Introduction
The Treatment Action Campaign has campaigned for Goal 6 since before the goal was adopted. This case study provides an innovative civil society response to holding their government to Goal 6 “Halt and begin to reverse the spread of HIV/AIDS and the incidence of malaria and other major diseases.” It is an excellent example of how to run a local campaign linked to an international movement.

On 10 December 1998, International Human Rights Day, a group of about 15 people protested in Cape Town to demand medical treatment for people living with HIV/AIDS. Passers-by were surprised. They did not realise you could treat AIDS or that medication was freely available in Western countries. By the end of the day the group had collected over 1 000 signatures calling on government to develop a treatment plan for people living with HIV, and the Treatment Action Campaign (TAC) was born. Following the death of his friend and comrade and his own illness, TAC leader, Zackie Achmat, decided it was time to take action – to fight for access to treatment.

The launch of TAC opened a new chapter in AIDS politics in South Africa. People were tired on messages of doom and gloom. TAC has engaged in an innovative and successful campaign. The message has been loud and persistent. Neither the government nor the pharmaceutical industry has been able to ignore it.

Context
Close to 38 million adults and children worldwide are living with HIV. Although Africa is home to only 10% of the world’s population it has 70% of people living with HIV worldwide. By 2004 the HIV/AIDS epidemic in South Africa had emerged as one of the greatest threats to society. It is estimated that 27% of pregnant women are HIV+ and approximately 5 million South Africans have HIV/AIDS. Adult mortality has undergone a real increase of more than 40% between 1997 and 2004. It is estimated that 1.5 million South Africans will die in the next few years from AIDS and by 2010 2 million children will become orphans because their parents have died of AIDS-related illnesses.

TAC campaign
TAC aims to:

• Campaign for affordable treatment for all people with HIV/AIDS
• Fight for treatment for pregnant women with HIV to reduce the number of children who contract the virus
• Campaign for a health system that provides equal treatment for all South Africans
• Teach ourselves and others about HIV/AIDS treatment
• Train a leadership of people living with HIV.

TAC has over 8 000 members and offices around South Africa. In addition, it has mobilised a network of supporting organisations including the unions, religious groups and an NGO coalition.

TAC has over the years focused on five major campaigns:

a. Treatment literacy
Perhaps TAC's greatest achievement has been to raise public awareness about AIDS treatment and to provide hope that poor people will be able to access treatment. Through public protests, presentations to Parliament, regular media coverage, community mobilisation and networking, TAC has put the issue squarely on the public agenda.

b. Mother-to-child transmission
TAC has campaigned tirelessly for treatment for HIV-positive pregnant women to reduce the number of babies contracting HIV. They campaigned against the government’s decision to suspend pilot sites in 1998. They have provided research to support the campaign. The findings of the research were presented to Parliament and the Minister of Health. In 2000 TAC organised a Global March for Treatment at the International AIDS conference in Durban. In August 2000 the Minister announced 11 pilots using Nevirapine to reduce Mother-to-Child-Transmission (MTCT). TAC vowed to continue legal action against the government if these pilots were not extended into a national programme.

In 2001, TAC mounted a legal challenge to government, nationally and in all nine provinces, to secure mother-to-child treatment, and won. The Court ordered both provincial and national government to make Nevirapine available to pregnant women with HIV who give birth in the public health sector, and to their babies. It also declared that the respondents are under a duty forthwith to plan an effective comprehensive national programme by the end of March 2002 to prevent or reduce the mother-to-child transmission of HIV.

The SA government challenged the ruling in the Constitutional Court. Again TAC won. On the 5 July 2002 the Constitutional Court affirmed the High Court ruling.

TAC then monitored the implementation of the court agreement and in December 2002 charged government with contempt of court through the Human Rights Commission for failing to implement the Constitutional Court judgement in one province. As the TAC statement explained, “Ms Manana (Provincial Minister for Health) has shown disdain for the lives of children and the dignity of their parents. Her failure to implement life-saving policies has made working conditions intolerable for many public sector nurses and doctors. She and her department have brought the government into disrepute.”

c. Campaign against abuse and profiteering by pharmaceutical companies
TAC has tackled private sector profiteering and abuse at every turn in its efforts to make treatment more affordable. In 2000, following the death of one of its members, Christopher Moraka, from AIDS-related illnesses complicated by thrush, TAC launched a defiance campaign. The drug fluconazole could have treated Christopher’s thrush, allowing him to eat properly and fight his illness. Sadly the drug was not readily available in South Africa and cost between R30 and R100 a capsule, way out of the reach of most HIV+ South Africans.

