Ancestors and Antiretrovirals:
The Biopolitics of HIV/AIDS in Post-Apartheid South Africa
University of Chicago Press, 2013, 324 pp.
The specter of “tradition versus modernity” returns as a conundrum for understanding and signifying HIV/AIDS in post-apartheid South Africa in Claire Decoteau’s sociological monograph, Ancestors and Antiretrovirals. Interpretive social scientists like Decoteau are well trained to referee this dueling dualism, which reappears in policy discourse, popular media, and peoples’ stories about their pasts and futures. The dualism does not always appear in the same form and is dependent on the discursive domain of its articulation, and the work of the social scientist is to situate its historical re-emergence in light of the many different meanings it may evince for different social groups. In the South African case of medical pluralism, “tradition” as indigenous healing, and “modernity” as biomedicine are uneasily paired and wielded in opposition to shore up projects of identity formation on levels of individual, community, and nation. The two medical systems evince a broader “postcolonial paradox” that haunts peoples’ subjective choices for healthcare and reveals their biopolitical inscription.
The postcolonial paradox as enacted by the ANC state reflects “a simultaneous need to respect the demands of neoliberal capital in order to compete successfully on the world market and a responsibility to redress entrenched inequality, secure legitimacy from the poor, and forge a national imaginary” (7). Through a critical analysis of neoliberalism focused primarily on state and non-state organization discourses, Decoteau traces how tradition and modernity were used as, “powerful tools in the tricky political maneuvering required of leaders who [had to] represent the interests of the people while subscribing to the economic policies of global capital” (14).
Decoteau shows how Presidents Thabo Mbeki and Jacob Zuma differently trafficked in tradition to cohere politico-cultural capital nationally and globally. The former was zealously anti-imperialist and promoted indigenous healing solutions to the emerging problem of HIV, aligning with unorthodox Western scientists to deny the efficacy of biomedical ARVs and delaying its rollout to the public. The latter, Zuma, gained eventual traction with the increasingly ill majority as Mbeki’s traditionalism was globally scorned. By simultaneously embracing modernist tropes in biomedical solutions to HIV and human rights, as well as shoring up his own traditional identity as an undereducated ethnically Zulu man, Zuma was able to garner popular support to succeed the presidency. “Wrapped up in the promises the nationalist fantasies of independence foretell,” the masses continued to vote for the ANC and support its leaders “because they desperately [needed] something to hope for” (17). Similarly, White (2012) argues popular affect for Zuma was structured by political economy: “the dynamics of identification with Zuma’s ethnic person should be understood as features of a broadly post-Fordist social situation.”
Zuma’s embrace of modernity in biomedicine and human rights, of course, followed up on years of successful community activism and legal battles against the Mbeki state and pharmaceutical manufacturers by the non-state organization, the Treatment Action Campaign (TAC). TAC initially struggled to leverage wider legitimacy because of its administration’s majority white racial make-up, a facile corollary to the tradition-modernity divide, but became instrumental in constituting biomedical hegemony for national health policy and programming.
For Decoteau, the eventual supremacy of biomedicine in health policy shifts the nation toward a model of “biomedical citizenship” where the population may access healthcare by adopting Foucauldian biomedical technologies of the self. For those at the social margins, these technologies become the means to access life itself. Antiretroviral therapy, CD4 checkups, participation in salvific NGOs, and adhering to prescriptions, “like a machine” in the words of one informant, feign inclusion in a healthcare system that is still exclusionary. The socially marginal are expected to participate responsibly and entrepreneurially, even if “their lives are subsumed by constant risk and unmooring contingency” (110). This shift in citizenship is congruent with the postcolonial yoke of the global neoliberal “rationality of rule.” “Capitalism is… implicated, constituted, and transformed through” (11) several social forces, rather than their singular foundation, and she notes that Mbeki, Zuma, and the TAC all channeled in capitalist-inspired and marginalizing projects, even if indirectly. “By granting minimal inclusionary provisions on the basis of behavioral change, the state and civil society are absolved of responsibility—they have washed their hands. If people die, it’s their own fault” (161).
In documenting the discursive political strategies involving tropes of traditional and modern healing, Decoteau shows how both state and non-state actors worked to cement their ideologies. Despite their macro-level, structural extensions, “the failures and fissures involved in population regulation and processes of incorporation [left] open important spaces of potential for radical social change” (11). Beyond a nuanced reading of the holes in state and civil society discourses, she takes on a micro-level analysis of indigenous healers and “the poors,” members of social movements “who fight on the front lines of a war against neoliberal capital and the postcolonial compromises made by the state and its ruling elite” (15). Interview and focus group data with these individuals and others from activist and health NGOs constitute her ethnographic sample.
