South Africa's Health Minister Accused of Drinking in Hospital

Last week's media storm in South Africa over the firing of deputy health minister Nozizwe Madlala-Routledge shows no signs of letting up. President Thabo Mbeki took the unusual step of releasing his letter of dismissal to the media over the weekend. In it, he declared that Madlala-Routledge was let go because of her "inability to work as part of a collective, as the constitution enjoins us to."

Mbeki was responding to continuing outrage from the government's coalition partners and others that Madlala-Routledge, widely regarded as honest and competent, had been fired instead of her former boss, the often erratic Health Minister Manto Tshabalala-Msimang.

But the President's move was quickly overshadowed by an explosive report in The Sunday Times of South Africa, accusing Tshabalala-Msimang of a "booze binge" while in the hospital two years ago for shoulder surgery.

Tshabalala-Msimang has in the past denied having an alcohol problem and press reports suggested she is considering suing The Sunday Times over the allegations. The newspaper's editors say they stand behind their story, which was based on a five-month investigation as well as leaked hospital records.

Read President Mbeki's letter to Madlala-Routledge on the official South African government site.

For related blog entries on Madlala-Routledge, click here.

Madlala-Routledge on True Leadership

Update: See video of Madlala-Routledge speaking out on why she was fired.

South Africa's sacked deputy health minister shared some incredibly thoughtful and eloquent reflections on the fight against AIDS in South Africa in this post-firing interview with The Independent. I highly recommend the article, which was written by Katherine Butler, who I got to know a little while traveling in South Africa last month.

"I don't regret saying that our political leaders should show the way and undergo HIV testing, in public," Nozizwe Madlala-Routledge told The Independent. "We need at least 25 million people tested. When you are in charge of the country, you have to offer leadership." Read the rest of Madlala-Routledge's comments here.

I've searched the Internet for an audio recording of today's press conference at which Nozizwe Madlala-Routledge spoke about her firing. Although the press conference was carried live on Cape Talk Radio, I still haven't found anything other than summaries and selected quotes. (Update: here's the video of Madlala-Routledge's comments.)

But the ANC's two coalition partners in government are clearly unhappy with President Mbeki, who axed Madlala-Routledge earlier this week. The Congress of South African Trade Unions said the firing would "deepen the culture of sycophancy among government ministers and officials," while the South African Communist Party, of which Madlala-Routledge is a member, said if they had been consulted, they "would have advised otherwise."

For related entries on Madlala-Routledge, click here.

Madlala-Routledge Tells Why She Was Sacked

South Africa's popular and now former deputy health minister told a press conference in Cape Town today that she was sacked because she visited a maternity hospital and publicly declared that deplorable conditions there constituted a "national emergency."

Nozizwe Madlala-Routledge also explained that she thought she had Presidential permission to attend a meeting about AIDS vaccines in Madrid when she left, only to discover when she arrived in Spain that it had been revoked. She then returned to South Africa without attending a single session.

Both issues came up when she was called to President Thabo Mbeki's office earlier this week and asked to resign. Madlala-Routledge refused, so Mbeki fired her.

Madlala-Routledge had won plaudits both in South Africa and internationally for her open and honest discussions about AIDS in that country and the need to bring treatment to a greater proportion of the population. Her boss, Health Minister Manto Tshabalala-Msimang, by contrast, had famously promoted ineffective remedies like beetroot and garlic for the treatment of AIDS.

It's not the first time that a politician has gotten rid of a more popular deputy. But that doesn't explain why a top doctor at the maternity hospital in question, who wrote a letter to the President supporting Madlala-Routledge's call for reform at the hospital, is also reportedly facing disciplinary hearings for her views. Still no word yet on whether Dr. Nomonde Xundu, chief director of HIV/Aids, Tuberculosis and Sexually Transmitted Infections at the Ministry of Health, has been able to renegotiate her "resignation" either.

For related entries on Madlala-Routledge, click here.

