Nelson Mandela’s Mixed Legacy on HIV/AIDS

December 6, 2013

By 1990, when Nelson Mandela was released from prison, nearly 1 percent of South African adults were HIV-positive and the country’s burgeoning HIV/AIDS epidemic was on the verge of exploding. When he became president, four years later, Mandela saw his job as reconciliation, holding his fractured nation together. Activists hoped he would also make time for AIDS.

A judge on the Constitutional Court of South Africa, Justice Edwin Cameron was one of those activists. Unfortunately, he told FRONTLINE, despite his efforts to get Nelson Mandela personally involved in South Africa’s HIV/AIDS crisis, Mandela’s greatest contribution to the cause did not come until after he left office. Those contributions “were magnificent acts,” Cameron said. “Just imagine if he had done comparable things … earlier.” This is the edited transcript of an interview conducted by producer Renata Simone in 2009. Simone produced FRONTLINE’s 2006 film The Age of AIDS, as well as Endgame: AIDS in Black America, which premiered in July 2012.

[question]When Nelson Mandela began his historic presidency in South Africa, AIDS activists in the country — and around the world — had high hopes that he would somehow engage in their efforts to fight HIV/AIDS. Why is it that he did not?[/question]

When Mandela came into office in April 1994, three things of significance had happened. One was that the epidemic was taking hold in South Africa. The estimated prevalence was about 5 percent amongst women presenting at antenatal clinics, perhaps a bit higher, and it was clear AIDS was going to be a massive epidemic of heterosexually transmitted disease.

The second was that within the African National Congress (ANC) there was consensus on the importance of HIV, but the third was that I think there was widespread involuntary denial about it. I’m not talking about ideologically motivated “denialism,” which President [Thabo] Mbeki introduced five years later. I’m talking about the defensive psychological mechanism of denial, where you know you’ve got a problem — you’ve got other things to deal with and you don’t want to accommodate the thing you have to deal with among your frame of action. So that’s what happened.

[question]There was consensus in the ANC about its importance?[/question]

There had been in 1992, a national convention on AIDS, which had produced a very good action plan, which the ANC formally adopted in August 1994. The health minister at the time was Nkosazana Dlamini-Zuma. So everything was there: the extent of the epidemic, the ANC’s formal commitment to it. The practical framework for an effective governmental response to it was there.

What was lacking was incisive, vocal and concerted political leadership. And that could only have come from President Mandela.

He was — and the stock phrase about him despite it being stock is absolutely correct — he was iconic. He was the leader who had been in prison for 27 years, who had emerged to lead his country through the constitutional negotiations and the instabilities of transition, into this glorious moment of democracy. He was the person who could have spoken with moral authority, with practical interceptive effect on AIDS. But he didn’t. He kept quiet.


The reason for that is that he had a set of pressing priorities, which took precedence over AIDS. He had the question of military and political stability against a diminishing but still powerful racist white minority — the far right wing I’m talking about.

He had the problems of economic policy. He was melding economic policy within a government that consisted of an alliance between the Communist Party, the ANC and the Congress of South African Trade Unions.

He had the question of reconciliation between moderate whites and moderate blacks, who had been kept apart for 300 years of history. He had, vitally, the question of the international relations. South Africa had been the polecat of the world for 30 or more years and Mandela was reintroducing South Africa.

[question]Are you saying that he didn’t have time, or that he didn’t have AIDS as a priority?[/question]

Now, I’m going to say something that is going to be harsher than most people have said about Mandela: There is no doubt that he was flattered and seduced by the thrill, the enticement, the allure of the international adulation. I remember when the Spice Girls came to visit South Africa. I remember thinking acridly — and I bit my tongue — he has spent more time with the Spice Girls than he has on AIDS!

At that time, we were begging for a meeting with him. We being myself as the co-chair of the National Convention on AIDS. I was still in the closet with my own HIV status, but I — both as policy maker and a judge and a human rights lawyer and as someone living covertly with the virus myself — had an intense sense of urgency about getting this man to take a leadership position.

