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The publication in 2004 of The moral economy of AIDS in South Africa is perfect timing. Appearing at a time when discussion is widespread on the proposed antiretroviral rollout in South Africa and the associated costs and prerogatives, Nicoli Nattrass thus dedicates her book “to all those children born HIV-positive because the South African government said it could not afford mother-to-child transmission.” Without vitriolic judgements or accusations, but rather with well-researched and persuasive discourse, Nattrass proceeds to utterly discredit the notion that mother-to-child transmission prevention (MTCTP) or antiretroviral (ARV) treatment programmes are too expensive and the government cannot afford them. In fact, Nattrass waylays the follies of this argument by proving that these apparently exorbitant programmes can pay for themselves, and also that the costs of not implementing these programmes are actually what the South African government cannot afford. In the current context of HIV/AIDS in South Africa, The moral economy delivers a pertinent message and the book is in itself a considerable theoretical and analytical achievement.
In the introduction to the book, Nattrass outlines the crucial issue regarding the proposed ARV rollout in South Africa: “The treatment ‘rollout’ will take time, and given the governments’ ongoing concerns about ‘affordability,’ it is unlikely to reach many (if not most) of those who need it. The burden of AIDS will thus continue to be borne unevenly in South Africa. This is largely because of South Africa’s high unemployment rate and the strong connection between unemployment, poverty and HIV-infection.” By perceptively outlining these nuances, Nattrass puts the impending rollout in the applicable context: the ARV treatment programme will not completely blunt the considerable impact of HIV/AIDS in South Africa, and it should not be seen in such an idealised manner.
Nevertheless, states Nattrass, “the amount of resources allocated to combating AIDS (through prevention and treatment interventions)…has major implications for the nature of South African society.” This is the case, quite simply, because “until the public sector HAART [Highly Active Antiretroviral Treatment, i.e. the ARV rollout] programme can reach significant numbers of poor people living with AIDS, the income gulf between the employed and unemployed will continue to harden into a socio-economic divide bringing life to one side and death to the other.”
Thus Nattrass effectively demonstrates why the South African government cannot afford not to propel the ARV rollout treatment plan in South Africa. In the process the hitherto seemingly endless procrastinations of the government on the issue inevitably recede into futility. Thus The moral economy is intended to illustrate (in the words of the author) “how economic analysis can help government and civil society think about addressing AIDS.” Nattrass incorporates such economic analyses into a comprehensive and forceful argument that makes it futile for anyone to disregard the general reasoning of The moral economy.
In an extensive chapter dealing with the history of HIV/AIDS policy in South Africa, Nattrass describes the South African policy responses to the epidemic as a “sorry tale of missed opportunities, inadequate analysis, bureaucratic failure and political mismanagement.” As alternatives to this ‘sorry tale’ of political mismanagement, Nattrass delivers an effective argument for a MTCTP intervention since such a programme would more than pay for itself with fewer children becoming HIV-positive – thus resulting in a lower net cost to the health sector. In a similarly detailed exposition, Nattrass makes a similar case for HAART in South Africa. By including the hospital costs associated with AIDS-related illnesses in her calculations, Nattrass provides seemingly irrefutable proof of the cost-effectiveness and practical value of introducing HAART in the public sector in South Africa.
After two further chapters on AIDS, HAART and behavioural change and on AIDS, economic growth and inequality in South Africa, Nattrass concludes The moral economy with the argument that “a broad process of social deliberation is required over AIDS policy and, in particular, over the additional resource requirements needed to fund a large-scale intervention including universal access to HAART.” Nattrass berates the government’s method of concentrating decision-making on the allocation of scarce resources in the hands of certain technocrats in the treasury and ministry of health. AIDS, says Nattrass, should be treated differently because “it is a public health crisis, which not only has deep social roots, but challenges the very notion of what it means to be a society.” Technocrats in South Africa have hitherto made decisions that disregarded the long-term immeasurable value of universal access to HAART. By means of a well-researched, detailed exposition, Nattrass has shown in The moral economy the ineluctable folly of such myopic decisions, and thus concludes The moral economy with the forceful statement: “AIDS policy is too important to be left in the hands of technocrats.”
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