Sustaining Life: AIDS Activism in South Africa 9780812296853

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Sustaining Life

PENNSYLVANIA STUDIES IN HUMAN RIGHTS Bert B. Lockwood, Series Editor A complete list of books in the series is available from the publisher.

Sustaining Life AIDS Activism in South Africa

Theodore Powers

U N I V E R S I T Y O F P E N N S Y LVA N I A P R E S S PHIL ADELPHIA

Copyright © 2020 University of Pennsylvania Press All rights reserved. Except for brief quotations used for purposes of review or scholarly citation, none of this book may be reproduced in any form by any means without written permission from the publisher. Published by University of Pennsylvania Press Philadelphia, Pennsylvania 19104-4112 www.upenn.edu/pennpress Printed in the United States of America on acid-free paper 1 3 5 7 9 10 8 6 4 2 A Cataloging-in-Publication record is available from the Library of Congress ISBN 978-0-8122-5200-2

For Kat, Emma, and Leo

CONTENTS

Preface

ix

List of Abbreviations

xv

Introduction. People, Pathogens, and Power: Situating the South African HIV/AIDS Epidemic

1

Chapter 1. Contact, Colonization, and Apartheid: South African Social Formations in Historical Perspective

23

Chapter 2. The Political History of South African HIV/AIDS Activism

53

Chapter 3. Occupying the State: HIV/AIDS Activism and the South African National AIDS Council

82

Chapter 4. A Policy Redirected: Transnational Donor Capital and Treatment Access in the Western Cape Province

104

Chapter 5. Community Health Activism, AIDS Dissidence, and Local HIV/AIDS Politics in Khayelitsha

134

Chapter 6. People Are the State: Activism, Access, and Transformation

158

Afterword. After Treatment Access: An Epidemic Unresolved

180

Notes

195

References

207

Index

229

PREFACE

Anthropology, it is often said, attempts to bridge social and cultural difference in order to make ideas and practices from the Global South seem more familiar to those living in the Global North. In this characterization, anthropologists are seen to act as mediators who engage with “the other” in order to make their lives more comprehensible to northern publics. In doing so, anthropologists are imagined as bringing a set of academic practices to bear relative to the question of cultural variation by brandishing an expertise of a particular sort. Inherent in this formulation is a hierarchy regarding academic knowledge and an understanding of the broader context within which ideas and practices are situated, purportedly the purview of the anthropologist. The situation that I encountered as I began research on the politics of the South African HIV/AIDS epidemic did not cohere with the generalized understanding of anthropological fieldwork described above. If anything, the hierarchy of expertise relative to the HIV/AIDS epidemic was reversed, as some research participants had contributed to publications in esteemed academic journals such as the Lancet. But, as I was to learn, the inverse relationship between researcher and expertise was not isolated to debates on epidemiology; it extended far beyond to the social dynamics that drove HIV infection, the politics that limited the public sector HIV/AIDS response, and the material privations that community-based HIV/AIDS activists navigated as part of their everyday lives. Indeed, while my name may appear on the cover of this book, it is the knowledge and experiences of those who opened their lives to me that has provided the basis for the ethnography that follows. I was, and remain, a student of South African society, and those whose lives are outlined in this book are, and continue to be, my teachers. This book would not have been possible without their generosity, patience, and understanding as I learned about the everyday challenges of HIV/AIDS and the political struggle required to expand HIV/AIDS treatment access in South Africa. However, the contributions of

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Preface

my research participants were not limited to the gathering of data. They were also central to the research design that I employed in my work. As I describe in detail in Chapter 1, I followed the life pathways of research participants in order to locate field sites where politics, policy, and HIV/AIDS treatment access were negotiated. Thus, rather than a predetermined conception of the field and research sites, my project grew out of the lived experiences of those navigating the landscape of HIV/AIDS politics in South Africa. Following people involved with the campaign for HIV/AIDS treatment access shed light onto how transnational forces articulate with HIV/AIDS politics, how debates on AIDS dissidence manifested in the townships of the Cape Flats, and how HIV/AIDS activists occupied the state to transform treatment access. This project—and the insights that it offers relative to academic debates on transnationalism, social movements, and the state—largely belongs to those who fought for HIV/AIDS treatment access in South Africa. I offer my deep thanks for their contributions, and I hope that I have done justice to their life histories and political campaigns in the pages that follow. The process of developing and finalizing this manuscript has led me to understand that writing a book is a social act that involves the direct support of a wide network of advisors, mentors, colleagues, and family members. I first encountered the core theoretical questions that this book engages with during my undergraduate studies at Bates College. There, under the guidance of Kiran Asher and Peter VonDoepp, I undertook a senior thesis that engaged with debates on globalization, the transnational movement of cultural practices, and political economy. Both Kiran and Peter have continued to offer their mentorship and support, and I offer my thanks to them. I am deeply indebted to faculty members in the Department of Anthropology at the CUNY Graduate Center for the rigorous training and professional guidance that I received over the course of my graduate studies. Particular thanks are in order to the members of my doctoral committee, which included Don Robotham, Ida Susser, and David Harvey. Each of my graduate advisors provided me with direction, critique, and encouragement as this project went through various phases. This book—and the ethnographic contributions that it offers—is reflective of the theoretical and professional direction that was provided by the members of my doctoral committee. Here I offer my full and unreserved thanks for their training, mentorship, and guidance. Thanks are also in order to other members of the department who provided mentorship and support during my graduate studies, including Michael Blim, Gerald Creed, Kate Crehan, Louise Lennihan, Shirley Lindenbaum, Jeff Maskovsky,

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and Katherine Verdery. I must also thank Ellen DeRiso for her guidance, support, and friendship as I navigated the institutional infrastructure of a large public university. I also offer my gratitude to T. Dunbar Moodie for reading an early version of this book and offering insightful feedback on areas for further development. In addition to my academic training in the US, I have been privileged to work with and learn from members of the South African academic community. I am grateful for the support offered by Nicoli Nattrass during my field research, as she generously offered institutional affiliation, personal support, and critical feedback. During my time as a visiting researcher at the Aids and Society Research Unit, a part of the Centre for Social Science Research at the University of Cape Town, I met colleagues who offered their support and insight on the politics of HIV/AIDS including Eduard Grebe, Elizabeth Mills, and Atheendar Venkataramani. I have also received encouragement and guidance from South African scholars including Patrick Bond, Bill Freund, Steven Friedman, Rob Gordon, Hylton White, Mugsy Spiegel, David Sanders, Zolani Ngwane, Devin Pillay, and Jeremy Seekings. My thanks to all those listed, and those who I may have unintentionally omitted, for their support of my work. This project has also benefitted from further training and mentorship that I received during the course of a two-year postdoctoral fellowship with the Human Economy Programme at the University of Pretoria. My thinking on HIV/AIDS politics continued to evolve in the vibrant academic environment cultivated by program codirectors Keith Hart and John Sharp. The conceptual approach toward transnational sociopolitical dynamics that I developed during my postdoctoral fellowship was buttressed by Keith’s uplifting positivity and support and by John’s probing inquiries. Thanks also to those whose ideas animated the active seminars within which some of the core ideas of this book were molded, including Theo Rakopoulos, Tijo Salverda, Doreen Gordon, Camille Sutton-Brown, Jürgen Schraten, Albert Farré, Juliana Braz Dias, Busani Mpofu, Mallika Shakya, Booker Magure, Vito Laterza, Marina Martin, and Francisco Ngongo. My time in Pretoria included a period when I worked as a senior lecturer in the Department of Anthropology and Archaeology. My thanks to all those who made my experience at the University of Pretoria productive, enjoyable, and irreplaceable relative to the development of this work. Thanks to Innocent Pikirayi, John Sharp, Detlev Krige, Fraser McNeil, Ceri Ashley, and Jimmy Pieterse for their collegiality, support, and friendship. I would also like

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to thank the late Lynnette Holtzhausen for her friendship and guidance as I navigated the process of securing work permits, acquiring visas, and learning the administrative norms of a South African academic institution. While core concepts and approach were developed during my doctoral and postdoctoral studies, this book was written in its entirety during my time at the University of Iowa, where I benefitted from the active support of senior colleagues. In particular, I offer my deepest thanks to Ellen Lewin, who read both early and refined chapter drafts, offering extensive and invaluable feedback and guidance on the narrative that became this book. Meena Khandelwal was also an essential source of support, offering guidance and reading chapter drafts as I navigated university life as a junior faculty member, developed articles, and wrote a book manuscript. I cannot thank either of my aforementioned colleagues enough for their mentorship and guidance. In addition, I want to thank Paul Greenough and Michael Chibnik for their input as I navigated the world of book publishing for the first time. Their feedback on early drafts of the book proposal helped me to better understand a different domain of academic publishing. I also benefitted from the active encouragement and support of other members of the Department of Anthropology, including James Enloe, Cynthia Chou, Andrew Kitchen, Matthew Hill, Margaret Beck, Elana Buch, Emily Wentzell, Scott Schnell, Laurie Graham, Katina Lillios, Heidi Lung, Bob Franciscus, Erica Prussing, and Russ Ciochon. Faculty members affiliated with the Global Health Studies Program were another source of guidance and support, and I offer my gratitude to Christopher Squier, Mariola Espinosa, Maureen McCue, Robin Paetzold, Mary Wilson, Jeanine Abrons, and Claudia Corwin. I would also like to thank Beverly Poduska, Shari Knight, Allison Rockwell, and Karmen Berger for their guidance and support in avoiding administrative pitfalls as I navigated the tenure track at the University of Iowa. Funding from several sources supported the process of developing my early research and this book project. An Africanist Doctoral Fellowship from the Woodrow Wilson International Center for Scholars, augmented by a grant from CUNY, supported my fieldwork. However, a key source of funding and support was Ida Susser’s research initiative South Africa’s Civil Society Organizations and AIDS Treatment Access, funded by the National Science Foundation. Regarding this, as in many other matters of professional development, my deep thanks to Ida. A fellowship at the Center for Place, Culture and Politics at CUNY supported the early stages of writing. In addition, a writing fellowship awarded through the City University of New York was essential to supporting the process of finalizing the work that eventually became this book.

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As is often the case, the book that follows has been completely rewritten and bears little resemblance to its first iteration. Indeed, follow-up research supported by the Human Economy Programme at the University of Pretoria was essential for re-examining my approach to understanding the politics of HIV/AIDS in South Africa. My thanks to both Keith Hart and John Sharp for their support of my continued research on the local politics of HIV/AIDS, public health, and treatment access in South Africa. The process of writing the book was supported by the University of Iowa granting a Flexible Load Assignment during the fall 2017 semester, which enabled me to finalize necessary revisions to the manuscript without the usual rigors of university teaching. In addition, the College of Liberal Arts and Sciences at the University of Iowa helped to finalize the book through subvention funding to cover the cost of indexing and image rights. I would also like to thank Peter Agree and Lily Palladino for their supportive editorial approach as I navigated the review process at the University of Pennsylvania Press. Last but certainly not least, my family has shown me endless support as I have worked through my studies and the early career stages of academia. Between completing my doctoral studies, navigating a postdoctoral fellowship, securing a visiting position, and life on the tenure track, my family has seen me through the ups and downs that inevitably accompany this process. My mother, Claudia; father, Richard; brothers Greg, Matt, and Thurston; stepmother Darcy; and sister Zoe have offered their encouragement and unconditional love throughout. I would also like to thank my godparents, Bruce and Jill Winningham, for their support and guidance over the years. In addition, my now-deceased grandmother Claudia and grandfather James were always extremely supportive as I worked through my graduate studies, and I offer them my gratitude. While everyone discussed above has helped to bring this book into existence in some way, it has been the support of my loving, intelligent, and beautiful partner Kat that has carried me through the peaks and valleys of the writing process. In addition to bringing positivity, perspective, and light to each day of our lives together, Kat has also brought our daughter Emma and son Leo into our lives, and they have provided me with new perspective on life and ceaseless joy. My endless thanks are in order to Kat for tolerating my mercurial tendencies and for her unconditional love as I worked through the many steps involved in securing one’s livelihood as an early-career academic. Thank you for standing by me as this project carried on; we did it.

ABBREVIATIONS

ABC AIDS ALN ALP ANC ART ARVs AZT BCM BEE CALS CBOs COSATU Eskom GASA GDP GEAR GLOW HAART HIV IMF Iscor LRC MK MSAT MSF NAPWA NEDLAC

Abstinence, Be Faithful, and Condomize Acquired Immunodeficiency Syndrome AIDS Legal Network AIDS Law Project African National Congress Antiretroviral Therapy Antiretroviral Drugs Azidothymidine Black Consciousness Movement Black Economic Empowerment Centre for Applied Legal Studies Community-Based Organizations Congress of South African Trade Unions Electricity Supply Commission Gay Association of South Africa Gross Domestic Product Growth, Employment, and Redistribution Macroeconomic Strategy Gay and Lesbian Organization of the Witwatersrand Highly Active Antiretroviral Therapy Human Immunodeficiency Virus International Monetary Fund Iron and Steel Corporation Legal Resources Centre Umkhonto we Size (Spear of the Nation) Multi-Sectoral Action Team Médecins sans Frontières (Doctors without Borders) National Association of People Living with AIDS National Economic Development and Labour Council

xvi

NGO NPPHCN NSP OLGA PMTCT PSP RDP SACP SANAC SANCO STIs TAC TB UDF USAID VCT WC-Nacosa WHO

Nongovernmental Organization National Progressive Primary Healthcare Network National Strategic Plan Organization of Lesbian and Gay Activists Prevention of Mother-to-Child Transmission (of HIV) Provincial Strategic Plan Reconstruction and Development Programme South African Communist Party South African National AIDS Council South African National Civics Organisation Sexually Transmitted Infections Treatment Action Campaign Tuberculosis United Democratic Front United States Agency for International Development Voluntary Counseling and Testing Western Cape Networking AIDS Coalition of South Africa World Health Organization

INTRODUC TION

People, Pathogens, and Power Situating the South African HIV/AIDS Epidemic

Matamela shook his head as he spoke to me, a wistful expression coming over his face.1 He turned and looked out of the window, pensively stroking his beard for a moment, deep in thought. Matamela was a leading activist for the Treatment Action Campaign (TAC) at the organization’s district office in Khayelitsha, a black urban township approximately twenty miles from Cape Town’s city center. TAC’s district office was housed in an off-white building in a shopping complex adjacent to the Nonkqubela railway station, and it was the base of operations for community-oriented activities designed to limit the spread and impact of HIV/AIDS in the township. As night fell we leaned toward the cracked windows, hoping to catch the last moments of light. Matamela adopted an urgent tone as he spoke of the daily obstacles faced by those accessing HIV/AIDS services in the South African public health sector. If you go out and you say to people, “We are coming to your community to talk about VCT [voluntary counseling and testing for HIV/AIDS]. Come out and go and have voluntary counseling and testing.” And people go to the clinic, and wait hours to go do VCT, and at the end of the day, they do not want to go to the VCT anymore, then there’s a problem there. That quality of service is compromised. Because no one wants to wait for two hours, three hours just for testing for HIV. No one wants to wait. Because you will wait, and at some point [you will be] be told that, “Come tomorrow, because we are about to close down now.” In some instances, you are being told that there is no medication for this particular illness that you are suffering from. It creates a problem.

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Introduction

Emphasizing how often people waited in line for hours but were unable to see a doctor, Matamela painted a picture of underresourced and understaffed public health services in a community where nearly one in three pregnant women are HIV positive. In this and other conversations, Matamela attributed the continuing challenges of HIV to the socioeconomic conditions created by colonization, segregation, and apartheid. His was a sobering analysis of the world’s largest HIV/AIDS epidemic. I met Matamela during one of my first visits to TAC’s office in Khayelitsha. A tall Xhosa-speaking black South African in his mid-thirties, his expression alternated between a broad smile and a searing gaze. As one of the senior activists at the district office, Matamela was often too busy to sit and discuss the broader politics of the South African HIV/AIDS epidemic. That night, another activist had left with the only set of keys, and we had been locked in the office due to a power failure in the township. As was the case for many homes and offices in South Africa, the TAC office had a steel gate and a locking door that had been installed to deter would-be intruders, imagined or real. As I had realized the first time I had locked a gate of this kind, the barrier not only prevents someone from entering but also restricts the movement of those inside. Now, fortunately for me, being locked in the office enabled me to learn more about Matamela’s background and his experiences confronting the HIV/AIDS epidemic. Matamela was born and raised in the Cape Flats, a series of townships that stretch out from the Cape Town city center across a broad floodplain. Brought up in a working-class household, he was radicalized by the Soweto student uprising in 1976 and the subsequent intensification of government violence. During the late apartheid era, Matamela was a member of the PanAfrican Congress, an African nationalist organization that was part of the anti-apartheid movement. He also helped to found TAC and subsequently served as a leading member for the district office and the organization as a whole. As we discussed the political history of the epidemic, Matamela underscored the significance of a TAC protest at the International AIDS Conference held in Toronto in 2006. The South African government delegation to the conference, which included the nation’s minister of health, Dr. Manto Tshabalala-Msimang, had placed garlic, lemon, and beetroot alongside antiretroviral drugs (ARVs) in their display of HIV/AIDS treatments. Protesters from TAC, including Matamela, confronted the delegation for suggesting equivalence between homeopathic remedies and ARVs. The health minister was part of a powerful dissident faction within the ruling African National Congress (ANC) that questioned the underlying science

People, Pathogens, and Power

3

linking HIV to AIDS. The faction critiqued the efficacy and toxicity of ARVs, challenged the characterization of Africans as oversexualized and unable to govern themselves, and condemned the global pharmaceutical industry for profiting from African illnesses. The messages emanating from ANC members in high government positions had a tangible effect on perceptions of HIV/ AIDS within TAC’s district branch in Khayelitsha. Matamela recounted: The problem is—with AIDS, which emanates from poverty—people deny completely that they are having HIV. And these people are going to deny that there is an existence of HIV, so there is no point for them to use condoms. So the rate of infection becomes high. The death rate is huge. There are people who are delaying to start treatment. There are people in TAC who have been delaying their treatment. You ask them “why?” [and] they say that they are afraid. “Of what? Of drugs, why?” “Because the minister is saying this.” Tell me, if people in TAC, who are more informed, are having those doubts, how much more for people who aren’t informed, who are listening only on the radio, watching the television, catching those messages from the minister of health and from the president? I stand by what I said. The president and minister of health, they need to be charged for genocide. Many people have died from AIDS because of their confusing messages. Matamela was not alone in offering a harsh assessment of the AIDSdissident faction within the ruling party and its effects on South African society. Its obfuscating statements on the relationship between HIV and AIDS and critiques of orthodox biomedical HIV/AIDS treatments provoked a transnational response that included American and European HIV/AIDS activists, scientists, academics, and international organizations. Within South Africa, TAC was at the forefront of the South African HIV/AIDS movement, confronting government inaction on access to HIV/AIDS treatment and highlighting AIDS-dissident attempts to limit the public sector response to the epidemic. But even an organization leading the campaign for HIV/AIDS treatment access was not immune to the broader social effects of AIDS dissidence. A brief window of political opportunity opened because the HIV/AIDS movement’s confrontation with South African AIDS dissidents in Toronto brought intensified international attention and the minister of health left office on sick leave in the aftermath of the protest. Over the next several months, HIV/AIDS activists, including Matamela, worked with government

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Introduction

officials to develop a new HIV/AIDS policy and revamp national health institutions to include input from the HIV/AIDS movement. Together, they made significant progress in laying the groundwork for expanding HIV/AIDS treatment access. South African activists’ participation in the transnational HIV/AIDS movement and their convergence at strategic sites was decisive for HIV/AIDS politics in South Africa, influencing sociopolitical dynamics and shaping the campaign for HIV/AIDS treatment, often in unpredictable ways. Focusing on activists such as Matamela, this book tells the story of how the South African HIV/AIDS movement transformed public health institutions and enabled access to HIV/ AIDS treatment, thereby sustaining the lives of people living with HIV/AIDS. Based on extended participant observation and in-depth interviews with members of the movement, I trace how the political principles of the anti-apartheid struggle were leveraged to build a broad coalition that changed national policy and institutions to increase access to HIV/AIDS treatment. From the historical roots of HIV/AIDS activism in the struggle for African liberation to the everyday work of community education in Khayelitsha, I show how people and organizations negotiated access to treatment in South Africa. Sustaining Life, then, offers an on-the-ground ethnographic analysis of the ways that HIV/AIDS activists built alliances, developed new policy, and transformed national health institutions to increase access to HIV/AIDS treatment. In analyzing how encounters among activists, state health administrators, and people living with HIV/AIDS transformed access to treatment in South Africa, the book addresses three key questions: How were the activists of the South African HIV/AIDS movement able to overcome an AIDSdissident faction that was backed by government power? How exactly were state health institutions and HIV/AIDS policy transformed to increase public sector access to treatment? How should the South African campaign for treatment access inform academic debates on social movements, transnationalism, and the state, and what insights does it provide for health care activism? To answer these questions, my account tracks the activities of the South African HIV/AIDS movement in space, through time, and across the institutional levels of the state. Having conducted research at multiple field sites, I link social process across institutional levels and identify important sociopolitical “hot spots” where the work of transforming life possibilities for people living with HIV/AIDS unfolded. As South African HIV/AIDS activists secured the right to health for HIV-positive people, they encountered many obstacles, including a powerful bloc of ANC leaders, dissidents who promulgated the

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virtues of alternative HIV/AIDS treatment and obfuscated the scientific link between HIV and AIDS. In order to understand how and why the political contestation over HIV/AIDS unfolded as it did, it is necessary to first situate the epidemic within its global and regional context, and within the circuits of social inequality that pervade contemporary South African society.

HIV/AIDS, Social Inequality, and the Global South The global HIV/AIDS epidemic is a phenomenon that is simultaneously everywhere and nowhere, contravening expectation and assumption as it manifests and necessitating a reconsideration of the foundational categories through which social scientists understand the world. The epidemic is intensely public, as evidenced through contentious debates on sexuality and public sector programs that address its social impact. Yet it is also private, via the networks of intimacy through which it is spread and through the intellectual property rights that govern access to life-extending medication (Thornton 2008). The epidemic transgresses the analytical categories of academic and social thought while exerting violence on the bodies of poor and working-class people across the world (Farmer 1992, 2004). The HIV/AIDS epidemic expanded alongside a process of increased political, economic, social, and cultural integration— what has come to be called globalization—that occurred in the latter half of the 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

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Introduction

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

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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.

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Introduction

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 and national eddies form in contrast to the flows of globalization is necessary for understanding the dynamics of social inequality, health, and illness (Edelman and Haugerud 2005).

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Anthropological analyses of the effects of HIV/AIDS treatment access have traced how transnational political and economic norms from the Global North create social effects on societies in the Global South. When making the connection between movement and context, these studies often presume that intermediary organizations, institutions, or interpersonal networks are a means of transmission rather than possible transformation. In short, they postulate that local actors and institutions are an extension of transnational movement and circulation. However, local organizations participating in such transnational circulations do not simply receive ideas, norms, and practices: they also shape them. Matamela’s experiences in Khayelitsha, where everyday material challenges weighed heavily in the lives of those who confronted the world’s largest HIV/AIDS epidemic, pointed to a different set of social dynamics than those imagined by Appadurai. How can contextual factors, such as those Matamela experienced, be brought into conversation with the movement and flows associated with globalization? Anna Tsing’s work (2000) offers a useful counterpoint here, as she is circumspect toward encompassing narratives of globalization and instead frames transnational dynamics as operating within locally situated sociopolitical processes, which she calls “projects.” Her ethnographically grounded approach considers how social processes operate at different levels in an increasingly interconnected world. While emphasizing the importance of context, Tsing’s concept of projects assumes a degree of continuity across levels, which may not always occur.4 Nevertheless, Tsing’s approach to locating transnational sociocultural process offers a useful tool for situating the sociopolitical dynamics of the South African HIV/AIDS epidemic. Particularly important is the continued role of the state in Tsing’s conceptualization of context. Rather than assume a state is withering away, her approach analyzes transnational influences on historically particular sociocultural circuits, enabling one to see how state institutions have transformed during the contemporary phase of globalization (Hibou 2004). Following Tsing, this book reincorporates the state in order to better understand the extended campaign for treatment access, as the ANC’s AIDS-dissident faction utilized state health institutions to limit public sector access to HIV/AIDS treatment. Furthermore, as HIV/AIDS treatment access unfolded unevenly in South Africa, with some cities and provinces moving ahead of others in providing public sector care, I engaged in multi-sited ethnographic research. This allowed me to follow the different actors, organizations, and institutions influencing HIV/AIDS politics and see how HIV/AIDS treatment access was manifested at different institutional levels.

10

Introduction

HIV/AIDS, Hot Spots, and Political Process in South Africa The primary challenge I faced starting fieldwork was how to follow individual HIV/AIDS activists while also studying larger politics surrounding HIV/ AIDS. I learned very quickly that research participants’ everyday life activities did not neatly correspond to any discrete notion of politics or policy. The daily work of HIV/AIDS activists focused on addressing the difficulties faced by communities infected and affected by the epidemic, and access to treatment was one of many issues in their portfolio. Conversely, when I focused on the political controversy that surrounded a new national HIV/AIDS policy, as played out in newspapers and political speeches, it was often peripheral to the rich ethnographic material of everyday life. The methodological tension between studying HIV/AIDS politics and studying HIV/AIDS activism came to the forefront when selecting appropriate sites for fieldwork. How was I to choose the sites for data gathering that would be central to the politics of treatment access? Should I assume that policy would be created within state health institutions? What of the daily work of HIV/AIDS activists in the South African HIV/AIDS movement, such as Matamela? How could I analyze both sets of sociocultural dynamics within a single research project? I approached fieldwork with the intention of understanding how HIV/ AIDS politics operated across institutional levels. As a result, I analyzed political activities involving different organizations and activists at several physical sites in South Africa. This included conducting participant observation among a range of institutions, from district coordinating bodies and community-based organizations in townships to a national meeting of the South African National AIDS Council (SANAC) and an array of ethnographic encounters in between. Accompanying research participants from one site to another played an important role in data gathering, and I followed HIV/ AIDS activists to different meetings, conferences, protests, and policy consultations. I also kept pace with the political conflict over HIV/AIDS treatment access, following how people, organizations, and institutions were enmeshed in a broader sociopolitical process. The two frames of movement and context were inseparable; people moved, the political conflict shifted, and, all the while, communities infected and affected by the epidemic continued to suffer amid the material conditions produced by South African history. Multi-sited research initiatives offer a way to study sociocultural processes that accounts for movement, time, and space in the ethnographic analysis

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of social life (Burawoy 1991; Marcus 1995; Lowe 1996; Ferguson and Gupta 1997; Fischer 1999a, 1999b; Wolf 2001). For my project, I linked together multiple field sites by “following” the movement of research participants. I built on George Marcus’s work, which outlines several permutations of following, including two that I employed: following the people and following the conflict.5 Anthropologists analyzing policy have adapted Marcus’s concepts to “follow the policy” and “study through” the policy process (Shore and Wright 1997). “Following the policy” involves analyzing the web of interpersonal, organization, institutional, and political relations that are engaged in the policy process (Shore and Wright 2011). “Studying through” traces those interpersonal connections in order to “illuminate how different organizational and everyday worlds are intertwined across time and space” (Wedel et al. 2005). While these approaches offer a way to study the policy-oriented conflict over HIV/AIDS treatment, they did not allow me to connect HIV/AIDS activists’ everyday activities to broader social processes, such as the development of national HIV/AIDS policy.6 A way to overcome the tension between movement and context grew out of my experiences moving alongside HIV/AIDS activists like Matamela. The pathways of different HIV/AIDS activists led me to intersections where HIV/AIDS treatment access was negotiated, and where I could combine the “following the policy” and “studying through” approaches. Field sites were determined by those who I followed: the HIV/AIDS activists, NGO representatives, and state administrators whose aggregated activities constituted South African HIV/AIDS politics. Following their pathways allowed me to identify field sites based on observed movements and connections rather than any predetermined notion of the field, policy, or the state. In short, it allowed me to identify particular sociospatial zones where the fight for treatment access was unfolding and the contours of local context were defined. Within these zones, HIV/AIDS activists and state administrators produced outcomes that affected HIV/AIDS treatment access. I conceptualize the interpersonal encounters I observed in this fieldwork as intersections of different pathways, laid out within a social field that is mediated by transnational influence.7 Following the pathways of people who had diverse institutional, organizational, and political affiliations enabled me to observe important variants of sociality within the larger field (Holston 1999). I observed a wide array of interactions and dynamics using this approach, with some involving small groups of people and others intense sociopolitical activity.

12

Introduction

I theorize these areas of concentrated sociopolitical activity related to the HIV/AIDS policy process as “hot spots.” In doing so, I build on the work of Hannah Brown and Ann Kelly (2014), who utilize the concept of hot spots to describe how infectious disease outbreaks grow out of a complex convergence of factors that create favorable conditions for transmission.8 In my study, localized political formations emerged at certain hot spots. Local actors and organizations transformed transnational forms of influence through their political activities, localizing the transnational dynamics of movement in a particular sociopolitical context (Powers 2017a). Where these hot spots emerged was dependent on the social and spatial concentration and interaction 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

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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

14

Introduction

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 fiftythree 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.

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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 broadbased 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

16

Introduction

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 to transform treatment access, and, in doing so, created a mechanism for amplifying the experiences of poor and working-class communities besieged by the epidemic. The HIV/AIDS movement laid claim to the socioeconomic rights that had been ensconced in the post-apartheid constitution—specifically the right to health—through their work within a state health institution. In doing so, HIV/AIDS activists changed the effects produced by the state on South African society. The South African HIV/AIDS movement’s success thus offers critical insight into anthropological theories of the state. Anthropological research on the state has emphasized the diverse forms through which state power manifests and produces effects. Contemporary analyses of the state focus on modes of knowledge through which people are disciplined and made productive, and how these modes of knowledge are disseminated, internalized, and reproduced (Foucault 1991; Scott 1998). These accounts tend to ascribe power to knowledge systems rather than people, tracing the ways that power and hierarchy are reproduced in a capillary manner. State power is thus understood through the ways that “state effects” are broadcasted, internalized, and regenerated, influencing identity formation and social reproduction (Mitchell 1991; Trouillot 2001). Other anthropological analyses of the state have emphasized how it holds power over life and death and can produce conditions of “bare life” for those deemed surplus to the formal political community (Agamben 1998, 2005;

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Hansen and Stepputat 2006). There are important corollaries between a state of exception, where martial law unveils the roots of sovereign power in liberal democracies, and the way that state power was exercised in colonized societies, such as South Africa. Here, rather than exercise power by producing discourses that are subsequently internalized and used by people to structure their actions and reinforce existing power relations, the state engages in necropolitics, that is, it expresses power by producing death (Mbembe 2003). These analyses show that the exercise of power, such as by colonial commandement, can also uphold power relations, but in an inverse manner relative to Foucauldian conceptions of the state’s relationship to human vitality. In contrast, the campaign for treatment access shows that the state can be transformed to sustain human life based on the principle of social justice. While the campaign for treatment access was based on a rights-oriented approach to health, it was not predicated on creating a productive citizenry that reinforced existing power relations in South African society. Indeed, the vast majority of people living with HIV/AIDS were black and poor and had subsisted in conditions of “bare life” during colonization and apartheid. A close study of the HIV/AIDS movement shows that a state once designed to produce the conditions of bare life among part of its population, as in South Africa, can be reformed to sustain those very same lives. The South African HIV/AIDS movement underscores that people can have a decisive impact on the effects produced by state institutions. Its transformation of state institutions depended on people working within the state to expand treatment access. Members of the HIV/AIDS movement worked within government to overcome AIDS dissidence, change policy, and expand treatment availability. They cultivated alliances with members of the tripartite ruling coalition, which included the ANC, the Congress of South African Trade Unions (COSATU), and the South African Communist Party (SACP). Rather than abstract economic forces or particular modes of knowledge, it was people—in long-standing interpersonal networks, with policy expertise, with biomedical knowledge—who expanded treatment access. By “occupying” the state, HIV/AIDS activists showed that state institutions have the capacity to amplify alternative visions of society that challenge existing power dynamics. The South African HIV/AIDS movement highlights that the state can produce a range of vastly different social effects; which ones come into being depends on which groups of people set policy and control government institutions. Indeed, analyzing the role of people in the state shows how local bureaucrats can blur the line between state and society while also

18

Introduction

making decisions that can define the life possibilities for those dependent on state support (Gupta 1995, 2012). One of the most important effects that a state can have is to sustain or end the lives of people (Agamben 1998; Mbembe 2001). The campaign for HIV/AIDS treatment access in South Africa shows that the politics of life and death can be altered based on sustained activism. Activists and people living with HIV/AIDS enabled a plurality of experiences to be incorporated into state policy, changing state effects. In the twenty-first century, notable US social movements such as Occupy Wall Street and Black Lives Matter have eschewed formal political demands and state-oriented strategies for securing social change, instead focusing on creating nonhierarchical social movements that enact the political dynamics its members want to see in society, what some scholars have called prefiguration (Maeckelbergh 2011; Yates 2015). In doing so, activists have built upon social movement practices developed elsewhere, such as Argentina, where “horizontal” forms of political association developed in the aftermath of financial crisis (Sitrin 2012a). In contradistinction to these examples, the South African HIV/AIDS movement enacted a formal political approach, including using legal activism to leverage the right to health and occupying the state to sustain the lives of people living with HIV/AIDS. The case of the campaign for treatment access is an important example that can broaden our understanding of why some social movements may succeed in changing a society while others fall short. The political principles of the anti-apartheid movement and the impact of the HIV/AIDS epidemic were elements that could be used to build a common platform to challenge government intransigence and expand access to treatment. These political principles united the members of the HIV/AIDS movement despite their different ethnic backgrounds, class positions, sexual orientations, and professions. People shared their concerns, developed organizations, put their thoughts into action, and, eventually, occupied the state and transformed treatment access in South Africa.

