Yet, even as he and his colleague Nonkosi Khumalo recounted the success of their activism and the example they hope South Africa will set for the rest of the world, Achmat was blistering in his critique of the failure of world leaders to confront the scourge of HIV. At the top of his list was the American president.
"The greatest threat to public health in the world is George Bush staying in power," he said, in a presentation at Columbia University’s School of Public Health on November 10. "George Bush is one of the prime evils we face in relation to effective prevention and treatment worldwide."
Achmat’s willingness to take on the U.S. president at one of America’s leading universities is not out of character for him; he has been causing trouble for well over half of his 41 years. An HIV-positive gay man born in a poor South African Muslim family, he joined the once outlawed African National Congress (ANC) as a youth to fight for the end of apartheid. At 14, when he had already lived on the street as a sex worker to earn money for his education, he was arrested after a partially successful effort to burn his school down to protest the government’s racist policies.
Between 1977 and 1981, he was jailed five times—in several cases under "preventive detention" provisions of the law—and spent a total of about two and a half years incarcerated. In 1981, he began a nine-year stint living "underground"—away from the watchful eye of a crumbling regime, but free to work as an organizer among trade unions and students.
The 1990s saw the realization of Achmat’s dreams—and those of millions of other non-white South Africans. Freed from years of imprisonment, the ANC’s leader Nelson Mandela rose to the presidency of post-apartheid South Africa. Yet during the same years that saw the flowering of democracy and the world’s first constitution that guaranteed the equality of gay men and lesbians, the full extent of the AIDS crisis in South Africa became clear. Today, the nation has more cases of HIV than any other in the world.
"It was a cruel irony that at the moment we won our political freedom, we faced the HIV epidemic in which our sexual freedom and our right to life was taken away," he told the audience at Columbia.
Achmat’s gay and AIDS activism in time put him at odds with President Thabo Mbeki, Mandela’s ANC successor, who for several years openly espoused the view held by a small band of dissident scientists that HIV infection does not cause AIDS. Achmat helped found and still leads the Treatment Action Campaign (TAC) to press the South African government, in spite of Mbeki’s denialism, to respond realistically to a crisis which causes 600 deaths and 1,500 new infections every day. Another key aim of TAC’s work has been to overturn the resistance of pharmaceutical giants and Western governments to the generic production of HIV treatments still under patent protection.
"Intellectual property rights are at the cutting edge of public health activism," he said at Columbia, in a statement which puts him squarely at odds with the influential U.S. pharmaceutical lobby. Activism like TAC’s, supported internationally by groups like Health Gap and ACT UP, are credited with loosening opposition within the Clinton administration to generic drug production. Achmat’s twice-a-day combination therapy costs his insurance company $40 per month, as opposed to a price tag of more than $650 prior to TAC’s efforts. A drug purchase agreement recently negotiated by the William Jefferson Clinton Foundation will allow public health facilities in South Africa access to the same treatment for $18 per month.
"People tend to get better when they leave office," Achmat said about the former president’s current efforts on AIDS.
In 1999, he began the world’s first known drug strike, refusing any HIV treatments until the South African government developed a comprehensive plan for universal access. Achmat stuck with his strike despite illnesses and a public plea last year from Mandela. But, this week, the South African government, after years of international pressure and civil disobedience by TAC members, announced its first formal treatment program, which by next year will put funding at a level of $150 million. The commitment, Achmat said, is significant, and will allow drug access and treatment education founded in sound principles of public health to be rolled out. Anticipating that the government’s agreement was forthcoming, and "unwilling to die for Mbeki," Achmat began drug treatment himself ten weeks ago.
Achmat and Khumalo were in New York for a whirlwind series of meetings that included visits to Gay Men’s Health Crisis, the world’s oldest and largest AIDS services agency that has become increasingly active in recent years in the global AIDS movement, to Doctors Without Borders/Médecin Sans Frontières (MSF), which worked with TAC to develop a pioneering initiative in community-based treatment efforts in Khayelitsha, South Africa, and to a fundraiser at the home of Dr. Mathilde Krim, the chair of the American Foundation For AIDS Research (AmFAR).
