Examination of Witnesses (Questions 320
- 339)
THURSDAY 29 JUNE 2000
DR BRIAN
BRINK, MS
JENNY CRISP,
MR CHRISTOPHER
WHEELER, MS
NAOMI JUNGHAE,
MR JAMES
COCHRANE AND
MS GEORGIA
FRANKLIN
Chairman
320. Mr Wheeler?
(Mr Wheeler) We are very much at the educational and
learning stage. Policies that we have introduced and the procedures
we have put in place in each bank are designed to establish where
we are in terms of the impact of the epidemic on our own workforce
and in the community. I think the principle of being able to provide
all sorts of medical care for individuals is good but we need
to look at the nature of HIV and AIDS and recognise that it is
a slightly different terminal disease than certain other ones
and look at the nature of the costings of the drugs that are available
and where they are available. There are very few places within
Africa, South Africa in particular, where you can access the cocktail
of drugs that would be most beneficial to individuals. I know
of a specific individual in Zambia recently—and I think
this is a very typical situation companies will have to deal with
and find difficulty discussing—who came to me through the
organisation and said, "I have got HIV and I am suffering
from AIDS-related illness. I know that I can get a certain set
of drugs in Johannesburg at a certain cost that will probably,
possibly extend my life expectancy by a few years." I am
not going to question the facts but let us presume that he was
correct. The question to the company becomes do you send him as
an individual or get the required drugs from Johannesburg and
provide treatment for that individual? What example does that
represent to your workforce as a whole? I have to say that the
reality must be that you have to treat everybody equally in terms
of debilitating illnesses and we cannot just look at an individual
example even if we know them personally and make them as an exception
as somebody we can treat particularly, but I think business managers
have got very difficult decisions, very difficult situations where
these particular examples come forward.
(Dr Brink) On this whole question of medical cost
escalation, which is a pervasive problem throughout our health
insurance plans, at this stage certainly in South Africa on our
typical plans I can safely say that the thing that is driving
our cost escalation is not HIV/AIDS and we do on our plan offer
a comprehensive treatment programme for managing HIV/AIDS. It
is done in a controlled setting on a strictly confidential basis
entirely voluntarily. We are absolutely satisfied that in managing
that illness there is no money wasted whereas on our other benefits
there is an extraordinary waste of money and that is the problem.
If we could focus the way in which the money is spent and not
waste it and use it appropriately, then I think we will be able
to cope. When it comes to HIV/AIDS benefits that is exactly what
we are doing and it has proven to be hugely successful.
321. So an employee who has HIV/AIDS who declares
this to you confidentially will receive treatment with anti-retroviral
drugs? Is that what you are saying?
(Dr Brink) We have got hugely different arrangements
across our companies but the one I am quoting would be where we
have a health insurance plan and what I would call the "comprehensive"
plan. In that circumstance the employee applies to the plan not
to the employer, it is a totally independent scheme. By doing
that they then join a programme and that programme offers the
full anti-retroviral therapy that is needed.
322. That is very interesting indeed because
what you will be normally dealing with, as I understand from what
you have told us, is somebody who has not voluntarily told you
that he has or she has HIV/AIDS. You are dealing with somebody
who is suddenly developing tuberculosis or who gets very serious
malaria or any of the other major killer diseases in the area.
You would not offer him anti-retroviral drugs because he is not
an HIV sufferer, as far as you are know. On the other hand, the
extra sickness that you are finding in the workforce probably
is related to HIV/AIDS.
(Dr Brink) Perhaps I can broaden it out. I have given
you an example which is at the top end of our health insurance
arrangements. The health care plans for the biggest section of
the workforce, which is the less skilled section on our mines
generally, is through company-owned medical facilities and services
which are provided free of charge to the employees. In that context
the employees receive the treatment which is appropriate for whatever
condition they have. The presenting feature often of AIDS in South
Africa is TB and so we have seen a very worrying increase in instances
of TB and that becomes first and foremost the thing that has been
treated.
323. And a major cost?
(Dr Brink) Yes, at a significant cost but it is a
treatable condition and a curable condition. To the extent that
it becomes known to the medical attendant of the patient that
the person is HIV-positive there are steps which you can put in
place which will keep that person healthy so you can have preventative
antibiotic programmes to prevent the opportunistic infections
taking root. You need not necessarily get into saying, "We
need to give anti-retroviral therapy." That is a long way
down the track. I would say at this stage as things currently
are to offer anti-retroviral therapy to the entire workforce would
cost too much and would not be affordable. Right now we are looking
at initiating a project in partnership with major pharmaceutical
manufacturers and Glaxo Wellcome would be the lead. We want to
try and find ways and means whereby we can make anti-retroviral
therapy, if it is needed, available on an affordable basis which
is sustainable in the long term and which is effective. I think
that is a hugely exciting project which we want to embark on.
Clearly it is at the feasibility stage at the moment. It is of
the nature of a research project but I think we would be able
to demonstrate clearly and to measure the cost and demonstrate
the benefit and hopefully the outcome would show that this is
the right way to go, that it is affordable, it is sustainable,
it keeps people well for longer and in that way we survive the
epidemic.