An Outline of the Book This Introduction outlines the book’s approach to analyzing the politics of the South African HIV/AIDS epidemic in relation to academic debates on HIV/AIDS, transnationalism, social movements, the state, and multi-sited research. The two subsequent chapters offer a historical overview of South

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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

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Introduction

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

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(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

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Introduction

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

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Chapter 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 provisions, and a bifurcated wage and labor system created a Keynesian welfare state, but it was one that supported the country’s white population. The period of unified white rule set into motion institutional precedents that expanded racial stratification, formalized land expropriation, and limited the scope of political, economic, and cultural autonomy for black South Africans. Building on earlier political, economic, and institutional dynamics, the apartheid era led to intensified racial segregation, state violence toward black South Africans, and “separate development.” However, those directing apartheid never completed their aim of “ordering” black urban and rural spaces in South Africa (Posel 1991). While traditional leaders exerting political authority in rural Bantustans may have functioned as “decentralized despots,” they also highlighted the limited reach of the South African state (Mamdani 1996). Recurrent forms of self-governance emerged intermittently in black urban areas: the history of the Soweto and Alexandra townships show how a lack of legitimate and representative political institutions led to political self-organization. The anti-apartheid movement also had urban roots, considering the complicity of rural traditional leaders with the apartheid state. Anti-apartheid activists built on the political principles developed by black urban social formations that served as the foundation for the Mass Democratic Movement in the 1980s that aimed to end apartheid and, subsequently, the South African HIV/AIDS movement. Tracing the political principles of the anti-apartheid movement to the HIV/AIDS movement, I take a multipolar approach to South African history, showing how the interaction between linked but distinct social formations produced unequal health effects that adversely affected nonwhite populations. But in order to discuss the historical context for the emergence of the world’s largest HIV/AIDS epidemic, I first outline how particular populations came to embody inequality. In addition, understanding how the HIV/AIDS movement transformed the state to sustain the lives of historically marginalized people entails understanding the roots and principles of political resistance across South African history.

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Precolonial Social Formations, Contact, and Colonization As others have emphasized, the peoples of the world have histories that do not begin—or end—with European contact and colonization (Asad 1973). The history of Southern Africa is no different. Prior to European contact, Southern Africa was populated by indigenous social formations that had a diverse array of political, economic, and cultural practices.2 Colonial settlement across the region was met with resistance, which continued until black South Africans liberated themselves from apartheid. The dualistic nature of colonization, with British and Dutch settlers bringing different modes of political, economic, and cultural organization, produced divergent regional dynamics, but these regional differences were eventually subsumed under the aegis of unified white rule. Initially, European explorers articulated with social formations located along the Southern African coast. Portuguese explorers and Dutch settlers first came into contact with the Khoisan, known to settlers as Hottentots and Bushmen, who descended from nomadic hunter-gatherers and pastoralists from across Southern Africa.3 Cape Town’s role as a refueling hub for European maritime trade led to Dutch enslavement of Khoisan people to support agricultural production and expand colonial trade, undermining life outcomes and social reproduction for South Africa’s first people.4 The violence of colonization extended beyond the domain of economic production, as Dutch settlers, who were predominantly men, took Khoisan women as sexual partners during the early colonial period.5 The forcible intermixing of people, culture, and language transformed the Dutch settler language of Afrikaans, among other cultural shifts.6 Nevertheless, the Khoisan did not passively accept the violence of colonization. Raids, slave rebellions, and migration were responses to the violent expansion of European settlements. Many Khoisan people dispersed northward, but their freedom from European settlers would be short lived. Toward the central and eastern stretches of South Africa’s coast, European explorers and settlers came into contact with Xhosa people who were part of a larger migration of Bantu-speaking peoples from Central Africa.7 Part of the group of Nguni-language speakers, the ancestors of the Xhosa people traveled from the Great Lakes region of the continent southward, eventually arriving in present-day South Africa. In contrast to Khoisan hunter-gatherers, the Nguni-speaking groups brought with them a society centered on cattle herding and iron technologies. Organized into autonomous but interconnected kingships, the Xhosa displaced the Khoisan as they moved into and

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settled central and eastern areas of present-day South Africa.8 In doing so, Xhosa culture was transformed, with key linguistic features adopted from the Khoisan, such as the characteristic Khoisan clicks. Notably, the word “Xhosa” roughly translates to “enemy” in the South African Khoisan dialect. European settler contact with the Xhosa was marked by armed conflict over land and resources, mirroring a similar pattern for indigenous social formations across Southern Africa. On South Africa’s eastern coast, Portuguese explorers and settler populations consisting of Dutch and British colonists came into contact with the Zulu Kingdom. The Zulu and Xhosa peoples shared several key cultural characteristics, including ancestral roots in the Nguni migration from central Africa, the displacement of Khoisan hunter-gatherers, linguistic and cultural influence from South Africa’s first people, and sustained conflict with European settler populations. The Zulu polity unified autonomous but linked kingships under the leadership of King Shaka, the figure for whom they are best known. From the outset of Afrikaner and British settlement, the Zulu Kingdom responded with considerable military force to European colonization.9 However, the Zulu polity was made up of regional kingships, where aspirant leaders negotiated with—and at times sided with—European settlers to maximize their power. The actions of regional power brokers and/or rival factions were central to the subsequent movement of European settlers into the Southern African hinterland, a fact that undermines simplistic narratives of colonization and conquest. The movement of Europeans inland was enabled by colonial war, and settlement contributed to changes in sociopolitical organization that reverberated across the region. Central to the settlement of South Africa’s interior was conflict between British and Dutch colonists in the Cape Colony, which encompassed the present-day Western, Eastern, and Northern Cape Provinces. In repossessing the Cape Colony in 1806, the British crafted an alliance with the Dutch elite based on shared political and economic interests, such as the continued function of Cape Town as a port of supply for mercantile trade. Political compromise led to the continuation of established colonial practices, such as the utilization of a pass system for black South Africans. Since the 1760s, a pass system had been used to distinguish between enslaved and free Africans, whereby those engaged in wage labor were required to present passes provided by employers to prove their freedom (Lester 1996, 24). The British adoption of the pass system maintained a racially defined labor structure established during early Afrikaner rule.10

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In adapting to local conditions, British colonial administration secured the support of Dutch farmers on the frontier who supported mercantile trade. There, Dutch settler social organization was associated with decentralized political and legal authority. Within each district (drostdy), a field cornet (veldkornet) combined the roles of district administrator, judge, and militia leader.11 The field cornet embodied, both de jure and de facto, colonial authority and law in rural areas under Dutch political control. While British legal and institutional norms were established in urban areas, rural areas maintained social order based on the practices developed by Dutch colonial settlers.12 One effect of British support for Dutch landholders was to uphold and extend their “labor-securing practices,” which in practical terms meant the conquest and enslavement of African people.13 The alliance between the British colonial state and the Dutch farming sector would not last long. The Cape Colony’s economic dependence on slave labor undermined the political and economic ties that bound two variants of European colonial settlement. The Slavery Abolition Act of 1833 banned slavery across the British Empire, and the formal end of slavery in 1834 undermined the farming sector across the Cape Colony.14 Dutch landholders sold their properties and headed north in search of farmland outside of British colonial oversight, producing a mass exodus of Dutch farming families. The migration of Dutch settlers to the areas north of the Orange River, known as the Great Trek, precipitated an increase in British landownership in the Cape Colony.15 In turn, British ownership increased the production of cash crops, reconfiguring the agricultural sector. As the economy and demography of the Cape transformed, the movement of Dutch settlers northward reverberated throughout Southern Africa as the settlers came into contact with established African polities and secured access to land and resources through varied means, including warfare.16 While Dutch settlers moved northward, British expansion of the Cape Colony eastward ran up against Xhosa lands, leading to conflict. Since 1779, Dutch and subsequently British settlers had engaged in intermittent conflict with the Xhosa social formations on which they had encroached in what are known as the Xhosa or Cape Frontier Wars.17 Xhosa cattle raiding and reclamation of former lands were central to intermittent conflict between Xhosa peoples and colonial settlers. British and Dutch forces fought together in many of these conflicts, as their political and economic interests aligned relative to the expropriation of African land.18 Continued conflict with the Xhosa on the eastern front enriched British traders and farmers who supplied the British

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Army, further entrenching the economic power of British settlers in the Cape Colony.19 However, conflict between settlers and the Xhosa came to a head via unforeseen means. A Xhosa prophetess named Nongqawuse experienced a vision that indicated that the gods would send settlers into the sea if the Xhosa people killed their cattle and destroyed their crops.20 The vision was presented to a paramount chief in 1856; however, the cattle killing expanded beyond the scope of his region to encompass Xhosa society. This millenarian response to British encroachment and violence was devastating, leading to famine, death, and the destruction of Xhosa society’s economic foundations. Cattle had been a central component of Xhosa society, and were particularly important for social reproduction, as they were used to the pay bride price (ilobola) necessary to consummate marriage. Without cattle, Xhosa people migrated westward, seeking wage labor in the Cape Colony’s agricultural sector, now primarily under British control.21 The cattle-killing crisis also moderated conflict along the Cape Colony’s eastern frontier, leading to the increased influence of Protestant missionaries. The missions established in Xhosa areas later known as the Transkei and Ciskei brought access to Western education, English-language training, religious conversion, and medical treatment based on Western conceptions of health and healing.22 The establishment of missions in what is today South Africa’s Eastern Cape Province transformed social dynamics among the Xhosa and African resistance to colonization. Children sent to receive mission education, learn English, adopt Christianity, and take on Western styles of dress became known as “school Xhosa.” Those who raised their children according to traditional modes of socialization were characterized as “red Xhosa,” as they continued to adorn their bodies with red ocher, along with other customary cultural practices (Mayer and Mayer 1971 [1961]). The increased exposure of Xhosa people to wage labor, education, and Christianity led to their involvement in early campaigns for African equality that took a political, rather than military, approach. The missionary movement contributed to the emergence of an educated class that sought to transform colonial society by expanding the political and economic rights of black South Africans.23 For example, Lovedale Missionary Station offered education to both white and black South Africans while also providing medical care via an adjoining mission hospital.24 Those who attended classes at Lovedale Missionary Station include Z. K. Matthews, who went on to study at Yale University and the London School of Economics before becoming a leading member of the ANC. Govan Mbeki, a leading figure within the SACP and father of future president Thabo Mbeki was also

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educated at Lovedale Missionary Station. In addition, Steve Biko, a leading figure in the Black Consciousness Movement traced his roots to the same rural mission. While many more attended and were educated at Lovedale Mission Station, the historical import of these figures underscores the influential role of rural missions in educating those who led early efforts for equality and justice.

Settler Expansion and Colonial War Alongside early movements for African equality, the nineteenth century saw an increase in export-oriented productive activities and growing economic power for the Cape Colony’s British settlers, which transformed the colonial state. A growing economy enabled infrastructural investment and the expansion of state institutions throughout the Cape Colony. The Cape Colony’s development was financed internally through the expropriation of land and resources from South Africa’s indigenous peoples, the maintenance of a lowwage labor environment to ensure profitability in the agricultural sector, and continued expansion of the colony’s productive base.25 Here, one can see corollaries with the experiences of other British colonies, where the land, labor, and resources of indigenous peoples served as the basis for colonial development (Rodney 1972). A bias toward the needs and interests of European colonists permeated the development of colonial state institutions, including those that focused on public health. The dynamics of colonial health in South Africa were based on a clear distinction between those who were defined as citizens (European settlers) and those whose health outcomes were seen as peripheral to public health (black South Africans). As with other colonies across the continent, health facilities were developed in urban areas and focused on providing curative services to white colonists (Packard 2000). When African people did receive medical care, it was often due to their proximity to white settler populations, as was the case for those who worked in the domestic sphere, or their significance for the colonial economy, in the case of mine workers. British control of the Cape and Natal Colonies led to the development of medical services in the cities of Cape Town and Durban, respectively, with the latter expanding on the heels of a large-scale colonial war with the Zulu Kingdom.26 As the British Empire transformed the social, political, and economic characteristics of the Cape Colony, the Zulu Kingdom expanded from South

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Africa’s eastern coast inland. Under the leadership of King Shaka, the Zulu polity subsumed autonomous regional kingships into one. One effect of Zulu expansion was the dispersal of contiguous social formations—known as the mfecane, which roughly translates to “the crushing”—from what is today known as the KwaZulu-Natal Province.27 Subsequent conflict between ethnic groups displaced by Zulu warfare spread across the central and northern reaches of the region (Comaroff and Comaroff 2001, 167). The mfecane led to new territorial borders for established social formations, the consolidation of new groups such as the Mfengu, and the restructuring of regional power dynamics. The aftermath of the mfecane saw widespread warfare and conflict led by the Matabele in the northern reaches of present-day South Africa, displacing other indigenous peoples and compounding the impact of Zulu expansion. War and migration depopulated a region that would soon be settled by the Dutch displaced from the Cape Colony. The Dutch population that left the Cape Colony following abolition traveled northward into the South African interior, moving into the wake of the mfecane and contributing to the restructuring of African social formations. In what was far from a homogenous process, Dutch populations had slowly expanded out from the Cape Colony since the early eighteenth century. The early wave of Dutch migration had consisted of “trekboers” (trekboere), who had moved to the eastern periphery of European settlement to escape oversight and taxation from Dutch colonial authorities.28 The trekboer population first oriented around a variant of pastoral nomadism and attempted to establish their own independent republics before later developing the eastern farmlands. This group made up a significant segment of the Dutch population that departed after the abolition of slavery. Known as the voortrekkers, which roughly translates to “pioneers,” Dutch people of different class orientations and backgrounds traveled north from the eastern areas of the Cape Colony, across the Orange River, and onto lands historically occupied by African social formations. The area directly north of the Cape Colony’s eastern region was settled by Dutch migrants and subsequently become known as the Orange Free State (Oranje-Vrijstaat). The areas immediately north of the Orange River were inhabited by Khoisan hunter-gatherers who had moved northward following the earlier wave of colonization and slavery in the Cape Colony. The Khoisan were once again displaced by European settler expansion. Further north, the migrant Dutch moved into the sociopolitical vacuum that emerged during

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the mfecane. There they established the Vaal Republic, which encompassed the northern region of South Africa from the Vaal River up to the Limpopo River. Neither British colonial authorities nor indigenous African social formations passively accepted the establishment of two Afrikaner republics. The voortrekkers confronted the Matabele, led by King Mzilikazi, as they moved up to the Vaal River, leading to armed conflict and the eventual establishment of the Vaal Republic, also known as the South African Republic. Intermittent conflict also erupted between the Afrikaner inhabitants of the Orange Free State and the government of the Cape Colony. Over time, conflict with the Basotho Kingdom led to the expansion of the Orange Free State as Afrikaner settlers subsumed its lands. In sum, Dutch migrants settling in the north displaced African populations while negotiating their autonomy from British imperial power. The movement of the Dutch pioneers northward was not a uniform process; Afrikaner migrants navigated their movement amid African social formations using various tactics, including negotiations, warfare, and enslavement. Some treks ended in ruin, with all who participated meeting their ends.29 While advanced military technology was central to the success of the Afrikaner migrants in their movement northward, so too was an ability to leverage internal fissures within African societies to the benefit of mobile settler populations. The diverse outcomes reached by different voortrekker groups underscores the contingency of these forays into the South African hinterland. While the eventual outcome of the treks has become accepted history, one must not fall prey to the bias of presentism in analyzing the movement of European colonial settlers northward. As the northern and central areas of present-day South Africa were settled by Dutch voortrekkers, a multipolar colonial arrangement came into focus. African social formations had been transformed and displaced by a combination of European expansion, slavery, colonial conflict, and warfare emanating from the Zulu and Matabele Kingdoms in the east and north, respectively. British control over the southern reaches of the African continent had expanded from the Cape Colony eastward, with Natal now an established British territory. A war with the Zulu Kingdom on South Africa’s eastern coast would also see British influence on the region expand. However, the accords that maintained an uneasy détente between the British Empire and Afrikaner republics would not hold for long. The discovery of vast diamond and gold deposits in South Africa’s northern reaches would irrevocably shift the balance of power in the region.

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Gold, Settler Conflict, and African Resistance The “scramble for Africa” among European colonial powers and the uncovering of South Africa’s vast mineral wealth instigated British imperial expansion and fomented further conflict between European settlers and African social formations. After an extended period of conflict that enveloped the lives of noncombatants, the British Empire and Afrikaner republics reached a compromise that unified white rule and expropriated land and other resources from African peoples. The transition from a multipolar colonial period to unified white rule set into motion political, economic, and institutional dynamics that expanded colonial pass laws, racial segregation, and the power of traditional authorities across rural South Africa. African peoples continued to resist the expansion of white political and economic authority through the vectors of armed conflict and political activism. The detection of vast mineral deposits in the northern areas of the region led to profound changes. An immense concentration of diamond reserves was uncovered in the settlement of Kimberley, located in the Cape Colony’s northern region. The discovery led fortune seekers from around the world to converge on the South African north, initiating an extractive economy that would be largely controlled by British interests. As the scope of South Africa’s mineral wealth became clear, the British sought to further their interests in the region, annexing Botswana, then known as Bechuanaland, in 1885. However, the decisive event for South Africa’s historical trajectory was the declaration of British control over the Vaal Republic in 1877. While the British had acknowledged the political autonomy of both Afrikaner republics in 1852, their relationship with the northern colonial settlements was characterized by intermittent conflict. British efforts to subsume the northern Afrikaner republics occurred alongside war with the Zulu Kingdom (1879), underscoring the colonial violence that emanated from British imperialism and settlement. The multipolar context within which the colonial wars of the late nineteenth century unfolded inexorably shifted with the discovery of substantial gold deposits in the Vaal Republic. Between 1884 and 1886, a series of mining expeditions uncovered gold in the Witwatersrand area of contemporary Johannesburg. The subsequent gold rush led to an influx of foreign miners in the area, and Johannesburg was established as the “city of gold.” The British initially engaged in conflict with the Vaal Republic from 1880 to 1881, but the commandos of the Afrikaner republic successfully engaged in guerilla warfare to undermine the British incursion. However, the discovery of gold and

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the threat of German and Portuguese regional claims precipitated the British initiation of the South African War (1899–1902). After the British failed in an attempt to spur an uprising against the leadership of the Vaal Republic in 1895, the commandos of the Afrikaner states attacked British-held areas across Southern Africa in 1899. Afterward, the Afrikaner commandos dispersed back into society, reverting to the guerilla tactics that had secured victory during the previous British invasion. However, this time British military commanders employed a new tactic to undermine Afrikaner resistance: concentration camps. Employing a scorched-earth policy, the British forcibly relocated the Afrikaner population into concentration camps, leading to the deaths of approximately twenty-six thousand women and children, primarily due to infectious disease, malnutrition, and lack of access to medical care. The aftermath of the South African War saw the Afrikaner republics annexed and incorporated into British colonial territory, along with the continued expansion of South Africa’s mining industry. British colonial authorities had long worked to establish a wage-labor system in Southern Africa, with the imposition of hut taxes payable only in hard currency a central intervention in this regard. But it was a pathogen, the rinderpest virus, which led many black South Africans to seek work at the mines or commercial farms controlled by white settlers. Nearly a half century after the Xhosa cattle killings, a rinderpest outbreak during the 1890s devastated cattle populations across Southern Africa, undermining social reproduction and the subsistence agriculture most African social formations depended on in lieu of wage labor.30 As black South African men were drawn into the wage-labor sector by the impact of rinderpest and the continued European encroachment on African land, traditional authorities emerged as important intermediaries for a transforming colonial state and economy. As colonial war waned and the colonial economy grew, the intermediary role of traditional authorities between the colonial state and rural black South African communities was formalized. The establishment of rural reserves, where traditional law governed social relations, formalized European settlement areas and reinforced the power of traditional lineages. As tradition was codified into law, women’s formal political roles waned, reflecting European conceptions of political institutions and gender hierarchies. Traditional elites, as intermediary political actors, also buttressed the growth of wage labor by serving as labor brokers for the mines, securing the participation of black South African men in the workforce on contracts ranging from six to nine

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months.31 The formalization of “native reserves” also produced stratification within the rural black South African population, as land and resources allocated within these sociospatial enclosures reflected political authority, with traditional authorities garnering the lion’s share. Poor and working-class South African families crowded into huts amid the pressure generated by the appropriation of land by traditional elites within the reserves and the necessity of paying hut taxes. The spatial densification and material deprivation associated with the rural reserves facilitated the spread of deadly pathogens, most notably tuberculosis.32 In concert with traditional authorities, the South African mining industry constructed a migrant-labor system that drew from the black South African population and other Southern African countries such as Mozambique, Lesotho, and Swaziland (First 1977, 1983). A circular pattern of labor migration was established during the colonial period as black male South African mine workers oscillated between contracted periods of labor in the mines and urban areas and their ethnically designated areas of residence in the rural reserves.33 Mine workers were housed in compounds, often divided according to ethnicity, while those working in urban areas stayed in all-male hostels (Moodie 1994). In Johannesburg, the nearly eighty thousand black urban residents lived in backyard shacks, overcrowded compounds, and informal settlements at the turn of the twentieth century (Harrison 1992). From the ethnic segregation of laborers to the exclusion of women and families from the mining areas, the mining sector set in motion particular modes of sociospatial organization that were to feature prominently in South African urban social life.34 The exploitation of South Africa’s vast mineral wealth also increased socioeconomic stratification within the white settler population. The extraction of profit created a new set of mining conglomerates, such as De Beers Consolidated Mines, founded by Cecil Rhodes. While the British figured centrally in the mining interests of the region, Afrikaner settlers also participated in the mining sector. The emergence of a new economic elite, the Randlords, marked the emergence of a white elite that spanned the British-Afrikaner political divide. The white South African elite incorporated black South Africans into the global economy as manual laborers, shaping class structure across the region. The transnational mining sector that encompassed South Africa set pathways for disease transmission that were first highlighted by a black rural and urban tuberculosis epidemic, evidence of the growing disparity in health outcomes between white and black South Africans. Socioeconomic stratification and increasingly unequal health outcomes were accompanied by the normalization of racial segregation across South

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Africa. Within the Afrikaner republics, racial segregation had marked social organization from the outset, with black South Africans restricted to settling in periurban areas. In British-controlled Cape Colony, urban segregation intensified in response to an outbreak of bubonic plague that had originated in Hong Kong. Growing international trade in the nineteenth century led to the increased movement of people, commodities, and pathogens, leading to racial segregation in colonial cities (Swanson 1977). Informed by miasmatic theories of disease, medical authorities utilized public health measures to implement racial segregation in colonial Cape Town and other cities across the European colonial empires. Black South Africans were designated as the source of disease, with their “unsanitary” residences, interspersed with white homes, designated as a threat to public health by medical authorities. Colonial authorities destroyed these homes, and black South Africans were moved against their will to racially defined urban areas. In Cape Town these measures were met with resistance by the black dockworkers and urban laborers who were forcibly removed from their homes. However, their protests did not prevent the deployment of public health concerns to create racially segregated urban spaces in Cape Town or elsewhere in South Africa. A period marked by European expansion and colonial war set into motion institutional dynamics that presaged the intensified racial segregation during apartheid (Cook 1986). Through political, economic, and sociocultural processes, racial segregation and socioeconomic stratification transformed urban and rural areas in South Africa during the late colonial period.35 A native reserve system demarcated ethnically defined rural areas, establishing formal institutional roles for traditional elites and regulating the movement of black South Africans. Urban segregation was also extended across South Africa, predicated on a policy of “influx control” that regulated the movement of black South African laborers between the reserves and urban areas. The structural segregation established during the colonial period continued to mark South African society as British and Afrikaner polities united in the aftermath of the South African War, leading to further disenfranchisement of black South Africans.

Unified Rule, the ANC, and the White Welfare State The social, political, economic, and institutional dynamics that emerged during the colonial period were carried forward with the unification of British and Afrikaner colonial polities. Unified white rule emerged in South

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Africa with the formation of the Union of South Africa in 1910, a white colonial compromise that was built on the expropriation of black South Africans. The power-sharing government of British and Afrikaner settlers reversed legislation that had granted limited citizenship rights to black South African during the late colonial period. For example, the Glen Grey Act (1894) had established limited citizenship rights for black South Africans within racially defined territories.36 However, the Natives Land Act (1913) reversed this policy by preventing land sales between white and black South Africans while formalizing expropriation, with 87 percent of the land set aside for white colonial settlers (WHO 1983). The exclusion of black farmers ended the emergence of a black South African peasantry and eliminated competition in the agricultural sectors since black South African farmers had generally outperformed their white counterparts with higher per-acre agricultural production (Bundy 1979). Black South African social formations, which constituted 70 percent of the country’s population, were left to carry out subsistence farming on poor quality farmland within densely settled reserves or seek out wage labor in the mines or in urban areas.37 Unified white rule was met with political resistance, most notably from the South African Native National Congress, which was established in 1912 and later renamed the African National Congress in 1923.38 Early leaders of the party such as John Dube and Sol Plaatje led campaigns against legislation that formalized racial segregation and limited the citizenship rights of black South Africans, such as the Natives Land Act. Early ANC leaders came from a variety of ethnic backgrounds but shared certain characteristics, one of which was missionary education and English proficiency.39 Many early ANC members were Xhosa, reflecting their relatively early exposure to missionary education and British colonial rule. However, as Dale McKinley (1997) emphasizes, early ANC leaders were not necessarily focused upon a radical reorganization of South African society. Rather, they represented an emerging black South African professional class whose political and economic interests were undermined by unified white rule. Despite class differences between the ANC leadership and the majority of black South Africans, the party rose to prominence in the 1920s, campaigning against racial segregation and the continued expropriation of black South African land and resources.40 The onset of unified rule was accompanied by an expanded use of state institutions to secure the political and economic interests of white South Africans, including legislation to address the growing population of “poor whites.”41 Increasing numbers of white South Africans living in poverty

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undercut the logic of segregation, which was predicated on the supposed racial supremacy of Europeans. The union government set out to reestablish the link between race and class as the foundation for a bifurcated wage-labor system across South Africa. Transnational interests influenced the unity government’s policies, as the Carnegie Corporation funded a commission that addressed the “poor whites” question in South Africa (Willoughby-Herard 2015). The commission’s findings were used to rationalize institutional mechanisms to support the social welfare of white South Africans, despite growing social inequality and disease prevalence among black South Africans.42 The development of state-owned enterprises that disproportionately employed poor and working-class whites accompanied a welfare state that defined South African citizenship in racial terms. State-owned enterprises such as the Electricity Supply Commission (Eskom), and the Iron and Steel Corporation (Iscor) expanded white employment and contributed to industrial growth in South Africa. The developmental state created during the interwar period was buttressed by the expansion of a state-led industrialization of the South African economy (Freund 2013). The Afrikaner population was the primary beneficiary of the white welfare state, which transformed their class position and reinforced the link between race and class. The rise of an Afrikaner working class was accompanied by the establishment of institutions created by an Afrikaner elite that espoused Afrikaner cultural particularity and white nationalism (O’Meara 1983). The broederbond, an elite network of wealthy Afrikaner men, backed the development of Afrikaner nationalist ideology, which focused on black South African urbanization and the social instability that was believed to accompany this process. Inspired by racialist conceptions of social Darwinism, united by Calvinist beliefs, and informed by the memory of concentration camps, the National Party was formed in 1914 to secure the interests of South Africa’s Afrikaner population. Industrialization and urban growth during the interwar period exacerbated contradictions in the white settler alliance that had held since the South African War. The development of a white industrial working class and urban economic expansion led to increased black South African participation in the workforce and growth in black urban communities.43 The rural reserves had never had sufficient arable land to support subsistence agriculture, and black South Africans increasingly depended on urban employment as soil qualities degraded and the rural population grew.44 As the pressure to garner urban wages to supplement subsistence agriculture in the rural reserves intensified, so did the size, scope, and complexity of black urban social formations.45 The growth of black

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urban settlements in response to employment opportunities led to new forms of social organization and decisive shifts in South African history.46 The early history of Soweto offers a useful example for understanding how black urban settlement expanded and developed in social and political terms. Squatter leader James Mpanza played a central role in Soweto’s settlement and in the development of mechanisms for self-governance,47 including the collection of fees for trading licenses that supported social policing initiatives and funeral arrangements, among other functions (Stadler 1979; Bonner 1990). However, many of those who settled in black urban areas were temporary residents, as black South African men were recruited to work in urban areas or the mines for a period of six to nine months, after which time they would return to their ethnic homelands (Mayer 1980; Sharp and Siegel 1985). While these areas of “separate development” were key sources of mining labor, women-driven agricultural production in the homelands subsidized social reproduction, since mining wages alone were inadequate to support a family. Despite the transience of some residents, urban communities such as Johannesburg’s Sophiatown blossomed with cultural expression during this time, including the publication of magazines such as Drum and the development of influential music scenes (Coplan 1985). The question of black urbanization had long figured in debates on traditional authority. Political leaders such as Jan Smuts were ardent supporters of racial segregation due to a belief that detribalized black South Africans would destabilize the country. British experiences with the issue of precolonial social organization had deeper roots, as their attempts to unravel the caste system in India had informed their subsequent colonization of the African continent. Indirect rule, which maintained traditional laws and customs in the native reserves and reinforced the power of traditional rule, was formalized following the violent suppression of African social formations during colonization.48 Debates on detribalization had simmered during the latter half of the nineteenth century, highlighted by a series of “rape scares” in several cities across South Africa (Etherington 1988; Scully 1995). That black urbanization was primarily male was a central component of growing white fear and mistrust, encompassed by the term swart gevaar (black peril).49 While many of the reported cases of sexual assault appear to have been baseless, the image of young black South African men roaming urban areas stoked fears of the tsotsi (youth gangster). As the black urban South African population grew, the political divide between the liberal-leaning British South Africans and nationalist-leaning

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Afrikaner South Africans expanded. Following urban industrial growth and commensurate increases in the demand for black urban labor during the Second World War, the South African public was faced with a clear choice on how to address racial segregation. A vote for the liberal United Party in 1948 would unravel the two-tiered racial structure of the labor market and move South African society toward desegregation. Conversely, a vote for the National Party would reverse black urbanization and deepen existing policies of racial segregation and “separate development.” Here again, South African history was marked by continuity rather than a break with the political, economic, and institutional dynamics of the past.

