GOEDEHOOP, South Africa — The sky is purple, just after dawn, and the air is still chilly in the veldt spring. A couple of hundred miners are milling around above the shaft elevators at Goedehoop Colliery. The miners wear thick green coveralls, white hardhats, big rubber boots. Some are young and lean; many are old and grizzled. They get their morning briefing: who's working where, lights are burned out here and cables aren't running there, what the day's targets are — all that, and a couple other things: One hundred per cent of employees who came back from leave last week volunteered to test for HIV, the supervisor tells them in Fanagalo, the miner's dialect that is a hybrid of South Africa's 11 languages. More than 8,000 condoms have been given out this week. He also tells them how to recognize and prevent tuberculosis, which is the main killer of people with AIDS.
This is not a special health bulletin, a message from the AIDS committee. Just like equipment updates and shaft closing warnings, information about HIV goes out in Goedehoop's every single interaction with its 2,000 employees. “It's been incorporated entirely — it's a factor in this business, like the price of coal or the strength of the rand,” said John Standish-White, the mine manager.
And as he stands in the roar of the mine yard, it's not difficult to understand why: One in five of the miners climbing into the steel-cage elevators has HIV (in other sections of Anglo American PLC's operations, the figure is one in three). This astronomical infection rate is a legacy of the migrant labour system on which the mining industry, still the backbone of South Africa's economy, was built, and it is more than a minor problem. “No one is going to say, ‘18 per cent of your work force has got HIV, oh bad luck, have a tissue' — this plant's got to run, there are trains waiting,” Mr. Standish-White said, gesturing toward the boxcars lined up at the bottom of the chutes for the day's haul of coal.
At the Goedehoop Colliery, two key things happen to keep those trains pulling out of the yard each day. First, there is a newly messianic drive (with incentives including T-shirts, gift packs and an annual cash bonus) to get employees to test for HIV at least once a year — only 5 per cent of the work force tested in 2003, before the drive began; last year it was 96 per cent And so far this year, 84 per cent of workers have tested again.
Coal miners at the Goedehoop Colliery in South Africa. Goedhoop is a division of the Anglo Group which has developed pioneering anti-AIDS programs in response to a 25 per cent HIV infection rate in its work force. (John Morstad/The Globe and Mail)
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Then, anyone who tests positive is enrolled in a care program that includes, if the person is sufficiently ill, anti-retroviral (ARV) treatment. There are 135 Goedehoop employees on the drugs now.
“All those guys on [ARVs] are back at work; they're not going to die,” said Mr. Standish-White. Die, or cost the company anything in terms of lost hours, missed targets or disability benefits.
It's all part of Anglo's comprehensive HIV-AIDS management plan, which is, in the opinion of both industry and many public health experts, far and away the best in the world. Now, after years where the mining company was the undisputed leader in its response to the disease, many other businesses are catching up — but they're doing so just as Anglo is grappling with the fact that managing AIDS at work is much, much harder than even their worst-case projections imagined.
By the late 1990s, Anglo knew it had a problem: It was starting to feel the impact of illness and death due to AIDS in its work force. Mining, with its reliance on the physical labour of young men — the worst-affected demographic — was the industry hit hardest. Anglo, with about 121,000 employees, was staring a crisis in the face. HIV infection in Botswana, where the company had huge diamond mines through its interest in De Beers International, was 37 per cent of adults; in Lesotho and Swaziland, the source of a vast pool of labour, it was 39 per cent. In South Africa, 600 people were dying of AIDS each day.
And while it was a looming disaster for Anglo, no business of any size was immune to what the disease was doing to Africa, just at the time that the international community was extolling private sector growth and foreign direct investment as the best way to end poverty. AIDS was exacting enormous costs from business — in everything from absenteeism to death benefits, plus intangibles such as low morale — and the spiking death rates were narrowing not just the labour force but also markets. Health economists were predicting that the disease could cost economies in the region as much as 1.5 percentage points of their growth per year.
Anglo had had an AIDS policy since the late 1980s — when it first became apparent that the disease could be a problem for mining, which in this region involves bringing hundreds of thousands of men from their rural homes to live in single-sex hostels at mine sites, where the sole forms of recreation are often drinking and commercial sex. The company pushed prevention messages and made condoms available. But it didn't work — or at least, not well. By the end of the century, some mines had HIV prevalence rates of 30 per cent.
Anglo's senior managers started to think about treatment: The experience of the developed world made clear that anti-retroviral drugs could turn AIDS from a death sentence into a chronic illness, and could have all those gaunt, gasping young men who were dying in their late 20s back at work. But at that point, the drugs cost as much as $12,000 (U.S.) per patient per year — or twice the salary of the average miner — and they have to be taken for life. It was an enormous burden for a private industry to take on; AIDS, the perception ran, was a health issue, and health services are best provided by government.
Except government wasn't. In most African nations, governments starved of both cash and skilled personnel could not dream of offering ARV therapy to people with AIDS. South Africa had the money, but it also had a president who had labelled the drugs “toxic” and was blocking the health service from providing them.