The harsh verdict Achmat delivered about Bush this week reflects his disillusionment with the president’s plan, announced with great fanfare in his January State of the Union Address, to provide $15 billion over five years to fight AIDS in 14 African and Caribbean nations.
"I was enormously hopeful when a president regarded as mean and stingy and conservative showed interest in this global problem," Achmat said in an interview at MSF’s New York office on November 12. "But we have not seen a cent."
Achmat faults the president’s plan on three counts—first, its emphasis on abstinence-only education; second, its small contribution to the Global Fund to fight AIDS, Tuberculosis and Malaria established by the United Nations; and third, the lack of follow through by Bush on actually appropriating the money.
As the Bush plan has been fleshed out in Congressional negotiations, at least one third of the money will be reserved for abstinence-only prevention programs, and the president aims to devote only $200 million each year to the U.N. Global Fund, compared to the $2.5 billion that Secretary General Kofi A. Annan has requested. As Capitol Hill negotiators became increasingly alarmed by the gaping growth in the federal deficit, the president has let it be known that he favors reducing the first year installment on his plan from $3 billion to $2 billion.
Achmat charged that Bush’s unwillingness to participate in the Global Fund reflects his disdain for multilateral solutions reflected in his foreign policy generally. Indeed, in September, U.N. AIDS released the first comprehensive survey of global efforts to address the HIV epidemic. More than 100 nations participated, but the U.S. did not.
Achmat reserved particular scorn, however, for the president’s emphasis on abstinence-only prevention efforts.
"For a South African youth with no job, no fees to go to school, no access to a public swimming pool, abstinence is a joke," he said. "For a young girl, a pair of earrings can be traded for sex, or sex can be traded for the fees to go to school."
He added that campaigns based on the message "Be Faithful" targeting African women put them at risk because the migratory pattern of work in which so many men are engaged leads to informal policies of polygamy, in which men have both a "town partner" and a rural wife, or engage in sex with prostitutes.
"’Be faithful’ is a disaster," Achmat said at Columbia. "’Be faithful’ kills. The most at-risk people in South Africa are faithful wives. We have to say, ’Be faithful with a condom.’"
Achmat also addressed the issue of educating gay men, in South Africa and in the U.S., and in doing so betrayed his willingness the flout politically correct conventions to get his message across. He seemed particularly delighted to do so in front a crowd as distinguished as the senior faculty at Columbia’s public health school.
"We all know that we gay men are very promiscuous," he said. "If you insist on saying that reducing partners will reduce infection without teaching the science, it is only a moral judgment."
Like U.S. AIDS activists of a decade ago, Achmat enjoys his ability to shock an audience, but also understands that he can use that skill to educate. When asked in an interview about his life as a Muslim in South African society, as a freedom fighter, and as an advocate for universal health care, he quickly added, "And as a fag."
When Achmat met in Washington with Ambassador Randall Tobias, the U.S. State Department’s Global AIDS Coordinator, he was wearing a TAC T-shirt that read "HIV Stigma." Apparently eager to make his South African guest feel comfortable, Tobias said he had never seen the slogan before, and wanted one of the T-shirts. Achmat responded, "We’ll give you one that reads ’Drug Companies Have Blood on Their Hands,’" and then added that he was taking generic Prozac.
Achmat’s U.S. visit affords him another chance to spar with the Bush administration, this time publicly. On Sunday, November 16, he is set to appear on a panel in San Francisco sponsored by the American Public Health Association that will also include Health and Human Services Secretary Tommy Thompson. When a Columbia professor in the audience suggested that he give the same speech in San Francisco that he gave on Monday, Achmat said, "I am looking forward to meeting Tommy Thompson. I will ask him to go to the demo at the White House," planned by AIDS activists for November 24, one week in advance of World AIDS Day.
Asked when he next expected to visit the U.S., Achmat said he hoped to return next October "to stump in swing states for whoever is running against Bush."