Unimagined Community: Sex, Networks, and AIDS in Uganda and South Africa. Robert J. Thornton.
University of California Press, 2008.
On the morning of November 5th, I dragged myself to the London School of Hygiene and Tropical Medicine in a state of exhausted euphoria. One of my colleagues had asked during the first week of term if I wouldn’t mind examining his student’s MPhil thesis and I agreed, failing to make the obvious connection with the date of the U.S. election. It was, at least, an interesting proposal. Drawing from his experience of working there as a medical doctor, the student planned to investigate the feasibility of Uganda’s Antiretroviral Treatment (ART) rollout strategy as a case study for Sub-Saharan Africa. Like many states in that region, Uganda suffers from a critical shortage of adequately trained health care workers. In the hopes of maximizing therapeutic access, the government will legally empower nurses to initiate and deliver ART. The problem, as the student saw it, was that there was little evidence on whether or not the nurses would be able to handle the subtle adjustments an ART regimen required and further, whether or not this task-shifting is something doctors, nurses and clients would accept. His PhD research proposal, therefore, focused on two key aspects of the program: the nurses’ technical competence in administering therapy and the acceptability of that care to clients. His analytical framework hinged upon producing indicators of Quality of Care (QoC), a slippery concept that encompasses technical standards, patient priorities and cost-effectiveness. Methodologically, this meant using a range of evaluative and descriptive instruments: vignettes developed by local ‘experts’, questionnaires, interviews, and focus groups with patients, doctors and nurses.
After two hours of sleep (last time, I went to be bed thinking Kerry had won), I was struggling. I simply could not get my head around the links being posed between competence, acceptability, quality and programmatic feasibility. From my rather limited experience with HIV/AIDS in Tanzania it seemed that patient compliance had much more to do with having the financial resources to get to the clinic than the nature of the care once they got there. Would QoC really say anything about the trajectory of HIV/AIDS in Uganda, let alone in Africa? These concerns were deemed by my colleagues as outside the scope of the project. The point, they reminded me, was to render visible the mechanisms through which resource-limited governments manage the disease, an objective that could be achieved by focusing on clinical attitudes.
I have taken the long way round to Robert Thornton’s excellent monograph and if you’ve stayed with me thus far my thanks. The greater relevance of this thesis will, I hope, become more evident. For now, I just want to stay with the confusion its units of analysis provoked. My main problem was with their aggregative dimensions: adding nuance to the issue of therapeutic access meant reframing issues of patient adherence as a collective experience of public health services. Providing the inductive steps between individual motivation and large-scale organization is one of Unimagined Community’s great achievements. Thornton’s analysis begins by rejecting notion that changes in individual health-seeking behaviours say very much about the epidemiology of the virus. Instead, his ethnographic attention is directed to the sexual network: HIV incidence and prevalence, Thornton argues, must be understood in terms of the links between groups of people that either promote or inhibit its transmission.
In the context of world health policy focused on education and awareness, his position is quite radical. It is also runs against the grain of anthropological research particularly the kind generally conducted in public health settings. Though Thornton grounds his study in personal meanings and experiences, Thornton’s pursues AIDS, a la Durkheim, as a social fact. At a point at which anthropologists have supposedly left the study of ‘peoples’ behind – (according to George Marcus, “ethnography is predicated upon attention to the everyday, an intimate knowledge of face-to-face communities and groups” (1999: 82)), Thornton returns us to the problem of aggregation and the constitution of the community.
To make this move, he uses another classic frame of anthropological research: comparative analysis. He juxtaposes Uganda and South Africa, two countries whose experiences of the epidemic are radically oppositional. Uganda, the site of some of the earliest HIV/AIDS cases in Africa and at one point considered the worst affected place in the world, is now currently held up as model for the containment of HIV prevalence. South Africa, with the strongest public health system on the continent, on the other hand, remains crippled under the weight of an epidemic which shows no sign of waning.
Why this difference? Thornton first turns to history: Uganda was a British protectorate and never a colony. This meant that kingdoms, tribal associations, marital practices and land tenure remained relatively stable for centuries. These isolated, yet strongly linked groups were reinforced by the political unrest of post-independence. Idi Amin’s dictatorship had the effect of bringing development to a halt; limited job opportunities kept people away from urban centres and violent attacks by the National Liberation Army (LRA) precluded most cross-country travel. After Amin’s exile, the Museveni government restored power to kingships, in an effort to stabilize the political landscape through local solidarity. In contrast, over the last two centuries, South African society has been relatively integrated. Despite the segregation enforced during Apartheid (and indeed, as Thornton points out, because of it), most South Africans are highly mobile and live in multiethnic communities. The struggle against apartheid, moreover, fostered a commitment to equality and autonomy: collective identity in South Africa is a product of political action and not of geography. Economic developments and improvements in infrastructure have enhanced the dense and interconnected nature of that social landscape.
