MBEKI VERSUS LEON
SA President Debates AIDS
Sunday Times (SA) 9 July 2000
'... as public representatives we have no right to be proponents and
blind defenders of dogma'
(Letter from Mbeki to Tony Leon)
July 1 2000
Thank you for your letters of June 19 and 27, 2000 relating to the AIDS
issue. Thank you also for the copy of the letter of the South African CEO
of Glaxo Wellcome, Mr J P Kearney.
As you are aware, during the last few months, I have tried to familiarise
myself with all elements relating to the HIV-AIDS matter.
Necessarily, this has also meant studying as much literature as possible on
the question of anti-HIV retroviral drugs.
What I said in parliament was based on the information I had managed to
garner on the issue you raised. As you correctly indicate, this related to
the efficacy of AZT in stopping HIV infection in cases of rape.
Your statement, that 80% of women raped by HIV-positive men would not
become HIV-positive if they are given AZT, has no scientific basis
In this regard, I suggest that, among others, you obtain a copy of the
publication of the US CDC, MMWR September 25, 1998/47 (RR17).
Among other things, the CDC says: "no data exist regarding the efficacy of
(antiretroviral drugs) for persons with nonoccupational HIV exposure... "
(As you must be aware, 'nonoccupational exposure' includes rape.)
"Some physicians believe that antiretroviral agents are indicated for
persons with possible sexual, injecting-drug-use, or other nonoccupational
HIV exposure. However PHS (the US Public Health Service) cannot definitely
recommend for or against antiretroviral agents in these situations because
of the lack of efficacy data on the use of antiretroviral agents in
preventing HIV transmission after possible nonoccupational exposure.
Efficacy and effectiveness data and additional epidemiologic information is
needed... " and,
"Research is needed to establish if and under what circumstances
antiretroviral therapy following nonoccupational HIV exposure is
The CDC makes this equally important statement:
"Postexposure antiretroviral therapy should never be administered routinely
or solely at the request of a patient. It is a complicated medical therapy,
not a form of primary HIV prevention. It is not a 'morning-after pill'..." (My emphasis).
In the same report, the CDC says that:
"The risk for HIV transmission... per episode of receptive vaginal
exposure is estimated at 0.1%0.2%."
In this regard, you might care to consider what it is that distinguishes
Africa from the United States, as a consequence of which millions in
subSaharan Africa allegedly become HIV positive as a result of heterosexual
sexual intercourse, while, to all intents and purposes, there is a zero
possibility of this happening in the US.
In your letter to me of June 19, you make the extraordinary statement that
AZT boosts the immune system.
Not even the manufacturer of this drug makes this profoundly unscientific
claim. The reality is the precise opposite of what you say, this being that
AZT is immuno-suppressive.
Contrary to the claims you make in promotion of AZT, all responsible
medical authorities repeatedly issue serious warnings about the toxicity of
antiretroviral drugs, which include AZT.
For example, in its Report, MMWR May 15, 1998/Vo. 47/No. RR-7. the CDC says:
"The selection of a drug regimen for HIV PEP (post-exposure prophylaxis)
must strive to balance the risk for infection against the potential
toxicity of the agent(s) used. Because PEP is potentially toxic, its use is
not justified for exposures that pose a negligible risk of transmission."
In this context, please bear in mind the 0.1%0.2% risk of transmission
indicated by the CDC with regard to receptive vaginal exposure.
The matter is not in dispute between us that AZT is not licensed by the
South African MCC for use in rape cases. Further to this, Glaxo Wellcome
has not applied to the MCC for such a licence.
Indeed, the approved package insert for AZT makes no claim about the
efficacy of AZT with regard to rape cases.
I would presume that the reason that Glaxo Wellcome has not applied for a
licence is precisely because it knows that there is no scientific evidence
it could produce to justify this application.
It is very strange that you have proven scientific information which Glaxo
Wellcome, the CDC, the MCC and every responsible medicalauthority does not
have, that 80% of rape victims in our country would not have become HIV
positive if they had been given AZT.
It may be that I underestimate the scientific expertise of which your Party
Accordingly, I am ready to change my views on this matter, to pay due
tribute to such expertise, if it is demonstrated that you do, indeed, have
If it is necessary, I can present the argument about the obvious logical
absurdity of the claim that viral infection can be stopped by the use of
drugs, provided that the virus was communicated in circumstances of forced
heterosexual sexual intercourse.
