The Moral Economy of AIDS in South Africa (Cambridge Africa Collections)

225 Pages·2004·7.51 MB·English

by  Nicoli Nattrass

r
The Moral Economy of AIDS in South Africa
Relatively few people have access to antiretroviral treatment
in South Africa. The government justifies this on grounds of
affordability. Nicoli Nattrass argues that the government's view
insulates AIDS policy from social discussion and efforts to fund
large-scale intervention.
Nattrass addresses South Africa's contentious AIDS policy from
both an economic and ethical perspective, presenting:
• a history of AIDS policy in South Africa
• an expert analysis of the macroeconomic impact of AIDS
• a delineation of the relationship between AIDS and poverty
and the challenges this poses for development, inequality and
social solidarity
• an investigation into how a programme preventing mother-
to-child transmission would be less expensive than having to
treat children with AlDS-related illnesses
• an exploration of the relationship between AIDS treatment and
risky sexual behaviour
• an economic and social case for expanded AIDS prevention and
treatment intervention.
This relevant and accessible work is a valuable resource for
readers with an interest in AIDS policy and the social and
economic implications of the pandemic.
Nicoli Nattrass is Professor of Economics and Director of the
Centre for Social Science Research at the University of Cape Town.
Her research interests include economic policy, unemployment,
inequality and AIDS in South Africa.

