TAC Electronic Newsletter
21 February 2005Contents
The second episode of Law and Freedom is on SABC 1 at 10pm tonight, Monday 21 February 2005. It examines court cases for housing, pensions and mother-to-child transmission of HIV.
TAC Says: Treat 200,000 People by 2006
The TAC notes the publication of Statistics South Africa's report Mortality and Causes of Death in South Africa, 1997 - 2003. This report, once more, confirms beyond reasonable doubt that South Africa is in the midst of an HIV epidemicthat is maturing into an AIDS epidemic. It also provides useful information on the nature of the epidemic.
Between 1997 and 2002, the total number of deaths increased by 57%. Deaths of people aged 15 years and above increased by 62%. While some of this increase is due to population growth (10%) and improved death registration, most of the increase can be explained only by an HIV epidemic. A number of studies, mostly conducted by Medical Research Council scientists, have demonstrated the increase in mortality in South Africa due to HIV, but the Statistics South Africa report is noteworthy for having been approved by Cabinet. The tragic implication of the report - that hundreds of thousands of South Africans have died of AIDS in the last few years without access to life-saving treatment - must be used as an impetus to speed up the delivery of treatment and prevention programmes. The report has been honestly conducted despite an overly-cautious tone with regard to causes of death due to HIV.
The report is based on an analysis of 2.9 million valid death certificates collected from 1997 to 2003. The causes of death as written on these certificates were processed using a computer programme. Statistics South Africa makes it clear that approximately 90% of deaths are now certified but that the quality of ceritification remains a serious problem. For instance the report says that factors limiting accuracy of the data based on death notification forms (death certificates) include:
"The data from death notification forms is subject to content errors and omissions. Even though provision is made on the death notification form to record marital status, education, occupation, and the industrial sector in which the person worked, these variable have not been analysed in this release, due to the lack of completeness. Location could be captured at the level of province only."
"Another limitation of the data used in this study is the probable under-registration of deaths, particularly in rural areas and of children. This leads to lower estimates of the total number of deaths that have occurred in the country and may lead to an underestimation of some causes of death...."
"The causes of death may also be misreported on the form. This happens when an incorrect cause of death is given or when the cause of death is not detailed. The quality of the reported information is determined largely by the ...certifying official -- physician, professional nurse or, in some rural areas, traditional headman. For example, the certifying officials sometimes write 'natural causes' instead of stating the actual cause.
"Assessing the quality of the information reported is beyond the scope of this release, and no adjustments were made for misclassification of underlying causes of death due to miscertification." (p.2 Mortality and Causes of Death in South Africa, 1997 - 2003)
HIV is frequently not stated as the underlyingcause of death. Instead, an opportunistic infection associated with HIV is usually indicated as the cause. Therefore, the number of AIDS deaths cannot be determined by simply reading the report. This is why the report states "This release covers mortality and causes of death broadly, and hence does not focus specifically on HIV and AIDS. It does, however, provide indirect evidence that HIV may be contributing to the increase in the level of mortality for prime-aged adults, given the increasing number of deaths due to associated diseases." (p. 2 Mortality and Causes of Death in South Africa, 1997 - 2003)
Causes of death due to tuberculosis and influenza and pneumonia, which are frequently opportunistic infections associated with HIV, more than doubled between 1997 and 2001. By 2001, these were the leading causes of death. Furthermore, the report states "The proportion of deaths in the age group 20-49 is increasing. While an increasing number of deaths are associated with lifestyle diseases (such as heart disease and diabetes) as the underlying cause, the dominant contributors to the growth in mortality are deaths associated with tuberculosis, and influenza and pneumonia." It therefore cannot be argued that the increase in mortality is due primarily to better death registration data and population growth, because neither of these would affect the proportion of deaths recorded in the 20-49category. These facts, combined with all the other overwhelming evidence that South Africa is experiencing an HIV epidemic (antenatal surveys, HSRC study etc.), demonstrate beyond reasonable doubt that HIV is causing a massive increase in mortality in South Africa. More than half the number of natural deaths in men and women in South Africa occur before they reach the age of 55.
Patterns of death among children also indicate the impact of the AIDS epidemic, with substantial increases in the proportion of deaths due to tuberculosis and influenza and pneumonia. Currently very few children are being treated in the public sector. The findings of this report, as well as others, indicate the necessity of increasing access to antiretrovirals for children with AIDS and improving the mother-to-child transmission prevention programme.
