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 has been shown to affect health outcomes through the impact of psychosocial stress on social and biological reproduction (Mullings and Wali 2001) and undermine subsistence strategies (Harrison 2007), particularly among female-headed households (Mullings 1995, 2005), leading to comparatively worse health outcomes for people of African descent in the contemporary United States (Dressler et al. 2005). That these patterns transcend national context and exhibit transnational tendencies has led some to characterize the contemporary context as “global apartheid,” while others have underscored the central role of race in forming the contours of neoliberal globalization (Harrison 2002; Thomas and Clarke 2013). Here, I build on anthropological approaches to studying race that contrast presumed sociocultural dynamics and observed sociocultural practices. Particularly significant for my analysis is Jackson’s (2001) approach, which juxtaposes “folk theories of race, class, and behavior” with the ways that people navigate a lived social context—Harlem, in Jackson’s work—that is circumscribed by the impact of race and racism. I adapt Jackson’s approach to address the disjuncture between how contemporary scholarship has characterized the South African state and the ways that HIV/AIDS activists experienced the power of race, and its relationship to the state, in their campaign for HIV/AIDS treatment access.
The HIV/AIDS movement offers a useful lens through which to understand how South African opposition to colonization, racial injustice, and social inequality continued to be manifested in the words and actions of those confronting the epidemic. Situating the South African HIV/AIDS movement within this broader historical arc yields important insights about the state, the impact of transnational influence, and the historically particular conditions that enabled the HIV/AIDS movement’s success in post-apartheid South Africa. The HIV/AIDS movement mobilized poor and working-class communities impacted by the epidemic and brought their voices and experiences into the state, transforming national HIV/AIDS policy and treatment access. It did so by expanding its representation in SANAC and creating space for people affected by the epidemic to have input into national HIV/AIDS policy. Indeed, the South African HIV/AIDS movement occupied the state