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Wits Med Anthro 3rd Year, Block 3

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Matthew Wilhelm-Solomon

on 16 October 2017

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Transcript of Wits Med Anthro 3rd Year, Block 3

Anthropology of Medicine and the Body - Teaching Block 3
Medical Pluralism



Dr Matthew Wilhelm-Solomon

Structural Violence
Student Zones
Politics of Reproduction
Simbarashe Nyuke snyuke@gmail.com

(a bird's eye
view of biomedicine)
(medieval Europe
to Rennaissance)

19th Century

(Expansion of Industrial
Capitalism, Empire, Humanitarianism, Town planning, health statistics , biopolitics)
1860s - Germ Theory - new aeteologies
of disease

Louis Pasteur Principles of Vaccination,
development of germ theory
Early to Mid 20th Century

(World Wars, penicillin,
pasteurisation, psychoanalysis)
Colonial phase of biomedicine
Post-WW 2

(decolonisation wars)
nationalist phase of biomedicine
early colonisation brought
powerful diseases, weapons,
and religions, not powerful

of clinical gaze,
(Da Vinci's sketches, probably partially
based on cows)
From middle ages to early 19th
century bedside medicine, mainly
opiates dominant.
(in 1846 Hungarian Doctor,
Ignaz Semmelweis discovered
that doctor's washing hands during
labour could prevent maternal deaths.
He was widely disbelieved, fired and
ended up in an asylum -
into late 19th C
Early Anthropological Studies
on causation
Evan's Pritchard - on Azande (1937)

"witchcraft explains why events are harmful
to men and not how they happen ... witchcraft is a causative factor in the production of harmful evphenonema in particular places, at particular times, and in relation to particular persons ..Zande belief in withcraft in way contradicts empirical knowledge of cause and effect"

Healing & Cure

late 18th C 19th C
-Hospital Medicine
Ngubane (1977) on disease causation
isifo -- applies to "disease manifested by somatic symptoms, to various forms of vulnerability to misfortune and disease"

2 levels of "natural" causation
The body as a natural biological entity
(illnesses in this category are "umkuhlane" - diseases which "just happen")

Disease of "ukufa kwabantu" - "disease of the African peoples"

"Good health means the harmonious working
and co-ordination of the universe"
Kleinman - illness is "the innately human
experience of symptoms and suffering"

Disease ... is what the
practitioner creates in the recasting of
illness in terms of theories of disorder"

"In the biomedical model, this means that
disease is reconfigured only as an alteration
in biological structure or functioning"

Sickness is "the understanding of a disorder
in its generic sense across a population in relation
to macrosocial (economic, political, institutional) forces"

"Cultural meanings mark the sick person, stamping
him or her with significance often unwanted and
neither warded off nor coped with"
Meghan Vaughan -
"If African systems are not homogenous,
neither is scientific medicine"
Medical Pluralism
Medical Pluralism

"The extent to which medical traditions other than
those of biomedicine continue to flourish and the fact that people everywhere in the world frequently
consult with more than one type of medical practitioner provide incontrovertible evidence that
biomedicine alone is not sufficient to meet the needs of vast numbers of people"

"the form taken by medical pluralism varies considerably depending upon geographical location, and the reasons for the choices that people make can only be fully appreciated in light of
local histories and current conditions"

(Lock and Nguyen, 2010)
1854, Dot Map, John Snow, Cholera
"What is at issue here
is not the efficacy of biomedical
forms of treatment, but rather the lack of
of trust that postcolonial subjects
have towards a country that has
a long history of domination and
exploitation of their societies"
Abdoulaye Kane "Medicine is part of the flows that characterize African transnational practices. The circulation of biomedicine and traditional medicine between the two spaces indicates that migrants want to take advantage of both systems"

Biomedical model
1. Mind/body dualism
2.mechanical metaphors
3.Technological imperative
4.reductionist (focus on biological,
not social/psychological)
5. doctrine of specific aetiology
(eg parasite, virus of bacterium)
(Nettleton, 2008)
Levis-Strauss (1963, Structural Anthropology)

"In contrast with scientific explanation, the problem here is not to attribute confused and disorganized states, emotions, or repre­ sentations to an objective cause, but rather to articulate them into a whole or system. The system is valid precisely to the extent that it allows the coalescence or precipitation of these diffuse states, whose discontinuity also makes them painful."