Apartheid, Traditional Authority, and Urban Revolt The dynamics of racial segregation, social inequality, and expropriation continued and expanded during the apartheid era in South Africa. The National Party’s rise to political power intensified racial segregation, exacerbated racial inequality, increased state violence toward black South Africans, and led to South Africa’s immersion into Cold War proxy conflicts. Support for African traditional elites was central to the apartheid state’s project of maintaining ethnically distinct reserves. The apartheid state supported and expanded the power of traditional leaders, designating customary areas as the basis for “separate development.” The process of reconstructing urban space along racial lines was contingent upon forced removals and the development of periurban townships, fundamentally changing urban sociospatial relations across South Africa. However, the “ordering” ethos of the apartheid system was never fully realized, and political opposition to the apartheid state grew in the black urban social formations that the National Party aimed to control. After coming to power via national elections in 1948, the National Party initiated the apartheid project of racial separateness. The apartheid system built on and expanded institutions developed during the colonial period to control the movement and residence patterns of black South Africans. The National Party’s strategies of segregating urban space and expanding the role of traditional authorities aimed to unwind South Africa’s rapid urbanization during the 1940s.50 In Johannesburg, the number of black South Africans living in the city increased from 244,000 in 1939 to 400,000 in 1946 (Harrison 1992). The industrialization of the rural farming sector and a growing urban economy meant that opportunities for wage labor had shifted, and rapid

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urbanization led to the proliferation of informal settlements in Johannesburg, Cape Town, and Durban. Among other legislation, the Group Areas Act (1950) and the Prevention of Illegal Squatting Act (1951) were enacted by the National Party to address the growing black South African urban population. The policies created separate residential areas for different races and legalized forced relocation to achieve this end. However, the apartheid system was created through a piecemeal process that was never complete. As Deborah Posel (1991) has emphasized, policies associated with apartheid were amended repeatedly, highlighting the gradual intensification of segregation rather than the imposition of a grand vision. For example, the Group Areas Act was enacted by Parliament in 1950 and amended five times before being repealed and reenacted in a new form in 1957. The 1957 version of the Group Areas Act was amended a further three times before being repealed and reenacted in 1966. The policy was amended an additional nine times before being repealed a final time in 1991 during the negotiated political transition. All this underscores Posel’s claim that “ordering” according to the logic of racial separateness was never fully achieved. Still, although racialized social engineering was left unfinished, the violent restructuring of urban space had destructive and lasting effects on black urban social formations in South Africa. The Group Areas Act’s implementation extended the apartheid state’s power to reorder urban space by enabling forced removals of black residents to periurban townships. The newly created Native Resettlement Board announced plans to destroy the area of Sophiatown in Johannesburg and remove the community in 1953 before initiating the process in 1955. Another famous instance of forced removal occurred in Cape Town with the community of District Six in 1968. The mass removal of black inner-city inhabitants across South Africa was accompanied by the development of periurban townships, such as Soweto (Johannesburg), Nyanga and Gugulethu (Cape Town), and Umlazi and KwaMashu (Durban). Primarily built by municipal authorities, the townships became overcrowded almost immediately. Indeed, the apartheid state directed new construction to occur in the rural reserves rather than build sufficient urban housing. The density of the townships was due also to the efforts of black South Africans to remain in urban areas and maintain their social, economic, and political ties. Thus, forced removals and relocations to the townships were accompanied by an increase in subletting, the construction of backyard shacks, and general periurban densification (Mabin 1992).

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However, apartheid’s scope extended beyond the reordering of urban space and into the domain of social reproduction. The Bantu Education Act (1953) mandated racially segregated educational facilities and limited black South African education to vocational skills associated with low-wage professions. Universities that provided education for black South Africans were also affected by the policy. For example, the University College of Fort Hare, where Nelson Mandela and Robert Sobukwe studied, was transformed by the apartheid state despite its history as an independent university. The Bantu education system was modeled on the “separate but equal” education system that was developed in the southern United States during the segregationist era. Policy development within the Union government had been facilitated by input from Charles Loram, who attended Columbia University’s Teacher’s College, and whose work influenced the development of the Bantu Education Act (Davis 1976). As with the “poor whites” question, interested parties from the United States played a significant role in defining the trajectory of legislation that deepened racial inequality in South Africa. Given the central role of rural missions in the development of black resistance during the colonial era, many were mandated to close by the apartheid state. The Bantu Education Act also impacted rural mission schools, as many maintained integrated student populations despite the entrenchment of racial segregation during the colonial period. For example, the aforementioned Lovedale Missionary Station was forced to close its doors by the apartheid state. The closure of rural mission stations also affected access to health care. For many black South Africans, rural mission hospitals were the closest source of Western biomedical treatment. As the missions closed, so too did access to basic medical treatment for rural black South Africans. The apartheid state also halted the development of innovative new solutions to rural health delivery that were implemented during the interwar period. Dr. Sidney Kark developed community-oriented primary health care, a groundbreaking approach to health in the ethnic homeland that was then known as Zululand. At the Pholela Health Centre, Kark and several colleagues trained black South Africans living in a rural community in basic epidemiological methods, data-gathering techniques, and clinical assessment. The project produced startling improvements in community health, particularly in the area of child health and nutrition (Geiger 1987; Tollman 1994). Kark’s aim was to empower rural communities through education and training to improve local health outcomes. The project was an undoubted success, and it formed the backbone of a new rural health system proposed in

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the Gluckman Report (1945).51 However, empowering black South Africans in rural communities was not a precedent that the apartheid state sought to reproduce. To the contrary, the National Party expanded the power and control of traditional authorities and limited access to health care and education for black South Africans. The expansion of state control over black South Africans during apartheid was contingent on the complicity of rural traditional authorities, the foundation on which the National Party developed the apartheid state. The logic of racial “separateness” reinforced the power of traditional elites, while ordinary black South Africans saw their rights, mobility, and ability to access resources limited. Once enemy combatants against colonial states, traditional authorities became local power brokers and political intermediaries. Regional kings, chiefs, and local headmen secured access to laborers for the mines and farms and maintained patriarchal sociopolitical relations, while men engaged in wage labor via circular patterns of migration (Vail 1989). An important component of the transition to rural traditional authority across Africa was the cessation of traditional institutions for women’s political influence. Reflecting the patriarchal terms on which European colonial administrators articulated with African social formations, leadership positions and traditional law were transformed to focus on male roles in regulating traditional societies (Van Allen 1982). Therefore, in addition to ossifying customary law, the development of native reserves also introduced new limits to women’s power and autonomy that were actively upheld by traditional authorities. Influx control, or the movement of black South Africans from rural to urban areas, was contingent upon the cooperation of the “decentralized despots” that maintained political authority in the reserves (Mamdani 1996). However, the symbolic role of traditional leaders shifted during the apartheid era due to the cultural underpinnings of “separate development.” Cultural explanations rationalized intensified racial inequality during apartheid, and the discipline of anthropology played a central role in buttressing the National Party’s claims to essential and incommensurable cultural differences between people of European and African descent. The volkekunde school of anthropology gathered ethnographic evidence and developed conceptual models at South Africa’s leading Afrikaner universities, supplying the cultural grist for the apartheid state machinery (Sharp 2001). Critically, the volkekunde school marked a sharp break with leading scholarship in South African anthropology, which had historically studied social change, urbanization, and the formation of ethnic identity in a critical manner (Bank 2013). The cultural

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explanation for racial segregation was deployed to rationalize the political separation of society and augment the authority of traditional leaders. The process of shifting the designation and function of the reserves began in 1951 with the adoption of the Bantu Authorities Act. The policy expanded the power of traditional leaders based on ethnic and territorial lines. As with the Group Areas Act, political change was gradual, and the Promotion of Bantu Self-Government Act (1959) established the former reserves as quasiautonomous ethnic homelands. The Bantu Homelands Citizenship Act (1970) further concretized the power of traditional leaders over their growing numbers of black South African subjects.52 The Citizenship Act transformed passes into passports between societies that had autonomous governments, however few states recognized them as such, other than the apartheid state. The National Party also sought to develop the infrastructure necessary to rationalize “separate development” with quasi-state institutions such as regional parliamentary buildings in the homelands. Of course, political representation was limited to the homelands themselves, which did not correlate to voting rights in the broader political context of apartheid South Africa. Intensified racial segregation exacerbated underlying inequities in South African social organization. Forced removals from urban to rural areas intensified an emerging crisis of social reproduction for black South Africans living in the rural reserves. As discussed above, the Land Act (1913) had sequestered 87 percent of South African land for whites, which resulted in increasing numbers of black South Africans engaging in subsistence agriculture in the rural Bantustans. Growing demand for land and increasing densification in the rural reserves led to soil degradation and lower agricultural yields, placing additional pressure on migrant wage earners.53 The apartheid state sought to address the crisis by shifting industrial production from urban areas to the rural Bantustans (Wolpe 1972). However, the industrial sector developed during apartheid largely sacrificed efficiency for the racial logic of separate-but-unequal development. The consequences of inefficient importsubstitution industrialization during the apartheid era would come full circle years later, following the negotiated political transition out of apartheid. As a social reproduction crisis escalated in rural areas, black South Africans responded with increasing levels of self-organization and resistance to apartheid. The violence of forced removals concentrated the black urban population into periurban townships, but it also led to increased levels of political organization and opposition.54 A long-standing source of opposition to white rule, the ANC had lost standing among black urban residents due to

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ineffectual leadership amid growing state violence. The ANC’s “young Turks,” led by Nelson Mandela, Oliver Tambo, and Walter Sisulu, revitalized the ANC by working with the SACP to challenge the implementation of apartheid laws. Walter Sisulu’s election as secretary general reflected a shift within the ANC away from an approach based on moderation to direct action and civil disobedience. The Defiance Campaign (1952) built upon growing opposition to apartheid in urban areas and consisted of nonviolent protests.55 Critically, the South African Indian Congress aligned with the ANC to build a nonracial platform for the campaign. Strikes, boycotts, and nonviolent resistance were the responses of an emerging alliance of anti-apartheid activists. A significant development for the anti-apartheid campaign was the adoption of the Freedom Charter by the ANC, the South African Indian Congress, the Coloured People’s Congress, and the South African Congress of Democrats in 1955. The Freedom Charter set the foundations for a nonracial mass movement to end apartheid, and it formalized several demands: a democratic political system, equality in political rights, equality in human rights, the equitable allocation of the country’s wealth, freedom of movement, access to land, and the nationalization of the country’s banks, mines, and industry. The aims of the anti-apartheid movement set out in the Freedom Charter were highly influential for the subsequent emergence of a broad-based movement to end apartheid that transcended the lines of race and class. The ANC played a leading role in formulating the Freedom Charter, but it did so in a consultative manner. Approximately fifty thousand ANC volunteers canvassed the townships and rural areas, gathering input from black South Africans on how the anti-apartheid movement should self-organize. Former Lovedale Mission Station attendee and ANC member Z. K. Matthews played a central role in compiling the charter.56 The National Party met this opposition to apartheid rule with violent repression. The year following the Congress of the People, the meeting at which the Freedom Charter had been drafted and adopted, the National Party arrested 156 meeting attendees on treason charges. While the case failed to secure a single conviction, the Treason Trials showed how apartheid security forces actively undermined the anti-apartheid movement via surveillance and prosecution. Presaging subsequent events, security forces opened fire and killed fourteen protesters at one protest in the mining town of Kimberley in November 1952. The apartheid security forces responded aggressively to the Defiance Campaign, using deadly force, and the period of open defiance toward the apartheid state came to a halt with the Sharpeville

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Massacre. On March 21, 1960, at a protest against the pass laws organized by the Pan-Africanist Congress, sixty-nine men, women, and children were shot and killed by state security forces. Within South Africa, the National Party responded by further repressing political activity. The ANC, Pan-Africanist Congress, SACP, and other organizations tied to the anti-apartheid movement were banned, and their members went into hiding. Internationally, the United Nations Security Council passed a resolution condemning the killing of nonviolent protesters by apartheid security forces and calling for an end to apartheid. The Sharpeville Massacre was a turning point in the mass movement against the apartheid state, one that led to the militarization of political struggle in South Africa. The Sharpeville Massacre and subsequent militarization of the apartheid state transformed the organizational composition of the anti-apartheid movement. The ANC moved its leadership into exile and formed its military wing, Umkhonto we Sizwe (meaning “spear of the nation” and abbreviated as MK), to engage in guerilla warfare against the apartheid government. Nelson Mandela was a founding member of MK and led a campaign to pressure the National Party to negotiate a new constitution. The campaign targeted government installations across South Africa and included a series of bombings over an eighteen-month period between 1961 and 1963. MK leaders were captured by state security services and prosecuted for “violent acts of revolution” in what became known as the Rivonia Trials (1963–1964). ANC and SACP leaders including Nelson Mandela, Govan Mbeki, and Walter Sisulu were sentenced to life in prison for their involvement in the MK attacks. The intensification of internal repression against the anti-apartheid movement shifted the military conflict from a domestic to a regional affair, with the ANC in exile serving as the apartheid state’s primary target. During the 1970s, the apartheid state shifted from racially “ordering” South African society to becoming a regional military and intelligence apparatus. However, the expansion of apartheid state violence across Southern Africa led to international isolation. In 1961, the National Party held a referendum, and white South Africans voted to withdraw from the British Commonwealth.57 South Africa’s exit from the British Commonwealth also entailed a transformation of Botswana’s political status. Formerly the British Protectorate of Bechuanaland, Botswana had been subsumed into the Union of South Africa as part of the political compromise leading to unified white rule. South Africa’s exit from the British Commonwealth foreclosed the possibility of Botswana’s incorporation into South Africa, and following

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the development of a constitution in 1961 the British approved an application for self-government in Botswana. While South Africa maintained political control over South-West Africa (today known as Namibia), Botswana emerged as an important “frontline state” in the militarized campaign against apartheid along with Mozambique, Zambia, Tanzania, and Angola. Given Soviet, Chinese, and Cuban support for African anticolonial movements, the regional conflict against the anti-apartheid movement was framed through a Cold War lens. While powerful international partners such as the United States became allies of the apartheid state, new variants of political struggle emerged within South Africa that challenged the racial logic and state violence of the apartheid era.

Black Consciousness, the Soweto Uprising, and Late Apartheid The intensification of state repression following the Sharpeville Massacre led to an interregnum for ANC-led internal opposition to apartheid, but it was followed by a new form of social justice activism in South Africa. The Black Consciousness Movement (BCM) traced its roots to the South African student movement and aimed to transform black South African social life. Growing out of transnational movements for black liberation and Frantz Fanon’s revolutionary thought, the BCM worked to undermine the discourse of white supremacy and set the foundations for the Soweto Uprising, which would take place in 1976. As the National Party turned state security forces on black South African urban youth with deadly effect, the foundations for another wave of broad-based opposition to apartheid began to form. Despite attempts by the National Party to control the townships, forms of selfgovernance and resistance reemerged within black urban social formations. Marked by nonracial solidarity that connected urban civics associations, a rising trade union movement, the student movement, and human rights activists, the Mass Democrat Movement set into motion dynamics that would lead to the end of apartheid. The National Party’s attacks on the anti-apartheid movement did not quell black South African resistance for long. As the ANC and other organizations were banned and their leadership forced into exile, the South African student movement led the resurgence in anti-apartheid activism. Up until the late 1960s, the nonracialist position established via the Freedom Charter

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held sway in a student movement led by the National Union of South African Students. However, debates on the efficacy and suitability of white liberal solidarity in the face of apartheid violence led to a fracture within the student movement. Inspired by the work of Frantz Fanon, student activists including Steve Biko, Barney Pityana, and Mamphela Ramphele argued that colonization and white settler violence were predicated on the rationale of white supremacy, which led black South Africans to internalize a sense of inferiority. For Biko and others, continued alliance with white liberal students would not address the need for an autonomous student movement that united those who had been historically disenfranchised. Critically, the conception of “black” that was developed by the student movement at the time included all who were discriminated against by the apartheid state: black, “coloured,” and Indian South Africans. The South African Student Organization was formed in 1968 based on the logic of autonomous black self-organization and precipitated the rise of the BCM. Emerging from the student movement, Black Consciousness activists subsequently shifted their focus away from university campuses and toward black South African communities. Early BCM history overlapped with the South African Student Organization in Durban, where both Steve Biko and Mamphela Ramphele were undertaking their medical studies.58 Biko was expelled from the university in 1972 due to his political activities, while Ramphele completed her medical degree that year. Biko was to live under further restriction, as the apartheid security forces limited his movement to King William’s Town, a small city located outside of East London in what is today South Africa’s Eastern Cape Province. There, Ramphele initiated a community health center that provided primary care and health education to black South Africans. The Zanempilo Community Health Centre was founded as part of a broader BCM campaign to provide medical care to underserved black South African communities.59 Ramphele was named regional director of Black Community Programs for the province, directing BCM programs with Biko, who remained under state surveillance. In addition to providing primary care, BCM activists led campaigns to organize communities and developed literature that challenged white supremacy. The Black People’s Convention, founded in 1973, served as the umbrella under which activities and campaigns across the country were coordinated. Publications such as Black Review aimed to promote self-respect, self-reliance, and human dignity among black South Africans. BCM activists also educated and mobilized high school students, leading to the establishment of the

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South African Students Movement in 1972. Students who attended leadership workshops coordinated by BCM activists played a central role in forming the Soweto Students Representative Council and in envisioning and planning the protests against Bantu education that became known as the Soweto Uprising (Ramphele 2016). On June 16, 1976, students from across Soweto stood up from their desks, left their classrooms, and began marching toward Orlando West Stadium. Approximately twenty thousand students took to the streets of Soweto to protest the Afrikaans Medium Decree (1974), which required that students be taught in both English and Afrikaans equally. As students marched through the township, they confronted police barricades and, shortly thereafter, gunfire. The young people shot and killed by the South African police included Hastings Ndlovu and Hector Pieterson. Pieterson’s death was recorded in what is now an iconic image, which circulated widely and became an inspiration for social movements globally. The violence spread through Soweto, leading to the deaths of many black South African students (estimates range from 176 to 700). The Soweto Uprising and its violent repression led to a fundamental shift in South African society. Student protests spread across the country after the uprising. Internationally, the United Nations Security Council passed a resolution that condemned South Africa for the killings, characterized apartheid as a crime against humanity, and called for self-determination. As a new generation of mobilized youth took the anti-apartheid movement forward, Biko remained under state surveillance in the Eastern Cape. After he was arrested at a security checkpoint outside Port Elizabeth, Biko was detained, transported to Pretoria, interrogated, and beaten to death. He died from a brain hemorrhage while in police custody. Following on the use of deadly force against black Sowetan youth, Biko’s death reinforced that the National Party would exercise lethal violence to maintain power. International condemnation rained down on the National Party but with little substantive effect. More significantly, the late 1970s marked the beginning of intermittent states of emergency as black South Africans living in townships rejected the legitimacy of the apartheid regime. The townships, the source of social mobilization to end apartheid in the 1950s, once again emerged as the core of opposition to apartheid state violence. A trade union movement that had begun its rise with a series of strikes in the early 1970s joined the movement, and solidarity actions by white South African organizations oriented around democratic and human rights principles also increased.

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Over the course of the late 1970s, an increasingly hardline National Party leadership group oversaw the militarization of the apartheid state.60 Responding to growing social unrest unleashed by the Soweto Uprising, the state centralized its security apparatus through the creation of the National Security Management System in 1979. The State Security Council also usurped many functions previously overseen by the cabinet, underscoring the military’s growing power within the apartheid state (O’Malley 2007). The state’s militarization culminated with the declarations of multiple states of emergency during the 1980s as the anti-apartheid movement attempted to make the country “ungovernable” through mass stay-away campaigns, rent boycotts, strikes, and demonstrations. Various forms of state violence were enacted against anti-apartheid activists, including torture and death. The surge in state violence within South Africa was mirrored by increasingly aggressive attempts to eliminate ANC leaders in exile. Ruth First’s assassination in Mozambique in 1982 is one example of the apartheid state’s violent impact on other Southern African societies. The increased aggression of the apartheid state led to fundamental changes in the exiled ANC’s leadership structure and political principles. During the 1970s, the intelligence services of the militarized apartheid state penetrated the ANC exile structures at the highest levels. The infiltration of the ANC forced the party to adapt its mechanisms for internal governance. Already noted for its strong organizational hierarchy, the ANC became increasingly centralized during late apartheid. An example of the ANC’s changed decision-making processes can be found with Operation Vula, in which Revolutionary Council–member Mac Maharaj transferred arms and set up a military underground within South Africa to wage a “people’s war,” modeled on Vietcong resistance to the American occupation of Vietnam. Operation Vula was only known to a handful of ANC leaders such as Oliver Tambo, Thabo Mbeki, and, later, Jacob Zuma. While many cite an ANC tradition of collective decision-making, Operation Vula shows that the process was often concentrated among the organization’s leadership during late apartheid. Given Thabo Mbeki’s leadership role, this closure of democratic space within the ANC was an important political precedent for his outsized role in postapartheid HIV/AIDS politics. While the ANC’s exile structures closed ranks, the numbers of black South Africans residing in urban peripheries continued to grow. As living conditions in the homelands deteriorated and political activity was limited by traditional leaders loyal to the apartheid state, what had once been a circular

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pattern of male migrant labor to and from cities increasingly included women and children.61 Densely populated periurban areas grew in the 1980s when large tracts of land for legalized informal residence were opened using Section 6A of the amended Prevention of Illegal Squatting Act (Mabin 1992). In Cape Town this was done in response to growing numbers of people moving to the city from the rural Transkei in the early 1980s. As these numbers grew, the apartheid state lost the capacity to monitor people’s movements and the spaces they inhabited (Desai and Pithouse 2004). As black urban and periurban communities grew, the anti-apartheid movement mobilized them to expand the fight against apartheid. Civic organizations, including street committees and township-wide governing bodies, developed that were based on the notion of community self-organization. The urban civics movement operated as the de facto local state in black urban areas during the 1980s. In addition, the United Democratic Front (UDF) formed in 1983 as an umbrella organization to house the growing trade union movement, faith-based organizations, and urban civics structures, among others.62 The UDF formed in response to the apartheid state’s proposal of a tricameral legislative structure, an attempt to ward off revolutionary social change.63 The apartheid state sought to include the limited input of “Indians” and “coloureds” but at rates that were not representative of population distribution and without meaningful voting power. Critically, the tricameral parliament excluded black South Africans, as they remained citizens of the “politically independent” Bantustans. The UDF combined the various elements of the anti-apartheid movement and included the powerful National Union of Mineworkers. When combined with the mass stay-away campaigns and rent boycotts coordinated by urban civics structures, the UDF served as the backbone for the emerging Mass Democratic Movement aimed at ending apartheid. The anti-apartheid movement within South Africa built upon structures of democratic decision-making and nonracial alliance building that were developed by early anti-apartheid activists. Building on the Freedom Charter and the forms of self-governance that had emerged in black South African urban areas, the anti-apartheid movement carried forward the political principles and social practices developed in response to white settler rule. These would inform the broad social mobilization that ended apartheid as well as social movements during the post-apartheid era. Anti-apartheid activists became centrally involved in a series of “new social movements” that emerged in response to post-apartheid austerity, and the political approach

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and practices of the anti-apartheid movement are also evident in the South African HIV/AIDS movement’s campaign for treatment access.

Conclusion The articulation of European settler polities and African social formations produced the social, political, economic, and cultural dynamics that mark contemporary South African society. The contours of the country’s population distribution—fundamentally racial in character—grow out of an extended history of deprivation among and violence toward African people across Southern Africa. The migratory routes that enabled black South Africans to sustain themselves also served as pathways for the spread of infectious disease. Syphilis and tuberculosis epidemics grew alongside circular migration, with their spread within urban and rural black social formations facilitated by insufficient access to land and nutrition. Unequal exposure to deadly pathogens meant that black South African lives were lost at rates not shared by the beneficiaries of unified white rule. As Fassin (2007) has argued, correlating death and disease with the disenfranchisement and impoverishment of black South Africans highlights how human bodies bear the burden of history. The unequal distribution of disease and mortality is thus a proxy for South Africa’s history of inequality (Crewe 1992). Alongside attempts to sustain black South African society within racially defined sociospatial enclosures, the anti-apartheid movement developed political principles that would influence subsequent social justice-oriented political activity in South Africa. The political principles developed by the anti-apartheid movement grew out of a broader history of African decolonization and liberation, which articulated with the life practices and everyday knowledge developed by black social formations. Particularly relevant for activism during late apartheid were the political principles upon which the Freedom Charter was established. The charter grew out of broad-based consultative process across urban and rural areas, and it concretized a new alliance that transgressed the racial boundaries that colonization and apartheid had established. The political principles of broad-based consultation and nonracialism were central to the rise of the Mass Democratic Movement during the late apartheid era. An emphasis on human rights can also be traced to the Freedom Charter. Certainly, there is an emphasis on economic redistribution in the document as well.

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The anti-apartheid movement also developed particular knowledge and practices that influenced the strategies and tactics employed by later social movements. Nonviolent civil disobedience was a central component of early ANC campaigns against apartheid, and it served as the basis for international support for the anti-apartheid campaign in the aftermath of the Sharpeville Massacre. The BCM was another influential component of the anti-apartheid campaign in terms of their framing of race and the focus of their campaigns. While rejecting the nonracialism of the Freedom Charter, BCM activists nonetheless promoted a conceptualization of race that encompassed all those who had been discriminated against by white settler polities. This provided a foundation from which to build a community-led movement that united poor and working-class people from diverse ethnic backgrounds. The focus on mobilizing communities through education and providing them with primary care was a significant contribution to subsequent health social movements in South Africa. Finally, the Mass Democratic Movement put into place campaigns that targeted economic activity, including strikes, stay-away campaigns, boycotts, and rent strikes. These approaches, implemented via direct action and civil disobedience, were central elements of the anti-apartheid movement during its later stages. The honing of these political principles and social movement practices would become central to the success of the fight for HIV/AIDS treatment access during the post-apartheid era.

CHAPTER 2

The Political History of South African HIV/AIDS Activism

Situating the campaign for HIV/AIDS treatment access necessitates a historical examination of the HIV/AIDS movement and its roots in the antiapartheid struggle. The South African HIV/AIDS epidemic and HIV/AIDS activism emerged during, and were deeply influenced by, the social, political, and economic conditions of the late apartheid era. The intensification of state violence alongside the growth of a broad-based anti-apartheid movement shaped the contours of the epidemic and the social response that emerged to counter its spread. In unpacking the roots of HIV/AIDS activism, I focus on tracing the interpersonal ties that endured over time and fostered the emergence of the HIV/AIDS movement. I argue that HIV/AIDS activism can be disaggregated into two waves that are differentiated on the basis of race, class, gender, sexuality, the role of transnational networks, and knowledge practices: a first wave led primarily by white, gay, and more-privileged activists; and a multiethnic second wave that organized black urban communities and built alliances with NGOs, community-based organizations (CBOs), and elements of the South African political elite to expand treatment access (Lear 1968; Heywood and Drake 1997; Kinser 2004). Whether one documents social movement practices such as coalition building or traces interpersonal relationships among leading activists, there are important connections between these two waves of HIV/AIDS activism that illuminate the historical foundations upon which the campaign for treatment access was built. In addition to outlining the movement’s historical roots, I focus on how the political struggle over treatment access unfolded between AIDS dissidents and HIV/AIDS activists. Given that state health institutions were a necessary component for achieving public sector access to treatment, I use

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a combination of biographical sketches and interview excerpts to analyze the political history of HIV/AIDS and the state’s response to the epidemic. I then offer a detailed institutional analysis of how members of the dissident bloc limited the availability of public sector treatment for HIV/AIDS and how their placement of dissidents in key positions of power enabled them to undermine the campaign. Finally, I show that the right to health was necessary but insufficient for creating the conditions to sustain the lives of people living with HIV/AIDS in South Africa, forcing second-wave HIV/AIDS activists to occupy the state to secure their rights.

Ending Apartheid, Confronting a Plague In 1982 the first case of HIV/AIDS in South Africa was discovered when a Malawian migrant laborer employed in the South African mining sector tested positive for the virus (Iliffe 2006). By the time it emerged in South Africa, HIV/AIDS had already spread across large swaths of West, Central, and Southern Africa, buffeted by the social dislocation produced by Cold War proxy conflict and the social effects of the World Bank and IMF’s structural adjustment and stabilization programs. The malnutrition and poverty unleashed by structural adjustment enabled the HIV/AIDS epidemic to spread as public health systems were weakened and people’s health deteriorated and their immune systems became compromised. It was simply a matter of time until the epidemic reached South Africa in force. The early 1980s saw HIV/AIDS arrive in South Africa as the internal anti-apartheid campaign shifted into a new phase: the apartheid state security apparatus was expanding, and the political violence associated with the anti-apartheid struggle was intensifying. Dismissing HIV/AIDS as a white homosexual disease, the apartheid state paid little heed to the epidemic (Van der Vliet 1994). Amid social upheaval and various states of emergency, the HIV/AIDS epidemic took root in South Africa. As internal and external campaigns to end apartheid gained momentum, a pathogen that would indelibly mark the post-apartheid era threatened to undermine the freedom long fought for by the South African liberation movement (Posel 2005). The emergence of HIV/AIDS alongside the mass mobilization and violence associated with the anti-apartheid struggle is an important and understudied aspect of this period. First-wave HIV/AIDS activists came from a range of backgrounds, including the gay rights movement, the human rights

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movement, and the primary health care movement, and they were involved in the anti-apartheid movement. While first-wave activists were predominantly white, male, gay, and from the middle or upper class, black South African HIV/AIDS activism also emerged during this time and was central to later ANC support. Activists from human rights organizations and progressive health organizations also contributed to the development of the HIV/ AIDS movement and the establishment of a rights-based approach to the epidemic. In this section, I focus on notable figures in the first wave of HIV/ AIDS activism and three organizations that contributed to the success of the movement: the Centre for Applied Legal Studies, the National Progressive Primary Healthcare Network, and the AIDS Law Project. Analyzing the rise of HIV/AIDS activism through these individual and organizational histories highlights the significance of interpersonal ties for the eventual success of the campaign for treatment access. Following the Soweto Uprising and prominent activist Steve Biko’s death while in custody in 1977, an array of social justice-oriented activities were used to challenge apartheid. Building on earlier work carried out by BCM activists, doctor-activists set up community clinics in historically underserved communities across South Africa. These clinics were later consolidated into the National Progressive Primary Healthcare Network (NPPHCN). Building on the call for “health for all” emanating from the 1978 Alma-Ata conference, NPPHCN health activists adopted a human rights approach and demanded universal access to primary care services. The NPPHCN also drafted policy proposals for the development of primary care in South Africa, which contributed to the development of the ANC’s National Health Plan (1994).1 The NPPHCN focus on access to primary care has remained central to the ANC’s approach to public health during the post-apartheid era. The NPPHCN manifested in a variety of black urban spaces across South Africa including the Cape Flats, a series of townships that stretch across a broad floodplain in the city of Cape Town. There, Dr. Ivan Toms established a primary care clinic and trained community health workers in the informal settlement of Crossroads during the height of the anti-apartheid struggle. The clinic treated a population of approximately sixty thousand prior to its closure by the apartheid government as a punishment for Toms’s treatment of antiapartheid activists (Bateman 2008). In addition to his health activism, Toms was also involved in the South African antiwar and gay rights movements, cofounding the End Conscription Campaign after refusing mandatory military service in 1983. The apartheid government then prosecuted Toms for

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refusing conscription, and he was defended at trial by human rights advocate Edwin Cameron, then based at the Centre for Applied Legal Studies. Toms also played a central role in the South African gay rights movement by working to end the whites only racial policy of the Gay Association of South Africa (GASA), which had been formed in 1982. In 1986, Toms cofounded the Lesbians and Gays against Oppression, later named the Organization of Lesbian and Gay Activists (OLGA), which linked the struggle for political freedom to sexual liberation (Croucher 2011). Despite the organization’s nonracialist platform, OLGA’s members were predominantly white and middle class, reflecting the composition of the South African HIV/AIDS movement at the time. NPPHCN activists were an important source of support for the rightsbased HIV/AIDS movement during the negotiated political transition. At that time, Toms served as national coordinator for the organization and oversaw the participation of doctors associated with it in the National AIDS Congress of South Africa.2 After democratic elections in 1994, Toms joined the Cape Town health department, playing a leading role in the development of programs for HIV/AIDS prevention and treatment across the city. In addition to leading the municipal response to the epidemic, he continued to participate in the HIV/AIDS movement, engaging with organizations including TAC.3 At the time of his sudden and unexpected death from meningitis in 2008, Dr. Toms had risen to the role of director of health for the city of Cape Town. Conceptualizing of sexual freedom as essential to the fight against political oppression, Toms was a central figure in South African gay rights, anti-apartheid, and HIV/AIDS movements. An important first-wave HIV/AIDS activist organization is the aforementioned Centre for Applied Legal Studies (CALS). Based at the University of the Witwatersrand in Johannesburg, CALS offers an example of human rights activists engaging in legal action to support socioeconomic rights. John Dugard founded CALS in 1978 in response to the intensification of state violence following the Soweto Uprising and Steve Biko’s death. In addition to defending the human rights of anti-apartheid activists, Dugard played a prominent role in developing the South African Bill of Rights and in negotiations over the post-apartheid South African Constitution (Du Plessis 2007). CALS has been home to other leading legal scholars, including the aforementioned Edwin Cameron, who emerged as an important gay rights activist during the negotiated political transition and went on to serve as a justice on the Constitutional Court of South Africa. Along with gay rights activist and ANC member Simon Nkoli, Cameron is credited with having put the issue of sexual equality on the ANC’s agenda during the negotiated political transition.

