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Postcolonial Plague: The Legacy of Apartheid South Africa in Addressing the HIV Epidemic

Image via Stephane de Sakutin/AFP

The South African government has a longstanding history of HIV denialism. Throughout his presidency from 1999 to 2008, Thabo Mbeki continually questioned the validity of HIV research. Infamously, he presented his dissenting positions in a letter to world leaders in 2000. In speeches that same year, he stated, “A virus cannot cause a syndrome. A virus can cause a disease, and AIDS is not a disease, it is a syndrome.” In addition to this rhetoric, Mbeki sponsored panels that highlighted dissenters from current HIV research, furthering his pseudoscientific views. As a result, HIV conspiracy theories became rampant in South African political life. Mbeki’s claims were met with immediate backlash from media outlets, AIDS activists, and healthcare organizations. However, these responses disregard the South African historical context. The legacies of apartheid, corruption, and colonialism that linger in the South African collective consciousness provided the perfect climate for conspiracy theories around HIV/AIDS to proliferate. 

In South Africa, public health and systemic oppression have been intertwined for centuries, with the racial segregation of healthcare codified by the 1883 Public Health Act. Under this act’s emergency provisions, Black South Africans were removed from urban centers during flare-ups of the Bubonic Plague. Between 1900 and 1910, this policy surrounding Plague epidemics resulted in the sweeping loss of property for Black South Africans. This period of racial segregation became impressed upon the national consciousness of South Africans. It was a time when racism was thinly veiled as public health policy. 

In later years, fearful of anti-apartheid movements, the South African government began investing in Project Coast, an operation within its chemical and biological warfare (CBW) department. Former military-doctor Wouter Basson headed this project, modeling it on programs in other countries. Allegedly, this bolstering of the CBW department was originally intended to combat chemical weapons threats during the South African conflict in Angola. Testimonies from the Truth and Reconciliation Commission (TRC) hearings, however, uncovered it to be an effort to possibly commit genocide against the Black population.  

Researchers attempted to create a bacterium to target Black individuals. Additionally, Basson’s team investigated how CBW such as cholera and micro-organisms could be deployed for population control. One of the most terrifying projects included a vaccine to covertly sterilize the Black population. This effort became extremely explicit during the TRC hearings, in which one doctor stated that their “final brief, […] was to develop a product to curtail the birth rate of the [B]lack population in the country. 

These genocidal plans coincided with the faulty AIDS response by the partheid government throughout the 1980s and 1990s. As soon as AIDS began afflicting the Black population, the government response reflected the enduring racism in South Africa. The voices of right-wing parliament members offered an alarming prophecy of the destruction to come. Dr. F. H. Pauw claimed that the Black majority would no longer be a threat due to many dying of AIDS. Conservative Party MP Clive Derby-Lewis stated, “If AIDS stops black population growth, it would be like Father Christmas.” While the government eventually attempted to advocate for contraceptives, this only aggravated anti-apartheid groups and was seen as another method of reducing the Black population. 

When Nelson Mandela was elected in 1994, his post-apartheid government inherited a public health system riddled with mistrust and an increasing number of people living with HIV. In fact, in 1994, 7.6 percent of South Africans were HIV positive (compared to 0.7 percent in 1990). This figure would only keep growing, hitting 22.4 percent in 1999. South Africa’s crippled healthcare system needed to address this growing crisis, yet officials refused to credit the results of  HIV studies, slowing government interventions.

One of the biggest failures of Mandela’s new government was its refusal to properly use the antiretroviral drug azidothymidine (AZT), the primary treatment given to people living with HIV at the time. In other countries, AZT helped address mother-to-child transmission, wherein children were infected by their mothers during pregnancy. Scientific evidence highlighted that proper use of AZT—when used in tandem with cesarean sections and formula feedings—results in a near-zero mother-to-child transmission rate. Still, Health Minister Nkosazana Clarice Dlamini-Zuma claimed otherwise, espousing the view that AZT was too expensive and ineffectively addressed the pandemic. Her successor echoed similar sentiments, arguing the drug’s benefits did not outweigh its toxicity. Dissenting from scientific evidence on antiretroviral drugs, the South African government failed to respond to the HIV crisis: A study from the Harvard School of Public Health estimated that more than 330,000 people died prematurely and 35,000 babies were born with preventable HIV infections. An antiretroviral treatment program was not implemented until 2003, three years after Mbeki’s troubling letter was presented.

Despite these obvious failures, they must be considered in the context of apartheid’s oppression. The legacies of a racist, morally bankrupt colonial government lent themselves to a poor response to the growing HIV crisis. This legacy helps explain why the government withheld the authorization of AZT. With the discovery of genocidal planning and anti-fertility research, the post-apartheid government was sensibly wary of drugs specifically marketed toward mothers. Coupled with the fact that Western pharmaceutical corporations were heavily pushing and profiting off of the drug, the government was extremely cautious of AZT in the post-apartheid era.

Mbeki was extremely hesitant to blindly accept wisdom from countries that participated in the oppression of his people. In his letter, he emphasized that prohibiting HIV dissent is “precisely the same thing that the racist apartheid tyranny we opposed did.” He also highlighted the unique nature of the African HIV crisis, a claim which some have misconstrued as stating that there existed a new African source of AIDS. Yet, the HIV crisis itself in South Africa—and other countries affected by colonialism—is unique. Many challenges come from grappling with the legacy of apartheid, which undoubtedly fractured the response from the onset. This begs the question: Can we really judge a leader for not trusting their oppressors? 

Today, the legacy of apartheid continues to influence public health in South Africa. In 2020, South Africa had approximately 7.8 million people living with HIV, and around 19.1 percent of people ages 15 to 49 had tested positive for HIV. South Africa has the fourth highest HIV prevalence rate and has the greatest number of people living with HIV in the world, making it a pressing matter of consideration for global health. 

This consideration became especially apparent once the Covid-19 pandemic struck. HIV has left many South Africans immunocompromised. Coupled with low vaccination rates, South Africa and other Sub-Saharan African countries were at high risk for Covid-19. This had a global impact: Some scholars believe that the Omicron variant originated in South Africa in part due to its sizable immunocompromised population, which put it at greater risk of  mutations appearing.  

While one cannot trace back every public health failure to apartheid governments, it is important to note the role of lasting legacies of oppression left by them. It forever changed the consciousness of South Africa, as the memories and trauma of apartheid have not been erased with transitions of power. This sentiment is not confined to South Africa, but rather, it is the case in every country with a deep oppressive history. Medical mistrust is especially pervasive among Black Americans due to systemically racist medical malpractice and a centuries-long legacy of chattel slavery. The Tuskegee Syphilis Study, while perhaps the most infamous, is only one example of a racist weaponization of science against the Black community. Similarly, many Indigenous populations also continue to distrust post-colonial medical establishments. 

Every colonizing power must reflect on its weaponization of health, as they have colored the modern-day responses to public health crises. How can we expect people to “trust the science” if the source has an untrustworthy track record? While it is easier said than done, governments must invest time and resources into mending the wounds that they inflicted. Without addressing past atrocities, conspiracies will continue to run rampant, frustrating the global response to future health emergencies. As the world is hopefully on the tail end of the Covid-19 pandemic, the present moment stresses the urgency of reconciling prior wrongdoings for the sake of the health of all eight billion people on the planet.

[Editor’s Note: This article was published in the Fall 2022 issue of the BPR magazine.]