It is in this context, apart from extant scientific information, that the
issue I raised in the National Assembly about AZT not being a vaccine
assumes its relevance. The PEP argument about AZT (and other
anti-retrovirals) cannot be sustained unless vaccine-like efficacy is
attributed to these antiretroviral drugs.
Accordingly, the statement you make in your 19 June letter that I am
"correct to indicate that AZT is not a vaccine, which I (you) did not
suggest it was", is inconsistent with your argument that AZT should be used
as though it were a vaccine.
I am very disturbed at Mr Kearney's statement that your incorrect
statements about AZT and rape are "essentially accurate on the scientific
aspects of using AZT as post-exposure prophylaxis in individuals who have
I imagine that all manufacturers of antiretroviral drugs pay great
attention to the very false figures about the incidence of rape in our
country, that are regularly peddled by those who seem so determined to
project a negative image of our country.
What makes this matter especially problematic is that there is a
considerable number of people in our country who believe and are convinced
that most black (African) men carry the HI virus.
In addition to this, reflecting a view among these about rape in our
country, Charlene Smith was sufficiently brave, or blinded by racist rage,
publicly to make the deeply offensive statement that rape is an endemic
feature of African society.
This is what she wrote recently in the US Washington Post:
"Here, (in South Africa), HIV is spread primarily by heterosexual sex -
spurred by men's attitude towards women. We won't end this epidemic until
we understand the role of tradition and religion - and of a culture in
which rape is endemic and has become a prime means of transmitting the
disease, to young women as well as children."
The hysterical estimates of the incidence of HIV in our country and
sub-Saharan Africa made by some international organisations, coupled with
the earlier wild and insulting claims about the African and Haitian origins
of HIV, powerfully reinforce these dangerous and firmly-entrenched
prejudices.None of this bodes well for a rational discussion of HIV-AIDS
and an effective response to this matter, including the use of
Whatever his obligations as the Chief Executive of the company that
manufactures AZT, I think it is grossly unethical that Mr Kearney should
seek to increase the sales of AZT, and therefore Glaxo Wellcome's profits,
by exploiting the justified health concerns of our people.
I consider it deeply offensive and contemptuous of our people, our country
and its laws that, as you and Charlene Smith say, Glaxo Wellcome should
promote the sales of AZT by selling 'cutprice' AZT in our country for use
by rape victims, knowing very well that this is in violation of the law and
that no scientific evidence exists proving the efficacy of this drug in
cases of rape.
I have noted the fact that Mr Kearney seeks to achieve his commercial
purposes "together with you and your Party."
It is amazing and completely unacceptable that you, the Leader of the
Official Opposition, should consider all of this, including blatant
disrespect for the rule of law, as "irrelevant", the word you use in your
letter to me.
You will remember that during the debate around the legislation we
introduced enabling the parallel import of drugs and medicines, to make
these affordable for our population that is deeply mired in poverty, your
party was correctly and needlessly very vocal about the necessity to ensure
that all pharmaceutical products available to our people should be subject
to approval by the MCC.
Why is a double standard now being applied with regard to AZT, making the
need for the certification of drugs by the MCC "irrelevant"?
Only recently, your party has been very strident in demanding respect for
the rule of law in Zimbabwe.
Why is a double standard now being applied with regard to AZT, making the
requirement for observance of the rule of law "irrelevant"?
In his letter to you, Mr Kearney says his company is committed "to improve
access to drugs for HIV-positive individuals."
In more direct and plain language, this means that, consistent with its
normal and understandable commercial objectives, Glaxo Wellcome is
committed to increase the sales of AZT in our country, in competition with
antiretroviral drugs manufactured by other companies.
If Mr Kearney did not pursue this objective as vigorously as possible, his
company would be entitled to terminate his contract.
You and I, as public representatives of our people, pursue, or should
pursue, a different objective. With regard to the matter under discussion,
our objective must surely be to improve the health of all our people.
I think that it is dangerous that any of our public representatives and
political parties should allow themselves to be used as marketing agents of
particular products and companies, including drugs, medicines and
I accept that it is perfectly within their right for private individuals,
such as Charlene Smith, to play this role, as it would be for you, in your
In the controversy that has attended the questions our government has
raised about various matters relating to HIV-AIDS, much has been said about
us, in a sustained effort to force us uncritically to accept a so-called
We have resisted this pressure and will continue to do so, because of the
decisive importance of an accurate understanding of AIDS and its specifics
in our own country.