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While human rights-oriented organizations such as CALS carried out actions in solidarity with the social revolt emanating from black urban areas, black South African gay rights activists exerted influence within the antiapartheid movement. Alongside the development of the mass opposition to apartheid during the 1980s, gay rights activist Simon Nkoli expanded the purview of the ANC’s political platform to include sexual discrimination. As Toms had, Nkoli left GASA due to its conservative political stance and purported racism. GASA’s politics were exemplified by its lack of support for Nkoli when he was charged with treason by the apartheid state in 1986 (Croucher 2002). GASA’s conservativism led Nkoli to help establish the multiracial Gay and Lesbian Organization of the Witwatersrand (GLOW) in 1988, which aimed to counteract homophobia and racism within South African society (Croucher 2002). Nkoli brought these issues into the ANC, challenging the revolutionary movement to address sexual discrimination within its ranks and policies. Nkoli was also central to coordinating South Africa’s first gay-pride march, in 1990, which was organized under GLOW’s aegis, underscoring his important role in early campaigns to counteract homophobia and sexual discrimination in South Africa (Gevisser 1999). Nkoli was also a significant figure in the first wave of HIV/AIDS activism, setting political precedents that would be adopted by second-wave HIV/AIDS activists. Upon learning that he was HIV positive, Nkoli publicly declared his status and in doing so set an important example. The approach of “living positively” has been depicted as deriving from transnational forms of influence generally and international health institutions particularly (Nguyen 2005). Nkoli’s decision to live openly with HIV/AIDS is a notable South African root for second-wave activists’ decisions to “live positively” and challenge stigmatization. Upon learning of his status, Nkoli organized for access to education and treatment while confronting the public stigmatization of people living with HIV/AIDS. These efforts were concentrated in the black urban settlements that surrounded Johannesburg’s white urban core. Nkoli’s approach was deeply influential for second-wave HIV/AIDS activism due to the social and geographical focus of his organizing work and his decision to live openly with HIV/AIDS,

HIV/AIDS Activism, the Negotiated Political Transition, and Austerity, 1990–1998 As the negotiated political transition unfolded, the world looked on in wonder as the violence that had marked the late apartheid era subsided. The

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intermittent clashes between members of the Inkatha Freedom Party and the anti-apartheid movement in KwaZulu-Natal Province ended, and the negotiated political transition led to what many argue is the most progressive constitution in the world. The political transition was also a decisive period for HIV/AIDS politics, as first-wave HIV/AIDS activists established a rights-based approach to the epidemic, developed progressive institutions, advocated for the adoption of constitutional protections against sexual discrimination, and recruited and mentored second-wave HIV/AIDS activists. However, the beginnings of democracy came with many challenges for the ruling party, which strained the alliance between the ANC and the HIV/AIDS movement. As the victors in South Africa’s first democratic elections, ANC leaders were confronted with the legacy of the colonial and apartheid eras. South Africa was one of the most unequal societies in the world, and the country’s black majority continued to be confronted with insufficient access to housing, uneven health infrastructure, and inequality in education. Despite pressing challenges, South Africa’s transition period was marked by a cohesive alliance on national HIV/AIDS policy among public health professionals, labor unions, academic analysts, and the ANC. The collaborative initiatives of this era are typified by a public health conference held in 1990 in Maputo, Mozambique, where senior ANC and SACP leaders such as Chris Hani and future minister of health Dr. Nkosazana Dlamini-Zuma identified HIV/AIDS as a serious challenge and called for a response to the epidemic (Susser 2009). The formation of a National AIDS Task Force at the Maputo conference led to a National AIDS Conference in 1992, where a coalition of health professionals, community volunteers, activists, and party leaders formed the National AIDS Coordinating Committee of South Africa. The committee was charged with developing a comprehensive policy for addressing the AIDS epidemic in South Africa, which culminated with the cabinet’s adoption of the National AIDS Plan in 1994 (Schneider 2002). The policy, developed through broad-based consultation, served as a pillar for the ANC’s agenda of extending health services to South Africa’s historically underserved black population. As part of an alliance of ANC and NPPHCN activists, first-wave HIV/ AIDS activists like Cameron set several important precedents during the negotiated political transition and its aftermath, including developing progressive institutions and establishing a rights-based approach to the epidemic. CALS served as the incubator for a rights-based approach via the Charter for Rights on AIDS and HIV (1991). Building on the expertise and experiences of health professionals, gay activists, and human rights lawyers, Cameron

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and others drafted the charter in response to ongoing reports of HIV-related human rights abuses across South Africa (Heywood and Cornell 1998). The charter then served as the basis for creating the AIDS Consortium, a national umbrella organization for organizations fighting the HIV/AIDS epidemic, which was cofounded by Cameron. Along with primary health care activists from the NPPHCN, HIV/AIDS activists pushed for principles from the charter to be incorporated into the National AIDS Plan. First-wave HIV/AIDS activists at CALS developed another important organization for the HIV/AIDS movement: the AIDS Law Project (ALP). Formed in 1993, ALP focused on using legal mechanisms to protect people living with HIV/AIDS from discrimination (Oppenheimer and Bayer 2007). Cameron once again played a key role, serving as cofounder and thereby linking the first and second waves of HIV/AIDS activism.4 Following Cameron’s initial leadership, ALP’s next directors were two of the most important second-wave HIV/AIDS activists: Zackie Achmat and Mark Heywood. Achmat and Heywood had intertwined political histories via the Marxist Workers Tendency prior to their involvement with ALP. The Marxist Workers Tendency was a Trotskyist anti-apartheid organization that was politically aligned with the ANC both internally and in exile (Grebe 2011). Although neither Heywood nor Achmat joined ALP as trained lawyers, they brought with them significant political training and experience from their involvement in the anti-apartheid movement. In sum, ALP was an organizational space that trained second-wave activists in the human rights approach pioneered by first-wave HIV/AIDS activists. After leaving ALP in 1994, Achmat worked with first-wave HIV/AIDS activist Nkoli on a campaign to secure constitutional protection against sexual discrimination. Within the United Democratic Front, an influential alliance of organizations fighting to end apartheid, Nkoli was a driving force behind the push to end sexual discrimination in South Africa (Cock 2003). As the political transition unfolded, Nkoli became an important figure within the National Coalition for Gay and Lesbian Equality. Combining the legal expertise of white human rights activists with the political knowledge of black anti-apartheid activists, the coalition successfully lobbied for the inclusion in the new constitution of a nondiscrimination clause that related to sexual orientation (Croucher 2002). Nkoli and Achmat also worked together on a campaign to repeal apartheidera sodomy laws and on a campaign to extend employment-related benefits to same-sex partners. These projects would be Nkoli’s last, as he succumbed to complications arising from HIV/AIDS on the eve of World AIDS Day in 1998.

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Indeed, Nkoli died due to a lack of access to life-extending HIV/AIDS treatment. Although he did not live to see the eventual success of the South African HIV/AIDS movement in securing public sector access to HIV/AIDS treatment, Nkoli’s fusion of political activism in black urban communities and openness about HIV would set the tone for the second wave of HIV/AIDS activism. A democratic South Africa emerged in a geopolitical context far different from the one other postcolonial African states had confronted. From the late 1950s onward, newly independent African states had vied for autonomy in a bipolar world, and heterodox developmental strategies intended to secure economic autonomy were undertaken under the aegis of the nonaligned movement.5 The fall of the Soviet bloc and the rise of the Washington Consensus in the early 1990s raised the question of how best to navigate a different geopolitical environment. ANC leaders came to power as global integration unleashed finance capital to move freely around the world, limiting the ability of national governments to pursue alternative development agendas. As a result, the ANC abandoned its policy of nationalization, which had served as a unifying principle within the anti-apartheid movement since the Freedom Charter’s adoption in 1955 during the political transition. Debates on economic policy led to policy decisions that had important effects on the social transformation that many anticipated would accompany the transition to a democratic South Africa, including the HIV/AIDS response. Shortly after coming to power, the ANC abandoned its election manifesto, the Reconstruction and Development Programme, and fiscally austere socioeconomic policies took its place, leading to a decline in spending on health and social services. Self-imposed structural adjustment limited the state’s response to the growing HIV/AIDS epidemic and development of public health infrastructure in historically underserved communities during the ANC’s first decade in power. Intermittent currency crises and a series of scandals in the National Department of Health further constrained the public sector response to HIV/AIDS. As the political transition unfolded and austerity limited the public sector response to the epidemic, HIV prevalence skyrocketed from less than 1 percent of the total South African population in 1990 to almost 20 percent of South African adults within ten years (UNAIDS and WHO 2005).

HIV/AIDS, Globalization, and Austerity The broad-based approach to consultation and policy development taken by the ANC and the internal anti-apartheid movement enabled rapid progress

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on primary care and HIV/AIDS policy during the negotiated political transition. Reflecting the central role of the labor movement and urban civics associations, the needs and interests of South Africa’s black majority lay at the center of negotiations over South Africa’s future. However, the political and economic situation navigated by the ANC was fraught with challenges. Ethnic conflict, high levels of racially informed social inequality, and a history of uneven and unequal development were but a few of the pressing social challenges faced by the ANC. Furthermore, South Africa’s democratic majority inherited an economy that had stagnated during the last two decades of apartheid, as investment in the country’s industrial infrastructure had declined steadily since the 1970s. The ANC developed the Keynesian Reconstruction and Development Programme (RDP) in 1993 to transform politically produced economic inequality. The RDP served as the ANC’s economic platform during the 1994 elections, and it reflected a compromise between business, labor, the National Party, and the ANC. Based on a philosophy of growth through redistribution, the RDP addressed a wide range of areas for socioeconomic development.6 However, clear decisions on macroeconomic and industrial policy were not included in the RDP, exclusions that would be revisited after its adoption. In addition, the RDP lacked institutional and financial support. A telling bureaucratic detail is that the Office of the Reconstruction and Development Programme was not given its own budget, and its director, Jay Naidoo, was expected to garner funds from different government departments to ensure the RDP’s implementation. Without budgetary control and appropriate administrative support, the RDP floundered. Despite the challenges faced with the RDP’s implementation, international observers concurred that South Africa’s difficult transition to democracy was a success and that the country, which had been on the brink of internal dissolution in the late 1980s, had stabilized. President Nelson Mandela was widely hailed for his role in returning a country ravaged by decades of internal strife and international isolation to some degree of normalcy. The international investor class appeared to concur with this assessment, as South Africa attracted over ZAR 30 billion in capital from the middle of 1994 to the end of 1995 (Stals 1996a).7 In South Africa the influx of capital proved to be a mixed blessing, as much of these investments were short-term and could be quickly shifted out of the country.8 Investors had sent money into South Africa to take advantage of high interest rates, but it could be moved out of the country at the first sign of instability, resulting in a shaky economic foundation. The ANC had inherited an economy that was saddled

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with debt and lacked currency reserves, had an industrial sector that had stagnated during late apartheid, and could not compete with Western multinationals in the global economy. Given this array of issues, the huge inflow of foreign investment from 1994 to 1996 indicated, at least superficially, support for the ANC government among international investors. The support of global financial actors proved tenuous, as currency crises in 1996, 1998, and 2001 stalled the economy. The movement of capital out of South Africa produced internal economic instability, threatening the ANC’s post-apartheid program of implementing broad-based redistributive policies that promised a better life for the historically marginalized black South African population. On February 13, 1996, South Africa’s post-apartheid honeymoon with global financial markets came to an end. Rumors about Nelson Mandela’s health shook the confidence of traders in foreign exchange markets and sent the value of the South African rand plummeting, causing it to lose nearly 20 percent of its comparative value in less than a month. Although the initial depreciation was triggered by an unfounded rumor, a second depreciation began in late March shortly after Trevor Manuel was named minister of finance in a cabinet reshuffle. Financial market actors seemed concerned that an ANC member had been named to the post, that he was black, and that he was not a financier (Hirsch 2005). The perception of weakness in the South African economy was a contributing factor to the length and severity of the currency depreciation. However, an additional factor figured prominently: apartheid debt. The debt that had been incurred by the apartheid state during the late apartheid era was a critical factor in the economic turbulence that the ANC faced upon coming to power. Janine Aron and Ibrahim Elbadawi show that the large inflow of foreign capital during the 1994–1996 period was used to pay off government debt of a particular kind: a “net open forward position” at the South African Reserve Bank (Aron and Elbadawi 1999). This position was essentially a guarantee of future payment for foreign currency subtracted by the reserves held by the government of South Africa. In December 1996, the amount of this position stood at a deficit of USD 22 billion. This was clearly a sizable sum and one that essentially doubled the debt that the ANC had inherited from the apartheid regime, creating a structural economic weakness that was exploited by global markets and undermined the ANC’s agenda of social transformation. The issue with the net open forward position is that it is a form of shortterm debt. When payment is due, US dollars must be procured to pay the

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debt, regardless of the exchange rate. If the exchange rate depreciates, this increases the repayment cost. In an attempt to cushion the severity of the currency depreciation in 1996, the South African Reserve Bank utilized resources that could have been spent on measures to alleviate poverty or to address the growing threat of an HIV/AIDS epidemic. Instead, the ANC-led government dedicated significant state resources to addressing the financial legacy of apartheid debt. Partly in response to this currency crisis, the ANC introduced a new economic policy in June 1996, the Growth, Employment and Redistribution macroeconomic strategy, which marked a clear break from earlier ideas about how to balance economic growth, redistribution, and social transformation. The RDP was abandoned in favor of the market-friendly Growth, Employment and Redistribution (GEAR) macroeconomic strategy, which emphasized debt repayment, lowering the budget deficit, lowering inflation, partial privatization of state assets, limited spending on social programs, and further opening the economy as a means of attracting foreign investment and spurring economic growth. GEAR, drafted by a small group of economists, was presented as a nonnegotiable policy proposal that had been created outside of consultative mechanisms for policy coordination between business and labor (Gumede 2005). In practice GEAR did stabilize South African macroeconomic fundamentals, most notably lowering inflation, the budget deficit, and the amount of debt held by the South African government. However, foreign investment and jobs did not materialize. While these deficiencies have been well documented, the ANC’s adoption of GEAR offers insight into the constraints encountered by democratic movements in the Global South as they navigate the demands of the global investor class and the material needs of postcolonial societies (Desai 2002; Bond 2004). It is now widely accepted that the GEAR imposed fiscal austerity and ran counter to earlier ANC policy models (Michie and Padayachee 1998; Bond 2004). Following the adoption of GEAR, the ANC’s economic policies focused on achieving neoliberal economic targets such as reducing inflation, liberalizing trade, limiting state spending on social programs, and restructuring the state bureaucracy. These policy shifts contrasted sharply with the RDP’s transformational agenda. Further, they can be broadly described as neoliberal and aligned with the key principles of the World Bank’s structural adjustment programs. Prioritizing these financial targets resulted in the privatization of public services such as electricity and water provision, which had a disproportionate impact on the health and livelihoods of the poor and

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underemployed (Benatar 2001; Pape and McDonald 2002; McDonald and Ruiters 2005). Water privatization led to cholera outbreaks in black urban communities, as prepaid water meters limited access to clean water for those unable to afford it (Deedat and Cottle 2002; Von Schnitzler 2008). Privatization led to higher costs for utilizing these services, transferring the cost of developing social infrastructure back onto historically underserved communities (Desai and Pithouse 2004).

HIV/AIDS Policy and a Lost Decade in the Department of Health After a decade during which the National Party had characterized HIV incidence as isolated to white homosexual men, a series of conferences and a comprehensive national AIDS policy marked a shift away from policies based upon the isolation of high-risk groups. There were early signs that the Department of Health was shifting toward a focus on heterosexual transmission as early as 1987, but the apartheid state did little to stem the tide of a growing HIV/AIDS epidemic (Van der Vliet 1994; Fassin 2007). Indeed, it was not until 1994 that national AIDS policy in South Africa took a decisive turn. Even then, the HIV/AIDS response was limited by fiscal austerity and the prioritization of other political and economic issues that had become pressing in the aftermath of the negotiated political transition. Alongside a growing HIV/AIDS epidemic, the implementation of fiscal austerity and adoption of cost-recovery policies imposed sharp constraints on the availability of health services. National spending on health did not increase in real terms from 1996 until 2006, limiting the public sector response to the HIV/AIDS epidemic (McIntyre and Thiede 2007). While the development of the public health sector slowly moved forward amid austerity, the opportunistic infections associated with a large-scale HIV/AIDS epidemic placed unrelenting pressure on all levels of the South African public health system. The HIV/AIDS epidemic hit South Africa’s informal settlements particularly hard, as those living within them had an HIV incidence nearly twice that of other urban areas (Thomas 2006). Further, townships lacked adequate health systems for their residents, an important legacy of South Africa’s unequal history. The resulting overcrowding of hospitals had foreseeable but nonetheless tragic results. In 2007 the Medical Research Council found that one in five infant deaths in the South African public health sector were avoidable

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(Beresford 2007). Limited by the self-imposed constraints of austerity, public health sector personnel worked to meet the health needs of those whose bodies bore the epidemiological scars of South Africa’s unequal history. Within this context, post-apartheid HIV/AIDS policy aimed to control the spread of the epidemic but was marked by systemic and financial constraints. The initial budget for the National AIDS Plan was only ZAR 20 million, however, nearly ZAR 80 million from the European Union and the United States Agency for International Development (USAID) increased the national AIDS budget by a factor of five.9 Nonetheless, the National AIDS Plan was unable to make an impact on the growing HIV/AIDS epidemic, as its implementation fell by the wayside among the various commitments that the ANC faced upon coming to power.10 This was due in part to institutional upheaval, which resulted from state restrictions, such as voluntary retirement packages offered to apartheid-era state officials, fiscal austerity, and a lack of public health infrastructure in black urban areas and rural customary areas (Schneider 2002). Despite the scope of the political projects involved— including drafting a new constitution, creating a novel system of government, and replacing state administrators—the ANC’s relative inattention to the epidemic marked a sharp turn away from its support for HIV/AIDS initiatives during the political transition. The unraveling of the National AIDS Plan was complicated by a series of scandals within the Department of Health that exacerbated growing divisions within the alliance between HIV/AIDS activists and the ANC.11 The Sarafina II scandal focused on the allocation of funds for a play that aimed to educate the public about the dangers of HIV/AIDS through the medium of theater. The play, which was first performed on World AIDS Day in 1995, was canceled in February 1996 when news of its ZAR 14 million budget became public.12 At the time, this was nearly one-fifth of the budget for the HIV/AIDS response (Fassin 2007). First-wave HIV/AIDS activists had already begun to question the prioritization of the HIV/AIDS epidemic by the ANC-led government, but the way that limited resources were being allocated provoked further concern. If the Sarafina II affair led to questions about the political management of the epidemic, a subsequent scandal would illuminate ANC leaders’ dissident views on the underlying science of HIV/AIDS. The Virodene scandal began in January 1997, when a team of researchers from the University of Pretoria claimed to have discovered a drug that counteracted the spread of HIV in the immune system. In an unorthodox turn, they presented their findings to the South African cabinet before they

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had been peer reviewed and published (Fassin 2007). The veracity of these claims was immediately called into question, as it emerged that Virodene’s key ingredient was an industrial solvent. Led by the AIDS Consortium’s Edwin Cameron, first-wave HIV/AIDS activists launched into action, calling a meeting and expressing their dismay with the government’s role in the Virodene scandal (Fassin 2007). A key concern was how and why a scientifically unproven remedy could be presented as a potential cure to the cabinet without proper vetting. These concerns were more than justified when it emerged that proper ethical protocols had not been followed with the human subjects recruited for the study.13 Another significant aspect of the Virodene scandal was an attempt by the ANC to exert political control over the Medicines Control Council.14 The institution first halted future research on Virodene in 1998, and the ANC responded by dismissing the chairperson and the registrar of medicines from the council. In addition, the council’s top staff was replaced. Subsequent appeals enabled some of these officials to retain their positions, however these events set a precedent. The Virodene scandal finally came to a close in February 2007 when the Medicines Control Council refused to permit any future experimentation with the drug (Geffen 2010). The two scandals were important for the HIV/AIDS politics that would emerge during the subsequent presidency of Thabo Mbeki. The Sarafina II affair showed that resource-allocation strategies within the Department of Health diverged from national HIV/AIDS policy, while the Virodene scandal underscored ANC leaders’ openness to considering unorthodox HIV/AIDS treatments. These dynamics would reemerge as central to the politics of HIV/ AIDS in the years to come. The ANC utilized state institutions to pursue a political agenda on HIV/AIDS that contradicted national HIV/AIDS policy and ignored biomedical norms, a pattern that would continue under the aegis of AIDS dissidence.

Second-Wave HIV/AIDS Activism, AIDS Dissidence, and Treatment Access (1999–2003) The 1999–2003 period in South Africa was marked by the continued impact of neoliberal macroeconomic policies, the emergence of AIDS dissidence, and a series of legal victories for the HIV/AIDS movement that forced the ruling party to provide HIV/AIDS treatment in the public health sector. The emergence of an AIDS-dissident faction began shortly after the ascension

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of President Thabo Mbeki and his appointment of Dr. Manto TshabalalaMsimang as minister of health. During its first years in power, the ANC had been constrained by apartheid debt, the transnational economic orthodoxy of the Washington Consensus, and the impact of global capital flows, all of which undermined a fragile politicoeconomic consensus. In this context, members of the ruling party both espoused a circumspect view of global forces—which included the global pharmaceutical industry—and critiqued orthodox biomedical perspectives on the HIV/AIDS epidemic (Schneider 2002). These views became associated with a political platform that enabled the ANC to mobilize its core constituency through appeals to nationalist sentiment and a critique of the unequal impact of neoliberal globalization on the Global South: AIDS dissidence (Gevisser 2007). Mbeki adopted alternative views on the HIV/AIDS epidemic after he discovered the work of “AIDS-dissident” American scientists who questioned the link between HIV and AIDS and claimed that azidothymidine (AZT), an early HIV/AIDS drug, was poisonous (Nattrass 2007; Fassin 2007). AIDS dissidence linked the epidemic to neocolonial depictions of Africans as diseased, oversexualized, and unable to govern themselves, framing the fight against HIV/AIDS within an African nationalist agenda (Nattrass 2004; Comaroff 2007; Gevisser 2007; Susser 2009). Mbeki actively lobbied leading members of the ruling party to taken on his views (Chikane 2013). The ANC’s AIDS-dissident faction argued for African solutions to the epidemic, opening the door to unorthodox forms of HIV/AIDS treatment to be considered. The campaign to secure access to treatment had taken an unexpected turn: a powerful segment of the ruling party now stood as an obstacle to accessing life-extending therapies. Soon after her appointment to the position of minister of health in 1999, Tshabalala-Msimang reinforced a central tenet of AIDS dissidence: the toxicity of antiretroviral drugs. Visiting an AZT clinical trial of in Uganda, she declared that no program using the drug for PMTCT would be initiated in South Africa before the Department of Health had run its own trials (Fassin 2007). Mbeki further discussed the toxicity of AZT during an address to the National Council of Provinces in October 1999, contradicting scientific evidence of AZT’s efficacy as a HIV-prevention tool, even though the drug had been proven to significantly cut the rate of mother-to-child transmission of HIV five years earlier (Musoke 2004). In addition, by February 1999 the Western Cape Department of Health had gone ahead with its own PMTCT program in which it had tested nearly six hundred women for HIV and given

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AZT to ninety-six women who were close to giving birth (Fassin 2007). The Department of Health intervened to stop this “experimental” program, and Tshabalala-Msimang then called upon the Medicines Control Council to review the safety of AZT for PMTCT in November 1999. In short, the AIDS dissidents utilized the jurisdictional hierarchy of national institutions to stop public sector use of AZT to prevent HIV transmission. The Medical Control Council was also directed to review a drug that had already been established as a proven intervention for HIV/AIDS treatment and prevention. The rise of AIDS dissidence also influenced the composition of national institutions. For example, SANAC was formed in January 2000 when the Inter-Ministerial Committee on AIDS was amended to incorporate broader societal representation. This was due in part to revised guidelines from international donors, such as the Global Fund, that required additional civil society representation for funding eligibility (Papadakis 2006). While this appeared to be a step toward a more open approach to HIV/AIDS policy, the newly formed SANAC did not include any medical practitioners, scientists, representatives from the Medicines Control Council, members of the Medical Research Council, or prominent HIV/AIDS activists (Butler 2005). The exclusion of biomedical practitioners underscored Tshabalala-Msimang’s influence in SANAC’s establishment. SANAC thus operated under the political control of AIDS dissidents and thereby supported party leadership on the issue of HIV/AIDS treatment. The clearest manifestation of AIDS-dissident influence on national health institutions came with the establishment of the Presidential Advisory Committee on HIV/AIDS in March 2000. This committee was comprised of biomedical HIV/AIDS researchers and individuals who contested the scientific link between HIV and AIDS. Orthodox HIV/AIDS scientists found participation on the committee demeaning, as it allowed AIDS dissidents to have their views represented in official state documentation (Susser 2009). The “inconclusive” findings of the Presidential AIDS Advisory Panel Report (2001) reinforced that the panel included members who did not see a causal link between HIV and AIDS. In this case, the office of the president established an institutional mechanism that furthered the dissident position on HIV/ AIDS within official government channels. The increasingly public profile of the ANC’s AIDS-dissident faction came to international attention at the 13th International AIDS Conference, held in Durban, South Africa, in July 2000. President Mbeki gave the opening speech at the conference, underscoring the central role of poverty in determining health outcomes while calling for more

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research on antiretroviral drugs. Mbeki’s refusal to distance himself from AIDS-dissident views did not go unnoticed, generating international backlash led by an increasingly radical South African HIV/AIDS movement. As policy initiatives developed by the first wave of the South African HIV/ AIDS movement floundered and AIDS dissidents took control of national health institutions, second-wave HIV/AIDS activists stepped into action. TAC, which had been founded by Zackie Achmat, Mark Heywood, and others in December 1998, had emerged as the leading edge of second-wave HIV/AIDS activism, challenging government intransigence and the impact of AIDS dissidence. For the Durban conference, mobilizing international networks of HIV/AIDS activists, TAC organized a march of five thousand people to protest Mbeki’s continued obfuscation of HIV/AIDS science and the efficacy of antiretroviral drugs (Geffen 2010). The protest was followed by the “Durban Declaration,” a statement published in the esteemed academic journal Nature that affirmed the scientific link between HIV and AIDS and was signed by more than five thousand doctors, scientists, and HIV/AIDS activists (Durban Declaration 2000). The campaign for treatment access was originally led by the National Association of People Living with AIDS (NAPWA), a South African civil society group. However, TAC broke with NAPWA leadership due to disagreements on political strategy. While NAPWA leaders backed the ANC emphasis on prevention and left dissident statements unchallenged, the TAC-led HIV/ AIDS movement directly confronted the dissident bloc in government over the course of a decade. Many HIV/AIDS activists, such as Achmat, were well versed in political struggle. Politicized by the 1976 Soweto youth uprising, Achmat famously burned down his school in the Salt River section of Cape Town to protest apartheid’s Bantu education policies (Achmat 1995). He served time in prison as a teenager for anti-apartheid activism before joining the Marxist Workers Tendency and the ANC as an anti-apartheid activist in the 1980s. As an openly gay anti-apartheid activist, he took on homophobia within the liberation movement, extending the work of gay rights–and ANC-activist Simon Nkoli, as mentioned earlier. Together, Nkoli and Achmat, along with other future TAC activists, developed a NPPHCN clinic in the Bellville area of Cape Town (Grebe 2011). The transition period also saw Achmat join ALP, where his work with Cameron would focus on the rights of HIV-positive prisoners (Achmat and Cameron 1995). In juxtaposition to Achmat’s background as an “internal” activist within the democratic movement, Mark Heywood underwent political training

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with members of the anti-apartheid movement who had gone abroad. Like Achmat, Heywood had been a member of the Marxist Workers Tendency during late apartheid, but he was part of the exile wing of the organization in London. Upon returning to South Africa in 1989, Heywood participated in several Marxist Workers Tendency efforts including the Philemon Mauku Defense Campaign and the Leeukop Political Prisoners Support Committee. In 1994, Achmat hired Heywood to join ALP, and the latter subsequently became ALP director in 1997. Heywood and Achmat represent a cohort of HIV/AIDS activists that straddled the two waves of HIV/AIDS activism and carried forward with them knowledge and practices gleaned from participation in the anti-apartheid movement. Central to this was Nkoli’s work in the black South African townships, as TAC built on this legacy to organize poor and working-class black South Africans communities while adopting a strategy of direct action in demanding HIV/AIDS treatment and prevention programs (Heywood and Cornell 1998). As the HIV/AIDS movement drew strength from the Durban conference, the ANC dissident faction’s dependence on state institutions to counter biomedical responses to the epidemic intensified. In the aftermath of the conference, the president of the Medical Research Council, Dr. William Makgoba, came under attack for research on the impact of the HIV/AIDS epidemic on mortality rates in South Africa. Statistics South Africa, a national institution, critiqued Dr. Makgoba’s use of apartheid-era statistics, and President Mbeki characterized the Medical Research Council as “irresponsible.” The ANC leadership’s furor over mortality statistics continued with an attempt by the minister of health to block the publication of the Medical Research Council report in September 2001 (Schneider 2002). These events led to Dr. Makgoba’s dismissal and his replacement by Dr. Anthony Mbewu, an Mbeki ally who purportedly supported his views on HIV/AIDS (Geffen 2010). As national health institutions fell under the sway of the AIDS-dissident bloc, TAC focused on increasing public sector access to the HIV/AIDS drug Nevirapine. This was a feasible goal given that the German pharmaceutical company Boehringer Ingelheim had offered the antiretroviral drug to developing countries free of charge since late 2000 (Boehringer Ingelheim Pharmaceuticals 2000). Despite this, the South African government announced that it would not expand use of Nevirapine for PMTCT beyond a pilot program at two public hospitals per province scheduled to begin in April 2001 (Annas 2003; Jones 2005). The pilot program galvanized the HIV/AIDS movement because the efficacy of Nevirapine-based PMTCT had already been

