The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS.
By Vinh-Kim Nguyen.
Durham, NC: Duke University Press, 2010.
Pp. 256. ISBN 9780822348740. (Paperback, US $ 22.95)
Reviewed by Betsey Brada (Princeton University)
In The Republic of Therapy, Vinh-Kim Nguyen traces responses to the HIV/AIDS epidemic in Francophone West Africa between 1994, when effective antiretroviral (ARV) treatments emerged, and 2000, a year marked by the 13th International AIDS Conference in Durban, South Africa and by “unprecedented attention to the issue of access to HIV treatments and, increasingly, the state of public health in Africa” (106-7). A physician as well as an anthropologist, Nguyen draws on his experiences working as a community organizer and consultant to international organizations in Francophone West Africa as well as his experiences as a volunteer physician in an ARV clinic in Abidjan, situating these against his medical training and clinical work in Montreal. Moving between the vast metropolis of Abidjan in Côte d’Ivoire and the smaller national capital of Burkina Faso, Ouagadougou, the book focuses on triage, the ways in which both local and international organizations responding to the epidemic “unwittingly sorted those who should live from those who could go without treatment” (6). In West Africa, Nguyen writes, triage “linked procedures for selecting people, the ways in which people seek to transform themselves, practices of ‘telling’ the truth about the self, and the paradoxical affirmation of citizenship” (109), and has “persisted in attempts to design, fund, and implement mass treatment programs in the developing world after 2000” (6). Nguyen’s first objective is to “explore and expose the obscene inequality and insidious logic” that constitutes triage, a logic that “values lives differently” (4). His second objective is to analyze the “forms of politics” to which triage gives rise, that is, a situation in which “the only way to survive is by having a fatal illness” (6). Drawing on Schmitt (2005) and Pandolfi (2000; see 2003), Nguyen argues that, “the informal and formal procedures, protocols, and policies that decide who should live that have played out in the AIDS epidemic in Africa… constitute an exercise of sovereignty” insofar as they constitute the power over life and death (6). Working across multiple scales (from individual confessions to “talking groups” and workshops to international clinical trials and multilateral organizations) Nguyen traces the ways the “technologies” (in Foucault’s sense) that link through and across these scales “constitute a kind of parallel therapeutic state” (186). This is the republic of therapy.
The book is divided into two parts. The first half, chapters 1-4, tracks back and forth between Ouagadougou and Abidjan and provides a close analysis of efforts, both local and international, to constitute and organize communities with HIV. In these chapters, Nguyen argues, we may see the seeds of “the historically unprecedented and massive global intervention into health in the developing world” (8) that has followed. Nguyen gives particular attention to “confessional technologies” (Hunt 1997), the testimonials and practices of disclosure that initially emerged as international organizations sought to give a public “face” to the epidemic, to foster acceptance among those affected by the epidemic in West Africa, and to demonstrate the effectiveness of their own programs. Chapter 1 opens with the story of one community health organization whose young founder assembled “a network of social relations where kinship relations and obligations furnished the idiom through which accountability and hierarchy could be expressed and relationships valued” (17-18). Nguyen contrasts this “moral economy” with the “ideology of patient empowerment” that had emerged in North America in the 1980s in response to perceived government inaction and public apathy (cf. Epstein 1996). Observing that “many Northern AIDS activists were hired to key positions in international organizations, Nguyen argues that the emphasis on and value of public testimonials was “a logical extension of the experience with the epidemic in North America and Europe” (26). As public testimonials of those infected with HIV became “indicators of success of governments’ national AIDS control programs and a key argument in favor of keeping aid money flowing to these programs” (31), this market for stories “disrupted existing moral economies that linked disclosure, trust, and social belonging” (33), leaving those involved in community health unsure how to receive and respond to these public confessions. Chapter 2 focuses on workshops as a primary site where international consultants attempted to foster collective “psychosocial support” for those with HIV, teaching participants to convey “empathy” through “active listening” and “open-ended questions,” using the tools of encounter groups developed after World War II. Drawing from Foucault (1985; 1998), Nguyen argues that confessional technologies “made an inner self available in new ways… as a substrate that must be worked upon” (40). While the techniques Nguyen’s informants and fellow participants learned “made certain assumptions about the relationship between questioner and respondent” (49), the workshops nevertheless provided participants with “powerful tools by which they could transform themselves and others” (40). These newly learned confessional technologies thus had consequences both unintended and unanticipated by those who promoted, planned, and implemented the workshops.
