Sustaining Life. Theodore Powers
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relied on judicial institutions to transform national policy, the ANC’s dissident faction managed to limit the availability of treatment by controlling state health institutions. In order to achieve the goal of treatment access, the South African HIV/AIDS movement had to change the state from within.
Chapter 3 tracks second-wave HIV/AIDS activists as they worked within national health institutions and developed new national policy. At the heart of this ethnographic chapter is an account of a SANAC national civil society meeting where new national policy recommendations were developed for the prevention of mother-to-child transmission (PMTCT) of HIV. The development of those recommendations was enabled by the influence of transnational biomedical norms and HIV/AIDS activists working in communities. While the recommendations largely reflected guidance from the World Health Organization (WHO), simply noting similarities between transnational and national policy processes does not explain how such an outcome came about. The guidelines from the WHO became intelligible only through accounts offered by HIV/AIDS activists on the everyday challenges faced in clinics and communities across the country. Thus, the campaign for treatment access at the national level reveals how policy development grew out of the experiences of community-based HIV/AIDS activists in tandem with biomedical experts rather than simply reflecting transnational norms.
In Chapter 4, my ethnographic analysis focuses on the campaign in South Africa’s Western Cape Province, describing a series of policy consultations carried out in each of the province’s six health districts. Providing evidence from participant observation and interviews, I show how relationships between activists, NGOs, and state health administrators produced unpredictable outcomes in the campaign for treatment access at the provincial level. The provincial meetings had been organized in response to a new national policy mandating that 80 percent of people in need should be provided with public sector treatment. However, the desire to secure transnational donor capital undermined provincial efforts. In the end, these consultations did not seek to expand HIV/AIDS treatment access but instead gathered data for funding applications to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). This redirection of national policy at the provincial level indicates that different actors and organizations at the subnational level have the capability to transform policy outcomes and inform the impact of transnational donor capital.
Chapter 5 focuses on the campaign for HIV/AIDS treatment access in the township of Khayelitsha. The chapter tracks the extension of HIV/AIDS activism from Site B Day Hospital in Khayelitsha, where health-related protests and the political campaign for access to treatment were focused, to other areas of the township, where AIDS dissidence limited community education and outreach programs. The pattern that emerged was activists’ isolation from local political venues such as street-level committees and community halls. In Khayelitsha, a local branch of the South African National Civics Organization (SANCO), an organization that played a significant role in the anti-apartheid movement, closed local political structures to discussions of HIV/AIDS and limited the oversight of local HIV/AIDS coordinating institutions. Indeed, SANCO played a central role in piloting an unproven vitamin-based HIV/AIDS treatment, which led to the premature deaths of people living with HIV/AIDS in Khayelitsha. The analysis of local-level HIV/AIDS politics highlights how national AIDS dissidence was enacted at the local level and the efforts of community-based HIV/AIDS activists to counteract these initiatives.
In the concluding chapter, I return to theoretical debates reviewed in the Introduction, situating conceptual insights gleaned from the ethnography within a discussion on transnationalism, social movements, and the state. The South African HIV/AIDS movement was built on the political principles of African liberation to transform the public health response to the epidemic and sustain the lives of people living with HIV/AIDS. My analysis shows that this connection was based on the interpersonal networks that connect waves of South African HIV/AIDS activism. These personal ties have served as conduits for the transmission of social movement knowledge and practices across time.
Rather than transnational biomedical norms simply being reflected, updated HIV/AIDS policy guidelines were created because of the efforts of the HIV/AIDS movement, including people living with HIV/AIDS. Provincial HIV/AIDS policy dynamics highlight the influence of local actors and organizations, showing how transnational donor capital was redirected to serve state interests and NGOs that were dependent on government financial support. The trajectory of HIV/AIDS policy at both the national and provincial levels was determined by local people and organizations rather than abstract transnational forces.
Much contemporary analysis has focused on the influence of experts in producing policy and their reliance on technical criteria rather than the needs of everyday people. The campaign for treatment access shows how the HIV/AIDS movement created space for poor and working-class South Africans to influence state policy and alter national health institutions. This was contingent upon members of the HIV/AIDS movement working within the state, where they were able to change how institutions operated and their effects on South African society. In sum, the book underscores that it is people who determine how state effects are produced and that those who control the state can fundamentally alter state effects.
What are the long-term effects of the campaign for treatment access in light of the continued impact of HIV/AIDS on South African society? In the Afterword, I describe how, despite access to treatment, the epidemic has continued to grow. Socioeconomic conditions continue to produce poverty and illness among South Africa’s black majority, and material privation and survival strategies continue to foment the spread of HIV/AIDS. While the campaign for treatment access successfully met its goal, the ongoing epidemic highlights the limits of a right-based social movement. That the relative success of the HIV/AIDS movement has not been enough to stop the expansion of the South African HIV/AIDS epidemic underscores that transforming the social determinants of health may require a different approach to social change.
CHAPTER 1
Contact, Colonization, and Apartheid
South African Social Formations in Historical Perspective
The South African HIV/AIDS epidemic developed within a set of historically particular political, economic, and sociocultural conditions that shaped the extended campaign for HIV/AIDS treatment access. A historical analysis of the African continent’s southernmost society shows how the contours of contemporary South Africa emerged out of its past. Uneven development and unequal health outcomes were produced by the interaction of South African social groups, or social formations, over five centuries. Starting with a review of indigenous political formations in Southern Africa, this chapter takes the reader through the history of contact, colonization, and apartheid, paying particular attention to the role of institutions in producing unequal health outcomes along racial lines.
The colonial period in South Africa was marked by contact and conflict between European settler states and indigenous African political formations, which influenced the subsequent development of South African society. From the slave economy of the early Dutch settlements to the British Empire’s extension of state administration, settler societies engaged with African political formations in ways that extended their interests while expropriating land and resources from indigenous peoples, producing negative health outcomes along the way. Alongside colonial states, the development of rural missions provided health services and education to indigenous South Africans while disseminating Christianity. Indeed, the diffusion of Western religion and biomedical practices across the South African hinterland occurred alongside expropriation and enslavement.1
As British and Afrikaner polities united following the South African War, social, political, and economic dynamics that had emerged during the colonial era were set into law. The institutionalization of indirect rule, segregation, and land expropriation was the bitter fruit of this white settler alliance in South Africa. The state produced by unified white rule was based on programs to address white poverty, which reinforced racial inequality. The establishment of large parastatal corporations, social welfare