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scientifically established in 1999 (Guay et al. 1999). The ANC’s decision to limit public sector access to Nevirapine-based PMTCT led TAC and ALP, with support from the Legal Resources Centre (LRC), to take legal action against the government, arguing that the unequal provision of Nevirapine violated the constitutional right to health in South Africa. In July 2002 the Constitutional Court agreed, ruling that unequal access to Nevaripine “violated the health care rights of women and new-borns under the South African constitution” (Annas 2003). However, the ruling party relented a few months prior to this ruling; in April the minister of health had announced that Nevirapine would be made available in the public health sector. The legal challenge ensured that all South Africans could benefit from the efficacy of Nevirapine-based PMTCT, and it highlighted the HIV/AIDS movement’s growing strength. Particularly significant for this campaign was support from COSATU, the labor federation that constitutes one-third of South Africa’s governing alliance. As the alliance now included members of the ruling party, it showed that members of government were increasingly accepting of the HIV/AIDS movement’s demand for treatment access. Alongside the campaign for Nevirapine access, the HIV/AIDS movement had been lobbying within the government to isolate the president, the minister of health, and other members of the AIDS-dissident faction within the ruling party (Geffen 2010). In May 2002, ANC cabinet members publicly broke ranks with the president and other AIDS dissidents by announcing that HIV caused AIDS. While some analysts have pointed to the “cabinet revolt” as a sign of democratic processes with the ruling party, this decision also highlighted fissures within the ANC on AIDS dissidence (Butler 2005). Around this time, TAC’s Achmat claimed that approximately half of the cabinet was sympathetic to the movement’s demand for antiretroviral therapy (ART) (Friedman and Mottiar 2005). In addition, both COSATU and the SACP, the ANC’s governing partners, publicly criticized Mbeki’s position on HIV/AIDS (Fourie 2006). While it has been postulated that TAC used its relationships with the members of the tripartite alliance “instrumentally” to achieve mass support, this interpretation neglects that these organizations represented South Africans whose socioeconomic rights were being violated by the ANC’s intransigence in implementing ART in the public health sector (Jones 2005). Despite a rising tide of resistance, AIDS dissidents continued to limit the availability of ART in the public health sector. Under Tshabalala-Msimang’s leadership, the Department of Health acted slowly in response to the Constitutional Court decision on Nevirapine. Thus, while TAC had scored a victory

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in the legal sphere, AIDS-dissident control of the Department of Health limited its impact. This lack of action led the HIV/AIDS movement to pressure the government to draft a comprehensive AIDS treatment program that included ART. In late 2002, Heywood announced a deal had been reached on a comprehensive HIV/AIDS policy within the National Economic Development and Labour Council, but the ANC denied that an agreement had been reached, and business leaders did not publicly support the draft agreement (Geffen 2010). Frustrated by the slow pace of implementation for Nevirapine and the disputed agreement, TAC planned a series of protest actions that grew into a civil disobedience campaign. The campaign began with the “Stand Up for Our Lives” march led by TAC and COSATU at the opening of parliament on February 14, 2003 (TAC 2003). This protest was supported by former president Nelson Mandela, had the participation of trade unions, and included between ten and fifteen thousand people (Geffen 2010). At the conclusion of the march, COSATU and TAC handed a memorandum to government officials that included a demand for negotiations on a comprehensive HIV/AIDS treatment program to be restarted by the end of the month (TAC 2003). When the deadline passed without any response, TAC began a civil disobedience campaign to pressure the ANC, which consisted of TAC members occupying public institutions such as police stations, where they demanded the arrests of the president, minister of health, and other leading AIDS dissidents on the charge of culpable homicide (Geffen 2010). The campaign tested TAC’s alliance with COSATU, as the trade union saw these actions as a threat to the state (Ranchod 2007). Following TAC’s decision to suspend the civil disobedience campaign at the end of March 2003, COSATU negotiated with the Ministry of Health and others to restart talks for a comprehensive HIV/AIDS treatment plan (COSATU 2003). While the 2002 draft agreement that had been announced by Heywood was not implemented at that time, it did serve as a model for the comprehensive HIV/AIDS treatment plan adopted later that year. The HIV and AIDS Care, Management and Treatment Plan (also known as the Comprehensive Treatment Plan) was developed by TAC and COSATU through negotiations with a moderate faction of the ANC led by Deputy President Jacob Zuma. Acting as an intermediary between the HIV/AIDS movement and the government, Zuma met with TAC leadership and promised that the government would commit to a treatment plan if the organization ended their civil disobedience campaign (Geffen 2010). Zuma kept his promise, and the South African cabinet instructed the Department of Health

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to draft an operational plan for rolling out ART in August 2003, marking the onset of widespread public sector access to HIV/AIDS treatment. Along with the Comprehensive Treatment Plan, moderate elements within the ANC agreed in December 2003 to restructure SANAC to allow for more representation from civil society (South African National AIDS Council 2010). Even as the ruling party created space for HIV/AIDS activists in national health institutions and expanded public sector treatment access, the AIDSdissident faction continued to discredit biomedical responses to the epidemic. The circulation of the “Castro Hlongwane” document at an ANC National Executive Committee meeting held from March 15, 2002, to March 17, 2002, is instructive. The document, whose authorship has subsequently been claimed by President Mbeki, elaborated the AIDS-dissident position at length and blamed the death of presidential spokesperson Parks Mankahlana on the consumption of antiretroviral drugs (Kenyon 2006; Mbeki 2016). The document was reportedly posted to the ANC website and distributed within senior ANC branches. During the same year, the minister of health offered public support for an alternative HIV/AIDS treatment called “Africa’s Solution,” which was a nutritional regimen supplemented by the consumption of garlic, lemons, and olive oil. Director General of Health Thami Mseleku confirmed that the creator of Africa’s Solution—nutrition nurse Tine van der Maas—had been invited by provincial health ministers to test the approach on HIV/AIDS patients at public hospitals in five provinces (McGregor 2009). Clearly, the fight for treatment access was not yet won.

The Struggle Continued: ART Rollout and AIDS Dissidence During the 2004–2008 period, the HIV/AIDS movement continued to create space within national institutions to influence policy, but AIDS-dissident control over the South African state continued to limit HIV/AIDS treatment availability. As a result, the Department of Health initiated patients on treatment at a rate far below the targets outlined in the Comprehensive Treatment Plan. As the April 2004 national elections loomed, the South African HIV/AIDS movement threatened legal measures to speed up the public sector rollout of antiretroviral drugs (Geffen 2010). Facing another legal challenge from the HIV/AIDS movement, the Ministry of Health relented and agreed to purchase HIV/AIDS treatment. The apparent need for oversight on policy implementation led the HIV/AIDS movement to form the Joint

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Civil Society Monitoring Forum, an umbrella organization made up of HIV/ AIDS activists, NGOs, and professional health worker organizations (TAC 2005). It operated as a parallel system for tracking the implementation of HIV/AIDS policy in South Africa, with clinical staff aligning with the HIV/ AIDS movement. The Joint Civil Society Monitoring Forum enabled pressure to be exerted on the government to speed up the accreditation of clinics for the dissemination of ART, purportedly the key factor slowing down HIV/ AIDS treatment access. Despite the HIV/AIDS movement’s efforts, by the end of 2004 only fifteen thousand patients were on ART nationally in a country with 5.3 million people living with HIV/AIDS (Steinbrook 2004; Wouters et al. 2010). By March 2006 less than one-third of those projected to receive ART in the Comprehensive Treatment Plan were accessing HIV/AIDS treatment (Susser 2009). The issue was not funding, as the Treasury supported treatment availability in the aftermath of austerity and the budget for HIV/AIDS treatment rose from ZAR 213 million in 2001 to ZAR 1.439 billion in 2004/5 (Wouters et al. 2010). Rather, public sector treatment availability was undermined by a health minister who “dragged her heels” in addressing clinic accreditation, human resources shortages, and problems with the drug procurement process (Nattrass 2008). AIDS-dissident control of national health institutions was also seen in the expiration of the HIV/AIDS/STD Strategic Plan (2000– 2005). Without a plan to direct HIV/AIDS policy, national decision-making was untethered from the policy guidelines that had been developed in concert with the first and second waves of HIV/AIDS activism. Concurrently, AIDS dissidents facilitated an alliance between an organization that disseminated alternative views on HIV/AIDS treatment, the Dr. Rath Health Foundation Africa, and a prominent national organization that had historically operated in black urban areas, SANCO. As the tide began to turn against the dissident faction, senior ANC figures reportedly developed ties with the Rath Foundation, which had been founded by German vitamin salesman Dr. Matthias Rath, who claimed that insufficient access to vitamins and micronutrients was the true cause of HIV/AIDS (South African National Civics Organization and the Dr. Rath Foundation Africa 2016). In March of 2004, the president of the Medical Research Council, Dr. Anthony Mbewu, reportedly met with Rath and suggested building ties with NAPWA as a “counterattack” against the HIV/AIDS movement (Geffen 2010). An alliance emerged instead between the Rath Foundation and SANCO to test and distribute a micronutrient-based vitamin regimen in South Africa’s

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black townships (discussed in greater depth in Chapter 5). Led by TAC, the movement responded to these events by filing a complaint with the Medicines Control Council and the Department of Health in February 2005 (TAC 2008). The South African Medical Association, COSATU, and public health workers from the Western Cape joined the campaign, mobilizing broad public support for government intervention against the Rath-SANCO alliance (Cullinan and Thom 2005). Building on the power of a broad coalition, TAC and the South African Medical Association took legal measures in November 2005 to challenge the Rath Foundation’s dubious claims to cure HIV/AIDS and the Western Cape Department of Health’s inaction in stopping an illegal clinical trial. The legal case was not resolved until June 2008, when the Cape High Court ruled in favor of TAC and the South African Medical Association (Gray and Jack 2008). While the AIDS-dissident agenda was advanced at the local level by the Rath-SANCO alliance, the ANC’s dissident faction continued to exert influence within national health institutions. Under the leadership of Minister of Health Tshabalala-Msimang, the HIV/AIDS movement made limited inroads into the National Department of Health. And while SANAC was restructured in 2003 in response to the influence of international health institutions and organizations, greater representation from the HIV/AIDS movement did not lead to significant shifts in national HIV/AIDS policy.15 I spoke with several civil society delegates who had participated in SANAC during the 2003–2006 period, one of whom described how ANC officials acted as a “united front” against civil society representatives, leading to “institutional dysfunction.” I also spoke with members of a leading labor union that participated in SANAC meetings at that time. We sat together in a conference room as they described, with quiet, controlled frustration, how a whole year had passed between SANAC meetings, and that attendance by key government officials was as sparse as it was erratic: “When we did meet, there were also problems because not all of the government representatives were present. There were many instances where there were only civil society representatives and no representation from government or very poor representation from government. These issues hampered our progress. We struggled to make progress because we couldn’t make decisions because, many times, the meeting would not even quorate.” The effects of state intransigence within SANAC were clear: the input of civil society sector representatives, and by extension the HIV/AIDS movement, was limited despite their involvement in the restructured national health institution.

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Another civil society delegate offered an edifying example of how SANAC operated during the 2003–2006 period with respect to decision-making processes. The delegate described how, as a civil society representative, they had been involved in a Global Fund application process, which necessarily involved SANAC, as it was the country-coordinating mechanism for the Global Fund. The delegate’s description of how the South African application was developed within SANAC reinforces how the Department of Health interacted with civil society during this time period:16 Now the Global Fund’s expectation is that this document is a constructed document, [with] government and civil society. That’s not the way it works. The department, Msimang’s department, they write the document.17 They write it, without consultation, and then send it to the SANAC members for signature. Now this is your problem. On the day I get a phone call to say that the courier is going to come tomorrow with a document, that the courier will wait there, you must sign the document immediately because it’s got to go off to New York or Washington or wherever the next day. If it doesn’t, that’s the end of the proposal, that’s the deadline. And along comes a document that thick [indicates 3–4 inches], which you’ve never seen, never even been part of, and now you’ve got a dilemma: if I don’t sign this damn thing, then there is no proposal to the Global Fund for South Africa. And the political response is going to be, “Well, they refused to sign it, that’s the sector representative who wasn’t willing to sign.18 So, people of South Africa, we’ve lost a couple billion because of them.” So I signed, and at the next meeting I registered my anger about this and the disrespect and [how] this must never happen again. The following year, a meeting on a Saturday up in Pretoria near Johannesburg, “There’s the book, sign.” Same story, because again, same power. We put up a bigger fight that day and said we’re not signing. We kept at this, those of us who were there, to create a strong front, but if you don’t sign this, that’s it, nothing goes forward. That’s it, so we signed again. Within SANAC, therefore, ANC leadership continued to exercise institutional power over the civil society representatives. Following the 2004 national elections, the possibility of making inroads into the Department of Health arose. After having been reelected as the president

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of South Africa in 2004, Mbeki named Nozizwe Madlala-Routledge as deputy minister of health. A member of the SACP with a history of social activism, Madlala-Routledge began holding meetings with TAC in 2005 regarding the campaign for treatment access. As HIV/AIDS activists started working with an important member of the state institution that had previously served as a roadblock to the dissemination of ARVs, the minister of health forbade MadlalaRoutledge from holding further meetings with TAC leaders (Geffen 2010). Barring TAC from meeting with the deputy minister of health proved to be a shortsighted decision, as it led Deputy President Phumzile Mlambo-Ngcuka to become involved, which would prove to be a decisive development when the minister of health went on sick leave in 2006. The HIV/AIDS movement’s alliance building was further boosted by political activism at the 16th International AIDS Conference, held in Toronto in August 2006, to which the South African government sent a delegation that included Minister of Health Tshabalala-Msimang. The South African display booth presented garlic, beetroot, and lemon alongside ARVs as HIV/ AIDS treatments. TAC activists led a series of protests at the conference, including a protest at the South African booth, shouting down the minister of health during her presentation, and making public demands for her immediate removal from office. In a parallel civil disobedience action, forty-four TAC activists in Cape Town carried out a sit-in at the Department of Health’s provincial offices, leading to their arrest (Maclennan 2006). The conference included an eviscerating critique of the ANC’s AIDS-dissident faction by the United Nations special envoy on AIDS to Africa, Stephen Lewis, who stated: “They can never achieve redemption” (Altman 2006). The international furor that ensued led to a shift in ANC strategy for HIV/ AIDS. A moderate faction within the ruling coalition, led by Deputy President Mlambo-Ngcuka and Deputy Minister of Health Madlala-Routledge, emerged to support greater access to ARV-based HIV/AIDS treatment. These senior government officials worked closely with leading HIV/AIDS activists in negotiating a new SANAC and drafting a new national HIV/AIDS policy, the National Strategic Plan (NSP). The deputy minister had been an ally of the South African HIV/AIDS movement for some time, openly critiquing government inaction on treatment access in lockstep with leading HIV/AIDS activists. The deputy president also maintained a close working relationship with leading HIV/AIDS activists, which highlighted the efficacy of the movement’s strategy of alliance building within the state. Minister of Health Tshabalala-Msimang was absent during these negotiations because she left

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office on sick leave, which created a window of opportunity for the movement to transform the state’s response to the epidemic from within. With the deputy president and deputy minister of health’s support, the HIV/AIDS movement developed an ambitious new national HIV/AIDS policy and transformed SANAC. The process of drafting the new national policy came together quickly as government officials worked with HIV/AIDS activists and health professionals after the conference in Toronto. The NSP set ambitious goals: to halve HIV infections and reach 80 percent of those in need of treatment by 2011. In April 2007 a large meeting of civil society organizations was held in Johannesburg to adopt the NSP, and in May the South African cabinet approved the plan. The deputy minister of health then hosted a conference at the University of Cape Town to coordinate the efforts of researchers and support implementation of the NSP. The policy was a something that the HIV/AIDS movement had fought nearly a decade for: a comprehensive policy for AIDS treatment and prevention that included enforceable targets for treatment availability. An expanded SANAC incorporated wide swaths of the HIV/AIDS movement into a joint civil society and government institution that oversaw the NSP’s implementation and advised the South African cabinet on scientific developments related to HIV/AIDS prevention and treatment. The restructured SANAC created a formal institutional space within the state for the HIV/AIDS movement to monitor policy implementation by the Department of Health and provincial health departments. As will be discussed in greater depth in the following chapter, SANAC’s revised structure included civil society representatives and the appointment of HIV/AIDS activists to leading positions within the institution. SANAC also took up the role of monitoring and evaluating the implementation of the NSP, replacing the functions performed by the Joint Civil Society Monitoring Forum with a formal governmental process. Critically, SANAC oversight of the Department of Health meant that the national health institution could be held accountable for failure to meet targets for public sector HIV/AIDS treatment availability.

HIV/AIDS Activism: Waves, Alliances, and the Right to Health The political history of the South African HIV/AIDS epidemic highlights several themes that connect the campaign for treatment access to the antiapartheid movement and early HIV/AIDS activism. Social movement

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knowledge and practices traveled through interpersonal networks, uniting the two waves of HIV/AIDS activism and shaping how campaign strategy unfolded. Continuities in social movement knowledge and practices can be seen in examples of alliance building, policy development, institution building, and direct action. The first wave of South African HIV/AIDS activism played an important role in setting the foundations for future mobilization by establishing rightsbased national HIV/AIDS policy and constitutional protection of gay rights, and by developing organizations that cultivated the development of secondwave HIV/AIDS activism. The rise of rights-based organizations during late apartheid served as incubators for the development of a human rights approach to HIV/AIDS, which was codified as law with the National AIDS Plan. Furthermore, the legal activists that established the LRC and CALS contributed toward the development of a new constitution that included the right to health. These organizations brought together different strands of activism from within the broad-based anti-apartheid movement. The stories of Edwin Cameron, Zackie Achmat, and Mark Heywood show how the legacies of human rights activism, gay rights activism, and anti-apartheid activism came together to help create a more just and equal South African society. First-wave HIV/AIDS activists targeted the institutions of the state and the constitutional basis of law by building coalitions within the Mass Democratic Movement. Indeed, first-wave activists were also integrated into high-level government positions and substantively affected policy-oriented debates. Transmitted from first- to second-wave activists through interpersonal relationships, the internal response to apartheid produced an array of mobilization techniques, coalition-building strategies, and campaign models (Powers 2017b). Second-wave HIV/AIDS activism, led by TAC and ALP, worked to achieve the right to health for people living with HIV/AIDS in South Africa by campaigning for treatment access. The HIV/AIDS movement drew on transnational networks of HIV/AIDS activists, medical professionals, and global health organizations during its second phase. Leading South African HIV/AIDS activists and organizations cultivated ties with moderate elements of the ruling party and mobilized an array of NGOs, community-based organizations, and professional organizations to join the fight for treatment access. The socioeconomic rights guaranteed in the South African constitution, particularly the right to health, were critical for the eventual success of the campaign, but they were insufficient to ensure that South Africans living with HIV/AIDS had access to treatment. Rather, the activation of these legal

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protections necessitated alliance building, direct action, civil disobedience, and the eventual restructuring of government health institutions. The alliance-building tactics utilized by the HIV/AIDS movement relied heavily on the support of COSATU, the labor federation that serves as part of South Africa’s tripartite governing alliance. The HIV/AIDS movement leveraged COSATU’s organizing power for many significant demonstrations, for introducing a draft national treatment plan, and for behind-the-scenes negotiations with the ANC during the civil disobedience campaign. In addition, COSATU members played prominent roles in the restructured SANAC. Support from both COSATU and moderate elements of the ANC proved to be decisive at several key junctures, particularly efforts to isolate the ANC’s AIDS-dissident faction. An important milestone in this regard was 2003, when the South African cabinet passed a resolution stating that HIV causes AIDS (Butler 2005). Building on the institutions, legal infrastructure, knowledge, and practices pioneered by the first wave, second-wave activists including Achmat and Heywood recruited a new generation of HIV/AIDS activists from the communities most infected and affected by the epidemic: South Africa’s black townships. As a result, poor and working-class black South Africans took up senior positions within TAC and the HIV/AIDS movement. A prominent activist in this regard is Vuyiseka Dubula, who joined TAC in 2001 upon learning of her HIVpositive status. Armed with a scientific rather than a political background, Dubula first served as TAC’s provincial treatment literacy coordinator for the Western Cape before taking on national and international roles.19 There is continuity between the work of first-wave activist Simon Nkoli, who organized around issues of gay rights and HIV/AIDS in the greater Johannesburg area from the mid-1980s until his death in 1998, and the focus on black South African communities among second-wave activists. However, the primary population involved in HIV/AIDS activism was quite different during the second wave. Rather than black gay men, those recruited to the second wave of HIV/AIDS activism have been primarily women. In large part, the demographic shift within the HIV/AIDS movement reflects the greater involvement of women in South Africa’s public sector HIV/AIDS programs. Shifting gender dynamics within TAC particularly also highlight the organization’s successful campaigns that transformed public sector HIV/ AIDS programs aimed at women, notably PMTCT.20 Buttressed by a constitutional right to health, success in prominent legal cases, growing support within the state, and a broad social coalition, the HIV/

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AIDS movement made significant progress toward public sector access to treatment during the post-apartheid era up to 2007. However, these were necessary but insufficient conditions to secure widespread access to HIV/ AIDS treatment in South Africa. Activating the right to health relied upon breaking the law in calculated acts of civil disobedience and occupying the South African state. As the ethnographic chapters that follow make clear, the process of transforming South African society to enable access to HIV/AIDS treatment required restructuring national health institutions, engaging with the state across institutional levels, and educating and organizing communities affected by the HIV/AIDS epidemic. Moving alongside HIV/AIDS activists, NGO members, and state health representatives, the following chapters trace how AIDS dissidence was eventually overcome to sustain the lives of people living with HIV/AIDS in South Africa.

CHAPTER 3

Occupying the State HIV/AIDS Activism and the South African National AIDS Council

Despite restructuring SANAC, developing the NSP, and working closely with leading ANC members, the South African HIV/AIDS movement could not prevent the minister of health’s return from sick leave and the resurgence of AIDS-dissident power within national health institutions. Many thought that the days of AIDS dissidence were gone, but the minister’s return was accompanied by renewed intransigence in the National Department of Health and the newly restructured SANAC. In response, the HIV/AIDS movement mobilized its members to occupy the state and overcome AIDS-dissident control, working within SANAC and with members of the ruling party who opposed the dissident faction. I accompanied HIV/AIDS activists as they took the fight for treatment to the state, driving national policy development within SANAC. In this way, members of the movement changed the future scope of the South African epidemic; as they moved into the national health institution, they were able to transform the public health response. One of the major accomplishments of the movement in shaping policy was the establishment of new PMTCT guidelines. Building upon updated WHO policy recommendations, these guidelines included dual therapy, or the use of two ARVs, and thus reflected transnational biomedical norms. However, to simply attribute the policy change to transnational influence obscures the work of the many HIV/AIDS activists, medical professionals, labor unions, and academic researchers in improving policy. The updated PMTCT policy guidelines were created through a consultative process that brought together people from across the country, including medical professionals and people

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living with HIV/AIDS. Despite attempts by members of the National Department of Health to undermine the new policy’s development, the HIV/AIDS movement pushed through the guidelines using sustained activism. HIV/AIDS activists fought against AIDS dissidence on a daily basis, engaging with communities infected and affected by the epidemic while leading national policy development. My extended participant observation with TAC activists and others in the HIV/AIDS movement allowed me to analyze how the struggle against AIDS dissidence unfolded across the country and within SANAC. As I moved alongside members of the HIV/AIDS movement, I observed a steadfast refusal to accept injustice. One of the ways that I saw this injustice challenged was the demonstration of solidarity with those whom South African society had neglected and left with bodies infected by illnesses of inequality. Unexpectedly, I was also drawn into an encounter that showed how HIV/AIDS activists challenged injustice and the arbitrary exercise of state authority in their daily lives. One Friday evening in central Cape Town, after enjoying dinner with friends, including one who was visiting from Johannesburg for the weekend, I noticed that we were being followed. I turned around and saw a car guard— an informal worker who watches parked vehicles in exchange for compensation—wearing the unofficial uniform of his profession, a neon-yellow reflective vest. We had left my car some distance from where we had eaten and up a steep hill, but the guard continued to follow us, undeterred. As we pulled into the road, he stood in front of the car, his arms raised above his head, preventing us from driving away. I rolled down the window to ask what the problem was, but he shook his head and only said that we could not leave. A line of cars began to form behind us, honking their horns in frustration. Still, the car guard did not move; instead he asked that we pull to the side of the road and wait. I refused, and the car remained in the middle of the road. We sat in the car, confused and asking each other what was going on. Why was a car guard detaining us? Could a car guard, who has no formal legal authority, prevent the free movement of people in South African society? Clearly not, but still, he had. A clarification of a kind came moments later. A police van pulled up in front of our car, lights flashing, and the car guard turned and walked toward the passenger side window of the vehicle, gesturing to what appeared to be the officer in charge. After nodding and speaking with his colleague on the driver’s side, this officer, a towering man, stepped out of the car. His cap and epaulets indicated that he was a captain. He strode toward us, and I waited

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to hear what we had done wrong, as his presence led me to believe that we had committed a violation of one kind or another. The captain told us to get out of the car; when we had done so, he then declared that one of us was a “notorious” drug dealer, the car would be searched, and we could not leave until that was done. At first we were incredulous, asking which of us was the drug dealer. But the captain was insistent, and the car guard pointed with enthusiasm at my friend who was visiting from Johannesburg. A mathematician working in the financial sector, my friend was not a dealer of anything other than financial instruments. However, our protests left the captain unmoved, and he indicated that we would be arrested if I did not allow the car to be searched. Since it was Friday evening, we would not be released until Monday morning if I refused to comply. Up until that point I was confident that we had the legal high ground in the situation, but the threat of a weekend in jail shook my resolve. I stepped away from the confrontation, walking toward the long line of vehicles that had assembled behind us. As I stood there, a familiar face emerged from a car window three vehicles behind my own. It was Francis,1 an HIV/AIDS activist who worked at TAC’s national office. He looked at me with a surprised expression on his face, asking if everything was okay. I shook my head and told him that there was a problem, and he emerged from the car, striding toward the police captain with purpose. Francis entered the conversation with the police captain without hesitation, immediately taking the lead from my friends and me. As Francis was well versed in constitutional law from his involvement with TAC, I felt reassured. After speaking with the officer for several minutes, he returned wearing a frustrated expression and explained that I would have to allow the police to search the car. If I didn’t, my weekend would likely be spent in confinement. I assured Francis that there was nothing illegal in the car, but I had resisted allowing access on principle. Francis assured me that he understood and indicated his own irritation with the available options. I thanked Francis for his efforts before yielding to what I thought was an illegal search. I unlocked the car and opened the doors, trunk, and all, accompanying a junior officer as he searched through various compartments and rummaged through my personal effects. At one point, the junior officer unfolded a small piece of paper he’d found in the trunk that indicated I had met with a minister of parliament. He looked at me with a searching glance, to which I responded with a dejected shrug, reiterating a sentence I had stated several times already: “I am in South Africa carrying out research on the AIDS epidemic.” The

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intensity of the search then diminished, and I was feeling a bit more relaxed when the junior officer reported back to the captain. With a sneer on his face, the captain said that we could go, emphasizing that it was only because he said so. In addition, he indicated that we were lucky to not be searched and have had our clothing removed in public as part of the traffic stop. I simply lowered my head and walked away, but Francis was infuriated by the exchange, particularly the captain’s final statements. Clearly, the TAC activist was not willing to accept that state officials wielded their authority arbitrarily, whether that meant searching my car or pursuing AIDS-dissident policies. In the months leading up to my encounter with the police, I had carried out participant observation in TAC’s national office to understand the organization’s role in the campaign for treatment access. Spending time with Francis and other activists made clear TAC’s influential role in national HIV/AIDS politics and policy development, as many of their activists were centrally involved in the newly restructured SANAC. TAC’s leaders were the radical edge of the South African HIV/AIDS movement, having led the campaign for treatment access for a decade, and they also coordinated organizational strategy. But as an anthropologist, I conducted research in the national office that was primarily observational: on one occasion Francis had politely inquired into what I “actually did.” I responded by describing participant observation, which, his puzzled expression testified, did not answer his question. Francis responded by stating, “Well, if you are going to be here you might as well do something useful,” and he asked me to get a representative from a South African pharmaceutical corporation on the phone. After I had gotten the appropriate person to speak with Francis, I felt somewhat vindicated, but it was only for a moment. After hanging up the phone, Francis turned to me and asked, “Well, what else can you do?” I became accustomed to Francis’s demeanor, a frankness that had an endearing quality, cutting through the careful statements that people usually make about HIV/AIDS. Rather than tiptoe around issues, Francis said exactly what he thought, which was a refreshing change of pace at times. I couldn’t escape the feeling that Francis was more than a little skeptical about the value of anthropology to the South African HIV/AIDS movement. In part, his attitude toward me grew out of his own experience and expertise, as he had been drawn into the HIV/AIDS movement from the domain of quantitative science. Francis subsequently played a leading role in defining TAC’s political strategy and the development of HIV/AIDS policy. In some respects, he represented the central values of TAC and the HIV/AIDS movement: he

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extolled the necessity of expanding HIV/AIDS treatment based on biomedical science, education, and human rights, the central pillars of the campaign for treatment access. My relationship with Francis had been one of friendly guardedness for many months, but something changed after my encounter with the car guard. In the days that followed, I attempted to understand what had occurred, feeling a new sense of vulnerability. Every time I passed a police car, I felt a wave of anxiety, which, I imagined, many nonwhite South Africans also felt. I wondered about the legal limits of police action, as my experience indicated that they were quite broad in practice. I tried to make sense of the event within the context of South African history, as I was convinced that race had played a role in what had occurred. A white American, I was accompanied by a white woman from the Netherlands and two black men, one from Zimbabwe and one from South Africa. The car guard, it seemed, was unable to imagine a scenario in which the four of us could be anything other than participants in a drug deal. My friends and I had blurred the lines of racial segregation that have characterized South African society since the colonial era. For those in positions of authority—and, in the case of the car guard, those who aspire to it—such mingling could only indicate that something illegal was afoot. Over the next several days, Francis and I exchanged many text messages. He expressed his outrage and frustration at what had occurred, and he urged me to bring the incident to public attention. Hesitatingly, I agreed to write about the incident, and the story was published in a South African newspaper with national circulation.2 The episode changed our relationship: Francis’s wariness toward me diminished, and we established a different sort of mutual understanding. While my own frustration with the incident faded, Francis seemed unable to let it go. It often came up in conversation between us, and I asked myself why this was the case. Was it that the police had declared us lucky to not have been strip-searched on a public street? Did the incident reveal the unstable social terrain on which constitutional law stood in South Africa? These issues likely contributed to Francis’s anger, but there was an additional factor at play as well. My interaction with the police captain mirrored much of what TAC and the HIV/AIDS movement encountered during the campaign for treatment access: state officials, in positions of authority, undermined constitutional law and socioeconomic rights while mobilizing state resources for their own ends. The incident with the car guard could be construed as a violation of the human rights that had been declared by the post-apartheid South African

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constitution, just as activists saw insufficient access to HIV/AIDS treatment as a violation of those human rights, a position that was supported by the Constitutional Court. Francis’s anger reflected his own engagements with the South African state or, more specifically, with how AIDS dissidents leveraged their control over state health institutions to stymie the campaign for treatment access. As my fieldwork with Francis and other members of the HIV/ AIDS movement made clear, these dynamics played a central role in national HIV/AIDS politics throughout the Mbeki era.