These kinds of self-transformations via confessional technologies, Nguyen argues, emerged within a broader context. In Chapter 3, he presents a “genealogy of technologies of the self and the related forms of social organization” (62) that the book documents, tracing connections “between testimonials, healing, and conversion outside of efforts to organize communities with HIV” (71). The chapter begins with William Wade Harris, an evangelical preacher who traveled across colonial West Africa in the early 20th century. Harris “set the stage for the emergence of anticolonial politics” (54) as Ivoirians, urged to abandon the old in favor of the new, took up the ideas and practices of a plantation economy that eventually gave rise to the first planters’ syndicate. Harris’ movement attuned Ivoirians to the power of “testimonials that bring awareness of gathering individual and social peril, incite hearers to transform themselves, and offer an power promise of redemption” (66). The voluntary associations of the colonial era also “furnished a space parallel to that of religion where new ways of life could be experimented with” (66), and that continued to do so in the postcolonial era as “social laboratories” for practices that “could produce new forms of social relations and even political consciousness” (70). Nguyen notes “the pervasive entanglement of religion and healing” (71), arguing that some church leaders, linking prophecy and self-transformation, “fashioned solidarity out of a highly individuated form of personhood” (74) that also supported members with material resources. These links between confession, self-transformation, and material benefit grew increasingly complex as more people learned they had HIV through recruitment for clinical trials, and some received stipends to speak about their status (76). Competition over resources and acrimony, rather than mutual support, characterized the AIDS organizations formed with the support of the state and Western “technical assistance.” This, Nguyen suggests, could only be the result insofar as the model of “coming out” and “self-help” promulgated by international development agencies relied upon the idea of that people form social relations by revealing “a hidden truth to the self” to one another, and “ignored existing networks of obligation, responsibility, and exchange that both constituted persons and bound them together” (83).
Yet, even as “coming out” placed at risk the truth and solidarity of kinship ties, it began to hold out the promise of benefits in unexpected ways. Chapter 4 examines the emergence of a “therapeutic citizenship” that “emerged in places where other forms of citizenship could not be relied upon to secure life itself” (108). Nguyen begins with the “therapeutic citizenship” of Northern activists whose willingness to take part in clinical trials “grew out of a sense of duty so that others may benefit from treatments eventually found effective” (92). He contrasts this with the therapeutic citizenship that emerged as West Africans, hoping to gain access to medical care and other resources, also sought to take part in HIV-related trials (96). The trials themselves generated a population of newly-diagnosed HIV-positive individuals, many of whom were disqualified from participating and who joined community organizations in hope of gaining support and access to resources. As the head of an organization in Ouagadougou began to receive medicines from concerned European friends, the organization’s “talking group” that seemed to model the ideology of “self-help” and “coming out” began to serve as a venue for the selective distribution of medications to “those who came regularly were more likely to observe the rigorous treatment schedules and those who “contributed” most to the group” (98-99). Thus, a person’s access to ARVs depended on his or her social networks. The connections between confession, self-transformation, and material benefit crystallized as the ability to “tell a good story” became the key to survival (99). Triage parried social relations into biological difference: For those who received treatment, “their ability to harness social resources to leverage access to the drugs translated into healthier bodies, a biological transcription of the discourse of empowerment” (101)—that is, therapeutic citizenship. The logic of triage and its biological consequences could be seen in an attempt make ARVs available to the general public in 1998 through the joint efforts of the Ivoirian Ministry of Health and UNAIDS. A lack of subsidies to cover three medications, repeated stock-outs of drugs, and an emphasis on “getting drugs into bodies” (104-6) meant that many Ivoirians received inadequate treatment, leading them to develop resistance to the medications they did receive.
The second half of the book deals more specifically with the history of Côte d’Ivoire, offering a genealogical account of the forms of politics, sociality, citizenship, and self-fashioning that structured the logic of triage in West Africa in the mid-1990s. Chapter 5 charts the development of a colonial biopolitics through biomedical and administrative technologies that constituted ‘ethnicity’ as an object of governance and spatially organized populations via urban planning policies that “materialized a differential calculus of the value of citizens that erased local notions of kinship” (113). This colonial biopolitics through which the metropole enacted sovereignty “shaped urban life and the forms of tactical citizenship that emerged” (113), laying grounds for the “newer, nongovernmental biopower” (114) that would emerge with the HIV epidemic. Chapter 6 examines how the collapse of the Ivoirian economy and the subsequent erosion of national sovereignty gave rise to “a logic of rationing and competition” (136) and to a form of citizenship “increasingly located… in the realm of self-fashioning” (135). As economic policy in Côte d’Ivoire gave way to the structural adjustment policies of international financial institutions, Ivoirians’ “tactics for disciplining body and mind” in the face of pervasive impoverishment shaped “the cultural logic of self-transformation” (138) that, in turn, shaped the ways Ivoirians took up the confessional technologies explored in the book’s first half. Chapter 7 offers a genealogy of practices of intimate disclosure in the context of the “zero-sum logic of competition” (157) that arose as material scarcity strained social bonds. “Talk about sex,” Nguyen argues,” was linked to economic changes and freighted with anxieties about the new inequalities these introduced” (159). In this context, “sexual and economic desire blended, making the ‘truth’ of sexual identity increasingly difficult to locate” (164). He emphasizes the increasingly political valences such disclosures and their ensuing scandals took on as talk about sexual deviance became a “moral barometer” and “a powerful metaphor for expressing concerns about the republic” (166). Thus, the ground was laid for two contrasting forms of disclosure available as the epidemic and efforts to combat it emerged: “a confessional one that required that attention be directed inward, and one of accusation that focused scrutiny away from the discloser” (173).