"Failure is secondary, and we see in all their statements that they consider it a function of another phenomenon, which is the disappearance of the social consensus, re-created at their expense around another practitioner and another system of curing. Con­ sequently, the fundamental problem revolves around the relation­ ship between the individual and the group, or, more accurately, the relationship between a specific category of individuals and spe­ cific expectations of the group".
Late 19th C,
early 20th, lab medicine

causation may be multiple
"umnyama" (pollution/darkness)-
"this condition may be accidentally
contracted in the environment or
caused by a harmful substance
said to have been deliberately
placed by a sorcerer"
Solutions include steaming and
"red medicine"
Frantz Fanon-

Born in Martinique 1925

Fought for French in WW2
Trained in clinical medicine and
as a psychiatrist in France

Worked in an aslyum in Algeria
for the colonial administration

Joined Algerian Liberation Movement,
died of leukemia in Algeria in 1960

"Western Medical science, being part of the
oppressive system, has always provoked in the
native an ambivalent attitude"

"The fact is that colonization, having been built
on military conquest and the police system, sought
a justification for its existence and the legitimization
of its persistence in its works"

"The traditional methods of treatment are applied
in addition to the modern medical techique. "Two
remedies are better than one". It must be remembered that the colonized who accepts penicillin or digitalin at the same time insists on folowing the treatment prescribed by the healer of
his village or his district. The colonized obscurely
realizes that penicillin is more effective, but for
political, psychological, social reasons, he must
at the same time give traditional medicine its due"

On the revolution of the National Army of Liberation:
"old superstitions began to crumble. Witchcraft,
maraboutism ... belief in djinn, all these things
that seemed to be part of the very being of teh Algerian, were swept away by the action and practice initiated by the Revolution"

Fanon (A Dying Colonialism)
Structural Violence
Medicine, the Body & Colonialism
"structural violence is violence exerted systematically - that is indirectly - by everyone
who belongs to a certain social order ...
In short, the concept of structural violence is intended to inform the study of the social machinery of oppression"

"an anthropology of structural violence
necessarily draws on history and biology,
just as it necessarily draws on political economy"

"structural violence is the natural expression of
a political and economic order that seems as old
as slavery. The social web of exploitation, in
its many differing historical forms, has long been

Paul Farmer
1980s- "non-governmental phase
of biomedicine", expansion of
"In Africa at least, colonial medics were simply
too thin on the ground and their instruments
too blunt to be viewed as either agents of oppression or as liberators from disease"
(Meaghan Vaughan)
A powerful justification for the Pastorian approach
but "the growing economic importance of the
African colonies for France made it increasingly
difficult to resist Pastorian campaigns on purely
ideological grounds because the need for preservation of the health of local labourers was
clearly essential". A denial of poverty - "social
conditions reduced to their impact on the circulation
of germs"

Biomedicine began "to be used as ideological tool, a way of winning "hearts and minds" and showing what colonial authorities believed to be the beneficial effects of colonialism" (Lock and Nguyen)
Colonialism, race and sexual violence

"The idea of race as a way of seeing, defining, experiencing and ordering the world is a fairly recent one in human history and it draws extensively on the creation of sexual difference and violence. Race as an idea becomes first, a form
of knowledge and ordering system, which is then
institutionalised thus gaining legitimacy
through the extensive use of sexual violence. The
history of race is the history of slavery, colonialism
and race science"

"with race, shame is produced through slavery, colonialism and the conquest that comes from these"

"the rape of slaves was an integrate part of the
architecture of slave-ordered Cape society"

Pumla Dineo Gqola (Rape: A South African

Biopolitics, Necropolitics,
and Biological Citizenship

HIV/AIDS: Therapeutic Citizenship
and Clientships

A brief history of HIV/AIDS (taken from Avert.org & UNAIDS)



"In 1981, cases of a rare lung infection called Pneumocystis carinii pneumonia (PCP) were found in five young, previously healthy gay men in Los Angeles.2 At the same time, there were reports of a group of men in New York and California with an unusually aggressive cancer named Kaposi’s Sarcoma."