Throughout 2000 TAC had tried to negotiate with Pfizer, the manufacturer in South Africa. In October 2000 TAC took a daring step. Leader Achmat visited Thailand and bought 5 000 capsules of a generic “fluconazole” for just R1.78 each and brought them into South Africa illegally. When TAC announced the successful mission, the outcry against Pfizer was immediate. The next day several prominent doctors came out in support of TAC’s action. TAC applied to the Medicines Control Council for a licence to distribute the drug. On October 20 Achmat was ordered to report to the Narcotics Bureau and the drugs were confiscated. Days later the MCC granted a medical centre permission to prescribe the drug. TAC then approached long-time supporter television soap opera star Morne Visser to collect the balance of the consignment of drugs purchased by Achmat. He received a hero’s welcome and the medicines were delivered to the clinic. “People were hugging and kissing me. I can’t describe how I felt. I had done so little but they made me feel like I had done so much.”

In 2001 TAC and Medecins sans Frontieres (MSF) took a similar action, illegally importing anti-retrovirals from Brazil. In 2002 it took its actions against profiteering one step further and along with other civil society organisations lodged a complaint with the Competition Commission regarding the excessive pricing of antiretroviral medicines by UK-based Glaxo-Smith-Kline (GSK) and Boehringer Ingelheim (BI), a privately owned group of pharmaceutical companies in Germany. The Commission found that the companies had contravened the Competition Act and referred the matter to the Competition Tribunal. At the same time TAC entered into settlement negotiations with GSK and BI. On 10 December 2003 GSK and BI accepted a settlement and TAC withdrew the case.

d. Campaign against the pharmaceutical manufacturing association
In 1998 the United States government put South Africa on a ‘watch list’ of countries that could face economic sanctions because of attempts by the South African government to reduce the prices of essential medicines by introducing the Medicines and Related Substances Control Act of 1997. In 2001, after three years of delaying tactics, the industry took to the courts to attempt to prevent the implementation of the Act. TAC campaigned vigorously in support of the Act, receiving extensive media coverage in the run up to the case. At the opening of the case the judge awarded TAC the status of a ‘friend of the court’. Soon thereafter the pharmaceuticals withdrew the case. In the following period, growing outrage over the lack of access to drugs sent the industry into panic. Suddenly new and larger discounts were announced, resulting in prices being slashed by up to 95%. The discounts showed just how much profit drug companies were making on life-saving medicines. TAC has maintained pressure on them to reveal what medicines cost and what their profits are.

e. National Treatment Plan
TAC’s call for a National Treatment Plan was first made in a Memorandum handed to the Minister of Health at the end of the Global March to Save Lives in July 2000. It was repeated in a memorandum to the opening of Parliament in 2001. Following the call, TAC began research work to provide the rationale and outline for the plan.

Workshops were held with practitioners, academics and NGOs to provide feedback on the ideas and flesh out the plan. This laid the foundations for a National HIV/AIDS Treatment Congress. TAC realised the eventual success of a plan depended on persuading both government and the ANC of its merits. It therefore spent a lot of time lobbying key decision-makers. Sadly, despite interest from individual members the officials did not come to the party. The Congress went ahead, hailed as one of the most representative meetings on health, resolving to refer its demand to the National Economic Development and Labour Council (NEDLAC), in the face of government’s stone-walling. NEDLAC is a statutory negotiating forum between representatives of government, labour, business and the community.

A framework for a treatment plan was hammered out by participants, but the process was then stalled by the Minister’s opposition.

Throughout this process TAC leader, Achmat, went public on his refusal to take ARVs until they were available through the public sector, despite his declining health. This caught the attention of the previous President, Nelson Mandela, providing new impetus and publicity to the fight for treatment. Achmat finally conceded to take drugs, once the government had made a commitment to rolling out a large-scale treatment programme through the public health sector.

Frustrated with National Government’s intransigence in signing the Framework Agreement for a National HIV/AIDS Prevention and Treatment Plan, TAC launched a civil disobedience campaign in March 2003. It was felt that non-violent civil disobedience was the only option left. The demands of the campaign were:

• Commitment to a public sector ARV programme
• Commitment to signing the Framework Agreement

In the first week of action, TAC members handed over documents charging the Minister of Health and the Minister of Trade and Industry with culpable homicide for failing to issue compulsory licences. Activists refused to leave police stations until the two Ministers were arrested. In Sharpeville a charge document was opened and members agreed to disperse. In Cape Town members were arrested and then released. In Durban police sprayed tear gas to disperse the crown and used water canons on demonstrators, resulting in the hospitalisation of a number of volunteers.

The action was supported with innovative posters and media releases.

On 24 April, International Day of Action, the second action took place. Demonstrations were held without permission, again with mixed reactions. This was supported by demonstrations around the world. For example, in Nairobi activists held a press conference. In Tokyo, 600 paper cranes, representing the 600 people a day dying of AIDS in South Africa, were handed over to the South African Embassy. In Amsterdam 600 red tulips were handed to the Embassy. In Los Angeles, London and Milan 600 pairs of shoes were placed before the Embassies.