One can begin to detect some of causes for difference in the efficiency of disease transmission between the two countries. However, Thornton’s analysis is more finely-grained than the number of connections in sexual network. The second chapter of the book looks in mathematical depth at epidemiological trends. Unlike most other viral and bacterial epidemics, HIV does not progress exponentially. Transmission is irregularly distributed through social structures and is highly periodic (an individual viral load decreases over time); rates of HIV prevalence and incidence, therefore, not only depend on the number of connections but also the ways in which those connections are made (36). Because South Africa’s networks involve many and multiple points of connection across wide spaces, transmission functions the way the internet does, becoming denser as the network grows. Alternatively, in Uganda, the connections within groups are greater than those between them. Thus, while infection at the ‘nodes’ can be quite high, the cross-links in Ugandan’s sexual network are minimal. This “lumpy” or “fractal” character means that while incidence will shoot up during the start of beginning of the epidemic, the clusters of sexual activity are easier to isolate. The upshot is that while they would do little for transmission in South Africa, changes in the individual behaviour of Ugandans can have an impact on epidemiology.
Negotiating the Scylla and Charybdis of accurate statistics and ethnographic robustness is tricky business: once you challenge the empirical foundation of the Gaussian curve it becomes rather more difficult to speak authoritatively about the collective. For instance, one could site Tim Allen (LSE), an anthropologist who has recently made the case against using Uganda’s experience with HIV/AIDS to develop insights about the virus in general (2005: 1-22). Having conducted ethnography among Internally Displaced Persons (IDP) in the camps in the north, Allen questions the reliability of data which shows that AIDS in Uganda is, indeed, declining. He reminds us that for the most part, public health data across Africa is derived from antenatal surveillance. This method of data collection poses several problems: HIV positive women are less likely to become pregnant, surveillance is more concentrated on peri-urban and urban areas and it excludes the numbers infected by non-sexual practices. The myths about decline only reinforce myths about how HIV/AIDS is spread. Based on speculative claims, Allen argues that prevention and treatment policies will prove ineffective and potentially counterproductive.
But regardless of whether or not Uganda presents a success story in the international struggle against AIDS, Thornton’s efforts to focus global public health on sexual networks has profound policy implications, which I believe, Allen would support. First and foremost, it reframes prevention as a problem of social structure rather than one of individual behaviour. This means privileging the everyday relevance of local norms rather than the moral message of ABC campaigns. There is a reason why Levi-Strauss insisted that mathematical and statistical models be treated separately: belonging to different orders of description, individual attitudes cannot be used to prove nor predict collective experience.
Moreover, turning to the shape of the network asks us to think about the relationship between AIDS and national identity. At the heart of Unimagined Communities is a fascinating argument about the ways in which political action can both advance and retard containing the epidemic. Due to its early emergence in Uganda the virus was given a local disease category (slim) before it was reclassified as AIDS. The effect of this categorization was that AIDS became a part of family history and a feature of community problems: deaths occurred among those one knew, their children taken in by neighbours and their graves were built within compounds. In the wake of Idi Amin, AIDS became linked with the country’s wider social political and economic troubles. Thornton suggests that the parity of the AIDS struggle with that of national development has had the affect of integrating prevention of AIDS within a discourse of social progress.
We are familiar with Mbeki’s denial of AIDs and the consequences of his etiological theories to the spread of the disease. What Thornton adds to our understanding of the role of the South African politics is the negative impact of the activist response. The fight for AIDS recognition, he argues, was cast with the same moral outrage expressed against the racist policies of apartheid. Rather than encourage widespread political mobilization, HIV activism rearticulated the tensions between government and society and entrenched the exceptional status of the infected (158). As opposed to Uganda, in South Africa, HIV/AIDS never ‘belonged’ to the people. In short, imagining the HIV/AIDS community can be done in more or less productive ways. Tied to a civic imagination, the epidemiological reality of the virus touches ground. Rather than a pandemic, a dark scourge on the political consciousness, a spectre of development’s failures, AIDS is a concern of and for the public. Countering its spread requires a social imaginary that, Thornton suggests, “can unite the larger scale political order with the small scale personal experience of sex, illness and death.”
One might also want to reverse the order of those scales (thanks JL!). The opposition between the particularity of civic language and the collective experience of death are what Benedict Anderson identifies as one of the formative sensibilities of nationalism. What real or imagined connections produce nationalist sentiments today, I would argue, requires some serious analytical attention. The day of the election I received a jubilant email from a Kenyan PhD student I had worked with while I was in Tanzania. On the topic of Obama he writes: “how great can our people be! How great is our nation”. As Thornton beautifully demonstrates, what constitutes “our” carries implications for global public policy, medical research practice, and international protocols of scientific accountability.