"In June 1982, a group of cases among gay men in Southern California suggested that the cause of the immune deficiency was sexual and the syndrome was initially called gay-related immune deficiency (or GRID).6

|In Uganda, doctors reported cases of a new, fatal wasting disease locally known as 'slim'"

1984: the National Cancer Institute announced they had found the cause of AIDS, the retrovirus HTLV-III.

1986 - In May 1986, the International Committee on the Taxonomy of Viruses said that the virus that causes AIDS will officially be called HIV (human immunodeficiency virus) instead of HTLV-III/LAV.

1995: "In June 1995, the FDA approved the first protease inhibitor beginning a new era of highly active antiretroviral treatment (HAART)"

1995 - Foundation of UNAIDS
Key Definitions

HIV incidence:

HIV - What is HIV?

"The human immunodeficiency virus (HIV) infects cells of the immune system, destroying or impairing their function. Infection with the virus results in progressive deterioration of the immune system, leading to "immune deficiency." The immune system is considered deficient when it can no longer fulfil its role of fighting infection and disease. Infections associated with severe immunodeficiency are known as "opportunistic infections", because they take advantage of a weakened immune system" (WHO)

"Acquired immunodeficiency syndrome (AIDS) is a term which applies to the most advanced stages of HIV infection. It is defined by the occurrence of any of more than 20 opportunistic infections or HIV-related cancers" (WHO)

"AIDS is not simply a case of someone suffering from immune deficiency. It is an epidemiological definition based on clinical signs and symptoms. It is caused by HIV, the human immunodeficiency virus. HIV destroys the body’s ability to fight off infection and disease, which can ultimately lead to death. Antiretroviral therapy slows down replication of the virus and can greatly extend life and enhance quality of life, but it does not eliminate HIV infection." (UNAIDS)

"HIV incidence refers to persons newly infected with HIV, whereas individuals newly diagnosed with HIV may have been infected years before being diagnosed" (CDC)

HIV prevalence: "The number of persons living with HIV disease at a given time regardless of the time of infection, whether the person has received a diagnosis (aware of infection), or the stage of HIV disease."

CD 4 Count "CD4 cells (sometimes called T-cells, T-lymphocytes, or helper cells) are white blood cells that play an important role in the immune system. Your CD4 cell count gives you an indication of the health of your immune system – your body’s natural defence system against pathogens, infections and illnesses" (AIDSmap)
Combination Antiretroviral

"Combination antiretroviral therapy (ART) consists of ≥ 3 antiretroviral
medicines that are capable of suppressing HIV replication. The current
recommended ART regimen contains 2 nucleoside reverse transcriptase
inhibitors (NRTIs) together with either a non-nucleoside reverse transcriptase
inhibitor (NNRTIs) or a protease inhibitor."
(SA clinicians society, 2016)


"No antiretroviral drug is resistance-proof. HIV drug resistance will evolve naturally, when confronted by the selective pressure from drugs or from the immune system.
When HIV replication is not fully suppressed, drug resistance results. This situation is frequently linked to non-compliance of ARV therapy.
Resistant viruses can spread and affect ARV therapy. Transmission of HIV resistance strains is of increasing concern in countries where ARV is widely used. Resistance can be contained; the likelihood of its occurrence can be reduced or prevented by an appropriate and careful choice of treatment and by monitoring for resistance"

ART scale-up

Late 1990s. Brazil begin to manufacture
generic antiretrovirals

In the 2000's major scale-up of
antiretroviral treatment

The Global Fund to Fight AIDS, Tuberculosis and Malaria (often called the Global Fund or GFATM)

