SOUTH AFRICA: President Mbeki has been persistently sceptical about the problem, reports Declan Walsh in Khayelitsha
Outside South Africa's elegant Cape Town parliament building, more than five million people are infected with HIV. Inside, the health minister recently announced a novel way to ease their pain: a mixture of beetroot, olive oil and spinach.
The concoction strengthens Aids sufferers' immune systems, the Minister, Manto Tshabalala-Msimang, told reporters. One day, she added, such remedies could replace anti-retroviral drugs (ARVs) in the fight against South Africa's greatest scourge.
Her homespun advice triggered a fresh wave of scorn in South Africa's battle over Aids. The long-running, bitterly-fought debate pitches President Thabo Mbeki and his loyal minister, on one side, against a phalanx of Aids activists, media and the entire medical establishment on the other.
Mr Mbeki has been persistently sceptical about the scale, nature and origin of South Africa's Aids problem, the world's largest. He has supported renegade scientists who doubt the link between HIV and Aids, he has questioned the value of life-saving ARV drugs and he has denigrated his critics as anti-black racists. Now he has handed the baton to Mrs Tshabalala-Msimang. The rancorous controversy, mostly played out through the media, has almost no middle ground.
Two weeks ago, the Johannesburg Star ran an interview with the woman behind the controversial beetroot diet under the headline "I'm no quack". Tina van der Maas, an unregistered nurse and self-taught nutrition expert, told the reporter: "You don't need anti-retrovirals if you are eating these foods."
The article carried a photo of Ms van der Maas in her suburban home brandishing a large bottle of extra-virgin olive oil.
Opposition parties seized on the controversy to erode the ruling African National Congress (ANC) party's broad popularity. Last year, for example, the mostly white Democratic Alliance party launched a website entitled www.firemanto.co.za
The paradox is that Mr Mbeki's government is now spending more money on Aids than ever before. After much delay, Mrs Tshabalala-Msimang finally announced a plan to provide free ARVs to almost 200,000 people by this time next year. In the recent budget, the Finance Minister, Trevor Manuel, allocated 1.9 billion rand (€228 million) to the programme for the next three years. Some provinces have already started distributing the drugs.
But already there has been some slippage, and a pledge to put 53,000 patients on ARVs by the end of this month will probably not be met.
Mrs Tshabalala blames the lack of qualified doctors, but aid workers say her confusing leadership on the issue - such as promoting obscure palliatives - is also slowing delivery.
The Nobel prizewinning charity Médecins Sans Frontières (MSF) distributes free ARVs in Khayelitsha, a rundown township near Cape Town. Even so, staff say they are regularly questioned about using nutritional remedies instead of proven drugs.
"Patients say 'My mother is cooking garlic and African potatoes will this work for me?' It's sad and it's frustrating," said Dr Gilles van Cutsem at his office, where dozens of patients waited outside the door.
For MSF, the benefit of ARVs is unquestionable. After one year of treatment, 83 per cent of people have "undetectable" levels of HIV in their bloodstream, said Bettina Schunter. "Their lives are transformed. They want to talk about getting a job."
Humphrey Quongo, an unemployed 35-year-old, started taking ARVs two months ago after his CD4 count - the measure of HIV's ravages - dropped below the critical threshold of 200. Initially there were some side-effects, he said, but now "I feel better, I'm stronger now. I don't feel I'm going to die any more".
The MSF programme only slices away a sliver of South Africa's vast Aids scourge. For example, in Khayelitsha alone there are an estimated 50,000 HIV-positive people, of whom 5,000 need ARVs immediately. MSF is treating just 800.
Mr Mbeki's first doubts about HIV/Aids were aired in 1999. He was approached by a group of dissident scientists, including one Nobel prizewinner, who claimed HIV did not cause Aids. Later, Mr Mbeki wrote to other world leaders, including President Bill Clinton, warning of a "witchhunt" against the group, even though most medical experts had already dismissed them as a loony fringe.
Subsequently, Mr Mbeki warned of the possible "toxicity" of ARV drugs. In a September 2003 interview with the Washington Post, he said: "Personally, I don't know anybody who has died of Aids."
A year earlier, an aide, Peter Mokaba, had died from the disease. So did Parks Mankahlana, a presidential spokesman, in late 2000.
The reasons behind President Mbeki's scepticism are difficult to penetrate. In so many other areas South Africa has made a miraculous transformation since apartheid ended in 1994: a bloodless transition to democracy, a model constitution, the Truth and Reconciliation Commission, housing and water for millions.
Yet Mr Mbeki's cantankerous approach to Aids has provoked howls of protest and, critics say, failed to prevent hundreds of thousands of deaths. "We can only speculate, but we think it is simple denialism The president does not believe HIV causes Aids, and the Minister of Health follows his orders," said Nathan Geffen, of Treatment Action Campaign (TAC), a vociferous lobby group which won a court action in December 2001 forcing the government to provide free drugs to pregnant women.
Even Nelson Mandela, who normally avoids comment, has waded into the debate. His admission that family members had died of Aids was seen as an implicit criticism of Mr Mbeki.
The storm has not abated. During his state-of-the-nation address last month, Mr Mbeki referred to Aids just once. In an interview two days later he questioned the accuracy of Aids death statistics, asking instead why nobody was concerned about diabetes.
According to the South African Medical Research Council, Aids was responsible for 39 per cent of lost life years in 2000, more than the next 10 diseases. Diabetes accounted for only 1 per cent.
One theory about Mr Mbeki's contrarian position is that he perceives a racist agenda behind his detractors. In a little-reported speech at Fort Hare University in 2001, he said that placard-wielding protesters saw black people as "germ-carriers, human beings of a lower order that cannot subject its passions to reason".
"Convinced that we are but natural-born, promiscuous carriers of germs," he went on, "they proclaim that our continent is doomed to an inevitable mortal end because of our unconquerable devotion to the sin of lust."
But the most acidic criticism has come from within South Africa, particularly from the TAC. Until last year, activist Zachie Achmat was on a much-publicised "ARV strike", refusing to take the drugs that could save his life until the government provided them to the poor.
He called off the action after Mrs Tshabalala-Msimang announced the ARV plan in November and has now been nominated for a Nobel Peace Prize.
The powerful campaign represented "the greatest post-apartheid challenge to government", according to Judith February, an analyst with IDASA, a Cape Town-based think-tank.
South Africa may soon turn the corner on Aids. The government's ARV roll-out, combined with private programmes run by corporate giants like de Beers, should start to dent mortality rates. Public awareness is increasing, as is condom use.
But it is already too late for some. With elections one month from now, an estimated 600 people are dying every day.
When he enters his third term on April 27th, President Mbeki will have to work hard to show that his ideas for those who are still alive involve more than garlic and beetroot.
Tomorrow: Black affirmative action in South Africa