Book Review: “Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa” by Claire Laurier DeCoteau
In her most recent book, Dr. Laurier Decoteau eloquently traces the politics of HIV and AIDS from 1994 through 2010 in Post-Apartheid South Africa. She describes important shifts in health policy and nestles them in real-life stories of people living with HIV and dying from AIDS. Her ethnographic data, collected over ten years, highlights several key issues including the changing relationship between indigenous and biomedical health care and the complex and often contradictory way that the South African government failed to balance a neoliberal existence (i.e., political movement beginning in the 1960s that blends traditional liberal concerns for social justice with an emphasis on economic growth.) with the health needs of its citizens. A major theme throughout the book is that AIDS continues to be terrain upon which many post-colonial paradoxes are played out in South Africa.
South Africa is heralded for adopting one of the most progressive constitutions in the world. It is one of the wealthiest countries on the African continent. And yet, South Africa still maintains the ….distinction of having the highest rates of HIV prevalence in the world, and ranks among the most unequal countries in the world in ….wealth and income distribution (Page 7)
The book has five chapters, each with its own major theme. Chapter one describes the ethnographic setting for the book and introduces the reader to the challenges of living in townships and squatter camps and dealing with the effects that HIV and AIDS can have on a person, family and community. We are introduced to the author’s method of presenting her arguments and raising important issues though the use of interviewee quotes. One quote captures the essence of this chapter. “Many people think that HIV might kill them in ten years, but poverty or violence will kill them first, so why worry about it?” (Page 49)
Chapter two describes President Thabo Mbeki’s reign as President and his “AIDS Denialism”. We learn how this denialism affects people living with and affected by HIV and AIDS. President Mbeki’s main premise was that that biomedical science was couched in an imperialist paradigm and ignored the cultural and racial identity of Africans. The chapter outlines how his infusion of AIDS denialism promoted indigenous healing as an alternative to biomedical approaches, going as far as delaying the rollout of antiretroviral therapy and life-saving medication to thousands of people. The author makes the case that his neoliberal economic policies required the state to cut social services, in essence, undermining ARV rollout. We also are shown ethnographic evidence that national discourses of self-responsibility became particularly prevalent during his tenure as well as a national environment that supported the individualization of blame for the spread of HIV.
Chapter three describes the efforts of the Treatment Action Campaign (TAC), a community-based advocacy group that took on the international pharmaceutical industry and ultimately brought free ARVs to South Africa. It also reinforces how structural obstacles often impede impoverished South Africans to participate in biomedical technologies. The term “Biomedical Citizenship” is introduced and explained as we see examples of people who only have citizen rights if they have disciplined behavior to adhere to ARV medication.
Chapter four, titled “The Politicization of Sexuality” describes President Jacob Zuma’s reign and his ability to speak to poor South Africans. Because he has been described as symbolizing many traditional aspects of an African Man, this identity is used to highlight several key issues. The author argues that during this time period, deindustrialization and AIDS challenged idealized and traditional notions of masculinity and increased informalized sex. This chapter illustrates how shifts in the political economy impacted gender ideologies and sexual practices in post-apartheid South Africa.
Chapter five analyzes the relationship between indigenous and biomedical healing in South Africa. We are provided an in depth analysis of indigenous forms of healing and how they have waxed and waned during the national discourse of AIDS over time. We learn that “indigenous healing helps situate illnesses and recognizes them as composites of cultural, social, environmental, historical, economic and biological factors.” (Page 225) The book closes with a short critique by the author of “the ways in which biomedical solutions have failed to address some of the underlying, fundamental causes of the epidemic” (Page 23). She argues that her research shows how an individualized, commodified approach to treating people, without regard for safety, sanitation and sustainability, might do more harm than good.
Having lived in South Africa between 2003 until 2007, this book was a trip down memory lane. Many of the author’s arguments and many of the ethnographic anecdotes spoke to me personally. At times I felt like a professor reviewing a doctoral dissertation and wanted to pull out the dictionary for words that I had never seen. At other times, I found myself nodding in agreement of the points she made. I regularly appreciated how she challenged core assumptions of Western social science. For example, she regularly offers evidence that the international epidemiological approach and a focus on individualized biomedical interventions decontextualize behavior and ignore the structural factors that create conditions of vulnerability to disease.
The book nicely captures the nuances of government policy choices and how these policy choices affect people’s lives. I lived in South Africa during AIDS denialism; a period where drugs were available yet hindered from entering the country. I fostered an HIV positive infant and worked through the systemic obstacles to get her on treatment. It was a horrible and life-changing event. I witnessed TAC marching at the international AIDS conference in 2000 advocating for ARVs on the continent. I appreciated the author’s detailed account of TAC and although controversial, a critical organization in the fight to get services to people. I saw an entire industry develop around the production of death and was maddened that people were denied ARVs. I lived through the government fiascos that labeled the President and Minister of Health as unreasonable. I remember the reshuffling of the Department of Health in 2006 after then Minister of Health Manta Tshabalala-Msimang displayed beetroot and lemon as a replacement for ARVs at the International HIV/AIDS Conference in Toronto.
Importantly, this book serves as a reminder that ethnographic methods are an essential tool for exploring the ways in which health and disease are experienced and understood by those most affected. My friends and colleagues shared their stories of the stigma and shame that surrounds this disease. In my opinion, donors and national governments have not paid enough attention to the power of stigma and discrimination. “With all of the obvious attention paid to the genocidal level of deaths the epidemic has produced, the words of HIV and AIDS are never mentioned at funerals. The bodies are piling up, but their significance is cloaked in silence.” (Page 76). I appreciated that the author used interviewee quotes to bring important issues to the surface; no amount of epidemiologic data can capture the nuanced social and cultural issues that have an impact on HIV and AIDS.
I found myself wondering if I would appreciate the book as much as I did had I not lived the experience of working in the AIDS field in South Africa at the time. I do, however, think that this book is artfully presented and an unusual read for those working in the public health arena. It consistently connects the macro and micro levels and highlights the often complex and contradictory relationships between global processes, national policies and local practices. The emphasis on the broader system, relevant to health and disease, is critical when dealing with complex health issues such as HIV and AIDS. Professionals and decision makers working on HIV and AIDS issues could learn lessons from disciplines such as sociology and anthropology, and would greatly benefit from a broader perspective than the strictly biomedical view of the world.