2003 foundation of The President's Emergency Plan For AIDS Relief (PEPFAR/Emergency Plan)

In spite of initial cynicism, it has been repeatedly shown, throughout Africa and elsewhere, that antiretroviral treatment can be provided in resource-limited settings with adherence rates as high, or better than, wealthy countries (Bennet et al., 2008:20)

2016: 17 million people were accessing antiretroviral therapy (UNAIDS) globally

Therapeutic Citizenship (Nguyen)

"Therapeutic citizenship broadens
"biological" notions of citizenship,
whereby a biological construct -
such as being HIV positive - is used
to ascribe an essentialized identity,
as in earlier forms of eugenics and
racial ordering. Therapeutic citizenship
is a biopolitical citizenship, a system
of claims and ethical projects that arise
out of the conjugation of techniques
used to govern populations and manage
individual bodies. The notion of therapeutic
citizenship points to the growing transnational
influence of biomedical knowledge and
practice in the government of human
and nonhuman affairs"

On Biopower: "While the globalization of HIV/AIDS
prevention set the stage for the emergence
of a globalized politics of access to treatment,
it also shows how a biosocial formation -
self-help organized according to a biomedical
diagnosis - can articulate with biopolitical processes
... the biopolitical production of subjects is ever
more tied to the biomedical"

Therapeutic Clientship (Whtye et al. 2014)

The "first generation"

"While patients should be passive and quiet,
clients are interlocutors who have expectations
about services"

"[Therapeutic] citizenship is a more abstract
relationship between categories of individuals
and forms of governance. Clientships corresponds
more closely to what Nguyen refers to as "local
moral economies" in which individuals call on
networks of obligation and reciprocity to negotiate
access to therapeutic resources"

Clientship is not "just a matter of whether or not
you belong, whether you have papers, a number,
a right to treatment. It is a question of what
belonging means for expectations, rights and obligations. The usefulness of the term "clientship"
is that it points to a concrete field of relationships, which can be differentiated and specified"

"The clients who could be considered activists were
a minority, but an important and high profile one
who formed part of the vanguard of the first generation"

"Clientship involved the exchange of medicine, compliance, dramatic stories, and job opportunities
between unequal parties"

Topographies of ART

"The topography of treatment facilities is overlaid
with the social topography of kinship"

Cimmotok - 'pointing at the back of someone's head'
Cik - 'law' or 'social norm'
‘They have made a law here in the camp against stigmatisation. If you are caught stigmatising someone or saying that this person is safe and this person is sick then they arrest you and they apply the law.’ (HIV positive woman, Lacor Camp)
Stigma Laws

In the late 18th and early 19th C a new form of power
emerged, "biopower" which entailed
"power's hold over life",
"the aquisition of power over man insofar
as man is a living being"

"the biological came under state control"

There was a shift in the sovereign right
"to kill" to a right "to allow people to live
or to leave them to die"

"One might say that the ancient right to take life or let live was replaced by a power to foster life or disallow it to the point of death" (History of
Sexuality, Volume 1, p 138)

In 17th and 18th Centuries emergence of an
anatamo-politics of the human body. Techniques
of disciplinary power.

"Discipline produced subjected and practised bodies, "docile bodies". Discipline increases the
force of teh body (in economic terms of utility)
and diminishes these same forces (in political
terms of obedience)" (Discipline and Punish, p 138)

"Unlike discipline, which is addressed to bodies,
the new non-disciplinary power is applied not
to man-as-body but to the living man, to
man-as-living being" - "the biopolitics of the
human race"

- New techniques of power -
"a set of processes such as the ratio of births to
deaths, the rate of reproduction, the fertility of the population and so on ... the development of a
medicine whose main function will be public hygeine, with institutions to co-ordinate medical, centralize power and normalize knowledge"

Biopower designates, "what brought life and its mechanisms into the realm of explicit calculations and made knowledge-power an agent of transformation of human life." (History of Sexuality,
Vol 1,