324. We have got a series of questions on the
group of five companies in the pharmaceutical industry who have
put forward this suggestion. We would like to put those altogether
and discuss them at once. Do you have anything else you wanted
to add?
(Mr Cochrane) I was going to talk about Glaxo Wellcome
as an employer in South Africa. We do not have anything like the
numbers of people you have been talking about. We do have 600
people employed by ourselves in South Africa today and our medical
insurance scheme does cover our employees for HIV-related illness
on a confidential basis and if they are diagnosed as HIV and wish
to have treatment they will get access to drugs whatever their
illness is.
325. That covers all 600?
(Mr Cochrane) Yes.
326. Does your insurance scheme cover all your
employees or just some?
(Dr Brink) There are so many different arrangements
across companies it becomes highly complex.
327. It does not always cover or some do and
some do not?
(Dr Brink) Yes, generally every employee has one or
other form of health benefit but the exact structure of that—
(Mr Wheeler) There is a health plan in each company
but the levels of those plans do vary company by company. They
largely reflect local labour legislation and the groups you are
insuring so that there is a non-discrimination view across employees.
Mr Robathan
328. But generally, I am afraid, it is rather
obvious that if you are a hewer of rock in Anglo American, you
are not covered by health insurance for anti-retroviral drugs
and the same in Standard Charter, not all your employees are covered
for treatment with anti-retroviral drugs?
(Mr Wheeler) Probably.
329. It must be because you have brought up
this example.
(Mr Wheeler) Yes.
Chairman
330. Can I just ask one brief question. Is there
evidence that in certain countries HIV/AIDS is a deterrent to
foreign investors, as we think that might have happened? Are there
companies diversifying their activities out of countries with
higher rates of infection or are there activities which are particularly
vulnerable to the economic effects of HIV/AIDS? Have you got any
evidence of that kind, Mr Wheeler, either in your own company
or in some of your clients' companies?
(Mr Cochrane) We have not noted it.
331. So it has not had an impact, it has not
had any influence on investment decisions taken in any of your
companies?
(Dr Brink) I think that, again, this is part of the
education challenge. As a company we have to demonstrate very
clearly that despite the fact that the epidemic is there, despite
the fact that it is hugely serious and has lots of problems, it
is still possible to run successful businesses and it is still
an attractive investment opportunity and it is what that region
of the world so desperately needs.
Chairman: Yes, indeed, as you have said
to us. Andrew Robathan, can you lead us on HIV/AIDS prevention
in the workplace.
Mr Robathan
332. Yes, but I am just going to throw another
question if I may. If you were a hard headed capitalist businessman
looking at getting a reasonable labour cost and you looked at
a very large knock-on effect in terms of sickness benefit and
widow's pension benefit for a population with a very high incidence
of HIV, surely one would look perhaps somewhere else than a country
that has a very prevalent rate of HIV? Mr Wheeler, you are a banker,
would you? You say you have not noticed it.
(Mr Wheeler) A hard headed capitalist would approach
it in that way but I think what businesses that do operate within
Africa would suggest is that there are many opportunities within
those countries for successful businesses at very good margins.
Mr Robathan: Thank you. I would like
to move on to prevention in the workplace really. We have covered
various of the questions I wanted to ask of you. What interventions
have been shown to work in educating workforces in HIV/AIDS prevention
and in changing behaviour?
Chairman
333. All of those AIDS protection things are
about changing behaviour, are they not?
(Ms Crisp) I have to say I think we were all hugely
naive ten to 15 years ago when we thought that simply telling
people about HIV and AIDS would result in behaviour change. We
have plenty of examples to look at from smoking, from other lifestyle
issues over the years, that have shown just providing people with
information does not necessarily result in a change in behaviour.
We have to understand what brings about behaviour change and what
determines behaviour and it is a whole range of issues. It is
cultural norms, it is social norms, it is peer group pressure,
it is the role of women in society, it is psychological. There
is a whole range of those issues. That is why it has been extremely
difficult to get a mass change in behaviour because what applies
to one individual and what will cause them to change their behaviour
is not necessarily what will apply to another individual. We have
moved over time. Initially we adopted the model that was used
worldwide, it was a three-pronged approach creating awareness
and particularly using a peer educator approach so that any prevention
messages could be culturally appropriate and acceptable, condom
distribution, and throughout all of our operations condoms are
freely available and have been freely available for some time,
for many years. For me I think importantly—
Mr Worthington
334. To save time later, what does "freely"
mean, free of charge or generally available?
(Ms Crisp) Both. Certainly free of charge. When we
first started they were available at the company clinic. That
did not mean that they were accessible so over time we have made
them available in the kind of shebeens that you have seen in the
Carletonville area, they are available in change houses, they
are available in bars as well as in the clinic. They are available
to people who need them.
Mr Robathan
335. Is that generally true of other companies
as well?