Even the Timid Get Axed in South African Health Shake-Up

Manto Tshabalala-Msimang is definitely consolidating her hold on the South African Ministry of Health. Not only has her outspoken deputy minister been fired, but her most senior AIDS expert, Dr. Nomonde Xundu, has reportedly tendered her resignation.

Dr. Xundu never contradicted her boss in public and faithfully used the government-approved terminology of "HIV and AIDS," which sees HIV infection and AIDS as two separate conditions rather than a continuum of illness. But Xundu clearly accepted that HIV causes AIDS and that anti-retroviral treatments are necessary to save lives. A report on news24.com says Xundu is trying to negotiate an extension of her contract.

For related entries on Madlala-Routledge, click here.

Deputy Health Minister Sacked in South Africa

Disturbing news from South Africa. President Thabo Mbeki has sacked Nozizwe Madlala-Routledge, the deputy minister of health. It seems Madlala-Routledge was just too good at her job, talking about the need for better AIDS prevention and treatment programs and encouraging ANC leaders to set an example by getting HIV tests in public.

The most immediate casualty, apart from the deputy minister herself, may be South Africa’s newly developed National Strategic Plan for AIDS (2007-2011), a highly regarded and forward-thinking blueprint for tackling the crushing HIV epidemic in that country. Nozizwe Madlala-Routledge played a major role in getting the plan pulled together, which was developed with input from many health experts inside and outside of government as well as civil society leaders. Madlala-Routledge was able to take that leading role because her erstwhile boss, Minister of Health Manto Tshabalala-Msimang, was out of the picture for a while with a serious illness that eventually required a liver transplant earlier this year.

The precipitous move is another sign of increasing strain within the African National Congress, as it prepares itself for party elections in December. Today, executives of the ANC's Women's League questioned the firing of Madlala-Routledge, coming as it did on the eve of Women's Day in South Africa. No word yet on the reaction of the South African Communist Party, which is a coalition partner of the ANC and of which Madlala-Routledge is a leader. (She is also a Quaker.)

The last straw for Mbeki and Tshabalala-Msimang, who has apparently made a full recovery, was when the deputy minister of health made an unannounced visit to a maternity hospital in the Eastern Cape. There, Madlala-Routledge found that the appalling conditions described by a local newspaper report were in fact true and that mothers and babies were dying needlessly.

Madlala-Routledge’s call for reform at the hospital was treated as insubordination by the Minister of Health. The ANC newsletter attacked the press reports as "dramatic but false" even as the Minister of Health began launching many of the needed changes.

The cause given for the deputy minister's removal was a trip she had taken in June to an AIDS seminar in Madrid, allegedly without Presidential permission. A one-sided press report suggested that she left in defiance of Mbeki's decision but rumors were rife in South Africa that she had been given permission to go, which was then revoked while she was in the air. As soon as she learned about the change, she took the next available flight home, without even attending the conference.

For related entries on Madlala-Routledge, click here.

Grandmothers Against Poverty

It was obvious everywhere we went in South Africa that grandmothers are the glue that holds most of society together, particularly in rural and impoverished areas. Before coming to South Africa, I had assumed that that was primarily because of the traditional role that grandmothers played in the care and rearing of their grandchildren while parents were busy at jobs far away.

While travelling to six of the country's nine provinces, however, it became clear that grandmothers also are a major economic force in large part because they receive a little over 800 Rand per month (about US $115) in old-age pension benefits. I met many older women--some of them in their 70s and 80s--who were caring for their grandchildren and even great-grandchildren, clothing them, feeding them, paying their school fees out of this modest pension benefit.


(Leonora Msikinya, 85, (pictured above) who I met in Ethembeni in the Eastern Cape has dedicated the remaining years of her life to fighting HIV by talking clearly in her community and church about sex, pregnancy and HIV. She has even been featured on anti-AIDS billboards throughout the country.)

What became very obvious to me, while visiting with these women and their families, is that they and their old-age pensions are also an important bulwark against poverty.

