestations
in some of the frontline states where many of the heroes of
the struggle lived. It is indeed a cruel irony that returning
heroes should have been conduits of this deadly virus.

Fourth, the illegitimacy of the apartheid state made it
unwilling or unable to tackle the HIV/AIDS pandemic in its
infancy in the 1980s when it could have been nipped in the
bud. We know from experiences of much poorer countries that
implementation of a comprehensive care and treatment
programme at a stage when the infection rate was low
contained its spread, to less than 3% to date in Senegal, for
example.

HIV/AIDS is one of the many costs of the legacy of apartheid.
Apartheid was an expensive experiment. It demonstrated
beyond doubt that inequality is expensive, not just for those
discriminated against, but for society as a whole.

HIV/AIDS and the present

The ideals we signed up for as a post-apartheid society are
enshrined in our Constitution. The gap between those ideals
and our practices as a society is large. Ours is a Constitution
second to none in enunciating commitments to the
fundamental rights of everyone. The rights of the child.
Equality between men and women. And the responsibility of
the state to ensure that the basic socioeconomic rights of
citizens are enabled.

There are a number of reasons for this large and in some areas
growing gap. First of these is the difficulty of overcoming the

A highlight of the 2nd South African AIDS Conference was
the first Nkosi Johnson Memorial Lecture, delivered by 
Dr Mamphela Ramphele. Nkosi Johnson, young man that he
was, warmed all our hearts when he courageously spoke out
against discrimination at the World AIDS conference in
Durban 2000. This lecture will be a consistent feature of the
SA HIV Conference, to mark this young man’s role in ridding
South Africa of HIV-related discrimination. Dr Ramphele, a
notable academic, activist and fine South African, gave a
stirring and thought-provoking lecture that really set the
tone for the conference. Unity and accountability demands
that we take stock and examine ourselves critically and
honestly. It is our pleasure to publish the First Nkosi Johnson
Memorial Lecture as delivered on 7 June 2005.



7

legacy of inequality. Policy commitments are often not
followed through into implementation, monitoring and
evaluation. Much of the problem comes from the weak
implementation capacity of the government machinery at all
levels of government, as acknowledged by the President in his
State of the Nation address earlier this year. There are notable
exceptions. Denial of opportunities for management training
and experience in the past, and the failure to acknowledge and
correct deficits since 1994, have left us in a weak position to
live out our commitments.

Second, there is the ‘Shouting Silence’ that Xoliswa’s
documentary speaks to. Xoliswa was moved by her personal
loss of her own mother to the pandemic to document the
harrowing lives of young people left to fend for themselves
following the deaths of their mothers from HIV/AIDS. The
loneliness of children walking the streets in search of love and
care is forcefully brought home to us. The heroic efforts of
grandmothers who come out of their retirement to become
both mothers and fathers to their orphaned grandchildren are
captured sensitively in this documentary. We know of many
more poor women all over our country who are rising to the
challenge in the face of great adversity.

But why the deafening silence from the rest of us? Why did we
have to be reminded by Nkosi to ‘care for us and accept us –
we are human beings’? Where is Ubuntu of the whole society
in the face of the estimated more than 5 million South
Africans living with HIV/AIDS under the cloud of stigma?
Where was Ubuntu when many of the 300 000 people who
died in 2004 from HIV/AIDS did so without the comfort of
loved ones because of the shame they felt? Where is Ubuntu
when close to 1 000 people in the prime of their lives (15 - 49
years of age) die miserable deaths each day, shielding from the
sting of stigma that still pervades our society and constrains
our response to the pandemic? Where is Ubuntu when the
caregivers of orphans and vulnerable children are not able to
access child support grants because of uncaring and corrupt
officials? Where is Ubuntu when children are sexually
assaulted by their fathers and other close relatives? Where is
Ubuntu when babies are raped in the vain hope of cleansing
infected men of HIV/AIDS? 

We are all challenged by the level of pain and suffering of
people living with HIV/AIDS and their caregivers to stop paying
lip service to the values and precepts enshrined in our
Constitution. The quality of our society will be judged by how
we treat the most vulnerable among us. We are not at the
moment doing well on that score.

Third, part of the reason for the silence is our embarrassment
about acknowledging the reality of HIV/AIDS, given its links to
sexuality. We are a socially conservative society. All the
cultures we bring into the new South Africa are prudish about
talking about sex. We just do it. But we have to talk about sex
as President Museveni of Uganda did, and made it part of the
responsibility of government officials to do the same. Captains
of industry and commerce must also step up and lead AIDS
campaigns with the same passion they devote to profits. AIDS

affects the bottom line by undermining the quality of our
human capital. Combating HIV/AIDS has to involve a
comprehensive approach that includes changing behaviours,
including the practices that make men and women more
vulnerable to infection. 