(Ms Crisp) The more enlightened ones, yes. Unfortunately
I have not done a survey of companies throughout South Africa
but certainly in the more enlightened ones, the ESCOMs, the Unilevers,
people like that, that would generally be true. We all now know,
but we did not five years ago, just how important a co-factor
STDs are in HIV transmission. I think the biggest lesson that
we have learned over the period of time is that whilst initially
we focused on our employees, we did not focus on their partners.
This is something which over the last few years we have turned
around totally. We were spending a lot of time, money and effort
educating the workforce, providing STD treatment for them, but
we were not seeing a decline in STDs, the reason being that treatment
was not available to the partners. Initially we offered it to
the partners within our own operations and that was not successful
for a whole range of reasons. Latterly in the last three or four
years what we have strived to do is to establish partnerships
much along the lines you saw at Carletonville. We have done that
in Mpumalanga Province and in the Free State Province as well
more recently we have established partnerships with local communities,
with the Government, particularly the Department of Health, to
provide similar prevention programmes, education, STD treatment
and condoms for the wider community. We are now beginning to see
that is having a significant impact. I do not know if you have
had the recent update of the Carletonville project but as a result
of the testing that was done last August those results are now
being processed and what they are seeing in that area—you
will have seen the emphasis that was put on the hot spots around
certain mines—is a decline in STD incidence. Whilst it was
eight per cent amongst mine workers in 1998 it had decreased to
one per cent in 1999. If that can be sustained that is hugely
encouraging. We have seen similar situations with projects in
Free State. We are certainly hopeful that these are now projects
that can be extended and will be workable and will actually result
in a change in behaviour.
336. If I can ask other people from Standard
Chartered and Glaxo Wellcome, is that a general perception amongst
responsible businesses—one cannot claim every business is
responsible—as a way forward in South Africa?
(Mr Wheeler) I think so. Most of the characteristics
of the business behaviour that have been outlined are right. I
think that the general comment I would make regarding behaviour
change is that in most countries it is too early to see a change
in behaviour and I think there has not been enough done in all
areas of the community.
337. Thank you. Could I ask you a specific question
about women's rights because you mentioned it, Ms Franklin, and
it is part of the whole empowerment of women. This is not my specialist
subject, if I might put it that way, however I do think it is
terribly important. For instance, in South Africa, as we know,
the incidence of rape is astronomical, sadly. The particular question
I have is as part of this education you use MTV, I understand,
and MTV is broadcasting sensible educational programmes or snippets
between their broadcasts. In this country there has been quite
a lot of criticism of rap music—which I should say again
is not one of my specialist subjects—because of its misogyny
and almost its anti-woman underlying theme. Rap music is very
popular amongst some Africans, I understand, in Southern Africa.
Does MTV take that on board? Does it broadcast rap music which
might be considered to be misogynist?
(Ms Franklin) Probably.
338. Do you not think this is a dichotomy?
(Ms Franklin) Absolutely. MTV and AIDS is a dichotomy.
The fact is on all of our channels around the world, probably
less so in China and India, on the majority of our channels we
are airing music videos because that is what MTV is about. We
are airing music videos with Madonna or by the rap stars that
are sexy, that encourage sex. You do not see Madonna taking out
a condom before she is shown in bed with her latest conquest.
That is what our audience want to see. They want to see this music.
We have to accept that otherwise our audience is going to switch
off in droves. What we also accept is that we have this audience
that we can influence. We have an audience of 16-24 year olds,
we reach 300 million homes around the world, least so in Africa
although we do export to Africa. What we can do without switching
off is actually talk to these kids in a way that they want to
hear, so we talk to them in their voice. We can accept the dichotomy.
We can play that rap music but then at the same time we can put
in responsible programming but not something the kids are going
to switch off to. We have clearly defined how we want to be involved
in AIDS and those are three reasons. We want to educate our audience
about how not to become HIV-positive, we want to help to eradicate
the stigma and discrimination that surrounds people who are infected
by HIV and AIDS, and we also want to be sure that our audience,
if they are in developed countries, understand the huge tragedy
and pandemic facing the rest of the world. We are not a channel
that is 100 per cent dedicated to eradicating AIDs on air but
we know that we do have the ability to do something about it.
We are not going to not play the rap music but we can make sure
that we address those issues somewhere else along the line.
339. I take the point that you are a commercial
channel but do you not think that what you have already said,
broadcasting videos that influence people's behaviour in one particular
direction, namely one might say sexual promiscuity, is flying
in the face of what most of us would agree is the real answer
to the AIDS pandemic which is to change behaviour away from irresponsible
sex or promiscuity?
(Ms Franklin) First of all, what I should say is if
there is a video or an artist who is outwardly discriminatory
then we actually would not play it. But, having said that, sexual
promiscuity happens in—I would not like to put a percentage
on it—a lot of our videos. Those same rap artists influence
the kids, as you say, so what we do is go out and every time we
interview every single artist anywhere around the world, we say
to them "great, tell us about your latest video but now will
you please give us a message for our audience about safe sex,
wear a condom, do not discriminate" and we then package that
together and air it around the world as well.
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