While both “therapeutic citizenship” and the concept of “biological citizenship” as developed by Petryna (2002), Rose & Novas (2005) and others denote a form of belonging “mediated by biomedical categories” (108), Nguyen argues they differ in the conditions of their emergence. Biological citizenship depends upon “an understanding of the role of the state and other large, stable institutions as guarantors of health care and social security” (109) insofar as they fulfill biopolitical functions of classifying and managing populations and individuals. Therapeutic citizenship, by contrast, is a “thin citizenship” (109) constituted through reference to a single disease, yet it may stand between life and death when that particular disease “may be the only way to get any of the material security one usually associates with citizenship” (109). Here, Nguyen joins others scholars who have analyzed the ways an HIV diagnosis can sometimes constitute the grounds for claims to political belonging and material security (e.g., Comaroff 2007; Robins 2006; Ticktin 2006), but he shifts the emphasis away from the state, insisting that triage “escaped the control” of the state as Côte d’Ivoire’s national sovereignty receded in the face of economic decline, structural adjustment, and ensuing social and political turbulence. If anything, these political forms unanchored by the state have only grown more pervasive and more robust: The logic of triage and the “therapeutic citizenship” to which it has given rise, Nguyen argues, can be seen in the “bundling” of services (such as food supplements, counseling, microcredit, school fees, etc.) for those with HIV provided by “an ever-more complex assemblage of institutions and management systems” that defy accountability (177). This “government-by-exception” (186; see Nguyen 2009) by foreign NGOs, research institutes, and other organizations on humanitarian grounds echoes the “scramble for Africa” of the late 19th century inasmuch as it has ushered in new categories of belonging, new ways of arbitrating life and death, and new forms of exception and exclusion. Under these conditions, Nguyen grimly suggests, the only exercise of sovereignty left to West Africans, denied even a readily identifiable oppressor, is to refuse to be made to live.
Nguyen’s work is path-breaking on several counts. First, though several anthropologists have touched on the subject (e.g., Booth 2004; Fassin 2007; Kalofanos 2010, to name only a few), The Republic of Therapy is perhaps the first book-length ethnographic and historical monograph that focuses of the emergence of an HIV/AIDS treatment apparatus in Africa. Like Paul Farmer’s milestone ethnographic treatment of the HIV epidemic in Haiti, The Republic of Therapy emphasizes the historical dimensions not only of the epidemic but of the responses to it as “manifestations of the large-scale forces of history and political economy” (Farmer 1992:8). Second, the book contributes substantially to an emerging literature focusing on the kinds of politics, subjectivities, and socialities that HIV treatment programs demand and produce (Biehl 2007; Kalofonos 2010; Frank 2009; Rhine 2009). The book is incredibly timely, given massive expansion of treatment programs over the past decade. (According to the World Health Organization, more than 5 million people in low- and medium-income countries were receiving antiretroviral therapy by the end of 2009.) Indeed, like Charles Piot (2010), Nguyen draws attention to the ways contemporary West African states challenge scholars to account for the new forms of life and death that have arisen in the wake of structural adjustment and the radical transformation of global politics that accompanied the end of the Cold War. Third, The Republic of Therapy complicates divisions between the biomedical and the religious, or between the symbolic and the political-economic that sometimes seems to emerge in the anthropological literature on HIV/AIDS. Nguyen’s focus on how confession and conversion as speech genres move across contexts as diverse as churches, sex scandals, and therapeutic groups, and how the successful performance of these genres can stand between those with HIV and the material substance of “life itself” is refreshing. The book’s focus on the stakes of confession and therapeutic talk complements recent linguistic anthropological literature examining the ways language ideologies structure confessions, their reception, and the subjectivities they both demand and produce (Carr 2006, 2010; Keane 2007).
Nguyen makes several interesting stylistic choices. For example, he leaves the lion’s share of his engagements with the theoretical, anthropological, and historical literature in the endnotes. This may render the book an easier read for those outside anthropology—a commendable goal, and even more so for this book—and Nguyen’s desire to reach a broader audience may also have influenced his decision to place the historical chapters in the book’s second half. This reliance upon endnotes can make the book seem light on citations, an impression belied by the notes themselves and the bibliography. Yet, the book engages less, even in the notes, with the substantial historical and anthropological literature on colonization, conversion, and confession in Africa and the politics to which these have given rise than one might expect. His intellectual debt to Foucault runs deep, and that debt serves his project well, particularly with regard to “confessional technologies,” with the one caveat that things sometimes seem to happen in the passive voice and concrete nodes of power can be difficult to locate. Nguyen’s strengths as an ethnographer are his capacity to move among different organizations and institutions, his sensitivity to the roles he plays in these contexts, and his long-term engagement with local activists and other informants, and he parries these strengths into a nuanced account of the urban politics of triage and HIV in West Africa.
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