The civil disobedience campaign generated a huge amount of activity over a short period of time and added to the public pressure on the government. With the adoption of the Operational Plan for Comprehensive Treatment and Care for HIV and AIDS on 19 November 2003, TAC formally ended its civil disobedience campaign.

Lessons

Campaign plan
Every successful campaign needs a clear analysis of the problem, a clear campaign goal and a well thought out plan that takes into account the local context and the organisation’s resource base. The TAC effectively identified the problem and a solution, and has focused on creating the political will to implement the solution. The campaign objective was always been clear – affordable treatment for all. TAC successfully identified supporters (HIV+ people, NGOs, unions), potential supporters (the medical profession, academics, officials), opponents (government and the pharmaceutical companies) and potential opponents (ANC). It worked on each group to win them over. At different times, different tactics and tools were used. Throughout all these actions the message was consistent.

Finally TAC continually expanded its support base by appealing to the public through personalised heart-rending stories about TAC members. In particular, people responded to the human angle and the drama contained in media coverage of Achmat’s declining health and his continuing refusal to take drugs until the Government committed itself to treatment for all. This was accentuated further by coverage of visits by Mandela to the ailing Achmat, with parallels being drawn between the two activists’ principled stands, demonstrating the power of public support by a high profile figure.

Networks
One of TAC’s real strengthens has been its network. Locally in South Africa TAC forged an alliance with the biggest trade union federation, religious leaders and NGOs. Every time it took a step, with the exception of civil disobedience, it brought these partners along with it. Internationally, TAC mobilised activists around the world to support its campaign and put pressure on the government. This meant that each time government failed to respond, the whole world knew. This proved to be deeply embarrassing for the South African government.

Lobbying government
While TAC has been in almost constant conflict with certain Cabinet members, it has maintained contact and collaboration with senior officials. In short, TAC has in the main managed to walk the advocacy tightrope. Whilst on the one hand it would threaten government with direct and legal actions, on the other hand it would offer government a partnership, research and rational arguments to complement the protests. For example, its support for government around the Medicines and Related Substances Control Act on the one hand, and its court case against government to secure mother-to-child-treatment on the other hand.

Wherever possible, TAC has used formal processes. It has made presentations to Parliament. It has participated in task teams. It turned its calls to the negotiating forum NEDLAC. This, combined with the direct action, led to the final victory around treatment.

Direct action
Marches, heckling, sit-ins, graffiti, walk-outs, breaking laws, treatment strikes and finally civil disobedience have all formed part of TAC strategy over the years.

Initially the organisation focused on more conventional forms of action – marches, pickets, etc. But in the face of government’s lack of action they became more assertive, heckling the Minister at meetings and walking out of presentations. Parallel to these actions, the leader of the organisation went public on his refusal to take ARVs until every South African citizen had access to the drugs. Finally in 2003, after five years of discussions, negotiations, public actions and litigation, the organisation resorted to civil disobedience.

TAC found that generally society welcomes a social movement that is skilful, loud and non-threatening as a victory for democracy. But there is greater ambivalence when the poor do away with decorum, display anger and break the law. This ambivalence was reflected in even TAC’s staunchest allies – the unions and religious leaders. Both refused to support the civil disobedience campaign. While this ambivalence was not shared by TA’s mass membership, who wanted an end to the political prevarication, the lesson for TAC and other campaigns is that civil disobedience can only ever be a last resort and needs to be very carefully considered.

Research
Research underpinned TAC’s proposals and recommendations, enabling it to win over practitioners and academics in the field. The research also provided a platform for engaging officials.

Using the law
South Africa’s Consitution provides one of the most progressive social and economic rights frameworks in the world. TAC used this to their advantage when they used the legal process to enforce people’s right to treatment. But as TAC discovered, winning a judgement is just the first step. Too often governments do not honour the judgement. Implementation needs to be carefully monitored and any transgressions brought into the public eye. This requires a pool of activists on the ground working alongside the legal team. Thanks to its mass base, TAC was quick to react against government’s non-delivery with its complaint to the Human Rights Commission.

Media strategy
The media has been one of TAC’s key vehicles from day one. It has planned events to capture and maximise media coverage, using this to spread their message. TAC’s focus on creative actions has been an important part of its media success. It has provided stories of real people’s struggle for life and through this, built up a core of ‘friends’ in the media who work with TAC. Where necessary it has used high profile people to carry its message forward.

Leadership
Last but not least every good campaign requires excellent leadership. TAC has benefited from the inspired and inspiring role of its leader, Zackie Achmat. He has provided the strategic leadership and courage to take difficult next steps each time the campaign has reached a stalemate. As important has been the role of the rest of the leadership team who have provided the management direction and capacity to realise TAC’s visions.

This case study has been extracted from TAC materials and publications. For more information on TAC see www.tac.org.za

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