TAC, SANAC, and Resurgent AIDS Dissidence Working within national health institutions enabled HIV/AIDS activists to transform national HIV/AIDS policy and oversee the National Department of Health, a bastion of AIDS dissidence under the leadership of Minister of Health Tshabalala-Msimang. While on paper the restructured SANAC appeared poised to expand treatment access across South Africa, a resurgent AIDS-dissident faction hindered it. Minister of Health Tshabala-Msimang had taken a leave of absence in late 2006, but when she returned in mid-2007, the intransigence that characterized the 1999–2006 period returned as well. The consensus among SANAC civil society delegates was that the return of the minister of health had closed the brief window of opportunity that had allowed them to transform SANAC. The institutional arrangements put into place following her return confirmed this assessment. Shortly after she resumed her duties, she was named chair of the SANAC Resource Management Committee. Another noted AIDS dissident, Director General of Health Thami Mseleku, was named chair of the SANAC Program Implementation Committee. Through these appointments, the ANC’s AIDS-dissident faction controlled SANAC’s resources and oversight capabilities. As AIDS dissidents moved back into SANAC’s organizational structure, meetings were canceled, government officials skipped meetings, and ANC members opposed policy input from the HIV/AIDS movement.3 The Department of Health also proved to be a significant obstacle to increased access to treatment during the 2006–2008 period. Under TshabalalaMsimang’s leadership, the department was slow to accredit public health facilities wishing to provide ART, which limited treatment access. By February 2008, only 407 of over 4,000 government health facilities were distributing HIV/AIDS treatment (SADoH 2008). Activists attributed the slow pace

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of accreditation to the dissident clique’s broader goal of limiting access to ART. The limited number of accredited facilities prevented the expansion of HIV-prevention initiatives and AIDS treatment interventions necessary to reach the goals outlined in the new national HIV/AIDS policy, the NSP. The divergence from national HIV/AIDS policy and the continued inaction within the National Department of Health exemplifies why South African HIV/AIDS activists sought to oversee implementation of HIV/AIDS policy through SANAC. Members of TAC’s national office played a large role in SANAC’s operations during the course of my research. SANAC’s role in overseeing the NSP’s implementation pulled academic researchers, leading practitioners in the public health sector, NGOs, CBOs, and HIV/AIDS activists into its orbit, siphoning time and energy from their day-to-day activities. The entities most affected by the labor-intensive process of maintaining SANAC were the leading organizations in the South African HIV/AIDS movement: TAC and ALP. Members of these organizations formed the backbone of SANAC’s civil society participants, pushing the treatment access agenda forward within the restructured institution. However, the time and effort put into supporting SANAC came at a cost to TAC. In an interview, Francis shed light on the central role that leading TAC activists played in expanding access to HIV/AIDS treatment and the difficulties that TAC faced in maintaining its operations while taking on new responsibilities within the restructured SANAC. Of the time when the NSP was being finalized, he recalled: The NSP was probably the most critical all-around development in several years for the organization, and Sipho [Mthathi] and Mark [Heywood] were all the time were dedicated [to] making the NSP work and consequently there was less focus on the internal running and the day-to-day running of TAC at the time. . . . And consequently, that the internal pressure of the NSP created this pressure inside TAC, and that was [a] very troubling time for the organization. And at the same time we got our biggest success probably in years, which was the adoption [of the NSP] in May 2007. So that was the price we paid for that victory.4 As Francis explained, TAC activists saw their workload increase due to their involvement in developing the NSP within SANAC, particularly those

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who held leadership roles within the HIV/AIDS movement. A comprehensive national policy was created, but it came at a cost, as it placed additional stress on activists who worked longer hours and traveled more, all of which required resources to support. TAC was far from the only organization to feel the impact of the additional workload required to transform the South African state from within. The HIV/AIDS movement had negotiated for the inclusion of eighteen civil society sectors within SANAC that organized input from NGOs, CBOs, and professional organizations based on thematic areas, such as the People Living with HIV/AIDS Sector and the Women’s Sector. At national meetings, three delegates were elected to represent each sector; consultative meetings were also held with constituent organizations to align sectoral activities and contribute to the development of national policy. At one national conference I met with several delegates who underscored the challenges they faced in coordinating the various civil society sectors, which included a lack of funding, unclear guidelines on coordination, and insufficient support from government administrators. In addition, several delegates described how ANC-affiliated government officials continued to adopt a “united front” against civil society input despite the 2006 SANAC restructuring. This is an important point: despite the development of new committees, the expansion of a representative structure that included the HIV/AIDS movement, and the appointment of a leading HIV/AIDS activist to the position of deputy chairperson, ANC officials in government posts continued to limit input from SANAC civil society representatives on HIV/AIDS policy. The daily challenges of coordinating a sector were underscored by Janice,5 who was elected to serve as a delegate for the Women’s Sector. Janice was a researcher based at an academic institution in the Johannesburg area, and her office reflected her position, as piles of books lay on various surfaces around a large and airy room. We sat down and spoke about Janice’s experiences, engaging in a conversation that lasted nearly three hours. From the outset, Janice expressed her frustration over the considerable time and resources the role of SANAC delegate demanded, typifying it as “overwhelmingly hard work” that included a “massive amount” of electronic correspondence. Clearly, coordinating the activities of the Women’s Sector was no small task. According to Janice, the work of a SANAC delegate was complicated by an undefined relationship between SANAC, provincial AIDS Councils, and any local-level HIV/AIDS structures that municipalities or health districts had set up to coordinate their efforts against HIV/AIDS. As several people involved in

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the development of the NSP pointed out, national policy had not defined these relationships to allow for the existing variation in local and provincial HIV/ AIDS institutions to be incorporated into the national HIV/AIDS response. As a consequence, sector delegates were left with the responsibility of navigating these relationships themselves. For Janice, this added a great deal of pressure to an already demanding workload, a situation that was far from unique. As Janice underscored, leading HIV/AIDS activists had recruited senior figures from the HIV/AIDS movement to serve as SANAC delegates, leading to the election of people with demanding professional positions and little free time who then held central—and time consuming—roles in the national health institution. As a result, much of the work of coordinating SANAC’s civil society sectors fell to larger organizations with greater capacity, such as TAC. A reliance on the labor of the South African HIV/AIDS movement reflected the broader limitations of resources within SANAC’s civil society sectors. One of the delegates for the Women’s Sector had secured a grant from a transnational donor to support coordination, policy development, and events. This grant supported the creation of a Women’s Summit report, the development of proposals for further funding, and meetings of the Women’s Sector reference group, approximately thirty people that represented organizations that worked to alleviate the HIV/AIDS epidemic’s impact on South African women’s lives. It had also paid for staff time at various organizations linked with the Women’s Sector. Resource shortages were not restricted to the Women’s Sector, as SANAC relied on donor capital to underwrite its activities. After an initial disbursement of ZAR 30 million,6 SANAC had received scant financial support from the government (Khumalo and Berger 2008). The HIV/AIDS movement sought out donor support that would allow SANAC to operate and achieve the goal of transforming the national response to the epidemic. The effort proved successful: in early 2008, the Bill and Melinda Gates Foundation provided a ZAR 6.3 million grant to SANAC through the Human Sciences Research Council.7 The grant provided resources for research, sector coordination, and an administrative assistant for TAC and ALP activist Mark Heywood, who served as SANAC’s deputy chairperson (Van der Linde 2008; Khumalo and Berger 2008). Notably, the administration of the grant circumvented SANAC’s institutional mechanism for donor funding, the Resource Management Committee. The committee was cochaired by the minister of health, so channeling the funds through the Human Sciences Research Council avoided any chance that the grant would be sequestered or diverted.

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The creative administration of the Gates Foundation grant led me to investigate how much influence the AIDS-dissident faction had within SANAC. In Janice’s experience, the political dynamics that marked the SANAC between 2003 and 2006 again haunted the institution after the minister of health’s return. She became visibly agitated as she described how government officials limited the impact of her work within SANAC: Firstly, I have found the government totally, utterly, completely, and unrelentingly resistant to having any input into it from anyone from civil society in any way, shape, or form. . . . The SANAC [meeting] in August [2007] I found deeply shocking because each sector had five minutes to present their implementation plan, and the Department of Health gave itself five minutes as well. And I mean that was just laughable, that a player as big as the Department of Health could think that it could do justice to the consultation process in five minutes. And then the SANAC [meeting] in November lasted an hour and a half so almost nobody presented anything; there was certainly no opportunity for any input. The SANAC [meeting] in March was cancelled, and we have a SANAC [meeting] coming up next week that I understand is a half-day again. . . . It would be laughable if it wasn’t so sad. I feel very, very cynical. While Janice was left disillusioned by the resurgence of AIDS dissidence within SANAC, the movement as a whole was not demoralized. The HIV/ AIDS movement leveraged its extensive membership and donor support, and activists, doctors, academics, and NGOs from across the country forged ahead in the campaign for treatment access, despite the challenge of renewed institutional obstruction within SANAC.

The SANAC National Civil Society Meeting on Implementing the NSP Through the networks I had established while conducting participant observation with TAC, I was invited to attend a national meeting that brought together members of the HIV/AIDS movement and state health officials from across the country in November 2007. In addition to coordinating civil society to support the NSP’s implementation, the conference aimed at developing

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HIV/AIDS policy recommendations. Entitled the National Civil Society Conference on Implementing the National Strategic Plan on HIV & AIDS, the conference was the culmination of a series of meetings that had been held within SANAC civil society sectors over the previous six months. The process of holding sector meetings, gathering input from sector members through consultations, and developing policy recommendations was led by TAC- and ALP activist Mark Heywood in his position as deputy chairperson of SANAC. I flew from Cape Town to Johannesburg with Francis and other TAC members to the national meeting, which was held at the Emperors Palace Convention Centre in Kempton Park, adjacent to OR Tambo International Airport. At the national civil society meeting, I carried out participant observation on the development of new national policy norms for PMTCT. I served as notetaker for one of two working groups that drafted revised PMTCT guidelines and developed a presentation to report the working group’s conclusions back to the conference. Comprised of a wide range of participants, from leading HIV/AIDS clinicians to community-based HIV/AIDS activists, the working group developed fifteen recommendations for revised South African PMTCT policy norms. These recommendations derived from updated guidelines from the WHO, but they also reflected the experiences of poor and workingclass people living with HIV/AIDS. The group embodied the promise of an inclusive consultative body that could pull together the perspectives of doctors, nurses, people living with HIV/AIDS, and HIV/AIDS activists working against the epidemic. On the morning of November 26, the conference hall hummed with conversation and excitement as the room filled with people representing a broad cross section of South African society, including government officials. SANAC civil society delegates had flown in from all over the country for a conference that was a litmus test for the HIV/AIDS movement’s ability to transform input from SANAC’s civil society sectors into policy. The conference opened with a series of presentations that focused on the four priority areas of the NSP: (1) prevention; (2) treatment, care, and support; (3) research, monitoring, and surveillance; and (4) human rights and access to justice. Each presentation was followed by a question-and-answer session during which SANAC civil society representatives offered their input on the points raised. There followed a series of presentations that focused on how civil society sectors could incorporate the NSP’s different priority areas into their organizational plans. The buzz generated by the morning’s sessions was palpable, but after a break for coffee, the atmosphere of the room changed dramatically.

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Dr. Nomonde Xundu, the chief director of the HIV/AIDS, Tuberculosis (TB) and Sexually Transmitted Infections (STIs) Unit within the National Department of Health, and one of the NSP’s coauthors, addressed the conference after the break. Her tone was authoritative and decisive from the start, and as she systematically discussed various aspects of the NSP and the government response, an incisive critique of the HIV/AIDS movement emerged. While Dr. Xundu had hinted at the opening of her talk that not all sectors were implementing the NSP, by the end of her presentation she leveled a forceful accusation. Gesturing toward the seated audience, Dr. Xundu asked what civil society had done for the NSP. She continued on to say that she had not seen a concrete program of action, nor was it clear who was directing the civil society response to the epidemic. Dr. Xundu concluded by stating that the HIV/AIDS movement needed organization and coordination to measure its contribution to the governmental response to HIV/AIDS. As she spoke, heads around the room began to shake, turning toward one another and carrying out hushed conversations in frustrated tones. Still, Dr. Xundu’s criticism could not be easily dismissed, as she was one of the NSP’s chief architects. Controlled but audible discontent was unleashed in the ensuing questionand-answer period. The first to speak was a SANAC representative from the Children’s Sector, who pushed Dr. Xundu to define the government’s position on new PMTCT guidelines before addressing what she saw as “accusations” toward civil society. The Children’s Sector representative opined that perhaps there was a misunderstanding, as the HIV/AIDS movement was not a government department, but a source for expert advice that derived from direct experience. To charge in a public forum that there was no plan, or there had been no action on the goals of the NSP, was a nonstarter for the sector representative. After all, she continued, “We work every day on these issues but without the glossy policies, plans, or funding that government departments enjoy.” Next to speak was a representative from ALP, which had been centrally involved in the NSP’s development. The ALP representative pointed out that since civil society had cowritten the NSP it was disingenuous for a government official to claim they “had no plan.” Others chimed in from the audience, pointing out that government had not yet distributed the funds to sectors for their development of NSP implementation plans. A COSATU representative reinforced this point, stating that the labor sector had submitted plans and was awaiting funding based on those proposals. Finally, a TAC activist from the Western Cape pointed out that policy was being developed in the province without input from stakeholder organizations in the

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movement. The activist then said that SANAC was repeating the mistakes of the past by creating a divisive relationship between government and civil society. SANAC deputy chairperson and leading HIV/AIDS activist Mark Heywood attempted to mollify the discontent before turning to Xundu for her response. Placidly, Heywood pointed out that over a year had passed since SANAC was restructured and that the NSP had not been implemented by the civil society sectors despite having been approved by the cabinet in May. It was almost 2008, a year into the NSP, he emphasized, and it was now vital that everyone work together. Dr. Xundu stood up and approached the microphone with the same stoic expression she had worn while weathering the pointed responses from those in attendance. She said that she was happy to engage but disappointed at how her message had been interpreted; she had hoped that they would understand where she was coming from by now. She closed by saying that her goal was to move forward in a spirit of working together. Heywood then attempted to reenergize the conference by urging attendees to transform the response to the epidemic. But as the conference broke for lunch, delegates trudged out of the hall. It was as if the air had been taken out of the room by Dr. Xundu’s negative characterization of the civil society response. While she was most certainly not an AIDS dissident, her position as a leading government official meant that her critical comments were linked to governmental opposition to the HIV/AIDS movement. The factional nature of South African HIV/AIDS politics meant that Dr. Xundu’s comments would lead to pushback from activists during the working group sessions that followed the lunch break, which indeed occurred. As the conference room began to fill again after lunch, civil society delegates broke into six working groups to develop policy recommendations for SANAC focused on communications, PMTCT, antiretroviral access, community education, behavioral intervention and positive prevention, human rights and stigma, and food security. I had spoken with Francis prior to the meeting, and he had indicated that TAC and SANAC leaders were focusing on updating national PMTCT guidelines as their next goal. I therefore decided to join one of two working groups charged with the development of new PMTCT guidelines; the group included a leading AIDS clinician, labor union representatives, HIV/AIDS activists, NGO representatives, and a member of the Department of Health. Everyone introduced themselves and the organizations and/or constituencies they represented, and then we began discussing the priority areas for updated national PMTCT norms. Each person

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was given an opportunity to offer input from their civil society sector, how and why they had reached these points, and the priority that should be given to each of their recommendations. Input was solicited from all participants, and together they painted a challenging picture of the South African HIV/ AIDS epidemic. The influence of policy expertise and biomedical knowledge was tangible within the PMTCT working group. A pediatric AIDS clinician named Steven8 emerged as de facto chair, as he stepped forward to outline the issues to be addressed from the outset. Steven had been one of the opening speakers to the conference that morning, and his expertise on the WHO policy recommendations and assumption of a leadership role were not challenged within the working group. However, the discussion did not initially focus on the particulars of the WHO policy recommendations but on comments from the representative from the Department of Health. The state health representative began by offering a critical assessment of the HIV/AIDS movement and outlined the shortcomings of the civil society contribution, echoing Dr. Xundu’s earlier speech. However, as sectoral representatives responded with story after story of the inadequacy of the government’s response to the epidemic, she fell quiet. Steven calmly chaired the group as working group members passionately shared stories of difficulties accessing HIV/AIDS treatment at clinics and children suffering from HIV/AIDS. The Department of Health’s representative shrank in her seat, visibly stung by the avalanche of responses. The contentious politics of HIV/AIDS in South Africa were clearly not new to Steven, and I learned more about his involvement in the campaign for treatment access during an interview after the conference. Steven had been involved with the public sector response to HIV/AIDS since 1998, when he chose to specialize in pediatric medicine for children infected and affected by the virus. At the time, he said, few young doctors were interested in pediatric HIV/AIDS interventions, and Steven saw a huge number of infected children during his medical training. Realizing that more needed to be done, he developed a clinic that operated once a week at a public sector hospital specializing in maternal and child health services, engaging with the obstetrics and gynecology departments to develop a PMTCT program based on international best practices. At the national level, however, South Africa lacked an official PMTCT policy to guide interventions across the country. In 1998, as GEAR was implemented and austerity lowered public sector spending on health, Minister of Health Nkosazana Dlamini-Zuma declared that AZT-based PMTCT was unaffordable and would not be pursued as a

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public sector HIV-prevention strategy. Steven became visibly agitated as he recalled how the minister’s announcement prevented him from using AZT to prevent pediatric HIV infections: “When the provincial department of health got wind of the fact that our hospital was going on its own doing something that wasn’t government policy, and there was controversy and politics around it, we were ordered to stop. And we stopped in 1999, when Nevirapine came on the scene. And so even before the government’s formal PMTCT policy, which started in 2001 with Nevirapine, we started with AZT [before moving] to Nevirapine in 1999.” His calm, cool demeanor was swept away as he described the ethical and moral conflict that he and other doctors experienced after they were forced to discontinue using AZT. No changes were made to government PMTCT policy despite a study showing that Nevirapine was feasible, affordable, and more effective in preventing mother-to-child transmission of HIV in 1999. Steven once again moved ahead of government policy, utilizing Nevirapine-based PMTCT at his clinic prior to it being established as policy. The development of new PMTCT interventions occurred alongside the rise of AIDS dissidence, which questioned the validity of ARV-based HIV prevention and treatment. As ANC leaders obfuscated the link between HIV and AIDS and critiqued ARVs as poisonous, Steven became increasingly frustrated with government inaction. Steven was drawn into the campaign for treatment access as he joined picket lines and marches that called on the minister of health to adopt a new PMTCT policy. He participated in the “Save Our Babies” campaign, which was developed by doctors, nurses, and others working in the medical sector. Through his involvement, he met allies in TAC, ALP, and other organizations that were part of the HIV/AIDS movement. He worked at one of the clinics that piloted Nevirapine-based PMTCT, working to stem the growing tide of HIV infections from his position in the South African public health system. Over time, Steven became more involved with the campaign for treatment access, supporting TAC in the Constitutional Court case that forced the government’s hand to implement Nevirapine-based PMTCT. While the Constitutional Court ruling allowed Steven to use ARVs to prevent pediatric HIV infections without fear of government intervention, there had been no subsequent changes to government PMTCT policy despite scientific evidence that dual-therapy PMTCT, which used AZT and Nevirapine, had been proven to be most effective in preventing HIV infections between mother and child.9 The WHO released new guidelines

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that established dual-therapy PMTCT as scientific best practice in 2006, the same year that the HIV/AIDS movement shaped national HIV/AIDS policy through its participation in SANAC and development of the NSP. The SANAC Children’s Sector had subsequently pushed for updated PMTCT guidelines in advance of the National Civil Society Conference described above. Steven was anxious to see the PMTCT guidelines updated, as the superior efficacy of dual therapy had been known since 2004. He felt that the public sector was three years behind the science and one year behind the WHO and that it was providing suboptimal care. Steven described how he once again began to experience a crisis of conscience, as he had when AZT-based PMTCT was suspended in 1998. Despite his calm and collected demeanor, updated PMTCT guidelines could not come soon enough for Steven. Driven by firsthand experience of the impact of HIV/AIDS and a desire to provide the best medical care possible, Steven led the PMTCT working group in developing fifteen policy recommendations. These recommendations drew on updated WHO guidelines and the experiences of people living with HIV/ AIDS in South Africa, and they included a recommendation for dual-therapy PMTCT. As notetaker, I compiled the working group’s input into a report, which Steven presented to the conference after a short break. His presentation offered an opportunity for additional feedback from SANAC delegates who had participated in other working groups. The working group’s recommendations were included in the report from the civil society conference, which guided the agenda for a SANAC plenary meeting the following day. At that meeting, the South African deputy president committed to publishing the updated PMTCT guidelines within two weeks (Geffen 2007). I waited for an announcement from SANAC, but two weeks came and went. I began to fear that AIDS dissidents had undermined the adoption of the PMTCT recommendations, but there were other factors that contributed to the delay. The SANAC civil society meeting was one of several forums in which people were working to revise PMTCT guidelines. Steven told me that a month earlier he had been called to a meeting at the Department of Health with government officials, provincial health administrators, South African academics, and representatives from UNICEF and the Elizabeth Glaser Pediatric AIDS Foundation where PMTCT policy was discussed. At this meeting, a task team primarily constituted by members of civil society was formed to continue work on new policy guidelines, with Steven appointed as chair. He was asked to gather input from the SANAC national civil society meeting, incorporate the recommendations provided by the HIV/AIDS movement, and take the

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PMTCT policy process forward within government by shepherding it through various committees and departments. According to Steve, the plan was for the policy to be implemented in November if all went smoothly. But obstacles were encountered after the development of policy guidelines within SANAC as government officials undermined expanded access to ARVs. The draft guidelines were sent to the government shortly after the civil society meeting, and Steven and the members of the PMTCT task team were called to a meeting at the Department of Health the following month. Steven described how government officials made arguments against dual-therapy PMTCT, the initiation of HIV/AIDS treatment at a CD4 count of 350, and providing postpartum treatment to mothers to reduce ARV resistance. They argued that insufficient evidence for these interventions existed, and the fate of the updated PMTCT guidelines fell to the interpretation of scientific evidence. In the end, postpartum treatment access and initiation of HIV/AIDS treatment at a CD4 count of 350 were cut from the proposed policy revisions, but dual-therapy PMTCT remained. As Steven emphasized, this trade-off provided better care for newborn children but left in place treatment guidelines that did not meet WHO recommendations for HIV-positive mothers. South Africa’s national PMTCT policy was finally updated in early 2008, marking a major victory for the HIV/AIDS movement and the participatory power of SANAC. The inclusion of dual therapy in the final policy guidelines was particularly significant for the politics of HIV/AIDS, as it meant that AZT would be included in public sector treatment. Debates over AZT’s toxicity were central to the AIDS-dissident position, which had informed the ANC’s decision to prevent Steven and other doctors from using the drug for PMTCT in 1998. In short, a central pillar of AIDS dissidence had been reversed in national HIV/AIDS policy with the updated PMTCT guidelines. This process of developing new guidelines highlights how the HIV/AIDS movement was able to transform SANAC and guide the national HIV/AIDS policy agenda. A cursory glance at the PMTCT recommendations that emerged from the SANAC national civil society meeting might lead one to conclude that they largely reflected policy guidelines disseminated by the WHO. Instead, a process of translation occurred: PMTCT guidelines were transformed as they traveled through the institutions of the South African state (Lendvai and Stubbs 2007). The process of translation resulted from both institutional oversight and the participation of HIV/AIDS activists and health professionals in the policy development process. The life stories and experiences of those infected and affected by the epidemic created space within

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the state generally, and the working group specifically, to discuss the new PMTCT guidelines. The SANAC civil society meeting itself was a product of the HIV/AIDS movement’s strategy of “occupying the state,” and it displayed the promise of a hybrid state-and-civil-society health institution that could pull together the knowledge and experiences of doctors, nurses, activists, and people living with HIV/AIDS.

Navigating Political, Institutional, and Economic Constraints within SANAC Despite significant constraints and the continued influence of AIDS dissidents, the HIV/AIDS movement continued to update national policy and push the NSP’s implementation forward, inch by inch. The SANAC National Civil Society Conference was a success amid the constraints imposed on SANAC by AIDS dissidents, as it led to the adoption of new national HIV/ AIDS policy. However, the success of that meeting masked ongoing difficulties within SANAC, in which political space for the HIV/AIDS movement closed with the minister of health’s return to office. In addition to the continued influence of AIDS dissidents, there were additional factors that limited the impact of HIV/AIDS policy decisions put into place by HIV/AIDS activists in SANAC. These included the definition of socioeconomic rights in the South African constitution, SANAC’s institutional mandate, and the relationship between SANAC policy recommendations and state budgetary practices. HIV/AIDS activists navigated these constraints by mobilizing the interpersonal networks of the HIV/AIDS movement and leveraging important institutional roles within SANAC. The HIV/AIDS movement populated the state with its members, activated their interpersonal networks to overcome AIDS dissidence, and transformed treatment access in South Africa. However, institutional mandates for SANAC and other state institutions limited the impact of consultative HIV/AIDS policy development. Led by the HIV/AIDS movement, SANAC provided the government with policy recommendations and oversaw the public sector HIV/AIDS response. But these recommendations were not binding, as they had to be adopted by the cabinet and the Department of Health to become HIV/AIDS policy. Senior figures within the HIV/AIDS movement contended that SANAC recommendations were enforceable through legal action in the Constitutional Court, should the Department of Health refuse to adopt an updated policy. Nevertheless,

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SANAC was unable to directly enforce the implementation of HIV/AIDS policy recommendations, let alone the development of implementation strategies at the provincial level.10 As such, SANAC’s position as an intermediary between the presidency and the National Department of Health only provided national policy guidelines rather than actual implementation strategies. National economic policy also placed limits on the HIV/AIDS movement’s initiatives within SANAC. Although space was created within the government for HIV/AIDS policy input, the ANC’s neoliberal macroeconomic policy imposed limits on health budgets. In line with neoliberal norms for budgeting, the ANC adopted a medium-term expenditure framework that projected government spending levels for a three-year period. In essence, the medium-term expenditure framework provided a predictable financial trajectory for foreign investors. It was set by the National Treasury, as were allocations to particular government departments, including the Department of Health. SANAC had no power over funding to support its policy recommendations, as that responsibility lay with the national and provincial treasuries and provincial departments of health. The net effect of this institutional arrangement was that funding was not guaranteed for national policy developed by SANAC structures, including the updated PMTCT guidelines. Despite so much progress in formulating national policy, SANAC’s key initiatives carried the possibility of becoming unfunded mandates. The power of SANAC to transform HIV/AIDS policy was also complicated by the way that socioeconomic rights are guaranteed by South Africa’s constitution. The constitution states that government has a responsibility to protect the socioeconomic rights of South African citizens “within available means.” What was considered “available means,” however, was shaped by the reigning economic theory. But the consequences of neoliberal macroeconomic policy were left unchallenged by the campaign for treatment access. The HIV/AIDS movement argued during the Constitutional Court case on PMTCT that increasing access to HIV/AIDS treatment would not increase government health expenditure rather than challenge neoliberal orthodoxy (Nattrass and Geffen 2003). The particular legal and institutional configuration within which the right to health is guaranteed meant that the National Treasury carried an outsized influence on treatment, and thankfully, despite its reputation for rigid neoliberalism, the Treasury increased the budget allocation for HIV/AIDS. The HIV/AIDS movement adopted different strategies in the campaign for treatment access. Large national meetings of the HIV/AIDS movement,

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like the one described above, were one avenue for the development of HIV/ AIDS policy. However, these required significant resources, as people had to be flown in from all over the country. As a result, a significant amount of consultation occurred within the civil society sectors via email, as Janice highlighted in describing her work as a SANAC delegate. The plenary meetings, which included much government representation and which Janice characterized as “laughable,” were not the only means by which civil society delegates consolidated their positions on policy recommendations. Rather, discussions took place over email and were largely coordinated by Deputy Chairperson Heywood, who would then present positions to ANC leaders involved in SANAC, including South African deputy president Phumzile Mlambo-Ngcuka, who served as its chairperson. The development of national guidelines for HIV/AIDS councils provides a useful example to discuss how HIV/AIDS policy development relied on the interpersonal networks of the HIV/AIDS movement. During the course of my research I met Petra,11 an academic researcher whose work focused on local HIV/AIDS coordinating institutions. While not formally part of any SANAC representative structure, Petra described how she was recruited to participate in HIV/AIDS policy development when she received a call from Deputy Chairperson Heywood. During this call, Heywood asked for a set of guidelines on provincial, district, and local AIDS councils. He indicated to Petra that Deputy President Mlambo-Ngcuka had asked him to provide this information by the following Monday, and Petra worked with a fellow researcher with expertise on HIV/AIDS councils to produce a set of guidelines by the end of that week. Therefore, the proposed guidelines for HIV/AIDS councils came from outside of SANAC’s representative structures and relied on the interpersonal network of a leading HIV/AIDS activist working within SANAC. This shows that institutional intransigence did not derail the work of HIV/AIDS activists; instead they circumvented committees controlled by ANC dissidents and worked directly with high-ranking government officials or academic researchers to continue expanding treatment access.

Conclusion The South African HIV/AIDS movement, in the face of daunting constraints, transformed national health institutions, enabled broad-based consultative processes, and channeled substantive input into the development of new

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national HIV/AIDS policy. While significant political, economic, and institutional obstacles continued to limit the campaign for treatment access, HIV/ AIDS activists occupied the state to transform national policy and treatment access through their participation in SANAC. The renovation of HIV/AIDS policy depended on a set of historically particular conditions: strategic relationships with the South African labor movement and ruling party, transnational donor capital, and alignment with transnational biomedical norms and the agendas of international institutions. The goals of the South African HIV/AIDS movement dovetailed with transnational biomedical norms and policy guidelines from international institutions, an alignment that significantly contributed to the success of the campaign for treatment access. An orthodox biomedical understanding of the relationship between HIV and AIDS served as a unifying factor for the HIV/AIDS movement and transnational forces. AIDS dissidents’ embrace of scientifically unsubstantiated treatment united the HIV/AIDS movement, bringing together academic researchers, clinicians, high-ranking members of government, and activists. The alignment between transnational biomedical norms and the HIV/AIDS movement’s political agenda led international organizations such as UNAIDS to actively support the development of national HIV/AIDS policy, and it enabled international solidarity with the global AIDS movement, human rights organizations, and global funding organizations.12 A consistent flow of donor capital sustained the campaign in the context of AIDS dissidence. The South African HIV/AIDS movement’s dependence on transnational donor support underscores a broader trend, where transnational forces play an increasingly large political role in societies across the Global South (Ferguson 2006). Relative to the HIV/AIDS epidemic, this dynamic is perhaps best evidenced by the impact of the United States President’s Emergency Plan for AIDS Relief (PEPFAR), which allocated USD 21.8 billion to address the pandemic between 2004 and 2010 (IOM 2013). In other contexts, this influx of donor capital was shown to have created a parallel and private clinical infrastructure that undermined public health responses to the epidemic by hiring away public sector health workers and other clinical staff (Pfeiffer 2003, 2013). For South African HIV/AIDS politics, transnational donor support extended a vision of science, society, and the state that was embraced and put forward by the HIV/AIDS movement. While some aspects of this broad conceptualization accorded with transnational norms, the historical particularity of the HIV/AIDS movement and the plurality of lived

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social experience in South Africa served to differentiate the campaign for HIV/AIDS treatment access from abstract global policy guidelines. The campaign to update PMTCT guidelines did not emanate from transnational institutions or organizations but from the South African HIV/AIDS movement. TAC and health sector professionals such as Steven actively pushed for revisions to national policy. Given the centrality of biomedical science to the campaign for treatment access, people with biomedical expertise wielded substantial influence on HIV/AIDS policy development within SANAC. But it was people’s experiences in communities infected and affected by the epidemic that created space for those with biomedical expertise to carry forward the HIV/AIDS policy process, a distinction that illuminates the different roles that members of the HIV/AIDS movement played within SANAC. SANAC’s restructuring had been driven by a particular vision of the state whereby activist, biomedical, and community-based responses to the social, material, and political effects of the HIV/AIDS epidemic were incorporated into the HIV/AIDS policy development process. The expansion of SANAC’s civil society sectors and the appointment of a deputy chairperson from the HIV/AIDS movement underscored a vision of the state where people’s experiences in confronting the epidemic were the driving force in the policy process. SANAC’s reconceptualization and reconfiguration reflected the political principles developed by the black liberation movement and underscored the decisive role that people can play when they operate within state institutions. While the HIV/AIDS movement overcame the odds and pushed the campaign for treatment access forward at the national level, in the Western Cape Province a different set of obstacles were encountered, which reflected the array of organizations, institutions, and people influencing HIV/AIDS politics there.