I wrote to him. I wrote to Deputy President Mbeki. I wrote to the secretary general of the ANC, Cheryl Corrolas. I wrote to Dr. Nklata Mklana and many of Mandela’s personal friends who have died since. I begged everyone for access to him, to press on him the need for his leadership.

What we wanted from him was not a framework for governmental action. In that regard, there were other failings. There were operational failings, management failings, output failings between 1994 and 1999.

What I wanted from President Mandela was something very specific. It was his personal presence, his voice, his leadership on AIDS. And that, we never got.

[question]That must have been very frustrating. Why do you think he gave time to the Spice Girls and not to HIV/AIDS?[/question]

The first time he spoke about AIDS at all was in February 1997, nearly three years after he took office. And he didn’t even speak on AIDS when he was in South Africa. He spoke in Switzerland, at Davos.

I know this is more ungenerous than anyone, but I think the seductions of international adulation reached the human fallibility of this wonderful man. This man whose stature and moral fiber had meant that we survived the risk of racial Armageddon, civil war, had given us so much, but he didn’t give us his time and attention and voice and leadership on AIDS. He saw the Spice Girls. He had an hour-long meeting with them and a photo opportunity with them afterwards. And I said to myself, “He has given more time to the Spice Girls than he has given to AIDS.”

I thought of saying so at the time, but respect for him and a certain deference to him made me bite my tongue. Now that it’s 10 years since he left office and we can look back, I don’t think it would have been an unfair thing to say. It sounded demeaning and bitter but it was factually correct.

And the emblematic significance of the Spice Girls — at the height of the time when we wanted him to do something about AIDS — I think he was drawn by the seductions and flattering, delightful allures.

[question]What impact could Mandela have had, if he had spoken out in those years while he was in office?[/question]

Now, I don’t believe that political leadership would have alleviated the epidemic, but I believe it would have blunted its extent. I think we were going to have a catastrophic AIDS epidemic regardless of Mandela’s leadership. When history looks back on the curve of the epidemic through the societies of Burundi, Uganda, Mozambique, Rwanda, Kenya Congo, Tanzania, Zambia, Botswana, there was going to be a catastrophe.

Mandela couldn’t have undone the force, might, the sweep of the epidemic. He couldn’t have kept the infection rate to 5 percent. We were going to have [an infection rate of] 10 percent or 15 percent. But we might not have had 18 percent, 20 percent and more infected. He could have blunted the impact. We will never know.

The other thing he could have done would have been to get out the message of anti-stigma early. Now, still, 25 years after the epidemic started in Africa, stigma is still a central problem.

[question]After he left office, he did speak out –[/question]

The most important thing he did was after his own presidency. He decided in 2001 that he was not going to be quiet about the etiology* of AIDS and the importance of treatment.

The fact that he stepped out and talked about this was enormously important. Before the opening of Parliament in 2002, he made a speech in giving his Health and Human Rights Award, which spoke about the importance of preventing mother-to-child (PMTC) transmission. This was at the very time that the Mbeki government was being dragged to court by the Treatment Action Campaign because it was refusing — on denialist grounds to give PMTC to mothers with HIV. So his intervention on that was crucially important.

President Mandela’s most decisive acts on stigma were fantastic. He donned the HIV Positive T-shirt in July 2002, and when he spoke about his own son, Matata Mandela, who died of AIDS. But those were later. And they were magnificent acts. All of that to his enormous credit. … Now just imagine if he had done comparable things seven years earlier.

[question]So taking into consideration Mandela’s inaction during his time in office and his actions afterwards, what is his cumulative legacy?[/question]

I condone much of what Mandela did. About his time in office, there were so many other things to do and it was impossible for him to do all of them. But the fact is that AIDS was the victim. AIDS fell out of his agenda during his term in office.

After he left office, his decision to confront Mbeki was stunning … So I give him huge credit and I don’t blame him too heavily.

*Editor’s Note: AIDS “denialists,” including Thabo Mbeki, Mandela’s successor as president of South Africa, do not believe HIV causes AIDS and therefore do not believe treatment works.

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