Q&A with the Deputy Health Minister
Kerry Cullinan speaks to the Deputy Health Minister, Nozizwe Madlala-Routledge.
You have said that Toronto was an embarrassment.
Yes, Toronto was a catalyst. It was a turning point. It galvanised government to be on a new footing, particularly around streamlining of communication on our strategy and our plan and greater mobilisation of all partners. In particular there was recognition of the fact that we need one another. This atmosphere of perpetual conflict with civil society is not helping.
Do you have a new role?
It’s not an officially new, defined role. But certainly I have seen spaces being created for me which I appreciate because I think we all have something to bring. Yes, indeed, I have assisted in drafting some of the departmental statements, in particular the one on the call by the TAC to MPs to a people’s parliament. I think I’ve been given the space to support the improvement of relationships but also, as part of the DOH, I think I have an important role to contribute to the government’s new drive.
Who has created the space for you?
As chairperson of SANAC, the Deputy President has indicated that she is aware of my abilities and strengths and she’s drawn on these.
The new environment has given DoH new purpose. I have been most encouraged by the spirit that I feel with managers of the HIV programme. Managers are very enthusiastic and are challenging themselves all the time. I think they have understood the present mood of saying we must increase access. The Deputy President mentioned at the civil society congress the call for the strengthening of primary health care. This is supported by the departmet. Care must be taken down to clinic level. And I was very excited to hear from the managers that they are really looking at accelerating the plan. They are looking at weak points and one important thing is that they are opening up to partnerships. So that mood is really encouraging and we need to do more to support the managers.
Where does the Health Minister stand in all of this?
The health minister has been ill but before she got ill, she was already participating in the Inter-Ministerial Committee (IMC) of AIDS. This is another important development. The IMC has been established with the Deputy President as chairperson. The DoH is still the lead department in terms of the govt programme on HIV and AIDS. But we are galvanising more and more departments.
In fact, it’s been a weakness in our strategy that we haven’t drawn on the huge resources and skills of other departments and created the impression that the reservoir of knowledge is in health.
So the Minister is part of the team. She’s political head of the DoH but there are more players participating at different levels. Having the Deputy President as chairperson of the partnership — SANAC — has also strengthened the new environment. She has experience and skill in negotiating in sometimes very difficult conditions but one special skill she has is of listening and making people feel we are taking them seriously and this is contributing to the new energy.
What are the immediate priorities? The TAC has said government must address the waiting list for people on ARVs.
The real work starts now. We must get the people off the [ARV] waiting list. There are just too many people waiting and when people come forward under the present conditions of stigma it is most discouraging when they must now wait in the queue; a long queue. Some of them have been told to come back next July. So that is the very immediate challenge.
But secondly I would say that in the interests of prevention and treatment, we need to encourage more and more people to test because the sooner a person knows their status, the sooner they seek help. The earlier they seek help, the more chance they will have of success.
We don’t have a national prevention campaign. Khomanani has been suspended. What is government doing to prevent new HIV infections?
The new strategic plan is focusing a lot in this areas because definitely the rate of new infections shows we need a more vibrant and effective prevention strategy. We are identifying the causes and determinants of new infections. Consider the high rate of sexual and gender-based violence in the country. This is more evident among the younger generation. Against this violence, the Abstain, Be Faithful, Use Condoms (ABC) is clearly not relevant in a situation where a person is being violated.
Social inequality is definitely also contributing where, for example, a woman is unable to negotiate safer sex. We have been talking about this but now the strategy must give us concrete actions that must be taken to address this matter.
There is the issue of economic inequality. Poverty is not always the reason why younger women are engaging in trans-generational sex, which is contributing. Younger women having sex with older men are predisposing themselves to infection. We find that it is not always because a person is poor. It is also peer pressure for materialistic possessions. The lifestyle in South Africa which promotes consumption leads young women into this kind of life.
This is not to disregard the very important role of poverty. Some people find transactional sex the most accessible way to make a living.
In the new strategy, we are going to be setting very tight targets, not just for DoH but other departments.
So the strategic plan for 2007-2011 will have definite targets?
There’s a huge commitment to set targets. To quote the Deputy President, ‘if you can’t see the figures you can’t count it’. If you don’t have figures, you don’t have something to work towards.
The major target that we are all agreed on is halving new infections by 2011. It’s an ambitious target but it’s one that we need to find very possible way to implement.
Khomanani has played an important role in mass education and mobilisation and indeed I was beginning to see people relating very well to the Khomanani messages. We are going to be prioritising improving our mass mobilisation and mass education methods and I am hoping this time that we are going to include treatment literacy because there is a lot of confusion and ignorance about what to take and how to treat HIV.
In the last few years, we have seen people promoting untested AIDS remedies such as Tine van der Maas, Matthias Rath and Zeblon Gwala. Are we going to see a tougher stance against people who promote untested remedies?
We are working hard in this. The foodstuffs and medicines control units are working together to develop regulations for the two laws that exist. One is the Medicine Control Act and the other has a long name but it controls foodstuff.
These two laws define what is a medicine and what is a foodstuff and it criminalises making claims about foodstuff, supplements and so on that have not been tested. If you make a claim about a foodstuff, this has to go through the proper testing for safety and efficacy as well as registration with the MCC.
Now South Africa is flooded — and this environment of no proper regulation has allowed this flooding — with untested remedies. They come from all over the world. We are really faced with a challenge because apart from legislating what can and can’t be sued as medicine, what is and what is not a medicine, we also have to step up our policing capabilities. It is easy for someone to put something on a shelf and say it is curing this or that. But our inspectors are supposed to go into all these areas where these things are being sold, and we are having a huge shortage of these inspectors.