Key Findings of the Statistics South Africa Report
Recorded Deaths in South Africa:
1997: 318, 287
1998: 367 689
1999: 381 902
2000: 413 969
2001: 451 936
2002: 499 268
The above table shows a 57% rise in recorded mortality from 1997 to 2002. The report estimates that 90% of adult deaths were recorded in 2002 and that the population grew 10% during this period. A report published by the MRC in the South African Medical Journal last year analysed death registration data over a slightly longer period, from 1996 to 2003, and found a 68% increase in adult mortality. These consistent findings cannot be explained by population growth or improved registration, but only by an HIV /AIDS epidemic leading to unncessary and premature death.
Adult deaths increased by 62% from 1997 to 2002, from 272 221 to 441 029.
Recorded deaths in the age-group 20 to 45 more than doubled between 1997 to 2002, from 106 033 to 221 260. That mortality in this age-group increased so much faster than mortality overall falsifies the argument offered by some AIDS denialists that the increase in mortality could be due solely to population growth and improved death registration, because the latter two causes of increased mortality would affect all adult age-groups in equal proportions. HIV mainly affects people in the 20 to 45 age-group and therefore the pattern of mortality is consistent with HIV.The number of recorded deaths of people aged 20 to 55 in 2002 was 250 873, more than 50% of all deaths.
In a population following normal mortality trends, a graph of the number of deaths per age-group would gradually increase for adults until the older age-groups. But in South Africa in 2002, this graph increases swiftly among young adults peaking in the 30-34 age-group. This is an abnormal situation that can only be explained by the HIV epidemic. This situation becomes steadily more pronounced in the years 1997 to 2002. The fact that this feature is already discernible in 1997 demonstrates that there were already large numbers of AIDS deaths in that year. We recommend that interested readers examine the graphs on pages 11 to 16 of the Statistics South Africa report.
Recorded tuberculosis deaths increased by 131% from 22 021 to 50 872 between 1997 and 2001. Influenza and pneumonia increased by 197% from 11 503 to 31 495 during this time. These two causes are frequently associated with AIDS-related opportunistic infections. While some people die of these diseases in the absence of HIV, the enormous increase in mortality in these categories can only be explained by HIV. The biggest recorded cause of death in 1997 was a category titled other forms of heart disease. By 2001 this category had been overtaken by both tuberculosis and influenza and pneumonia.
Adding the largest causes of death most frequently associated with AIDS (tuberculosis, influenza and pneumonia, intestinal infections, HIV, immune disorders), the number of such deaths rose by 244% from 45 978 in 1997 to 170 531 in 2002. Obviously not all of these deaths are due to HIV. Likewise, these are not the only HIV-related deaths. However, after correcting for population growth and improved registration, most of the 244% increase can be assigned to HIV.
Recorded deaths among males increased by 45% between 1997 and 2002, from 177 435 to 256 930. Deaths among females increased by 58% from 139 816 to 240 943. The report states "The figures suggest that there has been a significant increase in the number of deaths amongst men aged 30-44 and amongst women in reproductive ages." (pg. 13) This indicates the substantial effects of AIDS among sexually active young men and women.
Recorded deaths among children aged 0 to 4 increased by 40% from 1997 to 2002, from 34 779 to 48 572. Since the above point demonstrates beyond doubt that the increase in mortality is more than a result of population growth and improved death registration, it can be seen that the substantial increase in recorded child mortality is also consistent with a real increase in death that can only be explained by the HIV epidemic.Deaths of children are also under-reported. The largest cause of death in this age-group was consistently intestinal infectious diseases between 1997 and 2001. It is not possible from a cursory examination of the statistics to determine the effect of HIV on this cause, whose proportion of deaths has remained approximately the same. However, deaths due to influenza and pneumonia in this age-group increased from 8.1% to 13% between 1997 and 2001, and this is consistent with an HIV epidemic.
One of the largest categories of natural deaths are undetermined deaths where the cause remains unclear: in 1997, 45 182 natural deaths had no stated cause and in 2001 natural deaths without a stated cause were 35 328 people.
Deaths due to all types of heart-disease rose by 32% from 65 423 in 1997 to 86 589 in 2002. While much smaller than the HIV epidemic and generally affecting older people thereby having a smaller effect on lost life-years, heart-disease is clearly a significant cause of death in South Africa and the increase is cause for concern. Clearly there is a need for much greater investment in public health care in South Africa to manage not only the HIV epidemic, but also heart-disease.
