Select Committee on International Development Minutes of Evidence

Examination of Witnesses (Questions 320 - 339)




  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.


  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?


  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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