‘Thinking positively’ Brian Williams and Malegapuru Makgoba
South African Journal of Science 2000 96 262
Everyone knows that the epidemic of HIV/AIDS will have a devastating impact on the lives
of all South Africans. Everyone knows that dealing with the spread of the epidemic is the
most urgent task facing our society. Everyone knows that the responsibility must be taken up
by all sectors of society. Everyone knows that the way to stop the spread of AIDS is to use
condoms and to treat sexually transmitted diseases. What no one seems to know is this: how
do we get people, and especially young people, to change their behaviour? The fact that
disaster awaits us is now beyond dispute but what matters is how we respond.
Disasters are not new in South Africa. For two generations Apartheid tore us apart,
broke up families, killed our children, imprisoned those on whom we placed most hope. But
through all the ‘long, lonely, wasted years’, men like Mandela never despaired andordinary
men and women stood together and united across race, across class, across religion and in the
fire of Apartheid a new country was forged. The challenge that faces us now, therefore, is
this: We know that many of our children will die; we know that many of our industries will
come near to collapse; we know that hospitals will struggle to cope with the flood of sick and
dying people; we know that communities will struggle to give succour to the dying. But we
also know that dealing with AIDS means mobilising communities; it means dealing with
sexually transmitted diseases and tuberculosis; it means building up strong, community based,
primary health care; it means dealing with rape and gender violence and poverty. How then
shall we forge a new world in the fire that is AIDS? (?) How shall we fight so that one day
our children will look back with pride at our struggle to master the epidemic of HIV/AIDS as
we look back at those who sacrificed so much so that we could finally become one nation?
If we manage to turn the tide it will be because commercial sex workers have insisted
that their clients use condoms, because ordinary people have taken time to care for the sick
and dying, because the captains of industry have understood that the wealth of the nation
comes from the labour of people, because religious organizations have understood that death
transcends all divisions, and because our politicians have provided the drive and the
leadership to mobilise us all as they once did against that earlier threat. But where then does
the scientific community stand in all of this?
The pages of this issue stand as a testimony to the attempts that have been made by
scientists to understand the nature of the epidemic in South Africa and to contribute to the
development of ways to manage the epidemic. The contributions discussed in these pages
range from attempts to understand the social context of the epidemic to investigations of the
molecular biology of the virus that lives in so many of us. Scientists are engaged in attempts
to develop and to test interventions ranging from community based peer education to vaginal
microbicides to the syndromic management of STDs. Many valuable lessons have been
learned and we know a great deal about the natural history of the epidemic in South Africa.
But what the ante-natal clinic data depressingly confirm is that we have not managed to alter
the course of the epidemic significantly.
What then is they way forward for science in relation to this gravest of threats? First of
all we believe that a much greater scientific effort is needed. At present the number of
scientists that are available in South Africa is woefully inadequate but very many scientists in
other countries have already shown their eagerness to help address this problem. By
encouraging their participation we can strengthen our own resources and begin to train and to
develop a new cadre of young scientists who can work not only in the field of HIV but in
public health, infectious diseases, epidemiology, the social sciences and molecular biology.
We could see the flowering of a new generation of talented young people working on
problems that will be of benefit to all of us.
While it is important to continue the search for a vaccine and for more effective and
cheaper therapeutic drugs, not only for HIV but also for STDs, multi-drug resistant TB and
other opportunistic infections associated with HIV infection, the immediate priority must be
to dramatically cut transmission. To achieve this end we are not afforded the luxury of time to
carry out long term, community randomised controlled trials as were carried out in Mwanza
and Rakai. But we also cannot compromise our scientific standards lest we find ourselves
chasing shadows. We believe that the over-riding philosophy must be that we start from
interventions and then build our research strategy around these as several of the studies in this
issue have tried to do. It may be that rather than getting very precise information about
particular aspects of the epidemic, we get less precise but much broader information about
many other aspects of the epidemic. We shall have to integrate closely the biomedical and the
social sciences so that we understand not only the natural history of the disease but the social
context in which risk behaviour happens. The science will then be much more difficult to
carry out and to interpret, but the exciting prospect is that we may develop new scientific
ways of investigating health and disease that will have application far beyond this place and
this epidemic.
We all acknowledge that one of the legacies of the earlier disaster was that the majority
of our people were prevented from becoming part of the revolution in science that has
transformed the world, particularly in the second half of the last century. The very system of
education was designed by the architects of Apartheid to prevent young black people from
learning science. Now we need to develop a new culture of science, rooted in the reality and
the needs of our country, in which all participate as equals. A decisive moment occurred
almost 25 years ago when the school children of Soweto drew a line in the sand and said
enough! Let us turn the present disaster to our advantage and in overcoming the epidemic find
ways to teach those most affected, our young children still at school, that science can be used
in the service of people.
South Africa has one of the worst epidemics of HIV in the world. But the lessons we
learn here will be of benefit throughout the world. Let us show by our commitment and
courage, through our science and through our endeavours, that HIV is not invincible; that we
can turn the tide of infection; that we can again find the unity of spirit that brought us through
the dark years of Apartheid to a new dawn of freedom and hope.