The Moral Economy of in South Africa
AIDS
Nicoli Nattrass
School of Economics and the
Centre for Social Science Research
University of Cape Town
CAMBRIDGE
UNIVERSITY PRESS
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, Sao Paulo
Cambridge University Press
The Water Club, Beach Road, Granger Bay, Cape Town 8005, South Africa
http://www.cambridge.org
Information on this title: www.cambridge.org/9780521548649
© Nicoli Nattrass 2004
This book is in copyright. Subject to statutory exception and to the provisions of
relevant collective licensing agreements, no reproduction of any part may take
place without the written permission of Cambridge University Press.
First published 2004
Reprinted 2006
Printed in South Africa by Creda Communications
Edited by Douglas van der Horst
Proof-reading by Tessa Kennedy
Cover artwork by Bulelwa Nokwe (left bodymap) and anonymous
(right bodymap)
Cover design by Karen Ahlschlager
Typeset by Vanessa Wilson in Utopia 10/13pt
ISBN- 13 978-0-521 -54864-9 paperback
ISBN- 10 0-521 -54864-0 paperback
There are instances where we have been unable to trace or contact the copyright
holder. If notified, the publisher will be pleased to rectify any errors or omissions
at the earliest opportunity.
Contents
Dedication VII
Acknowledgements vm
List of abbreviations ix
List of figures x
List of tables xi
1 Introduction 13
1.1 An overview of the book 19
Why focus on AIDS? 23
1.2 The socio-economic determinants of AIDS in Africa 24
Poverty and AIDS 24
AIDS and economic growth 32
1.3 Economic analysis and the development dilemma 34
Some philosophical underpinnings 35
2 AIDS policy in South Africa 41
2.1 A history of AIDS policy making in South Africa 41
Disastrous high-profile quick-fix solutions 44
The discourse of unaffordability of mother-to-child
transmission prevention 47
Questioning the science of AIDS 48
The discourse of unaffordability of AIDS treatment 55
2.2 The moral economy of triage 57
What do Southern African citizens think about policy priorities? 63
3 Mother-to-child transmission prevention in South Africa 66
3.1 Introduction 66
Methodological considerations 67
3.2 Why South Africa cannot not afford mother-to-child
transmission prevention 70
Introducing substitute feeding 73
But will the state actually treat the HIV-positive children
for opportunistic infections? 76
What about orphans? 79
3.3 The government's response: a moral economy of triage? 81
The issue of resource availability 81
What has been happening to health expenditure on AIDS? 83
3.4 How many children could be saved from HIV infection? 88
Appendix: Costing mother-to-child transmission prevention 93
4 Expanding an AIDS intervention to include HAART
for all who need it 99
4.1 The impact of a limited AIDS intervention 100
Improving the treatment ofSTDs 101
Voluntary counselling and testing 102
4.2 The impact of HAART 104
The direct cost of providing HAART 107
4.3 The cost of AIDS interventions 109
Confronting the conventional economic wisdom 116
What are the budgetary implications? 119
What about rationing? 121
4.4 'Scaling-up' the use of HAART in the public sector 124
4.5 HAART or a disability grant? 127
5 AIDS, HAART and behaviour change 132
5.1 Does HAART lead to riskier sex? 132
5.2 Could failure to provide HAART lead to riskier sex? 139
Combating myths about AIDS 141
HAART and stigma 142
5.3 Voluntary counselling and testing and behaviour change 144
The challenge posed by sexual culture 146
6 AIDS, economic growth and inequality in South Africa 150
6.1 Some relevant demographics 150
6.2 Modelling the macroeconomic impact of AIDS 154
The ING-Barings and BER models 158
The Arndt and Lewis model 160
What can be learned from these macroeconomic
modelling exercises? 160
6.3 The impact of AIDS on firms 162
6.4 AIDS and inequality in South Africa 169
The economic impact of providing HAART 171
On sacrificing generations 174
7 Conclusion 178
7.1 The moral challenge posed by AIDS for society 178
7.2 Alleviating poverty and addressing AIDS 184
7.3 Why social deliberation is necessary 188
Notes 190
References 203
Index 223
F
or all those children who were born Hiv-positive because the
South African government said it could not afford to prevent
mother-to-child transmission. It is also for the doctors, nurses and
families who watched in anger and helplessness as more resources
were spent coping with the children's AiDS-related illnesses than
were needed to save them in the first place.
Acknowledgements
Special thanks to Jeremy Seekings for helping me sharpen my arguments
during many long dog-walks on the mountain. I am particularly grateful
to Jeremy, Sean Archer, David Benatar, Sean Muller, Evan Lieberman and
Alan Whiteside for their critical and constructive reading of the manu-
script.
I would also like to thank the following people for their comments and
advice: Faried Abdullah, Frikkie Booysen, Andrew Boulle, Mike Cherry,
Nathan Geffen, Alison Hickey, Leigh Johnson, Tony Leiman, Shannon
Mitchell, Rinette van Coller and Desire Vencatachellum. Celeste Coetzee
and Vicki Elliott were very helpful research assistants.
I am grateful to Rob Dorrington and Leigh Johnson for allowing me to
use the output of the ASSA2000 Interventions Model. I am grateful to the
Andrew W. Mellon Foundation for providing me with teaching relief to
complete the manuscript, and to SANPAD for their financial support of the
project.
All financial proceeds from the book will go to the AIDS and Society
Research Unit at the University of Cape Town.
Abbreviations
Acquired human immunodeficiency syndrome AIDS
African National Congress ANC
Antiretroviral ARV
Actuarial Society of South Africa ASSA
Zidovudine AZT
Basic income grant BIG
Centre for Actuarial Research CARE
Computational general equilibrium CGE
Congress of South African Trade Unions COSATU
Directly observed therapy DOT
Financial and Fiscal Commission FFC
Growth, employment and redistribution GEAR
Highly active antiretroviral therapy HAART
Human immunodeficiency virus HIV
Joint Health and Treasury Task Team JHTTT
Medicines Control Council MCC
Member of the executive committee
[of a provincial government] MEC
Medecins Sans Frontieres MSF
Men who have sex with men MSM
Mother-to-child transmission prevention MTCTP
Medium-term expenditure framework MTEF
National AIDS Committee of South Africa NACOSA
National Economic Development and Labour Council NEDLAC
New Partnership for Africa's Development NEPAD
Non-governmental organisation NGO
Non-nucleoside reverse transcriptase inhibitor NNRTI
Nucleoside analogue reverse transcriptase inhibitor NRTI
Pharmaceutical Manufacturers' Association PMA
Public works programme PWP
Social accounting matrix SAM
South African National AIDS Council SANAC
Sexually transmitted disease STD
Treatment Action Campaign TAC
Unprotected anal intercourse UAI
Value added tax VAT
Voluntary counselling and testing VCT