Recorded non-natural deaths declined slightly between 1997 and 2001 from 54 002 to 50 124. This is consistent with a reduction of murders reported in crime statistics. In 2002, there were more TB deaths than all non-natural deaths put together. But, the recording of non-natural deaths require improvement. 26 601 male non-natural deaths and 7 903 female non-natural deaths in 2001 were described as "events of undetermined intent". This means they could be murder, accidents, suicide or negligent deaths arising from medical care. 2,924 children age 0 to 14 died non-natural deaths described as "events of undetermined intent." These unexplained records may speak of a significant epidemic of violent death. In the same year 3 157 males and 569 women deaths from assault were recorded. This included the recorded deaths of 74 children from assault. Recorded non-natural deaths caused by transport accidents numbered 4 934. These transport accidents included 3 234 male and 1 184 female deaths. Children who died in transport accidents numbered 604. Overall, male non-natural deaths outnumber female non-natural deaths by a ratio of three to one.
For a further discussion on mortality due to HIV, see the TAC newsletter of 31 January 2005:
Time to treat and prevent - Time for clear public messages - Time to end pseudo-science
The implication of the report is clear. We must step up treatment and prevention efforts in South Africa to curtail the effects of the HIV epidemic. The premature adult death rate also speaks to an increase in the number of vulnerable children and orphans.
According to the Department of Health, as of the end of December, 27 000 people were on treatment in the public sector. This is not good enough, especially when one considers that Western Cape and Gauteng provinces accounted for more than 50% of those treated. In the Operational Plan released on 19 November 2003, government committed to treating 53,000 by March 2004. We are far behind this target. The TAC calls for government to treat at least 200,000 people with antiretrovirals by the beginning of 2006. Of these, at least 10% should be children. Furthermore prevention efforts must be stepped up. Public messaging by institutions such as LoveLife and Khomanani must be more explicit on the need for safer sex and condom use. Condoms must be introduced into all high schools, as well as sex-education. President Mbeki, Deputy-President Zuma and the Minister of Health must regularly, on television and radio, call for people to get counselled and, if necessary, treated.
It is time to end the pseudo-science emanating from some senior government officials about the HIV epidemic. In a question and answer session in Parliament on Friday attended by TAC members, the Minister of Health again expressed doubts about antiretrovirals and again suggested that traditional medicines and her nutritional recommendations offered a viable alternative to antiretrovirals. TAC members noted that she stated that she does not know howmany people have HIV, how many AIDS deaths there are or how many people are receiving antiretroviral treatment. The Statistics South Africa report was not produced with the intention of determining the number of AIDS deaths; this has already been done in several studies by the Medical Research Council (MRC). There are very plausible estimates of the number of people with HIV and the number of AIDS deaths in South Africa and they have become more plausible with time. Some of the best statistics come from the Minister of Health's department. These estimates should be the basis of government policy. The Department of Health estimates that 5.6 million people were HIV-positive in 2003. The department also released on Friday the number of people on antiretroviral treatment in the public sector. The minister's incompetence, obstructionism and denialism are hindering the response to the HIV /AIDS epidemic and the broader health care crisis.
[END OF ANALYSIS OF STATS SA REPORT]
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Thousands march to parliament demanding Treat 200,000 by 2006
At least 5,000 people marched through the streets of Cape Town to Parliament on 16 February, demanding that government treat at least 200,000 people with antiretrovirals in the public sector by 2006. People living with HIV/AIDS, the South African Council of Churches, Cosatu, nurses, doctors, TAC and other organisations marched to address the need for HIV treatment, the crisis in the public health system and the inequality between private and public health. The rural-urban inequalities were also addressed during the march.
At the end of the march Vuyiseka Dubula, (not Nonkosi Khumalo as stated in news reports) spoke of the responsibility of every person to get tested, to seek and demand appropriate treatment and to use condoms. She demanded that government takes action to ensure universal access to anti-retroviral treatment. Dr. Lydia Cairncross said that without antiretroviral therapy, the public health sector will collapse and that the conditions in the public sector had to be improved. She said that everyone had a duty to struggle for a unified peoples' health service that did not discriminate between private and public and rich or poor. Everyone has the right to decent, quality health care. Zackie Achmat called on President Mbeki to lead the camapign for HIV prevention and treatment. He said that we endorsed the President's efforts to ensure peace on our continent but neither our President nor Parliament had discussed the pain of death faced by people in our communities on a daily basis.