CHAPTER 4

A Policy Redirected Transnational Donor Capital and Treatment Access in the Western Cape Province

Because the HIV/AIDS movement’s campaign for treatment access operated at different levels of the South African state, I undertook an analysis of provincial HIV/AIDS politics in the Western Cape Province. The overlap I found there between organizations and actors working to influence both provincial and national policy processes made clear the extensive connections across the state’s institutional levels. My fieldwork with HIV/AIDS activists, NGO members, and state health administrators showed that HIV/AIDS politics operated differently at the provincial level despite these connections. Indeed, provincial actors and organizations were able to transform national HIV/ AIDS policy in ways that reflected organizational and institutional particularities in the Western Cape. The influence of transnational donor capital, such as grants from the Global Fund, was also an important factor in the reworking of national HIV/AIDS policy. The politics of the epidemic in the province, therefore, were a complex amalgamation of transnational, national, provincial, and local forms of influence that combined to produce unpredictable outcomes for HIV/AIDS treatment access. While I was conducting fieldwork in the Western Cape, an event in August 2007 garnered international attention: the politically motivated dismissal of Deputy Minister of Health Nozizwe Madlala-Routledge, an ally of the HIV/AIDS movement and a supporter of HIV/AIDS treatment access. In protest activists and organizations from across South Africa converged at “the people’s cathedral,” where Archbishop Desmond Tutu had led campaigns and marches to end apartheid.1 The HIV/AIDS movement came out in force

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in support of a member of the state’s health apparatus who had actively supported the treatment access agenda. I wanted to understand how provincial HIV/AIDS activists engaged with the treatment access agenda across the Western Cape, where the campaign for treatment access had encountered unexpected obstacles. TAC activists that I worked closely with in the Western Cape led efforts to address the deputy minister’s dismissal, including a major protest event that influenced HIV/AIDS politics across the institutional levels of the South African state. The event highlights how the South African HIV/ AIDS movement cultivated alliances and developed campaigns to sustain life amid the exercise of institutional power by AIDS dissidents. The cathedral was filled from front to back, the pews overflowing with protestors wearing the HIV/AIDS movement’s stigma-challenging “HIV Positive” T-shirts, which underscored that anyone could become infected with the virus, regardless of their ethnic background, sexual orientation, or socioeconomic status. Indeed, the vast majority of those in attendance wore the iconic shirts, a testament to unity in the face of adversity. Tall stone columns stood alongside a sea of bodies that moved in unison, hands clapping to songs that decried the impact of the epidemic and Madlala-Routledge’s dismissal, the ANC leadership’s most recent attack on HIV/AIDS treatment access. The joyous atmosphere created by the toyi toyi, the dancing and singing of protest songs, was contrasted by the serious expressions on the faces of many. The protest held at St. George’s Cathedral in central Cape Town included people and organizations from across the Western Cape Province. TAC had been founded at this very spot nearly a decade before, on the steps of the cathedral following the funeral of HIV/AIDS activist Simon Nkoli. But instead of government inaction on HIV/AIDS treatment, which had set the second wave of HIV/AIDS activism into motion years ago, it was the active efforts of AIDS dissidents that brought people together on this day. The dismissal of Madlala-Routledge was the latest chapter in the ongoing saga of AIDS dissidence. The deputy minister had been fired while on her way to a conference in Spain organized by the International AIDS Vaccine Initiative. President Thabo Mbeki had revoked the provisional trip approval while she was thirty thousand feet in the air. This sudden lack of formal approval meant that the deputy minister of health had illegally spent public funds and violated the Public Finance Management Act, leading to her ouster. In one fell swoop the ANC’s AIDS-dissident faction removed the primary source of support for the South African HIV/AIDS movement within the Department of Health.

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President Mbeki’s public statements on the matter sharpened the circumspect attitudes taken by many toward the deputy minister’s dismissal. Rather than underscore the illegality of Madlala-Routledge’s trip, Mbeki emphasized her inability to work “as part of the collective” in government. The meaning of the president’s statement was clear to HIV/AIDS activists: the deputy minister had been fired for supporting the HIV/AIDS movement in its campaign for treatment access. The deputy minister had grown increasingly bold with her public statements in the year leading up to her dismissal, breaking ranks with ANC leadership in declaring that the rights of people living with HIV/AIDS were violated when they were unable to access treatment. President Mbeki’s statement underlined what many already knew: Deputy Minister MadlalaRoutledge was fired for political reasons. Battle hardened after nearly a decade of political struggle, TAC and its allies reacted with purpose. The HIV/AIDS movement gave Madlala-Routledge a hero’s welcome on her return to Cape Town International Airport, inviting the press to document their support for the deposed minister. Organizations from across the political spectrum sent out press releases that decried the deputy minister’s dismissal, including the ANC’s alliance partners COSATU and the SACP along with leading organizations in the HIV/AIDS movement, including TAC, ALP, and the South African Medical Association.2 Critically, the messages of support linked Madlala-Routledge’s exit to the success, or failure, of the new national HIV/AIDS policy that had been developed by the deposed minister with the HIV/AIDS movement: the NSP. Building on the media attention that greeted Madlala-Routledge upon her return to South Africa, the HIV/AIDS movement initiated a campaign to support the deposed deputy minister with press conferences and small protests leading up to the rally at St. George’s Cathedral. After a series of speeches that underscored the impact of the epidemic, the importance of the deputy minister to the HIV/AIDS movement, and the continued influence of AIDS dissidence, the lead speaker took the stage. Standing at the lectern, Zackie Achmat commanded the room, exhibiting the charismatic leadership that had served him well as an anti-apartheid, gay rights, and HIV/AIDS activist. Fist in the air, Achmat called for continued activism to ensure that progress made by the HIV/AIDS movement could be sustained in the face of AIDS dissidence. His message to those in attendance mirrored what was emblazoned on the back of his purple “HIV Positive” T-shirt: a silk-screened image of the deposed deputy minister of health and the text “Support Nozizwe Madlala-Routledge, Implement the National

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HIV/AIDS Plan.” Winding up his speech, Achmat assured those assembled that there would be a campaign in the Western Cape to ensure that the new national HIV/AIDS Plan, the NSP, would be implemented. As Achmat finished his sentence, I turned and looked to Phaedra,3 a leading TAC activist who worked at the organization’s Western Cape provincial office. As our eyes met, she laughed and shook her head in disbelief at the possibility of having yet another campaign to manage. After all, Phaedra had just spent the last several weeks planning the St. George’s protest and the march to Parliament that followed. In the weeks leading up to these events, Phaedra had worked tirelessly to organize transportation for 1,500 provincial HIV/AIDS activists, print and distribute fifty thousand pamphlets, and garner the support of domestic and international organizations for the event. Achmat’s promised campaign to ensure the NSP’s implementation would fall onto Phaedra’s shoulders, adding additional tasks to the enormous amount of work she already oversaw. I had the privilege to be by her side as she took on the campaign, and I learned much about the daily work of South African HIV/AIDS activists by doing so. The planning process leading up to the St. George’s event coincided with a period of extended participant observation I undertook with TAC activists at the organization’s provincial office in the Salt River section of Cape Town, the majority of which was dedicated to following Phaedra. From her roots on the outer reaches of the Cape Flats, Phaedra had begun her social justice work with a position in the labor movement, but she was drawn into the social response to the HIV/AIDS movement in the late 1990s as she witnessed the impact of the epidemic on her community. Initially trained as a peer educator, Phaedra was involved in early efforts to address the epidemic in the historically “coloured” township of Mitchells Plain, where she carried out one-on-one counseling with people living with HIV/AIDS. Phaedra was soon organizing the community in response to the epidemic and critiquing government inaction, taking on the position of township-level coordinator of HIV/AIDS-related activities for Mitchells Plain.  After having cosponsored a number of events with TAC in Mitchells Plain, Phaedra began to work closely with the organization, eventually being urged by TAC leaders to apply for a salaried position. Once within TAC, Phaedra continued her rise to the leadership ranks of its Western Cape provincial office. It was in this role that I met Phaedra, and by her side I learned how TAC addressed the epidemic across the province and how central TAC activists were to the coordination of the HIV/AIDS programs there. Following the

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rally at St. George’s Cathedral, TAC’s provincial office was drawn into the NSP policy process, which necessitated engaging with actors and organizations at the national and provincial levels. Provincial activists like Phaedra were integral to ongoing policy debates at the national level, such as the national meeting of the SANAC civil society sectors discussed in the previous chapter. At that meeting I learned of a series of policy consultations linked to creating a provincial version of the NSP, which would prove to be decisive for the campaign for treatment access in the Western Cape. The importance of these consultative meetings was underscored by Achmat at the protest at St. George’s Cathedral: they would determine whether the NSP, the policy that the HIV/AIDS movement had occupied the state to create, would be implemented at the provincial level. Indeed, the provincial consultations would prove to be a focal point for HIV/AIDS politics in the Western Cape. Phaedra and another TAC activist, Nomfusi,4 took the lead for the upcoming meetings. I attended six consultative meetings with these and other HIV/AIDS activists, learning how the politics of the epidemic unfolded in each of the Western Cape’s six health districts. Doing so expanded the purview of my fieldwork, as I also followed the pathways of people associated with state health institutions and other NGOs operating across the province. In particular, I carried out participant-observation research with the Western Cape Networking AIDS Coalition of South Africa (WC-Nacosa), the Aids Legal Network (ALN), and the Western Cape Provincial Department of Health, accompanying members of these organizations as they participated in the provincial policy consultations. This chapter analyzes how provincial HIV/AIDS politics affected the campaign for treatment access in the Western Cape, tracing how the political process that unfolded did not align with the NSP’s ambitious targets for HIV/ AIDS treatment expansion. The divergent policy outcomes highlight the historical particularity of the Western Cape Province, tension between the HIV/ AIDS movement and provincial health administrators, and the influence of transnational donor capital on the HIV/AIDS policy process. In order to situate the argument that follows, I offer a brief historical analysis of HIV/AIDS programs in the Western Cape before turning to the consultative meetings for the NSP and the influence of transnational donor capital on provincial policy outcomes. While I focus on the consultative meetings for the Western Cape Provincial Strategic Plan (PSP), I also incorporate insights from fieldwork across the province with others who would influence the relationship between the NSP and provincial HIV/AIDS policy.

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HIV/AIDS Politics and Treatment Access in the Western Cape While the negotiated transition to democracy produced rapid political change in other provinces, the National Party maintained political control of the Western Cape. Rebranded as the New National Party, the organization that had designed the apartheid system maintained political power in the province following democratic elections in 1994. This continuity in political leadership produced a divergent post-apartheid political trajectory, particularly with respect to the HIV/AIDS epidemic. While the province deviated from national policy norms due to the opposition’s political control, it nonetheless developed an ART-based HIV/AIDS public sector response through a combination of innovative leadership in the provincial health department, the involvement of leading global health organizations, and the support of HIV/AIDS activists. In short, treatment access was enabled in the Western Cape by an unlikely alliance that transcended the political divides established by apartheid. Paradoxically, the political party that had maintained power by exerting violence on the bodies of black South Africans played a central role in extending the lives of people living with HIV/AIDS in the post-apartheid era, at least in the Western Cape. Building an ART-based public sector response in the Western Cape began with a PMTCT program in January 1999.5 With members of the dissident clique holding power in the presidency and the National Department of Health, officials in the Western Cape Department of Health began the program surreptitiously to avoid the attention of national government (Naimak 2006). The provincial PMTCT program did attract attention despite starting with only two pilot sites, but not from national government, at least initially. Instead Médecins sans Frontières (MSF) became involved with the PMTCT program in the township of Khayelitsha, establishing a pilot site to prove that it was possible to implement PMTCT in poor communities via resourceconstrained public sector health clinics (Stinson et al. 2014). With one of the most developed public health sectors in the country, Western Cape health administrators were able to rapidly expand the program to include three hundred clinics by 2001 (Abdullah 2004). The Western Cape Department of Health’s HIV/AIDS response was augmented in 2001, when the public sector began offering antiretroviral therapy at three clinics in Khayelitsha. With MSF once again taking the lead in managing the project, the pilot study served as a model for delivering ART

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in a resource-constrained urban health clinic (Stinson et al. 2014). TAC and other organizations allied with the HIV/AIDS movement worked with MSF to recruit patients for the ART program, serving as counselors and treatment literacy practitioners. Despite the success of the PMTCT and ART pilots, the national government intervened to stop the programs, on the principle that provincial policy could not deviate from national policy norms. Though the national government was able to interrupt the programs, the institutional foundation for HIV/AIDS treatment access had been established. When the Western Cape successfully applied for a grant from the Global Fund in 2003, the knowledge gained from earlier implementations of HIV/AIDS programs enabled a rapid expansion of HIV/AIDS treatment access. The development of ART-based HIV/AIDS programs in the Western Cape occurred largely due to the actions of important actors in the public health sector, including the director of the Western Cape HIV/AIDS programs, Dr. Fareed Abdullah. With roots in the Mass Democratic Movement to end apartheid, Abdullah worked closely with the South African HIV/AIDS movement throughout his tenure, enabling a dialogue between activists organizing communities and those leading the public sector response (KardasNelson 2012). When the ANC won the second round of elections in 2004,6 the subsequent reorganization of provincial leadership led to former apartheid politician Pierre Uys becoming the provincial minister of health.7 The shift had a deleterious effect on the cooperative environment that had developed between the Department of Health, the HIV/AIDS movement, global health organizations, and transnational donors. ANC political control in the Western Cape had mixed effects on HIV/ AIDS programs; most significantly, Abdullah resigned from his position in the provincial department of health. Based on discussions with staff members associated with provincial HIV/AIDS programs, political pressure played a role in this decision. Abdullah had been a vocal critic of the ANC on HIV/ AIDS policy, even wearing an “HIV Positive” T-shirt provided by TAC at political events (Thom 2005). As evidenced by Deputy Minister of Health Madlala-Routledge’s dismissal, AIDS dissidents had little patience for those who would not toe the party line on HIV/AIDS. The ANC’s political influence on the Western Cape Department of Health was immediately apparent to several TAC activists that I spoke with, including Phaedra. She described how avenues of communication between the provincial health department and the movement were closed after Dr. Abdullah’s departure. Phaedra wistfully recalled quarterly meetings that coordinated

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activities between the provincial department of health and TAC. During that time, open lines of communication between TAC and the provincial health department ensured that issues at HIV/AIDS clinics could be addressed without delay. The sudden shift in relations was attributed to Provincial Minister of Health Uys’s new position of leadership within the government, which bred mistrust among HIV/AIDS activists. For many, Phaedra included, Uys could not escape his history as a former National Party politician. He was a remnant of a political system she had been oppressed by and thus could not be trusted. Phaedra was not alone in her criticism of Uys, as doctors working with MSF in Khayelitsha harbored similar views. From his vantage point within the clinics, an MSF doctor named Claude8 offered a scathing review of the provincial health department. Discussing Uys, Claude stated that it was clear that he was “getting his orders from Manto,” a reference to Minister of Health Dr. Manto Tshabalala-Msimang, a leading AIDS dissident. Claude also described a lack of support from the provincial health department for additional ARV clinics, which MSF was prepared to build, and efforts by MSF to develop a human resource plan for the understaffed health clinics in Khayelitsha. As we spoke, Claude’s frustration was apparent. Despite his work and MSF’s efforts to provide treatment to people living with HIV/AIDS, political obstacles continue to stand in the way of their programs. HIV/AIDS activists’ reservations were exacerbated by an unapproved “trial” of vitamin-based treatment, which had not been scientifically proven, on the Cape Flats.9 The “trial” was overseen by the Rath Foundation, the international NGO founded by the German AIDS dissident Dr. Matthias Rath, in concert with a local SANCO branch. Despite TAC’s entreaties, Uys had refused to intervene and stop the trials and/or prosecute those involved. TAC and a broad political alliance subsequently initiated a court case against both organizations leading the unauthorized experiment and the Western Cape Department of Health for its failure to intervene. While TAC and the South African Medical Association eventually won the case, it was an ongoing source of tension between the HIV/AIDS movement and the Western Cape Department of Health. Relations broke down further after TAC occupied the provincial health department in a parallel act of civil disobedience during the 2006 International AIDS Conference held in Toronto. According to people in the Cape Town metropolitan health department, the protest action had irrevocably turned Uys against the HIV/AIDS movement. In sum, an environment of mutual distrust permeated the politics of HIV/AIDS in the Western Cape following Minister Uys’s ascension to power,

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limiting efforts to expand treatment access. As a result, the relationship between the Western Cape Department of Health and the HIV/AIDS movement was frayed leading up to the PSP policy consultations. As I followed TAC activists, state health officials, and NGO members, I was immersed in the tense political environment that had enveloped the campaign for HIV/ AIDS treatment access at both the national and provincial levels. As I was to learn, the lines of demarcation between the national and provincial HIV/ AIDS policy processes were overlapping, blurry, open to the influence of transnational forces, and informed by the actions of those participating in policy development.

Following the Policy: Nomfusi and the Southern Cape Meeting I rushed to make coffee, trying to wake myself for the long drive ahead as Nomfusi, an HIV/AIDS activist who worked with TAC’s provincial office, was on her way to my apartment from the township of Khayelitsha. I heard her knock just as the kettle reached a boil, and I dashed across the room to open the door. Nomfusi greeting me with a wan smile and a tired “Morning.” After downing a cup of coffee we drove to the N2 Highway, starting our journey to the city of George. It was only four in the morning, but there was not a minute to lose if we were going to make the 9:00 a.m. start time for the meeting, as it was a five-hour drive from Cape Town to George. Before long we had arrived at a meeting that would help determine the future of HIV/AIDS treatment access in the Western Cape Province. I had come to know Nomfusi through participant observation with TAC’s provincial office, and I had known her several months by the time we attended the PSP meeting together. Originally from the Eastern Cape, Nomfusi is an IsiXhosa-speaking woman in her midthirties who had first moved in 2002 to Khayelitsha, where she first stayed with family members.10 Over time, Nomfusi became involved with social justice-oriented activities, and in 2005 she launched a community-based organization focused on women’s issues. Nomfusi attempted to partner with TAC in developing an event for her fledgling organization, but she was instead convinced to join the leading activist organization combatting the HIV/AIDS epidemic. Nomfusi was soon training to become a treatment literacy practitioner and began to support mothers raising a family while living with HIV/AIDS shortly thereafter. At

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the time I began fieldwork, Nomfusi changed positions to work at TAC’s provincial office. Attending the provincial policy consultations was thus part of Nomfusi’s work as a provincial HIV/AIDS activist. The Western Cape Department of Health and WC-Nacosa were the primary organizers of the meetings, which were designed to gather input for the PSP from NGOs, CBOs, and HIV/AIDS activists. Members of the two organizations were the primary presenters at the sessions, which included authors of the draft policy document. At the time, WC-Nacosa offered training to approximately three hundred community-based organizations in the province, supporting their efforts to attract funding from international donors and the South African state. A third organization, ALN, also played an important role, making presentations at each of the six consultative sessions. A human rights organization that addresses HIV/AIDS-based discrimination through a legal approach, the ALN had mentored organizations, communities, and the government on their responses to the legal and ethical dimensions of South Africa’s HIV/AIDS epidemic since 1994. Presenters from these organizations led the first consultative session for the PSP, held in the city of George, which I attended alongside Nomfusi. The meeting was held in the Museum of George, in a large auditorium that displayed items associated with former South African president P. W. Botha, known as a hardline National Party figure and ardent supporter of apartheid. In the musty hall, rows of seats faced a rectangular table and a small podium topped by a projector aimed at a small portable screen. Meeting participants slowly filed in, and the four-hour conference began with a presentation from Lynette,11 a member of WC-Nacosa, who gave an overview of the epidemiology of the HIV/AIDS epidemic in Africa, South Africa, and the Western Cape. The presentation moved quickly, emphasizing statistical information and the NSP’s broad goals. Members of the audience squinted at slides that passed quickly, shifting in their seats as more complex points were covered. At one point, I turned to Nomfusi, who was shaking her head. She sighed, stating, “They are speaking too fast.” As she finished, Lynette stated that feedback could be submitted to WC-Nacosa via its website, emphasizing that if organizations failed to provide input, their initiatives might not be able to receive potential funding. This atmosphere of quiet confusion was exacerbated by the next presentation, which came from a senior health official who had contributed to the PSP’s development. The dense academic presentation emphasized epidemiological factors and the NSP’s goals, and information was again presented at

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a rapid pace as PowerPoint slides were quickly changed and briefly narrated over. I attempted to take notes on the presentation, my hand aching as I did so, but eventually gave up. The room was filled with hushed whispers between people trying to explain the slides to one another, the murmur at times rising to audible sighs of frustration. The two presentations lasted two hours, half of the time allotted for the consultative session. Esmée,12 the ALN representative at the meeting, gave the final presentation of the day. She asked questions and provided comments on the role of human rights in the HIV/AIDS response, giving rise to a more open discussion. She spoke at length on condom use and the importance of barrier methods if HIV infections were to be reduced by half, a goal set out in the NSP. Although Esmée’s presentation was cut short because the earlier presentations went too long, it enabled audience participation and discussion of the stigma faced by people living with HIV/AIDS. After Esmée’s talk, those attending were broken up into five working groups by subdistrict to answer a series of questions on the local-level response to the epidemic. Each group had twenty to thirty minutes to discuss local HIV/AIDS programs, HIV/AIDS coordinating institutions, the NSP, the PSP, and training opportunities in their areas. After groups had met and discussed these points, there were “report-back” presentations from each group, scheduled for five minutes each. The majority of presentations outlined the programs, projects, and institutions operating in each area, reflecting the criteria requested by organizers. In addition, there were requests for more access to and education on female condoms and for training for peer education, legal rights, and project management. The need for additional support was buttressed by stories of public sector nurses stigmatizing HIV-positive patients, struggling local HIV/ AIDS coordinating structures, and unlawful restrictions on condom access in schools. Despite limited time, participants gave coherent presentations that painted a challenging picture of the HIV/AIDS epidemic in the Southern Cape health district, but they did not directly address the PSP. The presentations at the George meeting did not address the details of the draft policy, instead they focused on general concerns about the impact of HIV/AIDS in communities. Indeed, provincial health officials described the PSP as a “first draft,” a “collation,” and “an audit of what people are doing.” However, one group critiqued the consultative process as part of their report-back, noting a concern with how the policy had been developed. More specifically, they stated that the draft PSP had been created without the input of people living with HIV/AIDS, and they argued that those people should be consulted as part of any initiative to expand treatment access in

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the province. The point was made politely and within the overall structure of the session; at the next meeting, community representatives and HIV/ AIDS activists made a similar critique of the consultation process, but more forcefully and in greater numbers.

The HIV/AIDS Movement Responds: Phaedra and the Cape Metropole Meeting Nomfusi and I returned to TAC’s provincial office in Cape Town, where Phaedra led a meeting to discuss the consultation that included members of TAC’s district office, such as Matamela. At that meeting, those in attendance articulated a clear critique of the consultative session, emphasizing a lack of substantive engagement in the PSP’s development. Various aspects of strategy were discussed that day, but there was unified agreement on one point: the policy was not being openly discussed with the HIV/AIDS movement, whose activists had driven the NSP’s development at the national level. Now that the policy process had shifted to the provincial level, a different set of actors and organizations had come to the fore, changing political dynamics and forcing provincial and community-based HIV/AIDS activists to reassess their approach to expanding treatment access in the Western Cape. The next consultative meeting for PSP was for the Cape Metropole health district and was held at the Novalis Institute in the Wynberg area of Cape Town. Located toward the southern reaches of the city and along the M3 Highway, the Novalis Institute was a central location for people working in communities infected and affected by the epidemic across the Cape Flats. The Novalis Institute’s meeting room had excellent acoustics, which projected the voices of community members and HIV/AIDS activists as they rejected what they saw as a flawed process. The meeting opened with a presentation from a new representative from the provincial department of health, Fikile.13 Another contributor to the PSP’s development, Fikile presented a similar overview of the NSP, although he placed more emphasis on the importance of monitoring and evaluation. There were other changes in the organization of the meeting, with Padmini,14 a representative from WC-Nacosa, serving as moderator for the consultative session. In addition, a large contingent of TAC activists from both the provincial and district offices were in attendance, bringing with them a critical perspective gleaned from Nomfusi’s experiences in George. Several of those present openly expressed their frustration with the focus and structure of

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the meetings during the first question-and-answer period, which followed Fikile’s presentation. A TAC activist named Allan,15 who worked at TAC’s district office in Khayelitsha, argued that the process needed to start in the districts and go from the ground up: This is a good forum. There has been a lot of talk about working multisectorally, working as a team. We need to rethink how this happens. The NSP sets out good overall objectives, but the PSP is about local implementation. I think that the term consultation is not right, it is about authorship. It is about things coming from the district up. We all know about our districts. A provincial plan should be a collection of the district plans. We should go back and have intensive meetings in our districts. I don’t like filter-down, I like filter-up. I want joint planning from the grassroots up. We don’t own it if we just give input, we own it if we write, if it starts with us. It is also about decentralization. We need intensive research in each district to find out what we need: human resources, which clinics have shortages, which have long queues. Where are doctors motivated? The Department of Health should facilitate a plan that is not for the people, but by the people. It must start with this, you must come and you must talk. Our provincial plan must be drafted in the districts, not in an office.16 The room broke into loud applause following Allan’s speech, galvanizing those in attendance. Padmini attempted to channel the feedback toward what she saw as a more “constructive” engagement with the policy document, but the trajectory of the meeting had been fundamentally altered by Allan’s incisive assessment. A series of critical comments followed, including demands that the consultation period be extended and for a health-needs assessment to be carried out at the district and subdistrict levels. A complaint that was voiced repeatedly was that no one had been able to look at the draft policy document prior to the meeting. Representatives from the provincial department of health and WC-Nacosa countered this point by suggesting that the details of the policy could be discussed within subdistrict HIV/AIDS coordinating institutions called Multi-Sectoral Action Teams (MSATs).17 A MSAT member offered a fierce rejection of the proposal to use the MSATs as a forum for discussing the HIV/AIDS policy:

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I am the chairperson of the [subdistrict omitted] MSAT: these are funded by the city of Cape Town, and you have no provincial people on the councils. Why should we put the responsibility on the MSAT? We have no support, none whatsoever from the Department of Health and any other department. We are not here to play games. HIV/AIDS is a serious thing that needs to be addressed. We are a year down the line with the draft PSP: what do you think of us when it cannot be distributed? There is nothing for us to take back to our constituencies? We are being made to look like fools and I am sick and tired of looking like a fool on behalf of someone else!18 The frustration of this MSAT chairperson was palpable, and her remarks were followed by loud exclamations from others in attendance. Lynette and Fikile responded by describing how WC-Nacosa and the Department of Health could support the subdistrict institutions, but the MSAT member who had voiced her frustration loudly interrupted them, characterizing the meeting as “disgusting.” Her angry intervention led to another round of applause and loud cheers. While TAC members had played a major role in establishing a critical dynamic at the meeting, they were far from the only group in attendance to critique the PSP consultations. The contentious atmosphere abated as the presentations ended and attendees broke into groups for report-backs on HIV/AIDS activities operating in their subdistricts. However, some groups were divided over whether or not to participate in, and thereby implicitly support, the consultative process; one group abstained from submitting any feedback as a protest. Phaedra was visibly frustrated in her working group, often shaking her head in disbelief. I spoke with her later, and I learned that her frustration was based on the fact that a meeting had been held the previous year in which a similar presentation on the draft PSP had been given and was met with an equally frustrated response. Those in attendance had demanded substantive input and asked for physical copies of the draft policy. History, it seemed to Phaedra, had repeated itself. The response from WC-Nacosa and the Department of Health to the tumult was to dismiss the critiques and demands. After the meeting, I approached Linda,19 a representative from the provincial health department, and Lynette from WC-Nacosa as they stood together in the parking lot. They wore grim expressions on their faces, and they said they “could not understand” why community members, staff from nongovernmental and

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community-based organizations, and HIV/AIDS activists were rejecting the consultative process. Although attendees had articulated the changes they wished to see, those in charge of the consultative meetings were still unclear on why they had been greeted with such a strong response. After a day of contentious debate, the Cape Town meeting adjourned without a clear way forward for the health district with the highest HIV prevalence in the province.

