Examination of Witnesses (Questions 264
THURSDAY 29 JUNE 2000
264. Can I begin by thanking you all for your
written evidence to us which we have been working our way through
and which we have distilled into a number of questions we would
like to ask. I think we had better plunge straight into questions
because there are a lot of them. We have divided this morning's
session into general impact in the private sector and then into
a second series of questions, which I hope Mr Cochrane will remain
with us for, and also Mr Saul Walker, to help us through the questions
specifically on drugs. We will have to be a bit disciplined both
on this side and your side if we are going to get through this
number of questions which are vitally important, to our understanding
anyway, of what we are facing in the private sector in dealing
with HIV/AIDS. First of all, we would like to ask a series of
questions on the impact of HIV/AIDS on the private sector. What
is the estimated prevalence of HIV/AIDS in your various workforces?
How does that compare with the workforce in general and with the
overall prevalence in each country? Does prevalence vary according
to the skill of the worker or their country of origin? Do you
have a sense of the extent to which workers are contracting HIV
whilst in your employment and the extent to which they are already
HIV-positive when joining the company? I wonder who would like
to start us off on that. We visited one of the companies in South
Africa, an Anglo American company, so could I invite Dr Brian
Brink to lead us off.
(Dr Brink) Thank you very much, Chairman.
It is a very difficult question to answer, as I am sure you anticipated.
265. We have not got any clear answers, that
is why we are asking the question, yes.
(Dr Brink) When asking the question one must clearly
understand what one means by prevalenceand that is the
pool of infected people. What perhaps is more important to us
is the rate at which new people are being added to that pool and
the rate at which people are leaving the pool through death, and
clearly those are much smaller numbers. When one first hears prevalence
figures the reaction often is one of alarm but, in fact, the situation
despite what might appear to be high numbers can still be very
manageable. So I would preface my remarks with that. Secondly,
with regard to prevalence figures, one must understand that they
vary enormously between countries and within countries. The next
big thing to remember is that very often the information is missing
and you have to ask how do you arrive at that figure and essentially
there are three different ways you can do it. One can rely on
surveys that have been carried out at a national level. The most
beneficial surveys that we have in South Africa, for example,
are the surveys amongst ante-natal clinic attenders and I think
the latest prevalence figure from these was 22.4 per cent. For
the extrapolation of that figure to the wider community one must
understand who you are looking at. For example, the level of infection
in women may be very different to the level of infection in men
so to say we will take that ante-natal figure and extrapolate
that to the whole population may not in fact be valid, so one
has to be very careful in using these figures. However, they do
give an indication of the prevalence within the adult pool. One
can get further down the road and employ statistical modelling
techniques to get more accurate prevalence figures which take
into account variable factors for the particular location you
are looking at, the particular company, the make-up of the pool
of people you are looking at, the demographics, and so on. Then
the last method would be to go to what we would call a sero-prevalence
survey where specifically you conduct an epidemiologically controlled
survey of a particular population, take a sample, do it on an
anonymous basis (completely unlinked, nobody can find out who
is HIV-positive and who is not) and that will probably give you
the best and most accurate figures.
266. Do you do that?
(Dr Brink) We carry out those surveys. I would say
that increasingly we are doing that because we are finding that
they are very useful things to do, for two reasons. One, when
you embark on such a survey first of all you have to get everybody
to agree. That means getting management and unions and employees
all together to recognise and to understand the problem. It is
that heightened awareness when you face up to how you are going
to do this. That in itself has a profound effect upon people in
terms of raising their awareness and raising their understanding
of the issues. It is good to do it from that point of view and
then you end up with a figure which quantifies the size of the
problem. Once you have measured the size of the problem you can
then say, "What are we going to do about it?" and put
in place a whole lot of plans to manage around what you have discovered
and come back later to re-measure to see whether what you have
done has had the required effect. So that is the importance of
such surveys. In a way I have been skirting around the original
question which is what are the numbers. I am doing that deliberately
because to just come out with the numbers is the wrong thing.
It creates the wrong impression. I think they are different in
different countries and different in different circumstances.
They can range between 10 per cent, 15, 20, 25, sometimes even
higher. You must understand what the figure that you arrive at
means and you must be able to do something with that figure in
terms of managing the epidemic.
267. In South Africa we have been given evidence
that there are different rates of prevalence of HIV/AIDS in different
parts of South Africa, as you have just stated and the Kwa-Zulu
Natal figure is the highest, we have been told, and the Western
Cape the lowest. Do you operate in each of the states of South
Africa and can you give us some idea of how you behave as a result
of different prevalence rates?
(Dr Brink) Our big operations in South Africa are
primarily based in Free State Province, Guateng and North West
Province. They are provinces which are pretty much middle of the
road when it comes to prevalence figures. Even so, again within
our workforces our emphasis is not so much on what is the exact
prevalence in that workforce, it is far rather getting an understanding
of what HIV/AIDS is all about with a very focused management effort
so as to prevent new infections. Whatever those prevalence figures
are, one must always remember that the greater majority of people
are not infected and we have a huge opportunity to try to stop
new infections, and that is a far more important message than
saying how many people are infected. I think for those that are
infected what is more important is how are we going to look after
and care for those people. They may be HIV-positive but they are
perfectly well and perfectly able to work and we like to find
ways and means of keeping them that way as long as possible.