Every speaker endorsed the demand to treat at least 200,000 people with ARVs by 2006.
A memorandum was handed over to Head of Communications in the Presidency, Comrade Murphy Morobe. He was accompanied by the chaiperson of the Portfolio Committee on Health, Comrade Jame Ngculu. Morobe praised the marchers, saying they are "our conscience". He urged TAC to continue marching and stated that he had personally lost six cousins over three years to HIV/AIDS.
A special thanks to everyone in the Western Cape who worked phenomenally hard to mobilise and to ensure that marchers had water, emergency care and transport.
Below is the memorandum handed over to Comrade Murphy Morobe:
Memorandum to President Thabo Mbeki, Deputy-President Jacob Zuma, Minister of Health, Dr Manto Tshabalala-Msimang and all MECs for Health
Parliament, Cape Town, 16 February 2005
Treat 200,000 People with Antiretrovirals by 2006!
Today, over 70,000 people in South Africa have had hope, life and dignity restored. They have access to antiretroviral treatment. Not long ago they faced almost certain death from HIV/AIDS. But now people like Sindiswa Godwana, Gordon Mthembu and Vuyiseka Dubula, who dedicate their lives to teaching people about the science, treatment and prevention of HIV, can look forward to living longer, healthier lives.
Yet hundreds of thousands of their compatriots cannot yet exercise this right. And this is why, again, we are marching to Parliament to demand that government meet its constitutional duties to respect, protect and promote life and dignity by ensuring access to health-care services. The TAC welcomed the Operational Plan published on 19 November 2003. We chose not to march to Parliament at this time last year because we were hopeful that a turning point had been reached in government's response to the HIV epidemic. Indeed, the response of some provincial governments, especially Western Cape and Gauteng, in implementing the Operational Plan has been encouraging.
Yet the National Department of Health continues to fail to show leadership on HIV. According to the Actuarial Society of South Africa, over 300,000 people died of AIDS last year. The Operational Plan committed to treating 53,000 by the end of March 2004. But as of end of December only 27,000 people were on treatment in the public sector. Very few of these were children. Inexplicably, the target for March 2004 was pushed to March 2005. This too will not be met. By the Department of Health's own admission, about half-a-million people needed treatment in 2003. The pace of implementation is far too slow and it is increasing inequity. 45,000 people are on treatment in the private sector, substantially more than the number in the public sector. The majority of people on treatment in the public sector are from Gauteng and Western Cape meaning that poorer provinces lag behind. People who have money can buy their lives and people who live in wealthier provinces have access to treatment.
This injustice exists because there is insufficient political leadership to make the programme a success. President Mbeki said in his State of the Nation address that we have one of the best AIDS programmes in the world. We would like to agree: the Operational Plan has the potential to be one of the best programmes in the world, but currently its is far short of this accolade. We need an honest assessment of the programme. Lives depend on it.
In 2005 TAC will campaign for the Operational Plan to be implemented properly.
We urge you to treat 200,000 people with AIDS using antiretrovirals in the public sector by the beginning of 2006, including at least 20,000 children.
The treatment targets of the Operational Plan have been missed for the following reasons:
Too few hospitals and clinics provide antiretroviral treatment, especially in rural areas and at primary level in urban areas. For example, hundreds of people with HIV/AIDS need to access treatment in Acornhoek, Limpopo, the area served by Tintswalo Hospital. The hospital staff are ready and willing to implement a treatment programme, but have not received permission or medicines from the Limpopo government. Residents of Orange Farm in Gauteng have to travel dozens of kilometres to get treatment at Chris Hani Baragwanath Hospital, a task that is unfeasible for many. Doctors and nurses at Madwaleni in the Eastern Cape, who serve in the public sector of this deep rural community with pride despite difficult conditions, want to start providing treatment, but here too they need the medicines, monitoring facilities and a state pharmacist to dispense them.
The drug supply is irregular and uncertain, largely because the procurement process has not been finalised, despite a commitment from the Department of Health to have done this by June 2004. There is still no generic competition on essential antiretrovirals such as efavirenz and lopinavir/ritonavir, resulting in stock shortages in some areas, as well as a lost opportunity to purchase these medicines at lower prices. There are not enough paediatric antiretroviral formulations and the supply is irregular by the few manufacturers producing these.