Enter Brian Brink, a soft-spoken, self-effacing South African doctor who has spent his working life with Anglo, first as a physician at a mine hospital and these days as the senior vice-president for medical affairs. Dr. Brink was convinced that treating employees with ARVs would ultimately save the company money (a conviction that grew as pressure from AIDS activists and developing country governments forced pharmaceutical companies to slash the drug prices). He argued in meeting after meeting that the company had an obligation to do it regardless. “It was a moral imperative,” he said. “There was life-saving treatment available and we could not be withholding that when it appeared affordable.”
It took two years. He wore them down. “Brian is the real hero of this,” said Richard Holbrooke, who heads the Global Business Coalition on HIV-AIDS, a network of 200 companies around the world. “He and Tony Trahar have been leaders in showing the world what a company can do.”
When Mr. Trahar, Anglo's chief executive officer, announced in August, 2002, that the company would provide free ARVs to employees with AIDS, the decision electrified the mining world, stunned businesses across Africa, and rattled South Africa's government, which was still insisting it didn't trust the drugs and couldn't afford them anyway. “Anglo's pretty conservative, a lumbering giant,” Dr. Brink acknowledged with a grin. “If Anglo was going to do it ... .”
Today, Anglo's experience with four years of AIDS treatment has redefined the debate in Africa. “The benefits outweigh the cost and we've got data to prove it,” Dr. Brink said. In the 12 months before and after the introduction of AVR therapy, sick leave at Anglo fell 69 per cent and total absenteeism was down 53 per cent. “The death rates are coming down and I can tell you, it's not due to fewer accidents.” Tuberculosis, for example, once a leading cause of deaths for the company, has dwindled to almost nothing.
The companies providing treatment quickly find other benefits, such as boosted worker morale and an overall lower prevalence rate. DaimlerChrysler South Africa began offering treatment to its 4,000 employees in South Africa in 1999 through its health plan. In 1998, HIV became the biggest cause of employee deaths at the company, and the directors realized it might behoove them to listen to people such as Clifford Panter, the manager of corporate health services, who had been pushing for an AIDS policy since 1991. But Dr. Panter understands the delay.
“You've got to feel it, I think, and some organizations have higher capacity than others [to carry on before they] feel it. But DaimlerChrysler is developing new business in the same places HIV is growing — India, China, Russia and South Africa, that's why it makes sense for us.” He believes that it is precisely because Daimler started early that its work force prevalence, of about 10 per cent, is lower than that in the surrounding population, which is estimated to be at least 15 per cent.
Today, it costs Daimler $150 (Canadian) a month for each of the 384 employees and dependents on ARVs. Drugs are a small part of that; there are also lab and hospitalization costs. But Dr. Panter, like Anglo's Dr. Brink, says it's a money saver. “There's still this question out there in South Africa about whether treatment is cheaper. All our numbers show definitively that treatment is cheaper than not for a health plan — it's much more expensive in the long run to treat the consequences of HIV than paying for counselling and treatment, getting people in early. The bottom line is that AIDS will cost the business, in death benefits and health plan [expenses], two to five times salary.”
Daimler has been singled out by AIDS organizations here for pledging to continue treatment for employees who are laid off. One of the biggest criticisms of most corporate programs, including Anglo's, is that employees who quit, get fired or are laid off, lose their access to the drugs, which means that unless they can pay for them privately, or survive the months-long waiting list at a public clinic, they will likely fall ill and quite possibly develop a drug resistance. Daimler also offers treatment to HIV-positive family members of employees through its health plan; Anglo does not and that has been one of the great debates at the company.
“We can't make an undertaking to employees that if you leave for any reason [we] will continue treatment,” Dr. Brink said. “That creates a liability — the actuaries would sink us.”
Mr. Holbrooke singled out diamond giant De Beers, the South Africa-based energy company Eskom, Coca-Cola Ltd. and Daimler as leaders in the response to AIDS in Africa. “It's all very encouraging — but I just will tell you, it's a drop in the bucket against the size and dimensions of the problem.”
An estimated three-quarters of businesses in southern Africa now have an HIV-AIDS policy, which includes a commitment to provide employees with prevention information and, in some cases, a non-discrimination clause. There is a tangible sense that this is an issue no business can regard solely as a health question — for example, the MBA students at Johannesburg's University of the Witwatersrand, the premier business school on the continent, do a compulsory module on how to manage a company in a climate of HIV and AIDS. Yet the South African Business Coalition on HIV-AIDS reported in 2005 that fewer than 10 per cent of South African companies offer treatment to employees, and Mr. Holbrooke says South African businesses are the regional leaders, doing far more than industry in neighbouring, much poorer nations.
“The majority of people in business still say, ‘It's not our problem,' ” he said. “They look first at the balance sheet and not intangibles, and health is always a drain — health is the bête noire of business. So we have to convince them that even though there are other serious diseases — malaria and TB — and some kill more people, AIDS is different because of this pathology, the incubation period where it lies dormant in the body and people can spread it ... . But the truth is that the overwhelming majority of workers in southern Africa work in very small enterprises which do not have the financial capability to give free testing, counselling and ARVs.”