One of the things that we want to accelerate is the formation of the interim council on traditional health practitioners. All people who claim to have training in traditional health must register. Once this council is formed, nobody will be allowed to practice if they are not registered.
There are indications that a number of traditional healers’ bodies are already collecting registration fees and registering anyone who claims to be a traditional healer.
The provincial DoH must monitor what is going to and supervise the process of registration. There is a plethora of these traditional health organisations and there is a need to streamline how and with whom they register.
But there is one thing I think all South Africans should be concerned about. I know people ask why traditional medicine should go under scientific scrutiny. We are providing the laboratories and asking them to test their so-called remedies. But South Africans must ask themselves: is it correct that traditional medicines should be tested on people? We have allowed a situation where a person who’s training we don’t know can see patients and prescribe for them and the way that the traditional practitioner can see if this [remedy] works is if the patient lives or dies. This is unacceptable because it is testing untested medicines on human beings.
I also feel it is unethical for senior people in the government to themselves promote these remedies. I confuses people. People say ‘I heard it over the radio. Minister so-and-so; MEC so-and-so was saying this is good. We can use it.’ I think that is irresponsible in the extreme. As MECs, ministers and government, especially in the health sector, we have a responsibility to protect our people and I think we must take this responsibility very, very seriously.
The MCC is weak, very slow and it has no ability to investigate claims independently. It relies on the DoH’s law enforcement unit. Is there any chance that it can be improved?
The MCC definitely needs strengthening. Many recent changes in the leadership of the MCC has also weakened the MCC. But having members of the council being part time has limitations as they don’t have enough time. Our Registrar for Medicines is at the moement also responsible for two other areas. She has three hats. That is setting her up for failure because she’s not going to be able to fulfil all these roles at the same time.
If the MCC depends on the DoH for inspections, then we have also set it up for failure as there is not enough capacity.
There have been complaints from industry that the MCC is not processing its applications fast enough and unfortunately this is the kind of situation that encourages the flooding of the market with unregistered medicines.
What about TB?
The TB epidemic is throwing up new challenges. The issue of staffing, infection control and the development of new drugs. We are lagging behind in the treatment of a treatable disease. If these is not enough monitoring, you will see the development of multi-drug resistance.
There has been criticism of DOTS, which does not seem to be working, but at the same time we have relatively good ARV adherence. Patients say they take their ARVs because they have had treatment literacy training, but with DOTS they are simply told to go and take their pills in front of a DOTS volunteer.
It is essential that you include your patients in making decisions. For too long we haven’t been listening to patients. It has come out quite sharply that the DOTS strategy is not working. It is patronising and we must take that into account. Fortunately the new strategic plan has prioritised TB and we must consider ways to address the (low rate of) TB cure rate.
What we have learnt from ARV treatment is that patients are quite able to understand even the most complicated treatment regimes. I’ve been most amazed listening to rural people telling you what treatment they are on. I think we have assumed people won’t know and this is old fashioned and we must dispense with it, particularly with TB, a disease that is threatening the public health and is the main killer among the AIDS-defining illnesses.
Hospitals have emerged as the most risky place for people with HIV to pick up TB, including MDR and XDR TB, because TB patients are not isolated from people with HIV.
This is not acceptable. I would have thought at this stage, with the understanding that there is a high rate of HIV-TB coinfection, this is logical to separate TB patients, especially TB patients who are not responding to treatment or people who have not been diagnosed. Once a person is responding to TB treatment, that person is not infectious. If a person has not been diagnosed, that person should be separated from other patients and even their family.
Our treatment strategy must also target family members.
Some people have this confused idea that respect for human rights. Rights are not limitless. When there is a public health risk, we can all understand why our human rights can be limited. If someone has a communicable disease and is going to endanger others, we must make sure that that person is not allowed to do so.
This brings me to the prisons. We need to screen inmates as they come into the facilities at the same time as when they take away your belongings, so we know how to manage whatever health problems people might have. This is not for discrimination but to protect not only yourself but the others, particularly in overcrowded conditions.
Has the IMC been strengthened or has SANAC’s role been enhanced?
In terms of the restructuring, we have looked at the role of the IMC and it remains an important part of the SANAC structure as this where government meets to look at government’s role. He DEPUTY PRESIDENT chairs that. We have also looked at how to strengthen the secretariat for SANAC and the IMC. We are looking at how to strengthen the technical support around SANAC. All our communicators from DoH and GCIS are being trained to work together to streamline our messages. All this is being lead by the IMC. The IC’s role is being defined and strengthened.
SANAC is going to be working at three levels. The top structure has DP as chair and senior members of different organisations. The second level is the sector level. Government departments are going to lead those sectors so more govt ministers are going to be involved. The idea is not to have a top-heavy unmanageable structure. The third layer is the one looking at programmes.
Will there be someone who permanently heads SANAC?
I think that the DP is developing a team around her to run SANAC. The secretariat is going to have technical expertise and not just deal with logistics like travel arrangements. There is going to be a team of people dealing with the meat of the programme. The DP has other people working on SANAC but she has prioritised this. The IMC is going to be reporting to Cabinet so that the whole of Cabinet is also involved.
What message would you like to like to give to South Africans about HIV/AIDS?
We are all infected or affected by HIV and AIDS. It’s not my neighbour’s problem. It is all our problem. We each have something to contribute and we must all look at what we can contribute. All of us must take responsibility for testing, supporting people to disclose and to go for treatment as early as possible. We must stop discrimination and stigma. We beat apartheid. We can beat this.