Indeed, a June 2007 study by Charles Meth, who is associated with both the University of KwaZulu-Natal and the University of Cape Town, concludes that of the three major social grants available in South Africa (old age, children support, disability), "old age pensions have the greatest impact on poverty. In 2004, the approximately two million pensions raised about 1.5 million people in 600 000 households over the poverty line."

Which brings me to my next questions: What hope is there for you if you're poor and don't have a grandmother in South Africa? Would a modest basic income grant for those living on less than a dollar a day--something that Archbishop Desmond Tutu brought up again at a church meeting in Johannesburg in July, but which doesn't seem to be getting much traction among the powers that be in South Africa--make a difference?

Using Search-Engine Journalism to Get Your Message Across

As I said back in June in a talk at the Global Health Council, search-engine journalism is changing the way interested folks get their topic in front of interested journalists. If you blog about your issues with insight and creativity, journalists will eventually find you, rather than waiting for you to cultivate them.

It's not that journalists necessarily read that many blogs or check that many web pages on a daily basis--there are just too many sites for that to be a practical approach. Our secret weapon is often a "Google alert" or a Yahoo keyword search that brings us some fairly well targeted urls that contain postings of interest. Indeed, I often create alerts based on people's names in addition to certain topics because I just like the way some people think--no matter what topic they write about.

Case in point: Ethan Zuckerman's ideas on incremental infrastructure, which he posted on his blog, caught the interest of an editor at the Boston Globe, who invited Zuckerman, a fellow at the Berkman Center for Internet and Society at Harvard, to write about the topic for the Ideas section of the newspaper. Basically, Zuckerman sings the virtues of small-scale, privately financed infrastructure that can be incrementally scaled up as opposed to many of the large-scale, government-and aid-financed programs that have become such white elephants in many parts of Africa.

Zuckerman's points on infrastructure are interesting and worth consideration. But as far as I can tell from his blog, he didn't call up a journalist to "pitch a story." An editor at the Boston Globe found him and his ideas in that incredibly democratic marketplace of ideas, the Internet.

For the record, I learned about Zuckerman's post through an RSS feed to my personalized iGoogle homepage. Mine is a modest iGoogle page that helps me follow my top about 50 news and blog sources for information. I use Google Reader, which also uses RSS feeds, to share some of those selections on a sort of mini-global health blog that also lives on the right hand side of the blog.

RSS--for really simple syndication--makes it more likely your creativity and insight will get picked up by people who are actually interested in your issues--and not just random searchers on the Internet.

Balancing Human Rights And HIV Testing

There's a growing movement to declare access to basic healthcare as a fundamental human right. And there's a lot to commend in this push. But great ideas and good intentions don't always guarantee desired results on the ground, as I learned in my recent trip to South Africa.

A case in point: the clash between those who champion voluntary counselling and testing (VCT) for HIV with the those who argue for the so-called opt-out model.

VCT grew out of the early days of the AIDS epidemic when people's legal rights were getting trampled right and left in housing, on the job, in schools and in clinics and hospitals. Back when there was no treatment for HIV, when AIDS was a new and terrifying scourge, it made a lot of sense to make sure that everyone understood before getting tested for HIV, what the test involved, what it meant to be HIV-positive, who could use that information and what your legal rights were.

But now that we have lived with AIDS for 25 years, now that there are treatments (albeit no cure or vaccine), now that anti-discrimination laws are stronger, voluntary counselling and testing may actually be doing more harm than good.

Or at least that's the feeling of a couple of doctors I spoke with in South Africa.

By making HIV testing such a big deal in that country, VCT has actually increased stigmatization, in their view, particularly in rural areas where all your neighbors go to the same clinic and know which chairs and which doors are designated for HIV testing and counselling. And in fact, studies show that under VCT programs fewer South Africans who actually are HIV positive opt for testing.