The first chapter grounds the obstacles behind this presumed “fault” by taking us into the slums of Sol Plaatjie and Lawley. Cold winds and dust blow through patchy shack walls. Households undergo forced and violent removals. “Upgrades” to cube-like smaller government flats are unannounced or never materialize. Electricity and water are only accessible through a prepaid system and long queues, and non-nutritious meals are prepared over noxious paraffin gas stoves. There is shit in the streets, literally, from poor or non-existent sanitation systems. There is also a malaise over the decline of neighborly exchange and moral relations of ubuntu, jealousy, and stigma. People face an ontological vulnerability, “a pervasive fear of something absolutely ubiquitous but unidentifiable,” along with “general unease about the loss of certain cultural practices and traditions” (70). Supported by fourteen striking pictures of the slums and her informants who lived there, eight tables derived mostly from the author’s own community survey data and many interview quotes, she paints a rough, convincing argument that poverty and AIDS are mutual pandemics: environment and wealth shape overall health.
Chapters four and five show especially how the poor move beyond discursive divisions between tradition and modernity. In the “Politicization of Sexuality,” Decoteau evidences that gender and sexuality have been socially reconstructed and revalued in young peoples’ exchange relationships, thus complicating public health concepts of transactional sex. In “Hybridity,” the traditional-modern healing dualism is said to generate culturally hybrid subjectivities for the poor: it “produces a whole series of disavowed hybridities… [P]eople infected with HIV are asked to ‘choose’ either indigenous or biomedical approaches to healing, but instead defy the state and the biomedical community by using both forms of healing simultaneously” (13). This chapter opens with several rich but short cases of people who have utilized both approaches. Their cases aim to align with descriptions of indigenous ontology in chapter one and its hybrid forms in chapter five, but the presentation of ontology is more a reiteration of secondary source literature, and concepts of bodily substances’ flow and permeability are not generally made concrete in sustained descriptions of peoples’ experiences with traditional healing. Fuller biographies and life trajectories of Pheello, Thulani, and Nozipho, or key others whose stories illuminate the text, rather than select interview quotes, would further realize how hybridized traditional-modern healing is affirmatively practiced and strengthen the linked micro- and macro-level analyses.
It was surprising to not come across more about Christianized faith-healers, congregations, or their ethical publics of healing in urban spaces, given their regional historical popularity, ubiquity and traffic in traditional materia medica especially in Zionist churches. One key informant Pheello is even said to visit a faith healer, but we don’t learn much more about the encounter. With scholars showing the powerful utility of Christian public life and NGOs for HIV/AIDS in Africa (Englund 2011, Pfeiffer 2004, amongst others), those who work on the new social movements and precarity might begin to consider how religion is real force—dialectical or otherwise—that differently animates political-economic life (cf. White 2013, Marshall 2009). The ancestors also don’t reveal their presence much beyond the book’s title, remaining spectral rather than vehicular for healing self and community through social action and embodiment.
Despite these points, which come from a cultural anthropologist of religion, Ancestors and Antiretrovirals is a highly accessible book for non-sociologists that does not sacrifice analytic rigor in its presentation of peoples’ lives. Decoteau is a gifted photographer and purveyor of mixed methods who skillfully interlaces seemingly divergent theorists to articulate complex distinctions and integrations of tradition and modernity. The two are more synergistic than syncretic for the poors and local healers, creating something historically new and offering possibilities to reach beyond what is prescribed by prevailing systems of governmentality. I would definitely teach several chapters in courses on South Africa, medical anthropology and medical sociology.
Casey Golomski, PhD (Brandeis University, 2013) is currently appointed at the University of Massachusetts Boston. He is a cultural anthropologist who collocates the roles of medicine and religion in socioeconomic reproduction. In June 2014 he will be a Postdoctoral Fellow at the University of the Witwatersrand, Johannesburg, in the Department of Anthropology, co-initiating a research unit, “Life Course, Obligation, and Dependency: Ethnographic Perspectives on Intergenerational Justice in South Africa.”
Works cited
Englund, Harry, ed. (2011) Christianity and Public Culture in Africa. Athens: Ohio University Press.
Marshall, Ruth (2009) Political Spiritualities. Chicago: University of Chicago Press.
Pfeiffer, James (2004) “Civil Society, NGOs, and the Holy Spirit in Mozambique.” Human Organization 63(3):359-372.
White, Hylton (2012) “A Post-Fordist Ethnicity: Insecurity, Authority, and Identity in South Africa.” Anthropological Quarterly 85(2):397-428.
White, Hylton (2013) “Spirit and Society: In Defence of a Critical Anthropology of Religious Life.” Anthropology Southern Africa 36(3-4):139-145.