Trust and distrust in Kwazulu-Natal

Confucius apparently once said that three things are needed for government: weapons, food and trust. But not necessarily in that order. A government can still rule if weapons are scarce and food is rationed, but loss of trust is fatal. When people don't trust each other, when they treat each other as unreliable, cooperative projects falter. The more distrust, the more relationships and institutions start to unravel. On the other hand, a surplus of trust -- what is perhaps better described as reverence -- is not healthy either. Those that are trusted (particularly those in positions of authority) might well not be trustworthy, after all. Too much trust gives too much power, and too much power is often abused.

These loose thoughts about trust came from reading about the latest misadventure of the Kwazulu-Natal Department of Health in South Africa. Kwazulu-Natal is the epicenter of the HIV/AIDS epidemic in South Africa, with 16.5% of its population over the age of 2 being HIV positive. Over the past few years, there have been a number of ugly conflicts between the Department of Health and those in the field delivering HIV/AIDS prevention, care and treatment. Not long ago, Dr. Colin Pfaff at chief medical officer at Manguzi Hospital, was suspended by the Department of Health for raising money to provide dual therapy (neviripine and AZT) to prevent transmission of HIV from pregnant women to their children. Although sufficient evidence for the effectiveness of dual therapy existed, the Kwazulu-Natal Department of Health had been dragging its feet on the issue for years, citing budgetary constraints or lack of feasibility. It may well have been that Dr. Pfaff's initiative exposed the Department's responsibility for preventable transmission of HIV to children, i.e. that they were asleep at the wheel. In any case, after an massive outcry, the Department reinstated Dr. Pfaff.

Now it is the turn of Dr. Mark Blaylock. He is accused of something apparently trivial, but actually more profound. At a launch of dual therapy back in February, the head of the Department of Health (Peggy Nkonyeni) saw fit to attack the integrity of those who would implement the therapy and question their motivations for expanding HIV prevention options for pregnant women. More specifically, doctors who had pushed for dual therapy in the past were accused of wanton behavior, being opportunists, creating anarchy and caring more about money than about the health of rural populations; at the same meeting, she even managed to cast doubt on the benefits of the very therapy she was there to launch. Soon afterward, Dr. Mark Blaylock apparently reached his limit, and tossed a framed picture of Ms. Nkonyeni into a trash can. For which he received a letter formally charging him of misconduct, having acted in an 'improper, disgraceful and unacceptable manner' towards the head of the Department of Health. Dr. Blaylock was sentenced to a month's unpaid leave, but he is reportedly taking permanent leave. While Kwazulu-Natal cries out for doctors, he has had enough, and is apparently heading off to Canada.

The incident exposes the level of distrust among those involved in fighting the AIDS epidemic in South Africa. All the infighting is bound to make a bad situation worse. But part of the problem has to do not with trust, but with reverence. The Department of Health in Kwazulu-Natal seems to think that any criticism of its policies is an act of betrayal, and by implication, that its recommendations ought to be accepted on faith. Dr. Blaylock was ultimately punished for having desecrated Ms. Nkonyeni's image, but the question is why the image should be considered 'sacred' in the first place. As a holder of public office, Ms. Nkonyeni is a servant of the people and open to criticism by the people. She and her Department should be taken to task -- loudly and publicly -- when it undermines trust in effective HIV prevention and the commitment of the men and women who labor daily to implement it.

Dr. Blaylock created a potent image by sticking Ms. Nkonyeni's likeness in the garbage. Of course, the phony sanctity of Ms. Nkonyeni can be exposed in other ways: she is currently under investigation for the purchase of a mammogram machine at three times the normal price, and she is alleged to be having a relationship with the head of the company from which the machine was bought.