As an alternative, a few South African healthcare workers are trying the opt-out model for HIV testing. Patients still get counselled about HIV but it's part of a broader panel of tests--for example, prenatal tests that look for Rh factor, diabetes and high blood pressure. And instead of actively making a decision to be tested (call it opt-in), the active decision after the counselling is not to be tested. In other words, if you do nothing, you'll be tested. But your rights are preserved by an "opt-out" option.

The opt-out approach has worked in Botswana and is being championed by the Centers for Disease Control for use in the U.S. It's gotten some pushback from those who were trained in and have championed voluntary counselling and testing. There is a legitimate human rights concern here--AIDS discrimination is still rampant, particularly in areas of extreme poverty. But being inflexible about how human rights are expressed or sticking with the first human rights response for too long can also lead to harmful and even fatal delays in care.

Jobs in Women's Health, PEPFAR, Climate Change

A few job listings that have come to my attention:

Senior communications advisor, President's Emergency Plan for AIDS Relief.

Director of Development, International Women's Health Coalition

Senior Program Officer, IWHC

Program coordinator for building resilience to climate change in Asia (based in Bangkok), Rockefeller Foundation

News Flash: Talking About Sex is Fun

I'm still trying to figure out what I think about loveLife, the ubiquitous sex education and teen-empowerment organization whose goal is to reduce HIV transmission among young people in South Africa. LoveLife's Y-Centers were frequent destinations for myself and my fellow journalists in July--all organized by the Kaiser Family Foundation for our traveling AIDS Seminar.

Clearly, Kaiser made a point of taking us to all these loveLife groups because the foundation is a major supporter--to the tune of more than $150 million about $80 million over the years. Some of us joked that we were going to know loveLife's slogans better than the kids did by the end of our trip.

More seriously, questions have been raised in the international press as to whether loveLife's approach has any effect on HIV rates. We also heard from parents who said their initial impression of loveLife was that it was a place where their kids went to find sex rather than to refrain from sex.

And it's absolutely true that loveLife's pamphlets and workbooks are pretty frank. One exchange between cartoon characters Miriam and Maxwell has Max telling Miriam that he has to have sex with her or his "balls will turn blue." Miriam replies, "Good. Then I can hang them on the tree this year for Christmas ornaments." That sort of no-holds-barred exchange probably goes a long way towards explaining why the Global Fund no longer supports loveLife.

Of course, anyone who has been around teenagers or remembers being a teenager knows that this is the way teens talk--the myth about blue balls, for one, having been around for generations.

Denying sexuality hardly seems to be the answer. Later in our trip, we heard anecdotal reports that anal sex rates are on the increase in South Africa because of the number of abstinence programs that promote virginity before marriage as well as the growing popularity of hymen examinations for young brides. Talk about unintended consequences. Unprotected anal sex is a much more efficient transmitter of HIV than unprotected vaginal sex. (See also this new report by Kristen Underhill and colleagues in the British Medical Journal, which concludes that abstinence-only programs have no effect on pregnancy or HIV rates in rich countries.)

Another challenge when trying to figure out how effective loveLife's programs are is the fact that official UNAIDS statistics are broken out by fairly large age groups. Teens are covered in the 15-to-24 year-old bracket. By not breaking out the lower end of the age group--15 to 17 or 18--you're not getting a good picture of whether prevention messages targeted at teens are working and then failing as they grow older.

I keep coming back to the energy and enthusiasm of the teenagers we met at the loveLife programs that we visited and the commitment of their peer educators--dubbed "groundbreakers" in the loveLife lexicon. There was certainly a sense of possibilities, of optimism for the future, of a life to live for and a reason to avoid becoming infected with HIV.

That positive spirit was quite a contrast with that of so many of the adults we met on other portions of our trip. I'm not a trained psychologist or anything but it certainly seemed to me there was a lot of depression amongst the adults we met. The end of apartheid did not magically erase the legacy of racism, extreme poverty, missed opportunities and mistrust. There is still so much left to do.