"deployments of power are directly connected to the body- to bodies, functions, physiological processes, sensations, and pleasures; far from the body having to be effaced, what is needed is to make it visible through an analysis in which the biological and the historical are not consecutive to one an­ other, as in the evolutionism of the first sociologists, but are bound together in an increasingly complex fashion in accord­ ance with the development of the modern technologies of power that take life as their objective." (HS)

Biopolitics relates to the industrialization, urbanization, empire and racism, techniques
of town planning and of regulating sexuality
through the confessional -
"Sexuality exists at the point where the body
and the population meet"

"Medicine is a power-knowledge that can be
applied to both the body and the population,
both organism and biological processes, and
it will therefore have both disciplinary and regulatory effects"

"It is in this moment that racism is inscribed
as the basic mechanism of power, as it is
excercised in Modern states ... [racism] is
primarily a way of introducting a break into the domain of life that is under power's control:
the break between what must live and what must

Mbembe, Necropolitics

"the notion of biopower is
insufficient to account for contemporary
forms of subjugation of life to the power
of death"

Introduces the concept of "necropolitics"
the ways in which "in our contemporary
world weapons are deployed in the interest
of the maximum destruction of persons and
the creation of death worlds, new and unique
forms of social existence in which vast
populations are subjected to conditions of life
conferring upon them the status of the living

This is related to "the repressed topographies
of the the plantation and the colony in particular"

Slavery is "one of the first instances of biopolitical

"The structure of the plantation system and its
aftermath manifests the emblematic and
paradoxical figure of the state of exception"

"The slave is kept alive but in a state of injury.
The slave's life, in many ways, is a form of

Apartheid -
"The most original feature of this terror formation
is its concatenation of biopower, the state of
exception, and the state of siege. Crucial to
this concatenation is, once again, race"

"the selection of races, the prohibition of mixed
marriages, forced sterilisations, even the extermination of vanquished peoples are to
find their first testing ground in the colonial

Developing Fanon, Mbembe argues that
"colonial occupation entails first and foremost
a division of space into compartments"

Fanon - "The town belonging to the colonized
people ... is a place of ill fame, peopled by men
of ill repute. They are born there, it matters
little where or how; they die there, it matters not
where, nor how"

"Late colonial occupation differs in many ways from early-modern occupation, particularly in its combining of the disciplinary, the biopolitical, and the necropolitical"

Necropower - dynamics of territorial fragmentation
and control of movement; combined with state of
exception (suspension of law) and "medieival
siege warfare adapted to the sprawl of urban refugee camps" and "sabotage of the enemy's
societal and urban infrastructure network"
Agamben and "bare life"

"the very body of homo sacer is,
in its capacity to be killed but not sacrified,
a living pledge to his subjection to a power
of death"

"In the figure of this "sacred life" something
like a "bare life" makes its appearance in the
Western World"

"Only because politics in our age had been
entirely transformed into biopolitics was it possible
for politics to be constituted as a totalitarian politics
to a degree hitherto unknown"
(Homo Sacer)

Schmitt(cited in Agamben, State of Exception) -
the sovereign is "he who
decides on the state of exception"

"if the law employs the exception - that is the suspension of law itself - as its original means of
referring to and encompassing life,
than a theory of the state of
exception is a preliminary condition for any definition of the relation that binds and, at the same time, abandons the living being to the law"

(State of Exception, p1)

"It is not possible to understand the
"national" and biopolitical development
and vocation of the modern state in the ninetenth
and twentieth centuries if one forgets
that what lies at its basis is not man as
a free and conscious political subject but, above all,
man's bare life, the simple birth that as such is,
in the pass from subject to citizen, invested itne
prnciple of sovereignty" (Homo Sacer, 128)

