overview of South African society and the politics of the South African HIV/AIDS epidemic, respectively. The ethnographic section of the book follows, with three grounded analyses of HIV/AIDS politics at the national, provincial, and local levels. The book concludes by relating the success of the South African HIV/AIDS movement to debates on transnationalism, the state, and social change.
Chapter 1 takes the reader through the history of contact, colonization, and apartheid, discussing the divergent sociopolitical trajectories that were subsumed under unified white rule following the South African War (1899–1902). The institutionalization of indirect rule, segregation, and social, economic, and political inequality were the bitter fruits of white settler alliances in South Africa. Analyzing the recurrent forms of self-governance that emerged intermittently across the twentieth century, I demonstrate that the apartheid project never fully succeeded in its mission of “ordering” in South Africa. Notably, attempts at autonomous self-governance in black urban areas led to the development of political ideals within the anti-apartheid movement, such as nonracialism, which subsequently influenced HIV/AIDS activism.
Chapter 2 presents a historical analysis of South African HIV/AIDS activism and the political struggle over access to treatment. Using biographical notes, interview excerpts, and ethnographic description, I ground historical events in the lives of those who led the campaign for treatment access. With a focus on interpersonal networks, I analyze how HIV/AIDS activism emerged from several groups involved in the anti-apartheid struggle: the human rights movement, the gay rights movement, the primary care movement, and the left. The first wave of South African HIV/AIDS activism (1982–1998) contributed to the development of the post-apartheid constitution, led the campaign for a rights-based approach to HIV/AIDS, and established organizations that cultivated second-wave HIV/AIDS activists. Indeed, the second wave of South African HIV/AIDS activism (1998–present) coalesced in response to the growth of the epidemic, government inaction to stem its tide, and the emergence of the ANC’s AIDS-dissident faction. This chapter shows that both the ANC’s AIDS-dissident faction and the South African HIV/AIDS movement depended on state institutions to achieve their goals. While activists initially 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