Dr. Brink, however, disagrees. “I just don't buy it that some businesses can't afford to do it. You can afford to respond to AIDS — I'm not saying you can afford to pay for treatment. But you can give your employees time off for testing, you can pay for testing, you can get them to treatment. It's more and more available in every country. You can get them to a place where treatment is available. Whether you're a big business or a small business without health service delivery, your obligation is to make sure the AIDS issue is being addressed.”
Dr. Panter said he believes many businesses that rely primarily on semi-skilled or unskilled labour aren't yet feeling the impact of the disease because, with regional unemployment rates running at 50 per cent, there is a “vast pool” of labour on which to draw. Dr. Brink, however, rejects the idea the businesses can simply keep replacing employees who die of AIDS. “It's about valuing each and every employee. The idea that people are not skilled and can be replaced is not compatible with good business.”
Today, Anglo has 28,000 HIV-positive employees. Every month, 150 of them begin ARV therapy through Anglo's own health service. The system involves streamlined treatment guidelines in multiple languages, a sophisticated drug-tracking system and eagle-eyed monitoring and data collection on every patient's progress. A gleaming model of private sector efficiency, it is the envy of governments across the region. (Because mines were historically located in remote areas, they provided their own health services, which has made it easier for them than many other businesses to provide treatment.)
The AIDS program cost $2,328 (U.S.) per patient in its first year, of which drugs accounted for 30 per cent, lab services 20 per cent, personnel 40 per cent, and the remainder for related supplies. Dr. Brink says the cost per patient has dropped since then, by up to a quarter in some facilities, because of economies of scale, and he expects it to keep falling.
“There are a hell of a lot of people who are here who would not be here,” Dr. Brink said. “All those people we've started would have been dead in two years — instead 8 per cent are dead. That's way, way, way less deaths than without treatment. And the vast majority of people who are on treatment [97 per cent] are at work. That for me is a good figure.”
And yet Dr. Brink fairly quivers with impatience when he talks about the program. Of 7,072 employees with sufficiently advanced AIDS to require the drugs today, 3,250 are on them. “Is it good enough? No it's not good enough. So we've got 3,250 — it's not big enough.” The missing half, Dr. Brink said, is not because the company cannot accommodate them, but because many sick employees are still not coming forward to test or to enroll in the program, most of them kept away by the huge bundle of shame, fear and discrimination that dog people with HIV and AIDS here.
Equally frustrating for Dr. Brink, three-quarters of the employees on the drugs started to take them when they were in stage 3 or stage 4 AIDS, the point when a person is very ill. In other words, they waited until a point when the disease had likely already had a significant impact on their productivity and absentee rate. This hasn't changed since the company enrolled the first patients in October, 2002. “That says to me we're not making [enough of] a difference,” he said.
He believes they should be catching them much sooner — hence the drive for testing at Goedehoop and across the company. “We've gone to the managers and said, ‘create a climate and get that done.' ” That means making sure people are certain their test results will be confidential and that testing is efficient and done in an environment of trust, care and support, he said. So now at Goedehoop, for example, nurses go down into the mine shafts and offer the tests right there (with Oraquick cheek swabs that produce results in six minutes). All of the mine's senior managers publicly test for HIV. Nobody on staff gets a bonus if 70 per cent of the work force doesn't come forward to be tested for HIV at least once a year.
In addition, the AIDS education staff has recruited sex workers from the communities around the mine, trained them as peer educators and supplied them with condoms. The latest target is traditional healers. “The vast majority of people we work with are not attaching equal weight to traditional and Western medicine,” Dr. Brink said. “So we need to work with the traditional healers and say, ‘You do the ancestors, we'll do the ARVs,' because I do think the psychological support is very important.”
And Mr. Standish-White took union representatives on a trip to neighbouring Mozambique, where he introduced them to people with late-stage AIDS. “We take our people to meet people like this because no one wants to believe HIV happens. We say, ‘Do you know how lucky you are to come from South Africa and from Anglo where we have hospitals? You don't need to look like this.' And then they go back and they talk.”
In fact, while unions in Africa have traditionally been wary or downright opposed to employers' AIDS plans, Anglo has their support. “It's not normal to have union leaders support an HIV program — it's rare here, because of the risk you'll be dismissed [if you test positive],” said Nick Bull, the United Association of South Africa's representative at Goedehoop. “I think one of the things that helped Anglo was that they were the first to come up with treatment: If the company is going to invest to keep you alive, that improves that relationship.”
Yet despite the push at Goedehoop, 19 people have become infected with HIV already this year. “Half the people I talk to think that's fantastic,” Mr. Standish-White said. That gives the mine rate of new infections of slightly below 1 per cent, compared with a national figure of approximately 4 per cent. Yet the mine manager is not consoled; in fact he is devastated. “We want them to say, ‘How can that happen?' If you're [HIV]-positive, fine, look after yourself. But there should not be any new infections, among any workers or their families. We've got to get there. With all that we're doing we're still not winning.”
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