Petryna Biological Citizenship

Developed from study of Chernobyl Disaster (1986)
and its aftermanth
- Biological citizenship emerges in
the context of biopolitical governance
"biological citizenship"- "a demand for, but limited access to, a form of social welfare
based on medical, scientific, and legal criteria that recognize injury and compen- sate for it. These demands are being expressed in the context of losses of primary resources such as employment and state protections against inflation and a deterioration in legal-political categories"
Biological Citizenship

Therapeutic Citizenship

Sources:“Gilbert, L., Selkow, T. & Walker, L. 2009. Society, Health and Disease in a Time of HIV/AIDS. Johannesburg: Pan Macmillan”
1860 - Florence Nightingale
founds nursing school

Four phases of biomedicine and colonialism

1. "imperial" 19th and early 20th C: biomedicine
used as a tool of empire to protect the health
of settlers and soldiers
2. 1920 "colonial" based on notion of
"biological commensurability" - biomedicine
focused on protection against epidemics,
and maintaining the colonial labour force
3."nationalist" -biomedicine an important
part of post-colonial modernisation drives
4. "non-governmental" - emergence of neoliberalism, humanitarianism. (Lock & Nguyen, 2010)
Sociological Conceptions
of the Body

Durkheim - "man is double"
universal physical body/ "higher" social body

Mauss - the corporeal body as tabula rasa
"first and most natural (Lock & Nguyen)
Critical Events

1679 - Founding of the Slave Lodge for Dutch
East Indian Company in Cape Town (housing 9000 slaves also a site of rape and sexual violence)

1714 - an estimated 90% of the indigenous San and Khoi population of Western Cape died from smallpox epidemic brought by the Dutch

1880 - 1920 Population of Belgium Congo dropped
by an estimated half (10 people people), as
a result of murder, starvation, exhaustion, new
diseases (Hochschild, King Leopold's Ghost)

1900 epidemic of sleeping sickness in
British Northern Uganda - "inaugerated
a global deployment of biomedicine"

Early 20th C, successful of yaws with potassium
iodide in Tanzania by the "Universities
Mission to Central Africa (U.M.C.A) which was explicitly opposed to colonial capitalism and
such policies of industrial medicine as the coercion of laborers. but which shared with other missions a
paternalistic civilizing mission and Christian evangelization." (Ranger, 1981)

1920's - biomedicalisation of child-birth in
Belgium Congo

1926 French West Africa -- partially succesful campaign against sleeping sickness (based on quarantine, marking, forced and ineffective treatment)

1928 - Penicillin discovered

1954 - Algerian Revolution

Competition among colonial powers for
medical knowledge.
Denialism, Activism
and HIV/AIDS in South

In 1990, at the Maputo AIDS conference the late Chris Hani said that “we cannot afford to allow the AIDS epidemic to ruin the realization of our dreams. Existing statistics indicate that we are still at the beginning of this epidemic in our country. Unattended, however, this will result in untold damage and suffering by the end of the century”
"Data from both population-based sero-surveys and sentinel surveillance of pregnant women suggest that the HIV epidemic has plateaued in South Africa. In adults aged 15-49 years, the three HSRC surveys estimated HIV prevalence at 15.6% (2002), 16.2% (2005) and 16.9% (2008, increase not statistically significant). In antenatal care (ANC) clients, HIV prevalence has gradually levelled off just below 30%, after steeply increasing for more than 10 years from 7.6% in 1994 to 29.5% in 2004."
The UNAIDS summarising the evidence in 2012 argued that HIV in “South Africa is transmitted predominantly heterosexually between couples, with mother-to-child transmission being another main infection route. Drivers of the epidemic in South Africa are intergenerational sex, multiple concurrent partners, low condom use , excessive use of alcohol and low rates of male circumcision.”

