AIDS in South Africa

South Africa is currently the leading victim of the HIV/AIDS epidemic, with the highest number of people infected in the world (almost 6 million or 1 in 8 of the total population). The next top five countries are all neighbours of South Africa. The proportion of sexually active South Africans infected reaches 30% in some social categories (such as pregnant women) and places (Kwazulu-Natal’s rate is five times that of the Western Cape). The disease first showed itself in the 1980s, became obvious in the 90s and has exploded in the last decade. Its history thus coincides with the transition from apartheid to African majority rule. Trying to keep track of all the contradictions entailed in this tragedy makes ones head spin.

It is first of all an issue of gender. Heterosexual women are the group most affected. Women and children are widely subjected to male violence. South Africa’s neoliberal economy has left many men unemployed or in informal employment which has certainly not reduced social tensions. On the other hand, women have been largely left out of the limited expansion of formal opportunities, being dependent on transfers and domestic subsistence. The ANC early on recognized gender discrimination as a source of inequality on a par with race. But the party has also relied on an alliance with traditional patriarchal elements symbolized so vividly in some ways by Jacob Zuma.

His predecessor as President, Thabo Mbeki, was responsible for South Africa’s political leadership becoming identified for a time with a denialist approach to the HIV/AIDS epidemic, offering a highly-placed home for several of the leading global activists in this camp. Mbeki, having spent his life in exile,mainly in Britain, was acutely aware of white people’s often unconscious desire to keep Africans in their place at the bottom of the world’s racial hierarchy. He dreamed of an African renaissance with himself and South Africa at its head and embraced a neoliberal path to economic emancipation more extreme than the World Bank’s. Mbeki was a Shakespearean figure and sometimes his language rose to that level, as when he described detractors of Africa who consider

“...that we are but natural-born, promiscuous carriers of germs, unique in the world; they proclaim that our continent is doomed to an inevitable mortal end because of our unconquerable devotion to the sin of lust.”

He appointed a Minister of Health who advocated use of indigenous herbal remedies as a cure for HIV and claimed that Big Pharma’s patented drugs were not only exorbitantly priced, but actually toxic, part of a global conspiracy to exterminate black people. Mbeki argued that the real problem was poverty, but his recipe for alleviating it only increased the gap between rich and poor. Access to antiretroviral drugs was impeded by the government and many died untreated. Yet South Africa took the lead in fighting the global intellectual property regime for poor countries’ right to produce cheap generic substitutes for the main drugs.

The contrast between Zuma and Mbeki could hardly be greater, a tribal chieftain in the mould of Bolingbroke or Henry Tudor against Mbeki’s Othello, a man happy to be photographed dancing in Zulu warrior gear versus the austere western intellectual with his stiff suits and goatee beard. The number of Zuma’s wives, lovers and children is uncountable. He was once tried for raping an HIV-positive woman who was the daughter of a trusted political aide; claimed that it was his duty to satisfy any woman who appeared to want him; and took a shower after the act so as not to catch the disease. Jacob Zuma epitomises the image of African male sexuality that Thabo Mbeki tried so desperately to counter. Yet Zuma appointed a leading progressive medic as Minister of Health; and he has pushed through drastic changes in government AIDS policy, winning singular praise from AIDS social movements for having committed state resources to the fight. Only recently Zuma made public his own HIV status (negative after four tests). Political leaders like this make nonsense of the stereotypes that pass for analysis of South Africa’s trajectory.

Now at last many more South Africans have access to the most effective sources of prevention and treatment known to normal science, although this is still highly unequal and plagued by Christian and traditional beliefs affecting the use of condoms, for example. The whole story is mind-boggling. You couldn’t make it up. Because of or despite all this, South Africa has stimulated a number of compelling book-length studies by leading anthropologists which, taken individually and together, offer a remarkable chance to reflect on how our discipline might illuminate a tragedy that has implications for how we all live in today’s world. Here I will briefly consider three: Didier Fassin’s When Bodies Remember (2007), Robert Thornton’s Unimagined Community (2008) and Ida Susser’s AIDS, Sex, and Culture (2009).