I trust that our discussion about AZT and rape will convince you that
despite the fervent reiteration of various assertions, supported by many
scientists, medical people and NGO's, about the existence of some
unchallengeable and immutable truths about HIV-AIDS, as public
representatives we have no right to be proponents and blind defenders of
Whatever the intensity of the campaign to oblige us to think and act
differently on the HIVAIDS issue, the instinctive human desire in the face
of such a barrage, to obtain social approval by succumbing to massive and
orchestrated pressure, will not lead us to become proponents and blind
defenders of dogma.
The cost of AIDS in human lives is too high to allow that we become blind
defenders of the faith.
Unless you have evidence to demonstrate that what I have said about AZT and
rape is wrong, I would expect that you make a public statement distancing
yourself from the false claims so regularly propagated in this country,
concerning the efficacy of AZT as post-exposure prophylaxis in cases of
rape, propaganda in which you joined.
Not only is this the only honourable thing to do, but, as a high-level
public representative, I believe you have an obligation to correct the
misleading impression on the matter we are discussing that you and your
Party have conveyed on more that one occasion, in parliament and elsewhere.
Needless to say, to uphold the rule of law and to fulfil the government's
obligations with regard to the health of our people, we will follow up on
the matters you have brought to our attention, concerning the disturbing
behaviour of Glaxo Wellcome.
Given that the matters about which you have written to me were discussed
openly in the National Assembly, during which debate I suggested that you
convey my views to Glaxo Wellcome, I believe that it would be correct that
we make the correspondence between us available both to the National
Assembly and the general public.
Once again, I would like to suggest that you inform yourself as extensively
as possible about the AIDS epidemic. Again, for this purpose, I would like
to recommend that you access the Internet.
On the various websites, you will find an enormous volume of literature,
including CDC, WHO and UNAIDS documents, editions of various highly
respected science journals as well as "dissident" articles.
As you know, many frightening statements are made with great regularity
about the incidence of HIV-AIDS in our country and continent and the threat
this poses to our very survival as a country, a continent and as Africans.
I believe that it is imperative that all our public representatives should
base whatever they say and do on the HIV-AIDS matter, on the truth and not
necessarily on the comfort of fitting themselves into the framework of
whatever might be considered to be 'established majority scientific
'What concerns me about your letter is the tendency to turn questions of
fact into questions of motive'
(letter from Tony Leon to Mbeki published in Sunday Times July 9, 2000)
DEAR PRESIDENT MBEKI
July 7 2000
Thank you for your letter of the 1st of July. I appreciate the great time
and effort that you have obviously put into your response, although I find
much of the tone and content unhelpful in promoting rational debate on this
If I understand your letter correctly, you argue against the provision of
AZT to rape victims on two grounds:
Firstly, you argue that there is "no scientific evidence" to support the
argument that the provision of AZT could prevent the transmission of HIV to
Secondly, you claim that the risks of potential transmission are so low
that they do not warrant the use of AZT, which as you correctly point out
can have severe side effects.
You base your argument on numerous quotes from the publication of the
Centers for Disease Control in America, Morbidity and Mortality Weekly
Report, September 25, 1998/ Vol 47/ No. RR-17. I do not believe that, when
read as a whole, the document supports your arguments. I will deal with
each argument in turn.
The evidence from the CDC report which you provide to support your first
argument is a quote from the CDC which says "no data exist regarding the
efficacy of (antiretroviral drugs) for persons with nonoccupational HIV
exposure ... "; the fact that the US Public Health Service "cannot
definitely recommend for or against antiretroviral agents in these
situations because of the lack of efficacy data"; and that further research
is needed "to establish if and under what circumstances" such therapy would
The CDC report is extremely even-handed. It scrupulously weighs up the
evidence both for and against the provision of anti-retroviral drugs
following non-occupational HIV exposure. You have unfortunately only quoted
the arguments against. A point that must be made at the beginning is that
the CDC does allow the provision of anti-retroviral drugs by physicians to
rape victims. The document is an attempt to highlight the "potential
benefits and risks" and so provide a guide to physicians on whether or not
to pursue such a course of treatment. The CDC has published formal
guidelines for physicians should they choose to use AZT.
The reason for the lack of "efficacy data" is that there have been no
prospective trials conducted to measure the effectiveness of AZT for
non-occupational exposure. It is simply impossible to conduct such trials
because one would need to establish beyond doubt the HIV status of both the
rape suspect and the rape survivor before and after the rape.