But the conditions for the spread can also, to an extent, be located in the political economy of South Africa and apartheid involving inequalities, the migrant labour system, regional displacements during war, an unequal health and education system, and high rates of sexual violence (Fassin &
Schneider, 2003)
HIV/AIDS response in SA

1994 "HIV/AIDS was made one of 22 lead projects of the new government’s Reconstruction and Development Programme (RDP)" http://www.sahistory.org.za

1996 - Sarafina 2 scandal
"The Sarafina II scandal saw European Union funding to the tune of R14,27-million channelled to playwright Mbongeni Ngema after he won a contract to write a play about Aids" (Daily Maverick, 2016)

1997 - Virodene Scandal

1998 - Suspension of trial mother to child transmission programmes

1998 - The Treatment Action Campaign was formed in 1998 to promote treatment access in South Africa. Initially the TAC worked with Dlamini-Zuma to take legal action against the pharmaceutical Glaxo-Wellcome to reduce to the costs of antiretroviral treatment.

"on April 30 1999, just before the second democratic elections, Dlamini-Zuma met with TAC representatives and agreed on the need for united action to reduce the price of AZT. In a joint statement, the parties noted that the price of AZT was the major barrier to the introduction of an MTCT prevention programme. Dlamini-Zuma promised that government would take action"
(Berger, ConMag, 2016)

However, in 1999 when Mbeki became the president of the ANC, and Manto Tshabalala-Msimang the new health minister, this movement stalled and there was an engagement with so-called AIDS denialists who put in question the causal relationship between HIV/AIDS, arguing in various forms that HIV could not be the sole cause of AIDS, and in same cases even that antiretroviral treatment was the cause of the death in many deaths considered AIDS death. These views were against the overwhelming scientific evidence and consensus, promoted by only a few mainly American scientists, but were to influence Mbeki’s thinking and lead to a delay in the delivery of ART in South Africa.

In 2001 Mbeki convented a Presidential AIDS Advisory Panel where AIDS denialists were invited. In 2002, Mbeki co-authored a a document called Castro Hlongwane which made the claim that “it rejects as illogical the proposition that AIDS is a single disease caused by a singular virus, HIV” and that “It accepts that HIV may be one of the causes of this immune deficiency, but cannot be the only cause.”

2002- Constitutional Court Judgement
"The judgement was unanimous – the courts ordered the government to “remove the restrictions on the availability of Nevirapine and to permit doctors to prescribe it where needed”

Scientific consensus is widely accepted that HIV is the cause of AIDS, but that immune deficiency allows for opportunistic infections and co-infections like TB, forms of cancer and so which contribute to death.

HIV fulfills Koch's 3 postulates for infection
disease causation (Chigwedere et al., 2008)
Epidemiological association; Isolation:.
Transmission pathogenesis

Chigwedere et al., that “More than 330,000 lives or approximately 2.2 million person- years were lost because a feasible and timely ARV treatment program was not implemented in South Africa”.
How does one understand Mbeki's stance?
“Since the country’s national antiretroviral therapy programme was rolled out in 2004 life expectancy has risen by nearly ten years – from 53.4 in 2004 to 62.5 in 2015 – and the antiretroviral therapy programme is partly credited for that.”
3.1 million people on treatmentStatistics South Africa estimated that in 2015 there were 6.2 million people in the country living with HIV. According to the department of health, half of those were antiretroviral therapy at the end of March 2015.”
(Africa Check)

Fassin , although not justifying Mbeki’s response seeks to locate the response in a wider-scale history of racial violence and suspicion, noting for instance the use of disease as a legitmation for fored displacement, and the apartheid regimes attempt to develop biological weapons. Fassin and Schneider propose an approach to HIV/AIDS which attempts to understand suspicion and denial as “rooted in history”.

But the article which came in 2003 angered many activists, who were still fighting against denialism, and who themselves were anchored in the anti-apartheid movement.

