twentieth century. Characterized as a disease of the global system, the spread of HIV/AIDS is linked to several dynamics associated with contemporary globalization, including increased population movement, growing connectivity between the world’s regions, and mounting levels of socioeconomic inequality (Altman 2001; Benatar 2001; Baer et al. 2003).
Starting in the 1980s, the imposition of stabilization and structural adjustment programs by the International Monetary Fund (IMF) and the World Bank influenced the expansion of poverty, illness, and HIV/AIDS across the Global South. These programs mandated the slashing of state spending on health, education, food subsidies, and social services to secure debt repayment; at the same time trade liberalization and currency devaluation opened recently decolonized societies to economic competition with the industrialized societies of the Global North (Pfeiffer and Chapman 2010). Structural adjustment was followed by sharp increases in chronic malnutrition, stunted growth, and the numbers of low-birth-weight babies alongside declines in state support and rural incomes (Schoepf et al. 2000). Given these socioeconomic effects, it is unsurprising that the implementation of structural adjustment policies, and the “structural violence” that they produced, coincided with the expansion of the African HIV/AIDS epidemic (Farmer 2004).
The link between poverty and HIV/AIDS is clear: facing a lack of access to resources, more people turn to survival strategies that spread the virus, and malnutrition compromises the first line of defense against the pathogen, immune systems. Increased poverty, migration, and sex work as well as a decrease in public sector treatment capabilities were the bitter fruit of structural adjustment across the African continent (Sanders and Sambo 1991). As public spending on health was cut across the African continent, the HIV/AIDS epidemic expanded alongside other infectious diseases such as malaria and tuberculosis. The budgetary ramifications of structural adjustment undermined nascent postcolonial health sectors, and the HIV/AIDS epidemic expanded from Central to West Africa before moving into Southern Africa. The South African HIV/AIDS epidemic emerged from a crucible of transnational political, economic, and epidemiological dynamics that reflect the rise of neoliberal globalization.
“Neoliberalism” refers to a reemergence of liberal economic theory as an organizing principle for national economies from the 1970s onward.2 Neoliberal theory claims that free markets are the most efficient means of allocating goods and services and that the state should focus on economic growth instead of regulation; put into practice with structural adjustment programs, this means the privatization of state assets and the deregulation of markets. However, the unfettered movement of finance capital has also fomented a “race to the bottom” in global labor standards, declining wage levels for industrial workers, and a decline in corporate taxation levels (Sassen 1990; Robotham 2005). Scholars critique the neoliberal turn by pointing to geographic and demographic shifts in industrial production, rising levels of social inequality, the state’s retreat from providing social services, and the growing political and economic power of elites (Comaroff and Comaroff 2001; Schneider and Susser 2003; Duménil and Lévy 2005; Harvey 2005). Neoliberal reforms were self-imposed in South Africa, but despite being voluntary they too were accompanied by social effects that mirrored the impact of structural adjustment in other societies.
Understanding the explosive growth of the South African HIV/AIDS epidemic also necessitates engaging with the country’s history of profound inequality, which neoliberal reform exacerbated (Terreblanche 1991). Liberation for black South Africans only arrived with the transition from apartheid in 1990 and democratic elections in 1994. Settler colonization, segregation, and apartheid had produced vastly different socioeconomic conditions for racially defined populations. Over time, material inequalities were embodied in compromised immune systems, chronic malnutrition, and a growing burden of disease among black South Africans (Fassin 2007). Politically produced social inequality led to persistent tuberculosis, syphilis, and HIV/AIDS infections among those who had been deemed subservient to the needs of white South Africans (Platzky and Walker 1985). Indeed, South Africa’s unequal history has had a disproportionately negative effect on the health of black South Africans, a social dynamic that has continued during the post-apartheid era.
Preying on bodies ravaged by historic inequality, the South African HIV/AIDS epidemic has grown to be the world’s largest over the past four decades, having expanded on the back of fiscal austerity, state inaction, and AIDS dissidence. The explosion of the epidemic in the 1990s precipitated the political struggle between the ANC and the HIV/AIDS movement, which critiqued government inaction and the political agenda of AIDS dissidents in the ruling party. On the heels of the country’s first democratic election, the ANC implemented a fiscally austere macroeconomic policy that cut social spending to ensure debt repayment, liberalized trade, and privatized state assets. In short, the ANC imposed a variant of structural adjustment amid the exponential expansion of the South African HIV/AIDS epidemic. The limits on treatment access imposed by austerity champions and the ANC’s dissident faction led to the premature deaths of approximately 330,000 South Africans living with HIV/AIDS and shortened the aggregate South African lifespan by 2.65 million years (Chigwedere et al. 2008; Johnson et al. 2017).
While unfolding within a historically particular context, the growth of the South African HIV/AIDS epidemic cannot be disentangled from the broader processes of neoliberal globalization and international activism, which necessitates that the epidemic, and the politics that arose in its wake, be situated within a transnational frame. And while the ANC’s AIDS-dissident faction was inspired by American dissident scientists, it was leading South African politicians that limited access to HIV/AIDS treatment, underscoring the continued importance of state institutions and local actors in HIV/AIDS politics. How can the global influences and local actions that drove the South African epidemic be understood? Contemporary anthropological debates on globalization and transnationalism have focused on movement and context as particularly significant for making sense of sociocultural dynamics in an interconnected world.
Ethnography and Globalization: Navigating Movement and Context
Scholars have analyzed how flows—of information, people, money, and even pathogens—are actively reshaping the world alongside neoliberal expansion.3 For example, Arjun Appadurai (1990) conceptualizes the contemporary global era as typified by different sorts of flows. Technology, media, finance, and other domains can be traced as they operate transnationally, bypassing the presumed site of politics, economics, and society: the national state. Appadurai charts the distribution of images, technologies, and people via new patterns of movement, arguing that this approach allows for a more accurate depiction of the world. However, when focusing on flows of people and things, one must be careful not to lose track of the context in which particular sociocultural practices unfold.
Studies have drawn attention to how transnational interpersonal networks span societies, organizations, and communities and how some of these networks have taken on state-like roles, such as providing HIV/AIDS treatment to people living with HIV/AIDS in West Africa (Nguyen 2005, 2010). Emphasizing ties across national boundaries, such studies have illuminated the movement of people, pathogens, and pills across disparate social, political, and historical contexts. Other investigations have underscored how international institutions and multinational pharmaceutical corporations influence price-setting dynamics, and how this affects access to HIV/AIDS treatment in the public sector (Biehl 2007, 2008). States do not determine HIV/AIDS treatment availability in isolation; rather, it is the combined efforts of multinational pharmaceutical corporations and the World Trade Organization that set the cost of HIV/AIDS treatment.
Emphasizing movement may also lead to privileging some contexts while others are left unattended. After all, capital flows do not reach all corners of the world in equal measure. That the areas left outside of Appadurai’s analysis include large swaths of the African continent highlights the unfortunate correlation between neoliberal globalization, structural adjustment, and the spread of infectious diseases, including HIV/AIDS. In contrast, a focus on uneven development across space and time yields insights on how social inequality and illness are reproduced rather than mirroring the inequalities created by neoliberal globalization (Smith 1984; Harvey 2003). Considering how regional