268. We are going to come to how you do that
in a series of questions we have later. Mr Christopher Wheeler,
would you like to make some comments about the prevalence of HIV/AIDS
and how you see it from your point of view?
(Mr Wheeler) As you know, the Bank has operations
in 12 countries across Africa. If I can give a little bit of context.
Approximately three years ago we started to notice a higher incidence
of sickness, of death in service, and so forth, and it was at
that point in time that we decided that we had to look further
at causes. We are obviously very aware of an increasing prevalence
of HIV and we decided the statistics that we were able to obtain
publicly were not completely reliable and from our own point of
view we thought what we needed to do was to look internally at
our own workforce initially and then see from within, if you like,
some of the issues that would need to be managed. I think the
caution that has been expressed in terms of the data is probably
one that has been expressed to you before. I think what it is
fair to say is there are broad areas of prevalence of 20 to 40
per cent, depending on which country you talk to and which region
of which country you are looking at. Within the bank's organisation
we are not able to determine whether or not there are distinguishing
characteristics between skilled and non-skilled. Looking at our
own incidence, for example, data from medical suppliers in Zambia,
for example, suggests that perhaps up to 30 per cent of the workforce
that we have could be infected. The data is "could be infected"
because we cannot insist that individuals have testing and we
would not suggest that they do so, but we would encourage people
who are unwell to go to our medical suppliers and they provide
broad, generic data on the nature of the illness. It is from that
basis that we have developed our own policies to learn more about
our own workforce and the incidence within each country.
269. Do you do a similar thing in bringing about
the workforce and management agreement to test a sample of your
(Mr Wheeler) We are talking with the unions and the
labour force on voluntary testing and we are encouraging staff
to undertake voluntary testing on a no-names basis such that we
are able to get the data back. It is from those sources, Zambia,
Ghana, Kenya, South Africa, that we have started to collect the
data we have referred to in our written submission.
Chairman: Shall we go on to other questions
or are there other points that other witnesses would like to add
on prevalence? Then can I ask Mr Robathan to lead.
270. When you are doing these anonymous tests
do you do a 100 per cent survey, Dr Brink?
(Dr Brink) We like to get as many people involved
as possible. It is a very big company. You do not have to
271. Take a mine like Carletonville, have you
ever done a survey of the complete workforce of the mine?
(Dr Brink) Not on that magnitude at all. Jenny has
(Ms Crisp) Carletonville is a particularly big mine
and gold mines are very much larger than the coal mines. The areas
in which we have carried out these anonymous sero-prevalence surveys
have been predominantly in our coalmines where the numbers were
about 1,000 per mine and around about 80 per cent of the workforce
has come forward. Initially we suggested to the unions that we
would just do a ten per cent sample but they were much more comfortable
to ask all the workers to come forward so that there was absolutely
no question of anybody being pinpointed at the end of the day.
Simply because the union has been on board and has agreed up front
there has been that kind of level of participation.
272. If you take this coal mine and test 800
people you would find a prevalence rate of 20 per cent?
(Ms Crisp) Slightly lower than that, just under 20.
273. This presumably is a matter of great concern
to employees. What has been their reaction? Do they then go out
and get another test?
(Ms Crisp) It has not been totally unexpected to them
because prior to doing this testing we have had huge education
programmes in place for four, five or six years prior to doing
any testing so they are aware of the situation. I think throughout
Africa what we have seen is a lot of denial about the epidemic.
I think it is like all of us. We do not want to think that anything
like this is going to affect us. So even when the results are
made known (and that is always done on a joint basis to management
and unions at the same time and testing is carried out by external
agencies) yes, there is shock, but there is still unfortunately
in our experience some kind of denial.
274. "Not me"?
(Ms Crisp) Not me.
(Dr Brink) I could reinforce that because alongside
all of these surveys at the same time we offer quite independently
voluntary, specific, individual AIDS testing at a completely separate
site free of charge. If you want to find out your own HIV status
that is where you go and do it.
(Dr Brink) Yes, confidentially. The take-up of that
offer has been extremely low. In the Carletonville survey they
surveyed 1,500 employees in that survey and not one, I am told,
went for the voluntary individual testing.
276. That is very interesting. I notice that
Anglo American do not have compulsory testing. Do any others?
Is it possible to have compulsory testing? Is it against the law?
(Ms Crisp) It is certainly against the law in South
Africa. We have an Employment Equity Bill which specifically prohibits
compulsory HIV tests.
277. So it has to be voluntary?
(Ms Crisp) It has to be voluntary.
278. I am not quite sure about employment practices
in South Africa but here a good employer might give every employee
a health check each year and almost certainly they will give a
blood test. If there was a high prevalence of disease such as
HIV that would be tested. Does that happen at all?
(Mr Wheeler) There is testing on a voluntary basis,
no names basis. We will collect data generically, not specifically.
279. Would you as an employee, Mr Wheeler, have
an annual health check? How far down the company does that go?
(Mr Wheeler) Not very far.