“Considering the past experience, which combines the ordinariness of colonial occupation with the exceptionality of the apartheid regime whose details are only now being revealed in the public space, enables us to account for the government’s statements and policies much more effectively than does the vague notion of “denialism” commonly used to describe it. In fact, two logics are at work: an economy of resentment, whereby the past constittuions an inexhaustible reservoir of painful memory, and an economy of suspicion, whereby the present is interpreted through the lens of an intense mistrust of anyone making any claims to authority” (Fassin, When bodies remember)
Mbali (2004) “Government denialism has fundamentally been a response to beliefs that Western biomedical mainstream understandings of the causes and treatments of HIV and AIDS are part of a plot to discredit Africans, their culture and sexuality. As a discourse, government denialism wrestles with the ghosts of colonial medicine and old traditions in Western culture projecting negative sexual practices and sexual traits onto the Other. The fact is, though, for the most part overwhelming consensus had already shifted by the late 1990s in the AIDS worldí of doctors, medical researchers, NGOs, and most governments internationally, to more human rights based discourses around policy responses to AIDS.

Seen in this light, government denialism has done nothing to address what is easily the biggest public health crisis South Africa has ever seen. It can only be hoped that the efforts by civil society and AIDS researchers to convince the government of the need for the rights-based policy response of providing HIV treatment for all who need it prevails over policies informed by AIDS denialism.”

Pithouse, drawing on Fanon, provides a different critique of Mbeki, based on two fallacies. The first is “the binary opposition between white/Western and African science” He notes many African and other scientists have contributed to the development of biomedicine, and that “not all Westerns scientists work for elite Western interests and not all African scientists work for general African interest” The second fallacy is the assumption that “that if some people in the West make racist comments in the context of AIDS then all “Western” knowledge about AIDS is either fatally infected with racism or is nothing but racism”

“A Fanonian analysis would conclude that Mbeki has failed to transcend Manichean binaries” He notes of TAC activists that “both the struggle and the medical knowledge needed to wage it are firmly rooted in their life-world”

Speaking of Fanon he writes, “And here is the dialectical synthesis – the technologies of modernity that has generally objectified Africa are absorbed into an African life-world to serve the intersts of people on whose land, labout and communities modernity has been so violently parasitic” (Pithouse, 2003)

"Death, after all, is the kind of epistemic litmus test the existence of which relativists wish to deny: provided other possible causes have been ruled out with sufficient probability, the fact that a given treatment led to a patient’s death is enormously good reason to believe not only that the treatment itself is inadequate, but also that the theory used to justify the treatment is probably false. Analogously, the fact that Mbeki’s ‘treatment’ led to the avoidable death of hundreds of thousands is enormously good reason to believe not only that it is inadequate, but also that the postmodernist/ postcolonialist theory of science he used to justify it is probably false.”
(Kowalenko , 2015)

Steven Robins

“the illness narratives and treatment testimonies that are analyzed in this article suggest that the experiences of illness, treatment, and participation in TAC and MSF can produce radical transformations in subjectivity and identity that go well beyond conventional liberal democractic conceptions of “rights” and “citizenship”

He argues that treatment involves a Turnerian ritual procedure transforming those taking treatment into “responsibilized citizens”

Turners ritual” 1. Separation. 2. Liminality/communitas and 3.Integration
First stage, individual becomes “sick, is afflicted with opportunistic infections, and may already be in an advanced stage of AIDS. The illness may be understood by sick persons, family members, and neighbours to b the work of abthakathi (witchcraft), a sign of having been chosen by the ancestors to be a sangoma (traditional healer or divinder), or simply an ordinary illness such as “flu” or tuberculosis” Often involves stigma, isolation.
2. Second phase, “the sick person may seek biomedical treatment of opportunistic infections, join a TAC support group, and enroll, depending on clinical indicators, for ART. The patient-activist learns basic scientific and biomedical knowledge about HIV/AIDS.”
3. “Finally, the recovery of the patient-activist with HIV/AIDS can be likened to Turner’s third phase of “reincorporation”. In the third stage, the individual starts getting physically and psychologically well, the CD4 count increases, and viral load drops, and the person begins putting on weight and rediscovers his or her appetite for food, sex and sociality”

“HIV/AIDS activism in South Africa has also contributed toward new forms of health citizenship that are concerned with both rights-based struggles and creating collectively shared meanings of the extreme experiences of illness and stigmatization of individual AIDS sufferers”

HIV/AIDS responses time-line
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