Many health facilities remain short of health-care workers, despite the promise of the Operational Plan to hire an additional 22,000 health-workers by 2008. The public sector is understaffed because of uncompetitive salaries, poor working conditions, death and illness due to HIV/AIDS, low morale caused by death and illness among their patients due to HIV/AIDS and a lack of career development opportunities. The Eastern Cape government has frozen posts in the health sector because of its poor governance in other areas of social delivery. As a result the national plan to treat our people is undermined.
Too many people are not getting tested for HIV and dying unnecessarily, often in hospital wards. The opportunity to save lives by actively offering HIV tests and treatment to people who present at health facilities is being lost. This is especially the case with those who present with symptoms of AIDS. Public messaging on HIV/AIDS remains weak. Not enough is being done to encourage people to get tested and, if necessary, get treated.
To overcome these problems the following must be done:
The National Department of Health must direct provinces to make treatment available wherever capacity exists at primary care level. Where capacity does not yet exist, the resources, including training and health-workers must be provided so that antiretroviral treatment can commence. Treatment must be made available in Tintswalo, Madwaleni and Orange Farm.
The procurement process must be finalised. Government must also put pressure on pharmaceutical companies such as MSD and Abbot, the patent-holders of efavirenz and lopinavir/ritonavir respectively, to allow generic competition to ensure a sustainable supply of affordable medicines. If necessary, government must use its powers to license generic competitors where companies like MSD and Abbott refuse to co-operate. Pressure must also be exerted on manufacturers to supply paediatric formulations of antiretrovirals.
A human resource plan for the public health system must be published. This plan must cater for improved conditions of service, including higher salaries and real career growth opportunities, as well as the recruitment of thousands more workers to the public health-system immediately. Undoubtedly, this will have budgetary implications, but the Freedom Charter and the ANC's visions of health-care for all cannot be met unless we are prepared to invest in the public sector.
President Mbeki and Health-Minister Tshabalala-Msimang must lead the struggle against the HIV epidemic by making regular calls on television and radio for people to access testing and, where necessary, to get treated. Nurses and doctors should routinely offer access to HIV-tests to patients presenting at public hospitals and clinics, regardless of their state of health.
TAC, on our part, will assist government with meeting its targets by continuing to increase the scale of our treatment-literacy programme, providing treatment to our volunteers and community members through our treatment project and promoting prevention of HIV transmission. We will continue to campaign for cheaper medicines and more competition among pharmaceutical companies. We will also campaign for a more effective antiretroviral regimen than single-dose nevirapine to be introduced for the mother-to-child transmission prevention programme, as has already been done by the Western Cape government.
Yet again we are marching in the streets and using the courts to safeguard our constitutionally entrenched rights to life, dignity and access to health-care services from our government of liberation. But if the above demands are met, there will be every opportunity for us to work together productively and harmoniously.
We call on you to lead the struggle against HIV/AIDS. Save lives and ensure that we treat 200,000 by 2006.
Thembeka Majali Nomfundo Dubula
TAC WC CO-ORDINATOR TAC WC TREATMENT LITERACY CO-ORDINATOR
[END OF MARCH REPORT]
BACK TO CONTENTSStatement by Rural Doctors Association of South Africa in support of antiretroviral rollout in rural areas
The Rural Doctors Association of Southern Africa (RuDASA) believe that rural people have the right to access quality health care. We share the TACís concerns about the poor access that many rural people have to treatment of opportunistic infections and ARVs.
We hereby recommit ourselves to work with the Department of Health as well as other organisations, to speed up the roll-out of medicines and support to people living with HIV/Aids.
RuDASAís 2004 Rural Doctor of the Year Award went to Dr Hermann Reuter for his groundbreaking work in Lusikisiki. Dr Reuter and his team have proven that ARV roll-out is possible in under-resourced rural areas.
We recognise the challenges in rural hospitals and clinics, especially the shortage of medical staff. We support the TACís call for improved conditions of service for health workers, and look forward to the implementation of a National Human Resources Plan by the Department of Health.
RuDASA spokesperson: Elma de Vries Ė 082 8286259, firstname.lastname@example.org
[END OF RUDASA STATEMENT]
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[END OF NEWSLETTER]