While this in itself is almost impossible, the fact that it is illegal to
test for HIV against a person's will makes such research harder still. The
best that can be done is to conduct a retrospective case control study. One
is currently being conducted by the CDC.
It is for this reason that the CDC is unable to recommend either for or
against antiretroviral drugs for rape victims. This does not mean that
there is "no scientific basis whatsoever" for my statement that the
provision of AZT would reduce HIV transmission to rape survivors.
In fact, the CDC report evaluates data from various trials, which could
have a bearing on the potential efficacy of anti-retroviral PEPs. It makes
reference to various trials conducted on animals, but I will deal only with
its references to studies on humans. Two are of significance: Firstly, the
CDC quotes the study (which I referred to in my letter) from a 1995 survey
where investigators used "case control surveillance data from health care
workers" in Europe and America to document that AZT use "was associated
with an 81% decrease in the risk for HIV infection after percutaneous
exposure to HIV-infected blood." According to the CDC this study
"demonstrated antiretroviral effectiveness" following needle stick
The CDC also refers to the study where there was a 67% reduction in
transmission of HIV from mother to child when AZT was administered during
pregnancy, labour, and for six weeks after birth. The CDC states that there
was evidence that a "prophylactic effect" on the foetus before, during or
after birth "could account for some reduction in perinatal transmission".
Although the CDC report acknowledges that these studies "might not be
directly relevant to non-occupational exposure" they do "suggest that
antiretroviral agents are potentially valuable for treating HIV exposures
in these settings".
These trials are obviously not conclusive for they have to be extrapolated
to nonoccupational settings. However, they do suggest that antiretroviral
agents can act as a postexposure prophylaxis and reduce a person's risk of
acquiring HIV infection after exposure. The CDC report states "it can take
several days for infection to become established in the lymphoid and other
tissues. During this time, interventions to interrupt viral replication
could represent an opportunity to prevent an exposure from becoming an
Thus, if providing AZT to rape victims can prevent an exposure to HIV from
becoming an established infection (and there is substantial evidence to
suggest it can) the benefit is massive, if not priceless. The victim is
literally saved from a death sentence.
Which brings me to your second argument, which is that the chances of HIV
transmission from rape are so small, and the side-effects of AZT are so
large, that providing such treatment to rape victims is not really worth
You quote the CDC as saying that in selecting a drug regimen for
post-exposure prophylaxis the physician should "balance the risk for
infection against the potential toxicity of the agent(s) used. Because PEP
is potentially toxic, its use is not justified for exposures that pose a
negligible risk of transmission." You then state, "in this context, please
bear in mind the 0.1% - 0.2% risk of transmission indicated by the CDC with
regard to receptive vaginal exposure." You seem to be implying that
"receptive vaginal exposure" constitutes a "negligible risk of
transmission" and that consequently it is not worth providing rape
survivors with AZT with potentially toxic side effects.
This is disingenuous for two reasons: Firstly, the risk of HIV transmission
following rape (particularly in South Africa) is not "negligible" at all.
Rape does not constitute "receptive" sex and as such is likely to lead to
trauma and consequently a far greater risk of HIV transmission. The risk is
compounded in South Africa by the high levels of HIV in the population as
well as the prevalence of Sexually Transmitted Diseases, which greatly
increase the possibility of HIV transmission. Secondly, the CDC is not
referring to rape or consensual sex when it states that PEPs are not
"justified for exposures that pose a negligible risk of transmission".
Rather, it is referring to contact between infected body fluid and intact
skin. This would be clear had you quoted the whole sentence from the CDC
report, which reads, "Because PEP is potentially toxic, its use is not
justified for exposures that pose a negligible risk of transmission (e.g.
potentially infected body fluid on intact skin.) " (My emphasis.)
This is just one example of where you have pruned quotes to make them fit
your argument. Elsewhere you quote the CDC report as saying "Postexposure
antiretroviral therapy should never by administered routinely or solely at
the request of a patient. It is a complicated medical therapy, not a form
of primary HIV prevention. It is not a 'morning-after pill ... ' (your
emphasis)" Yet you omit to mention that the report continues (from
precisely the point where you left off) "but, if proven effective, can
constitute a last effort to prevent HIV infection in patients for whom
primary prevention has failed to protect them from possible exposure." (My
Reading through your letter I had the strong feeling that you have reached
your conclusions already. You then selectively choose quotes to support
your argument, and ignore others that don't. If the quotes do not quite fit
your purposes, you lop off the awkward parts.
