Nelson Mandela’s Public Health Legacy

December 30, 2013

By Patches Magarro

Nelson Mandela is an icon revered for his role in ending apartheid in South Africa and becoming the nation’s first black president after being held as a prisoner for 27 years.

The system of apartheid was crumbling when he was released from prison in 1990. Once returned to freedom, he embraced President F.W. de Klerk, with whom he was awarded the Nobel Peace Prize in 1993. Mandela was elected president in 1994 and a year later set up the Truth and Reconciliation Commission (TRC).  Although controversial, many credit Mandela’s employment of the TRC with facilitating the healing necessary to unite the country.

The significance of the effects of Mandela’s activism prior to 1994, and of his presidency from 1994 through 1999, cannot be overestimated and are praised throughout the world. President of the South African Medical Research Council Dr. Salim S. Abdool Karim wrote in a statement shortly after Mandela’s death:

He has set us on the path of truth, the path of selflessness, and the path of freedom. His long walk was the first step towards our freedom – freedom from oppression, freedom from want and freedom from disease. We have so much more to do in fulfilling his dream. We will humbly try to continue following in his footsteps in the enduring quest for justice and freedom for all the peoples of the world.

But, Mandela has garnered less attention as a public health hero. His contributions to the well-being of South Africans and globally for his work on HIV/AIDS would be enough to earn most a place in history. He is not known for those achievements simply because his political and human rights triumphs overshadow his momentous accomplishments in the realm of health.

In the years before Mandela’s time in office, there were drastic inequities in treatment and facilities for white and black citizens in South Africa. The crowding in black delivery wards meant pre- and postpartum mothers had to lie on mattresses on the floor and share five toilets with up to 140 other patients. If an ambulance was summoned for an emergency and a white-only ambulance arrived for a black patient, it would turn around no matter how long it might take for an ambulance to arrive for a black patient. Spending was brutally unequal. In 1985, the annual per capita spending on whites was 451 Rand and just 115 Rand on blacks. Doctors were saddled with caring for victims tortured at the hands of the military—men who had suffered electric shock to the genitals or who had been burned with boiling water poured over their chests and genitals.

Then apartheid fell, and Mandela was elected.

HIV/AIDS is notably absent from his achievements as president. In 1994, the rate of HIV infection was doubling every year. Some have criticized Mandela’s administration for doing too little to address HIV/AIDS, which grew into an epidemic during his term.

Ronald Bayer, professor and Co-Chair of the Center for the History & Ethics of Public Health at the Mailman School of Public Health, wrote in a statement:

Nelson Mandela was a towering figure. He knew how to lead a struggle to tear down a vicious, racist regime using the power of mass mobilization and the targeted use of violence. He also had the wisdom to move on to challenges of building a nation that could well have descended into civil war. It is one of the tragedies of his life that his new government so filled with promise presided over the explosive escalation of the world’s worst HIV epidemic exacerbated by the blind and utterly incompetent leadership of Thabo Mbeki, Mandela’s successor as President.

However, once he stepped down from office, Mandela did focus his efforts on HIV/AIDS, and in 1999 he founded the Nelson Mandela Foundation. On World Aids Day in 2000, Mandela pronounced, “Our country is facing a disaster of immeasurable proportions from HIV/AIDS. We are facing a silent and invisible enemy that is threatening the very fabric of our society. Be faithful to one partner and use a condom… Give a child love, laughter and peace, not AIDS.” Michel Sidibe, head of the UN’s AIDS agency UNAIDS, praised Mandela: “His influence helped save millions of lives and transformed health in Africa… he used his stature and presence on the global stage to persuade world leaders to act decisively on AIDS. His legacy will be felt by generations.”

Mandela delivered a speech to the International AIDS Conference in 2000 that Francoise Barre-Sinoussi credits with directly influencing the progress against HIV/AIDS. The Nobel Prize winner who co-discovered HIV said, “As a direct result of his speech, mother-to-child transmission in the region almost immediately became a priority and so did access to antiretrovirals. I have no doubt that his words that day did indeed save the lives of so many people and continue to do so.”

Dr. Zena Stein, professor emerita of epidemiology and psychiatry at Columbia University, and Dr. Mervyn Susser, former chair of epidemiology at Columbia University, are South African-born and life-long anti-apartheid activists. Both were medical students at the University of Witwatersrand while Mandela was attending law school there and shared the platform at an anti-apartheid meeting with Mandela and others. They, too, recalled Mandela’s International AIDS Conference speech as a seminal moment when his influence served to counter the failures of then-President Thabo Mbeki, whose inaction was decried by AIDS activists. Stein said, “On that day, he held his head up and held the issue up.”

Mandela’s support went beyond speeches. In a memorable demonstration of solidarity, Mandela publicly donned a white T-shirt with the phrase “HIV Positive” in 2002. A small act had it been committed by a lesser-known figure, wearing the T-shirt was elevated to significant advocacy because of his global stature.

In 2005, Mandela made a most personal declaration demonstrating his commitment against stigma. He called reporters to his home to deliver the simple message, “My son has died of AIDS.” His openness to discussing the disease and to fighting the taboo and stigma, which significantly exacerbated its spread through South Africa, was certainly among his greatest contributions to the fight against HIV/AIDS. He bravely urged, “Let us give publicity to HIV/AIDS and not hide it, because the only way to make it appear like a normal illness like TB, like cancer, is always to come out and say somebody has died because of HIV/AIDS, and people will stop regarding it as something extraordinary.”

His legacy will shape progress in South Africa and beyond far into the future. In the following reflection, Stein and Susser consider the role of Mandela in health and history:

In all that is being written in media around the world today to memorialize the death of Mandela, it is appropriate to search amid the many fine actions of thousands of men and women, courageous, committed, across the world, ex-prisoners, victims, who played their parts in achieving the miracle that ended apartheid in South Africa, what could we say was the unique contribution of this one man?

I point here to just one, and this is an example of his leadership: and this you can understand better if you read the long speech he made at the Rivonia Trial in 1964, when he and fellow trialists were convicted of treason and sentenced to life imprisonment. He describes here his set of demands for a new South Africa, famous especially for the last four lines:

‘During my life I have dedicated my life to the African people. I have fought against white domination and I have fought against black domination. I have cherished the idea of a democratic and free society in which all persons will live together in harmony and with equal opportunities. It is an ideal for which I hope to live for, and it is an ideal for which I am prepared to die.’

Unlike the famous sparse lines of Lincoln at Gettysburg, this conclusion was preceded by a speech of four detailed hours of great importance to public health and social equity. But the circumstances and meaning of this manifesto, by a man risking the death sentence, have lived after him and inspired those who fought with him and the generations living after him. And the spirit of harmony, its freedom from bitterness and revenge is his true legacy: not all of his hopes have been achieved but they remain as a guide from a great leader.

It is through his influence that others continue to fight for equity and improvements in public health that make up but one part of his immense legacy.

This article originally appeared on 2x2 Project, sponsored by the Department of Epidemiology at the Mailman School of Public Health.