Didier Fassin trained first as a medical doctor and subsequently carried out ethnographic research on black HIV/AIDS sufferers in South Africa’s townships and homelands, notably in Soweto (‘South West Township’) which is about the same size as Johannesburg, Cape Town or Durban. Following the French tradition, he combines sociological and anthropological approaches. Fassin’s book is sensitively written, focusing on the tragedy for South Africa’s blacks who, having just won political emancipation from the apartheid system, are now faced with the appalling consequences of this epidemic. He combines detailed life histories with an investigation of the politics of AIDS which draws mainly on secondary sources and is both national and international in scope. We thus get morally uplifting insight into the lives and deaths of ordinary people, the author’s personal command of the medical background and a trenchant critique of the wider political context. Fassin’s writing is passionately engaged and not indifferent to history.

Robert Thornton is an American who moved to Uganda when he was young and has since settled in South Africa. He has carried out extensive ethnographic research there, but Unimagined Community’s method is strikingly different. Uganda was once in the forefront of the epidemic, but the infection rate fell dramatically in the 1990s. HIV/AIDS took off later in South Africa and has since continued to grow unchecked. Thornton’s implicit model is Durkheim’s Suicide (1895), a statistical demonstration of how social structure influences the most intimate decisions. HIV infection is a property of invisible sexual networks and a sustained attack on the epidemic must be directed at these, not just at treating individual cases. He argues that, for all its racial ideology, South Africa’s sexual networks are unusually open, less segregated in practice than his original Chicago home. Uganda’s corporate kinship system, on the other hand, was mobilized to create barriers against the spread of infection. Thornton is scathing of the Mbeki government’s anti-scientism, preferring to emphasize social prevention rather than antiretroviral treatment. He makes use of mathematical arguments in what is an unusually reductionist and certainly heterodox approach for an anthropologist.

Ida Susser started out in South Africa as the child of activist doctors who soon left the country, first for Britain and then the United States. She has carried out ethnographic research on numerous occasions, mainly in Durban and Namibia. But her dominant method in AIDS, Sex, and Culture is historical. This extends from a full account of her own life history to a global history of politics, ranging from apartheid, through gender to neoliberalism. This focus on historical narrative is matched by her self-identification as an activist, concerned with how social movements emerge to advance the interests of people on the ground. She contrasts the ideological focus of religious and traditional groups on issues such as “abstention” and “virginity” with the practical rationality of infected women, aided in their struggles by “organic intellectuals”. The result is certainly the most wide-ranging and informative of the three books.

Each of these anthropologists has lived a nomadic life and cares deeply about South Africa’s tragedy. The relative emphasis on local ethnography, national politics and world history varies considerably between them. Thornton’s is the most self-consciously “scientific” approach, with less apparent moral/political commitment; but then he is the one author who has been living with this epidemic for two decades. Much writing about South Africa abstracts from the wider world, which cannot be said of these books. Yet none of them gives a convincing account of South Africa’s changing social structure after apartheid; and the questions concerning entrenched inequality here and more generally require anthropologists to take an even broader historical perspective than they already have, including one that pays more systematic attention to South Africa’s relationship to the rest of Africa, a question that Thabo Mbeki cannot be said to have neglected.

For all the ravages of AIDS, Africa still has by far the highest population growth rate of any major region. The latest projections forecast an African population in 2050 of 1.8 billion or a quarter of humanity. The Asian manufacturers have already woken up to the implications of this development, but, in Europe and America, Africa still features largely as the playground of the four horsemen of the apocalypse, not as a significant player in the world market. South Africa, as the only African country to have made the transition to national capitalism, in however flawed and partial a form, is bound to play a strategic role in the continent’s future development.

It is hard to imagine a more hectic and contradictory social history than South Africa’s last two decades. The overall picture there can be heart-breaking, but there is still a lot to play for too; and the outcome will have serious consequences for the world as a whole. South Africa has long been and still is a major crucible of innovation in anthropology, reflecting its pivotal role in world history. The challenges posed by this living symbol of our divided humanity should ensure that it remains so in the decades ahead.

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Comment by Huon Wardle on April 28, 2010 at 11:33am
This BBC series with Desmond Tutu has some interesting angles. The most recent one focused on African women discusses HIV/AIDS
Comment by Alice C. Linsley on April 26, 2010 at 2:20pm
The link between higher risk of HIV and use of oral contracdeptives may be a factor also.

Iqbal Shah of the World Health Organization recently stated, "sub-Saharan Africa has endured decades of contraception-focused population control programs and countless hormonal-contraceptive trials. “Among the six [African] countries hardest hit by the HIV/AIDS epidemic … two in three users in the six countries rely on the OC (oral contraceptives) or injectables." Read more here:

This is a complex problem.


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