of actors, organizations, activities, and forms of influence. These hot spots produced “heat” via the concentration of political activity and the “friction” generated by the influence of transnational donors in the South African HIV/AIDS policy process (Tsing 2005). These areas where HIV/AIDS treatment access was negotiated were oriented around state health institutions but were not exclusive to them. Policy process is frequently conceptualized as unfolding within state institutions, which it quite often does. However, such a conceptualization may reify normative notions of the state and its institutions that may not be applicable in all societies, particularly those in the Global South, where state institutions and power dynamics were molded during the colonial era. Policy-making also happens along pathways, at intersections, and in hot spots.
Over the past two decades, a growing focus on nongovernmental organizations (NGOs) has given rise to a series of debates among anthropologists that focus on research methods and conceptual approaches to studying the state. Proliferating alongside the expansion of neoliberal globalization, NGOs have been characterized as a means of extending state power (Fisher 1997), mediators and translators for transnational flows of various kinds (Lewis and Mosse 2006), the glue that holds global neoliberalism together (Schuller 2009), and a productive site for examining the messy interface between state and society (Bernal and Grewal 2014).
However, NGOs can be defined differentially depending on the situation, transforming their shape relative to context, audience, or particular goals (Sharma 2006), leading to their characterization as a “productively unstable” site from which to study the contemporary age (Lewis and Schuller 2017).
As the South African HIV/AIDS movement was populated by NGOs of various kinds, the question of how best to study NGOs is a point that requires reflection. Indeed, as with the literature on “embedded” anthropology, research focused on individual NGOs can restrict analyses to the boundaries of a particular organization and limit the capacity of the researcher to understand broader sociopolitical processes. While anthropologists have long called for research both within and through NGOs, there has been a marked tendency to limit the scope of analysis based on affiliation with a particular organization (Fisher 1997; McKay 2017; Reed 2018)
In assessing this literature, David Lewis and Mark Schuller (2017) have called for a multi-sited, multilevel approach to studying the broader social dynamics within which NGOs are enveloped, a call that this book addresses through the methodology of pathways, intersections, and hot spots.
Similar debates have emerged from anthropologists analyzing the expansion of global health interventions over the past two decades. NGOs have played a central role in the growth of transnational projects that address large-scale epidemics, and similar methodological and conceptual concerns have emerged among those engaging in “critical global health.”
For example, João Biehl (2016) calls for “broad analyses of the power constellations, institutions, processes, and ideologies that impact the form and scope of disease and health processes” (130). Here, Biehl proposes a multilevel ethnographic analysis to address the complex social dynamics that global health interventions entail. Carrying out fieldwork across multiple levels and focusing on people’s experiences can produce different kinds of evidence, which can allow us to see the “the general, the structural, and the processual while maintaining an acute awareness of the inevitable incompleteness of our own accounts” (Biehl and Petryna 2014, 386).
Building on these conceptual concerns, I carried out fieldwork across multiple field sites in South Africa between June 2007 and June 2008. My research concentrated on the cities of Cape Town and Johannesburg, although research participants led me to every health district in the Western Cape Province. Building on the methodology outlined above, I followed research participants across the South African landscape as they navigated the politics of HIV/AIDS treatment access. Here, I encountered what Paul Wenzler Geissler (2014) has coined the “archipelago of public health” as I observed how the scattering of NGOs and clinics across South African society simultaneously “projectified” the landscape of care and created new barriers to access based on interpersonal networks (Whyte et al. 2013). Research participants’ pathways converged at multiple points during the course of fieldwork, including at various regional meetings and local gatherings, some with more than two hundred participants and other quite small gatherings in communities infected and affected by the HIV/AIDS epidemic. Analysis of these convergences shows that HIV/AIDS treatment access was negotiated not only in the Ministry of Health but in a wide variety of settings.
I collected research data through participant observation of community meetings, subdistrict HIV/AIDS coordinating institutions, the Western Cape Provincial AIDS Council, and a national meeting of the SANAC civil society sectors. At these hot spots I identified and recruited research participants involved in the HIV/AIDS policy process. In total, I conducted fifty-three interviews with community members, HIV/AIDS activists, doctors and nurses working in the public health sector, NGO representatives, and state health officials. Interviewees were invited to participate in the research based on their involvement in the campaign for treatment access and were sampled based upon their involvement in the HIV/AIDS policy process; participants held a wide variety of organizational affiliations and diverse demographic backgrounds.9 Moving alongside those struggling for treatment access, I observed how the fight against the ANC’s AIDS-dissident faction unfolded and how the South African HIV/AIDS movement transformed the state from within to sustain the lives of people living with HIV/AIDS.
HIV/AIDS Activism and Social Change in South Africa
Mobilizing communities infected and affected by the epidemic, the South African HIV/AIDS movement’s campaign for treatment access offers a means for understanding how a social movement—constituted by a broad alliance of activist groups, professional entities, scientific associations, NGOs, and community-based organizations—was able to successful engage with the state to increase treatment access. While supported by transnational donor capital and buttressed by international solidarity, the HIV/AIDS movement was made up of interpersonal and organizational networks based in South Africa and populated by South Africans. These networks can be traced back to the Mass Democratic Movement to end apartheid. The South African HIV/AIDS movement was built upon this shared history and a common terrain of symbolic imagery. For example, HIV/AIDS activists adapted the songs and dances, known as the toyi toyi, that had been developed by the anti-apartheid movement to energize and unite people as they marched long distances (Robins 2004). Indeed, the HIV/AIDS movement built on these and other practices developed by the anti-apartheid movement to mobilize people during the campaign for treatment access.
The HIV/AIDS movement was also organized around political principles that emerged during—and were central to the unity of—the anti-apartheid movement, such as nonracialism, consultative decision-making, and broad-based alliance building. Thus, the notion that flows and NGOs from the Global North simply transport particular social, cultural, political, and economic tendencies to the Global South may not offer the most useful lens for understanding the South African HIV/AIDS movement. This book presents an in-depth analysis of the historical roots of South African HIV/AIDS activism, tracing its development alongside the anti-apartheid movement, to frame the campaign for treatment access as an extension of the struggle for black liberation in South Africa.
Incorporating the impact of race and racism is particularly significant for analyses of South Africa, as it is a society whose history is deeply marked by racialized inequality. As Saul DuBow (1995) has outlined, the development of racial segregation in South Africa was associated with scientific racism during the colonial period and carried forward into the apartheid era. The impact of South Africa’s history of racial inequality was an active presence in the lives of those who participated in my research, and it also influenced their attempts to expand HIV/AIDS treatment access. Their experiences demonstrated resonances with anthropological analyses of race in other contexts, where the intersection of race, class, gender, and sexuality has been demonstrated to have significant public health effects (Harrison 2005; Mullings and Schulz 2006).
Race