Fourth, the clash between customs that create a breeding
ground for sexually transmitted diseases, including HIV/AIDS,
and the demands of combating the pandemic have to be
acknowledged and challenged. Polygamy and multiple sexual
partners, inheriting widows, unprotected sex, non-sterile
initiation rites etc. all have to give way to safer practices. There
is just too much at stake for us to let customs continue to put
people at risk.

Finally, there is a cruel irony in that of all African countries
affected by HIV/AIDS South Africa has the greatest ability to
combat the disease, yet we are under-performing. Why? How
do we explain Brazil’s better performance with more or less
the same level of scientific proficiency and economic
development? We have a serious problem of mistrust in our
society that prevents us from acknowledging our problems
and using the resources we have to address them.

Take the case of the causation of HIV/AIDS. Why did it take so
long to have clarity infusing our policy responses? We have
the depth of scientific know-how and economic resources to
have been a front-runner in comprehensive care and
treatment and deal a mortal blow to the disease, as Brazil did.
But the scientists were largely white, male, urban based, and
outside the policy-making domain of government. Mistrust of
the racist system that denied the majority of South Africans
scientific literacy and proficiency, constrained evidence-based
policy-making.

To add insult to injury, the same racist system had over
centuries in many parts of the world stigmatised black male
sexuality as dangerous and driven by uncontrollable lust.
Unless we acknowledge the pain of those so stigmatised, we
are unlikely to overcome our mistrust and build a better life for
all. But those wounded by the past also need to transcend the
past and take ownership of shaping a future of dignity for all.
‘The reconstruction of the soul’, as former President Mandela
reminds us, is still unfinished business in South Africa.

Scientists must stand up more and often to say no to those
bent on misleading the public. This is particularly important in
a society with such low levels of literacy, numeracy and
understanding of established basic scientific facts including
how our bodies function. Confusing advice to those already
overwhelmed by the trauma of HIV/AIDS should not be
permitted. The highest ethical standards should be upheld in
the care and treatment of HIV/AIDS-affected people and in
clinical trials involving them.

The medical profession needs to play the role of watchdog for
poor and vulnerable people. The South African Medical
Association should be at the forefront of the protection
campaign. Silence makes all of us accomplices. How can we

THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                        SEPTEMBER 2005  



allow confusion between the role of specific treatment with
antiretrovirals on one hand, and the benefits of good nutrition
and supplementary nutritional agents such as vitamins for any
health care process on the other? It sounds so medieval.
Remember the sanatoria of pre-industrial Europe where many
died of tuberculosis before the advent of antimycobacterial
remedies? Remember that those early TB drugs too had toxic
side-effects – but they were better than placebos? Toxicity
diminished with better drugs invented later with the benefit of
better knowledge. Why are we not drawing on rich medical
history to help our society cope with this present challenge?

The way forward

The best way of honouring the memory of Nkosi Johnson and
many other children who met premature deaths at the hands
of HIV/AIDS is to end denialism now. Our democracy is over
ten years old now; we need to take ownership of shaping our
country’s future and create a better life for all. Blaming
apartheid has its limits, just as blaming one’s parents for one’s
failures has its limits too. We need to transcend our past and
build a better future by playing to our strengths and
minimising our weaknesses.

We need to promote a rights-based value system in our
society at all levels. The President and his Cabinet should lead
the charge on this. No government official should be allowed
to undermine the rights of citizens without being held
accountable. Official acts of omission or commission and
institutional arrangements that infringe on the rights of
people should be tackled urgently. For example, overcrowded
prisons and failing public services undermine what our society
stands for.

Education and training programmes for all public officials is
of key importance, and public education programmes,
including school-based ones, should be vigorously promoted
too. Men need to be educated about the difference between
manhood and male dominance. Real men do not need to
violate the rights of women and children to assert their
manhood. Women need to be part of the teaching and
learning of husbands, sons, brothers and significant others
about gender relationships in a human rights culture. It is only
when a critical mass of citizens is confident enough to
demand their rights that a human rights culture will flourish.
In such a flourishing human rights culture, accountability of
public officials will be better enforced.

We need to enforce the rights of citizens, especially the
vulnerable ones. It is a sad reality that law enforcement
agencies do not yet see human rights violations as a crime.
Domestic violence is still treated as a private affair even as the
rights of women and children are violated. Recent reports of
the epidemic of violence against women and children add
urgency to this issue. Training and linking incentives to
enforcement of rights is urgently needed in our law
enforcement system. There must also be penalties for failure
to perform in this area. 

Those citizens who are enlightened have a responsibility not
only to demand their rights, but also to ensure that the rights
of the least in our society are respected and protected. Only
then can we call ourselves a civilised country. Only then will
we have honoured the memory of Nkosi.

MAMPHELA RAMPHELE
7 June 2005