What is most disturbing about your letter is the way you impute sinister
motivations on the bona fide actions of others. You seem to believe that
the request by my Party, Charlene Smith and others for the government to
provide AZT to rape victims, and the offer by Glaxo Wellcome to provide it
at greatly reduced prices, is all part of a giant conspiracy. You imply
that this conspiracy is the result of some unholy alliance between a civil
society motivated by racism and an international pharmaceutical industry
driven by greed.
It seems that underlying your letter is a belief that civil society is once
again being driven by an overriding desire to reaffirm "its belief that its
racist stereotype of Africans [is] correct" (ANC statement to HRC on racism
Out of a "determination" to project a "negative image" of South Africa
unnamed forces peddle what you describe as "very false figures" on the
incidence of rape in this country. You claim that the AIDS debate in South
Africa is being driven (and distorted) by people "who are convinced that
most black (African) men carry the HIV virus". Among their number you name
Charlene Smith who you claim was "blinded by racist rage" when she wrote
that rape was endemic in South African society.
You proceed to complain that by publishing "hysterical estimates" (your
emphasis) and by making "wild and insulting claims" about the African
origins of HIV, the international community is (whether out of accident or
design) acting to "reinforce these dangerous and firmly-entrenched
You then claim that the international pharmaceutical companies are driven
by even more sinister motivations. You suggest that the sole and overriding
desire of the pharmaceutical companies is to maximise their profits by
exploiting every available opportunity to flog their drugs to South Africa,
regardless of their efficacy or toxicity . You claim that having had their
interest pricked by the high incidence of rape in this country, Glaxo
Wellcome set out to cynically exploit the "justified health concerns of our
people" in order to (once again) "increase the sales of AZT". To top off
this giant-racialcapitalist-conspiracy, you accuse Charlene Smith and I of
being "marketing agents" of the pharmaceutical companies.
(For the record: Neither I nor the Democratic Party have received any
financial assistance of any nature from Glaxo Wellcome.)
What concerns me about your letter is the tendency to turn questions of
fact into questions of motive. This method of propaganda may be useful
means of silencing (or isolating) your critics without responding to their
arguments, but is not particularly conducive to rational debate.
It is somewhat hypocritical to accuse overseas opinion of intolerance and
then to try to shut down dissent domestically by labelling people "racists"
or "pawns of the pharmaceutical industry".
Your statement that the government will take steps against the "disturbing
behaviour of Glaxo Wellcome" is frankly sinister.
Your determination to resist the imposition of what you call the "dogma" of
scientific opinion seems to be matched only by a desire to impose your own.
Yet what is most worrying for South Africa is that it seems your party has
actually started to believe its own propaganda. Instead of identifying,
confronting, and then dealing with the immense problems facing our country,
the ANC is perpetually chasing shadows.
You seem more concerned with the possibility that high rape and AIDS
figures might confirm the prejudices of some, than with the massive human
tragedy in our country which those figures are merely an indication of. In
consequence, your obsession with the motives of others has begun to harm
the interests of the very people you claim to represent.
As the earlier part of my letter has indicated, there are strong scientific
grounds for providing post-exposure prophylaxis to victims of rape. I
cannot see how the offer by Glaxo Wellcome to provide AZT to rape survivors
at reduced prices can be described as "grossly unethical".
Similarly, I cannot see how you can equate the provision of AZT to rape
survivors with the state sponsored campaign of terror and intimidation in
Zimbabwe. It is a nonsensical comparison.
I, like you, am a layman on these matters. You are entitled to your
personal opinion on whether AZT is effective in reducing HIV transmission,
and indeed, whether HIV even causes AIDS. However, it is wrong for you to
use your current position (which was gained on the basis of political
rather than medical talent) to block the provision by your government of
It is perfectly consistent with the CDC report (which you quote!) for our
government to make available AZT for prescription to rape victims.
Obviously, our doctors must weigh up the risks and benefits of prescribing
such treatment. They must act both with the informed consent of the
patient, and according to proper guidelines such as the CDC provides.
The point is that the physician and the patient must be left to make that
decision. By denying rape victims AZT you are denying them the choice.
With all due respect, you lack both the moral right and the medical
expertise to make such a life and death decision.
I agree that this correspondence should be made available to the National
Assembly and the general public.