Locating Transnational Donor Capital: Lynette and the Overberg District Meeting The next consultative meeting was held for the Overberg health district in Caledon, a town situated approximately one hundred kilometers (sixty-two miles) from Cape Town. The meeting was held in Caledon Town Hall, a Dutch colonial building painted in an understated tan, with columns and other architectural details contrasting in white. The second floor of the building had a large meeting room, which was used for community meetings like the consultative session. I first met Lynette in December 2007, when I returned from the SANAC meeting where PMTCT guidelines were updated by the HIV/AIDS movement. I had kept in touch with Padmini, a WC-Nacosa coordinator who participated in the national PMTCT policy development process, who then introduced me to Lynette, her coworker. A white, middle-aged Afrikaansspeaking South African, Lynnette had held managerial positions in government during the late apartheid era and the early post-apartheid period. After joining the organization in 2005, she led efforts to grow WC-Nacosa from a small, activist-oriented group into an organization that provided mentoring services to community-based organizations across the Western Cape. Financially supported in large part by the South African government, WCNacosa mentored community-based organizations in their efforts to access donor capital. WC-Nacosa, therefore, was positioned as an intermediary organization between the state, donor capital, and community-based initiatives related to HIV/AIDS in the Western Cape. Based on their role in the PSP consultative meetings, WC-Nacosa’s activities also included HIV/AIDS policy development at the provincial level. In contrast with the previous meeting in Cape Town, the Overberg district consultative session was attended by no more than thirty people. Lynette opened the meeting with the same presentation that she had given at the

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previous meetings. However, following the uproar at the Cape Metropole meeting, she stated that WC-Nacosa was only consulting with organizations that they directly mentored. This was puzzling, given that WC-Nacosa was mandated to gather input from all of civil society, not just organizations that were part of its network. In addition, Lynette claimed to have TAC’s support for the policy consultations. Again, this was a spurious claim, given the outright rejection of the policy consultations by TAC activists at the previous meeting. Lynette’s presentation was followed by a discussion about district coordinating institutions. Representatives of community-based HIV/AIDS organizations expressed concern that the Department of Social Development was attempting to create a district HIV/AIDS forum, which would duplicate existing health and welfare committees. I was puzzled. What could motivate the creation of duplicate institutions that received little funding? The reason for this soon became clear, as it related to donor support from the Global Fund. When addressing a comment on the role of the Global Fund, Lynette responded in the following manner: “Round seven of the Global Fund is ending in June of next year, and the government has not applied for additional funding. People were stressed about continuing funding for structures such as MSATs.20 Nacosa will apply for this round of funding to continue funding, and we are having a meeting with the Department of Health to discuss this. We will be conducting a review to evaluate the structures to see what is working and what is not. If there are needs, we will capacitate them to enhance the response.”21 An attendee asked further questions: “Does the money from the GF [Global Fund] go to the municipality? Would the money be solely available for AIDS? There is a sub-committee for the municipality, but it is not doing much to deal with the problems.”22 Lynette replied: “The GF would go through the district municipality to the community-based organizations [CBOs]. The CBOs apply directly, they are asked to hand in proposals. A committee reviews the application and decides which ones go forward. In each municipality, there is an MSAT, they have a profile for the area and they decide how to move forward for the area. Maybe for here we can expand the health and welfare communities, but they must be able to play the role of recommending which organizations should get funding.”23 The debate on local coordinating structures was not simply about whether or not existing institutions worked: it addressed who would serve as the local gatekeeper for access to transnational donor capital. As Lynette made clear,

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WC-Nacosa would be centrally involved. WC-Nacosa’s purpose in coordinating the consultative meetings came into focus: they would serve as a mechanism for expanding the organization’s role from being part of direct relationships with CBOs and district-based coordinating institutions to becoming an intermediary institution for accessing transnational donor capital. Fikile from the Department of Health then gave a dense, technical presentation that focused on the monitoring and evaluation criteria set out in the NSP. Next, Esmée from ALN opened a discussion with those in attendance. Once again, Esmée’s collaborative approach enabled a more inclusive conversation to unfold. A significant point of debate that emerged was the stigmatization of people living with HIV/AIDS and the disclosure of HIV status without a person’s consent. One local health worker described how a specific color of folder was used for HIV-positive patients at local clinics in the area, which in effect disclosed a person’s HIV status to all those attending a clinic. Many women shared their concerns about the threat of disclosure, highlighting it as a significant deterrent to HIV/AIDS testing and treatment uptake. As Esmée finished her portion of the meeting, a woman from the audience characterized it as the first honest discussion they had participated in for a long time. Given that WC-Nacosa held meetings in the district every three months, the comment was disconcerting.

Race and HIV/AIDS: Fikile and The Central Karoo Meeting The next policy consultation, for the Central Karoo health district, took me across the Western Cape Province to the town of Beaufort West, located on the outskirts of the Karoo Desert. Prior to the meeting, Linda, the representative from the provincial department of health, asked if I could drive Fikile to Beaufort West, and I quickly agreed. I had spoken briefly with Fikile on several occasions, but six hours in a car together offered uninterrupted access to a state health representative and the possibility of understanding his perspective on the HIV/AIDS epidemic in greater depth. Given that Beaufort West was such a distance from Cape Town, we decided to leave the day before the meeting in the early afternoon. As my vehicle had no air conditioning, traveling later in the day would make our trip through the desert far more comfortable. After a few hours, we began to talk about South African politics, including topics such as water privatization, land restitution, crime, education, and

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post-apartheid South African society. Fikile had an academic background, and he had joined the Western Cape Department of Health after publishing research on a wide range of topics. I was impressed by the range of his knowledge, nuanced perspectives, and progressive attitude toward pressing issues for poor and working-class communities. I couldn’t help but notice that his participation in the consultative meetings betrayed little of his background and broader knowledge of South African society. Indeed, his statements remained focused on policy details rather than broader insights on the social drivers of illness and HIV/AIDS. After arriving in Beaufort West, Fikile and I sat down for dinner at a restaurant in town, only to be met with stares from both patrons and staff, presumably because it was unusual to see a black South African dining with a white American. Fikile seemed to shrug off the hostile reception, but it was difficult to ignore. I attempted to divert my attention as well, following Fikile’s lead, but I remained struck by the racial legacy of apartheid and segregation. The racial undertones of the situation were further clarified when Fikile’s pasta arrived without any noodles. His plate was instead filled with what appeared to be the remnants of several preparations of pasta, which were embedded in a thick cheese sauce. Fikile’s frustration was palpable, and he protested that his dinner had not been properly prepared. The white, male, Afrikaans waiter, wearing a smug smile, replied that this was the style of pasta that the restaurant served. Fikile did not let the statement stand, informing the server that all pasta had noodles, and that he had been to Italy and knew something of the topic. Nevertheless, the waiter refused to add noodles or replace the dish, suggesting instead that if Fikile did not like the food that they served, he should eat somewhere else. I offered to leave, but Fikile insisted that we stay, wearing a stoic expression as he ate his pasta dinner minus the pasta. Despite his status as a state health representative, Fikile could not escape the thinly veiled racism that permeated rural areas of South Africa. The next morning, we drove across town to a small local church for the meeting, which was well attended for a rural district, with between forty-five and fifty people in attendance. Notably, Lynette was not present, and her whereabouts that day would prove to be an important point of discussion for those in attendance. As it turned out, the previous meeting in Overberg was the last she would attend. A different representative from WC-Nacosa led the meeting in her stead and gave a similar presentation based on the same slides, mentioning that Lynette was not attending due to her presence at a Department of Health workshop on fundraising. When pushed by attendees to elaborate further,

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the representative clarified that Lynette was involved in “high-level strategic consultation over funding and strategy” linked to a Global Fund application. The mention of the Global Fund produced a wave of hushed whispers across the room. The possibility that WC-Nacosa might secure additional funding produced palpable excitement, but there was little mention made of the PSP during the presentation and discussion that followed. The excitement regarding Global Fund financing contrasted with the conservative atmosphere that reflected the religious setting. A representative from the Department of Social Development repeatedly interrupted the presentations to argue for the superiority of the Abstinence, Be Faithful, and Condomize (ABC) approach to preventing HIV transmission. Clearly, the moral undertones that PEPFAR-funded global health programs and the ABC approach carried with them were powerful forces in this rural district (Susser 2009). These interruptions led to a forceful discussion between the representative and Esmée regarding the age of consent and condom availability in schools. Esmée explained why education and access to barrier methods were crucial for lowering infection rates among young South Africans, and constitutional rights figured centrally in the discussion. The rest of the meeting unfolded with a sense of unease after this sparring. The discussions within working groups focused on an entirely different set of issues, including funding for treatment, empowering community-based organizations, and transportation to clinics. Report-backs from working groups touched upon several topics, including the inaccessibility of female condoms and how a human rights approach to HIV/AIDS could not work without sufficient access to voluntary counseling and testing. But these points did not give rise to a substantive debate: the unease produced by the earlier tête-à-tête about ABC and condoms appeared to have limited further discussion.

Internal Fissures Emerge: Esmée and the West Coast Meeting The West Coast health district meeting was held in a small rural church in the town of Piketberg. The church was located amid a series of rolling hills, an idyllic scene emerging out of a sea of green. After having lost my way, I arrived at the meeting only to find out that others had run late as well. In fact, only Esmée had arrived on time, and so we sat outside the church together until the others arrived. While we waited, Esmée and I discussed the PSP

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consultations and her perspective on the policy process. At the first few meetings, Esmée and I had talked briefly on several occasions, but I was unsure what she thought about the policy consultations. Her perspective was made abundantly clear that morning. The bucolic setting was a sharp contrast to the feelings Esmée shared of disillusionment with the consultations and how the process was moving ahead despite its rejection in Cape Town and a lack of substantive engagement at other district meetings. As with Fikile, Esmée had an academic background before becoming involved with the HIV/AIDS response. Having lived in South Africa since the early 1990s, she had a deep understanding of South African HIV/AIDS politics, and she was also involved in the policy-development process at the national level. As someone well versed in human rights law and HIV/AIDS, Esmée served on SANAC, contributing to the development of national policy norms. She had a clear vision of the broader political environment within which the PSP consultations unfolded, and she did not pull her punches when discussing how they had not furthered the goals of the HIV/ AIDS movement. Though Esmée and the ALN took a critical position on the policy process in public discussions, they did not openly critique the health department or WC-Nacosa within the meetings themselves.24 The meeting started forty-five minutes late, as the Department of Health and WC-Nacosa delegations arrived together after also getting lost on their way to the church. A local community leader from the Piketberg area chaired the meeting. After the forty or so individuals in attendance had taken their seats in the pews, the community leader, a “coloured” woman in her midforties, asked that everyone move to the front of the seating area to ensure that they could hear. No one budged, and the meeting chair again exhorted attendees to find a new seat. Still no one budged, though bemused glances were exchanged across the room. But the meeting chair was insistent, and she waited to start the meeting until everyone in the room had moved forward a few pews. As we stood up to move, Esmée and I turned and looked at one another incredulously. Forcing everyone to move seemed to be an arbitrary exercise of power, a precursor to dynamics that would repeat later that day. After everyone in attendance settled into their new seats, a WC-Nacosa representative offered the familiar presentation, which gave a broad overview of the epidemic. When she invited questions, she was greeted with silence, with many people wearing confused looks on their faces. Next, Fikile once again gave a technical presentation that focused on monitoring and evaluation, which was clearly an area of policy that he knew a great deal about.

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However, he started by making the following statement, which momentarily unveiled underlying power relations within the consultative meetings: “I am going to try and be very brief today. Because Nacosa is so close to government sometimes they speak on our behalf. I am going to try to stick to the issues which are most important for our purposes today.”25 Fikile smiled while he spoke, leading to nervous laughter from the WCNacosa representatives in attendance. Clearly, the close relationship between WC-Nacosa and the Western Cape Department of Health was widely known, if seldom spoken of. The statement unmasked the power of the state in the meetings and the subsidiary position maintained by WC-Nacosa, as Fikile’s personal views appeared to break through the well-practiced façade he maintained as a state health representative. Esmée spoke after Fikile, and she went on to facilitate a discussion focused on human rights and access to HIV/AIDS counseling and support. This time, her attempt to engage with the issues of rights and HIV/AIDS did not lead to a debate on local issues but was instead met with an uncomfortable silence, after which a question-and-answer period followed. Meeting attendees asked for more information on issues including funding and training for homebased care, access to food, and locations for condom distribution. In a continuing theme, neither the NSP nor PSP figured prominently in a meeting that was created to focus on gathering input for developing policy. When addressing questions, the WC-Nacosa representative and Fikile linked back to a general discussion of national policy, but they did not address the policy details sufficiently to satisfy those posing questions. This was particularly the case when a question was raised regarding additional government support, and the temperature in the room rose as the topic was broached. A middle-aged black South African woman pushed Fikile to offer further clarification on the extent to which the state would support community health work in the district. At this point, the “coloured” community leader chairing the meeting stepped forward and, in a stern tone, admonished the woman and all those in attendance to not complain about what they did not have but do the best with what they did have. In closing, the meeting chair told those in attendance that the government knew the challenges that they were facing and were doing the best they could. The reassertion of power seemed to subdue those in attendance, and the balance of the session unfolded with an air of weary acquiescence. That the community leader’s show of power corresponded to racial divisions was not necessarily surprising given what Fikile had experienced in Beaufort West.

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Indeed, the influence of race would indelibly mark the dynamics of the final consultative meeting.

The End(s) of Consultation: The Cape Winelands Meeting The closing consultative meeting for the PSP policy process, in the Cape Winelands district, was held in the town of Worcester, in another stately Dutch colonial building, which served as the Department of Education’s district office. The large meeting room was divided by large round tables, each seating between six and eight people. The presenters sat on an elevated platform that faced the participants at a table with a podium on one end. As with the previous meeting in Piketberg, a community member chaired the meeting. This time, however, the local chair was from the government, the Department of Education to be exact: a tall “coloured” man in his late thirties who took an assertive tone from the start. As he stood at the lectern, he opened the meeting by indicating that he would keep presenters to time and use his authority as chair to maintain order. Clearly, news of upheaval at the Cape Metropole meeting had traveled. A representative from WC-Nacosa began the meeting by giving the same general presentation of the epidemic as had been given at the other meetings. However, this time she offered the following statement: “We were invited to lead consultation for HIV/AIDS civil society, but especially for our members, even though others are welcome to come.”26 Once again, the goalposts seem to have shifted on precisely how consultation was defined relative to the PSP policy process. Following the first presentation, the following exchange occurred between the WC-Nacosa representative and an older black South African woman in the audience: Meeting Attendee. The presentation was too fast, and I didn’t really understand the sense of what she was talking about. The next time it should be explainable. The presentation was too fast. WC-Nacosa representative. Basically what I did was explain the problem. Do you want me to start at the beginning? Meeting Attendee. Can we have access to the statistics? WC-Nacosa representative. We will put it on the website. Are you covered? Meeting Attendee. No, I’m not covered, you need to explain it to us.

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Meeting chair. What she did was to explain the problem: where are we, and the structure of what Nacosa will be doing with different levels. I think that when [Fikile] does his presentation, some of the stuff that she has talked about will be clear. Meeting Attendee. One last question of the presentation, she spoke about the PSP, how do we get access to that? WC-Nacosa representative. A draft of it was sent through the email. But we also have a shortened version of the NSP here. Other than that you can also go to the website. What we are talking about is the NSP, the PSP is basically not the issue. Ok, are we all covered now?27 The WC-Nacosa representative’s characterization of the meetings as focusing on the NSP rather than the PSP was disconcerting. The woman who had inquired about the PSP asked for a copy of the policy, repeating a request that had been iterated throughout the consultative meetings. Rather than facilitate access to the policy and discuss the draft PSP’s details, the WCNacosa representative described the policy for which the meetings had been organized as “not the issue.” There are two dynamics relating to the above exchange that are worth noting, regarding tone and physical proximity. There is always something lost in the translation from a lived experience to the written word. In this case, the representative from WC-Nacosa was unhappy about being challenged and spoke with an increasingly frustrated and condescending tone over the course of the exchange. This was particularly the case when the WC-Nacosa representative stated “Are you covered?” in a tone that dripped with antagonism. The meeting chair rose and stood directly next to the WC-Nacosa representative during the exchange. Shoulder to shoulder, they represented the united front between the state and the NGO. The meeting chair’s imposing stature only added to his assertion of authority over the meeting. The presentations continued after this expression of state power, with Fikile offering a long and thorough analysis of the epidemic’s local complexities. Once again, monitoring and evaluation served as the focus of his narrative. Esmée from ALN followed, critiquing a lack of confidentiality in health clinics, the need to protect the human right to health, and decrying the lack of condoms available in schools. Various participants had raised these concerns during the five previous meetings, bringing the local difficulties they faced

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into tension with abstract policy norms. Esmée’s comments were greeted with a series of challenges from meeting attendees, who argued that school governing boards in each community had the right to control the availability of condoms in schools. Esmée explained that national law overrode local preference and that school governing boards had to operate within the laws of society, which were developed in accordance with the post-apartheid constitution. Interestingly, the chair chose not to intervene in the exchange despite the confrontational style taken by Esmée’s interlocutors. Report-backs from working groups then ensued, collating information on the local HIV/AIDS response in the Cape Winelands district. It had become abundantly clear that the report-backs were serving as a data-gathering exercise for WC-Nacosa and the state. The question that remained to be clarified was the ends to which the information would be used. As the meeting adjourned, I approached the older black South African woman who had the exchange with the WC-Nacosa representative described above. As I introduced myself and asked if she would like to talk more about her experiences, I saw her look over my shoulder worriedly before she quickly looked down and declined to participate in my research. I turned around to look at what had come to her attention and saw the meeting chair staring at us, unwavering in his gaze. Startled, I turned back around to see the older woman hurriedly walking out of the room.

Speaking Back: Perspectives on the PSP Consultative Meetings Over the course of the PSP consultative meetings, I approached many of those attending to participate in my research on the politics of HIV/AIDS treatment access. I carried out interviews with members of the provincial government, NGOs, CBOs, members of local HIV/AIDS coordinating institutions, and HIV/AIDS activists. The questions that I posed grew out of the political conflicts that manifested in the policy consultations and the comments provided by those in attendance. I also wanted to know whether the meetings conveyed clear and comprehensible information about the NSP or PSP, and the perspectives of meeting attendees on the relationship between WC-Nacosa and the Western Cape Department of Health. Finally, I inquired into the influence of transnational donor capital, in the form of the Global Fund, and how participants saw this informing the PSP policy process.

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I sought clarification from Nomfusi, the TAC activist with whom I attended the first policy consultation, about the selection of meeting attendees because I had noticed that the way WC-Nacosa defined civil society varied meeting to meeting. She replied: “Probably, the consultation was meant for Nacosa affiliates because all the groups there were Nacosa affiliates. They have received some kind of assistance from Nacosa in one way or the other.” Given that WC-Nacosa used its quarterly meetings with partner organizations for the consultative structure, Nomfusi’s response should not be surprising. But it is still noteworthy, because the meetings were framed as a means of gathering input from all of civil society. While Lynette shifted her framing of the consultations after a critical response at the Cape Town meeting, characterizing them as “primarily for our members,” it is nevertheless the case that the sessions were required to involve all provincial civil society organizations doing work in relation to the epidemic, whether they were in WC-Nacosa’s network or not. Nomfusi’s insight regarding organizational representation at the consultative meetings also helped me to understand why the Cape Town meeting had been so different from the others. Initially, I assumed that it was simply due to TAC’s influence in setting a critical dynamic at the meeting, which opened the door for others to offer their own views. Undoubtedly this had some influence on proceedings at the meeting for the Cape Metropolitan health district. However, the majority of attendees for the other consultative meetings were affiliated with organizations that worked closely with WCNacosa and were dependent on their mentorship to a degree. Communitybased organizations and NGOs that worked with WC-Nacosa thus had a vested interest in maintaining a cordial working relationship with an organization that provided mentoring and support for accessing donor capital. The critical feedback unleashed at the Cape Metropole meeting reflected the fact that far fewer organizations in the urban district depended on WC-Nacosa’s support. Further discussion of the consultative meetings with Phaedra reinforced Nomfusi’s characterization of the urban/rural divide in WC-Nacosa’s network. As someone who had attended the Cape Metropole meeting and had long worked across the city, she was something of an authority on the matter. As Phaedra recounted her experience of the Metropole meeting, she pointed out that a similar event had occurred the previous year. At a meeting called by the provincial department of health and WC-Nacosa, the draft PSP had been introduced to organizations working to address the epidemic in the province. Phaedra recalled how those in the audience had pressed presenters on the

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process through which the PSP had been drafted and the degree to which it incorporated the input of civil society. Phaedra laughed incredulously as she described how the dynamics of the Cape Metropole meeting were nearly identical to the introduction of the policy a year prior. Given that Phaedra was far from the only individual who had attended both meetings, the dissatisfaction unleashed at the Metropole meeting also reflected the continued exclusion of the HIV/AIDS movement from substantive policy input at the provincial level. Nomfusi offered another reason why organizations may have limited their feedback during meetings: they were instructed to submit feedback via WCNacosa’s website. At each of the sessions, meeting organizers asked participants to draft proposals specifying how their organization would meet the NSP’s targets and then upload these plans to WC-Nacosa’s “interactive website.” The reason given for this exercise was that WC-Nacosa could incorporate the proposals into their submission to the Western Cape Provincial AIDS Council, which evoked the possibility of donor support. Nomfusi pointed to the material realities faced by many in South Africa, which served as barriers to submitting feedback electronically: How many people have access to the internet? I can tell you: people who go to the library. If you have a card, a library card, you have forty-five minutes access in the library on that computer. So maybe they have five computers, and the computer is so slow that it takes twenty minutes just to upload one page. Now think about going to a website, clicking the website, and now it takes another twenty-five minutes to upload. So your forty-five minutes is gone before you even feed the submission. So even in that room maybe you will find those two or three people who have internet access because they have a well-funded, or well- supported group that maybe accesses Nacosa’s funds. But it’s people who could be aligned closely to Nacosa who might have access to their website and they can do that interactive thing. But the rest of the community, the rest of the people who don’t have access to the internet, they’re not going to participate, they’re not going to care about this because it does not talk to them. It’s not about them. It’s about people who have access to electricity and computers and email at home. Requiring electronic submissions limited the feedback of people and organizations with fewer resources. Each participant or participating organization

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was assumed to have the necessary grant-writing and technological skills to upload proposals through the WC-Nacosa website,28 and this assumption limited input from historically disadvantaged people across the Western Cape. Another issue Nomfusi discussed was the close relationship between WC-Nacosa and the Western Cape Department of Health, which Fikile had highlighted during the meetings. My conversation with Nomfusi reinforced a perception that several research participants had also relayed when we had discussed the meetings. However, Nomfusi added an additional layer of interpretation when pointing to the influence of donor capital and WC-Nacosa’s sustainability as an organization: What made me nervous the very first time was that people from Nacosa and the people from the provincial health department were very buddy-buddy, you know, very close. . . . I still felt that they already have in mind what they want to achieve and what they want to get out of the consultation process. So, it is not really about telling people what the NSP is or what the PSP is, but what there is in these communities that can make it get support from international donors or whoever so that they can roll it out. . . . They already have an idea of what they want to achieve and for them this is to apply for the funding. And whatever happens with the implementation of the plan really doesn’t matter to them as long as they have access to the funding, which is vital to sustain the organization and the other organizations they are mentoring. Nomfusi’s insistence that WC-Nacosa’s leaders were only involved in the consultative meetings for access to donor capital struck me as uncharitable at the time. Since the consultative meetings had not yet ended, I thought she had rushed to judgment. But her words stuck in my mind, particularly as the PSP consultations devolved into a data-gathering initiative, which led me to investigate the financial relationship between WC-Nacosa and state health institutions. WC-Nacosa’s funding for coordinating and mentoring CBOs had historically relied on donor capital from the South African state. In 2006, 74.8 percent of WC-Nacosa’s budget came from the South African government. The following year, state contributions increased in total but decreased to 61.9 percent of the organization’s annual budget. The Department of Health figured prominently, contributing 40 percent of WC-Nacosa’s 2006 budget and

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30 percent of the 2007 budget (WC-Nacosa 2007). Given the fraught political environment between members of the HIV/AIDS movement and state health administrators at the provincial and national levels, HIV/AIDS activists took a critical view toward WC-Nacosa’s dependence on government support. I spoke with several HIV/AIDS activists about their perception of WC-Nacosa, many of whom offered a circumspect view of the organization. Despite tracing the organization’s roots to the first wave of HIV/AIDS activism, a leading TAC activist characterized WC-Nacosa as “collaborators.” The implication of the statement was clear: WC-Nacosa worked with, and depended on, the state health institutions that were limiting access to HIV/AIDS treatment and enabling unapproved clinical trials to occur in Khayelitsha. The suggestive title of the organization’s newsletter, the Nacosa Informer, might not discourage such associations. While WC-Nacosa’s dependence on government funding explains their close working relationship, it did not offer insight into the trajectory of the PSP consultative meetings. Here, the influence of transnational donor capital, in the form of a Global Fund grant, looms large.

Things Fall Apart: Donor Capital and the PSP WC-Nacosa’s inclusion in a Global Fund reapplication process exacerbated tensions between the HIV/AIDS movement and state health administrators in the Western Cape, transforming the PSP consultations into a data-gathering exercise aimed at accessing transnational donor capital. As I came to learn, findings from the meetings were of no consequence for the PSP’s implementation in the Western Cape. In my role as notetaker I collected approximately ninety pages of feedback from NGOs, CBOs, and HIV/AIDS activists. Shortly after submitting my notes to WC-Nacosa, I interviewed members of the Western Cape Department of Health, who indicated that the PSP was already being implemented prior to the incorporation of community feedback. This outcome was strikingly different from the spirit of cooperation and inclusion that had marked the development of the NSP at the national level, where the HIV/AIDS movement had worked hand in hand with state health administrators and the deputy president to develop new national HIV/AIDS policy and to restructure SANAC. Simmering tension among TAC, WC-Nacosa, and the Western Cape Department of Health was brought to a boil by the redirection of the PSP policy process, as it undermined the HIV/AIDS movement’s campaign to

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expand treatment access in the province. Developed by the HIV/AIDS movement and government health officials while the minister of health was on sick leave, the NSP had marked a sharp break with earlier HIV/AIDS policies by including treatment access targets and mandating that a transformed SANAC oversee policy implementation. While the HIV/AIDS movement found success within national institutions, the NSP ran aground on the shoals of provincial politics. Despite efforts led by TAC activists to extend and restructure the policy consultation process to include a needs-based assessment of each health district, the PSP policy process ended without changes to HIV/AIDS programs in the Western Cape. The consultative meetings for the PSP highlight how contradictory dynamics unfolded at different institutional levels in South Africa. Even though the PSP policy consultations gathered input from NGOs, CBOs, and HIV/AIDS activists, the feedback gathered via these sessions was not incorporated into the policy development process. Far from producing substantive change, such as expanding treatment access to 80 percent of those in need, the consultative meetings instead underwrote a reapplication process to extend access to transnational donor capital in the Western Cape. Notably, WC-Nacosa would play a central role in the reapplication process, underscoring why the organization’s interest lay in gathering data rather than developing substantive changes in provincial HIV/AIDS policy. Both the national policy and the provincial version of the HIV/AIDS policy were influenced by the composition of the sociopolitical formations that drove HIV/AIDS politics at the national and provincial levels and by the influence of transnational donor capital. The balance of power between actors and organizations, and the ways they channeled the influence of transnational donor capital, created divergent outcomes for HIV/ AIDS policy at the different institutional levels of the state (Powers 2016). The demise of the PSP process highlights the unpredictable ways that transnational donor capital can be leveraged by local actors and organizations to influence the policy process, which can lead to divergences at different institutional levels. These meetings were sites where sociopolitical activity was concentrated for HIV/AIDS politics in the Western Cape and where the possibility of transnational donor support was leveraged to transform a consultative process for a provincial HIV/AIDS policy. These zones of concentrated sociopolitical activity, or hot spots, were the points where “friction” was produced between localized sociopolitical formations and transnational influence (Tsing 2005),

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and where actors and organizations converged and transformed the trajectory of ideas, money, and medicines. I encountered similar dynamics in the township of Khayelitsha, where community-based HIV/AIDS activists fought to limit the impact of AIDS dissidence, which manifested through the organizational and political particularity of the post-apartheid township.

CHAPTER 5

Community Health Activism, AIDS Dissidence, and Local HIV/AIDS Politics in Khayelitsha

While the campaign for HIV/AIDS treatment access at the national and provincial levels focused on policy, state institutions, and the right to health, the politics of HIV/AIDS in communities infected and affected by the epidemic unfolded around local social and political institutions, which were influenced by national politics and historical continuities with the late apartheid era. Fieldwork across the Cape Flats and, in particular, in Khayelitsha highlighted the social factors driving the epidemic. In these areas, material deprivation, insufficient health education, and inadequate access to health care produced social conditions that facilitated the rapid expansion of the disease. Focusing on the politics of HIV/AIDS in the township of Khayelitsha, I followed HIV/ AIDS activists to learn how they counteracted the epidemic and the ways that AIDS dissidence manifested in their community. As I learned, the community was deeply enmeshed in the political legacies of late apartheid and the anti-apartheid movement. In Khayelitsha, the struggle over treatment access, and the life-and-death consequences that it entailed, was waged using social institutions that shaped everyday life, such as street committees and area development forums.

Conversations with Moeletsi: Navigating Life in an Urban Township Moeletsi1 and I first met at TAC’s provincial office and quickly bonded. A Xhosa man in his midtwenties, Moeletsi moved from the Eastern Cape during

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his youth and completed his secondary studies in Khayelitsha. He had followed his mother, who had left the Eastern Cape seeking work. Moeletsi had lived in the township for seven years at the time we met, and he was kind, soft-spoken, and always quick to make light of the difficulties that HIV/AIDS activists faced in the course of their work. Our relationship grew from chance encounters at TAC meetings into an enduring friendship, and we regularly spent our off days together, watching Nigerian “Nollywood” films and partaking in the delicacy that is township-style grilled meat, known as shisa nyama. While I grew close to several other members of the HIV/AIDS movement in Khayelitsha, Moeletsi was my initial link to township life. One midmorning on a holiday Friday, I had made plans to spend the day with Moeletsi at his shack in Khayelitsha. As I drove toward the township from the Salt River area of Cape Town, the searing summer sun burned off the clouds, turning a cool morning into a scorching day. I turned off the N2 Highway and made my way toward Zone P, where Moeletsi lived, an area of Khayelitsha close to the highway. To reach the shack Moeletsi called home, I drove to the end of a street, where several concrete toilets and a water tap were located. I parked at the end of a line of cars, all perched on the curb along the edge of the road. As might be expected of facilities that were utilized by several hundred people, the ground around the toilets and tap was soaked. I tiptoed carefully around the sandy soil, nevertheless failing to keep my feet dry. I followed a winding path past the toilets toward Moeletsi’s shack, my steps supported by submerged sections of carpet that provided structure to the soil. As the path turned to the left, I saw a familiar fence. I had arrived. I had visited Moeletsi’s home several times before, but the contrast between the outside and inside of his shack still struck me. The dullness of the corrugated tin roof and exterior walls could not have been more misleading. Warm and inviting, the interior walls of Moeletsi’s shack were lined with several layers of newspaper and magazines; this inexpensive form of insulation doubled as a bricolage of South African popular culture. In an effortless style, images of soap opera stars were juxtaposed with advertisements for washing powder. The eclectic ballet of images reminded me of the Japanese aesthetic of wabi-sabi, which is based on the idea of seeing perfection or beauty in imperfection. Moeletsi’s home was organized into two rooms, the first of which was a cooking-and-eating area, where an old wood-composite tabletop sat on top of an improvised stand in the center of the room, its legs long forgotten. Old plastic milk crates that served as chairs circled the makeshift table. To the right side of the room, a plush but dilapidated brown couch sat in front of a television. In the next room was a sleeping area.

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The unexpected heat led us to sit outside, in the shade created by the edge of the corrugated tin roof, as the inside of Moeletsi’s home was getting hotter by the minute. As we sat, Moeletsi discussed his life story, tracing the challenges he had faced in becoming a leading member of TAC’s district office. After completing his secondary studies, Moeletsi was unable to find work, and he did not have money to continue his studies at the university level, like many young men living in Khayelitsha. He tried to get involved with a local organization based in Khayelitsha, to find something that might translate into paid work and, at the same time, to do something for the community. But he had not been able to find anything that could pay him a wage, as most organizations wanted someone who had experience of some kind. Moeletsi made intermittent trips back to the Eastern Cape, relying on his family amid the material difficulties he faced. His rural-urban pathway of circular migration continued for some time, with his sojourns to the Eastern Cape taking the form of extended visits at times. But he chose to stay in Khayelitsha, reasoning that, although he did not have money, he might find work there and that there were far fewer possibilities in the Eastern Cape. But, one day, Moeletsi’s fortunes changed when he followed up with an organization he had heard about on the radio. “I just heard, one day when I was listening to the radio, about this Silver Ring Thing. That’s when I just made a call, made contact with them, and after a month, I joined them, because I was having nothing to do. And after that, I was just saying, this is not making any progress, so I just resigned.” A mix of luck, good timing, and effort had led to Moeletsi securing a position with Silver Ring Thing, an American nonprofit organization that seeks to prevent premarital sex and pregnancy through championing sexual abstinence and Bible readings, echoing the moral imperialism associated with PEPFAR (Susser 2009). During one visit Moeletsi showed me a video of a Silver Ring Thing workshop, and I watched him and others perform a set of scenarios where young people navigate social pressure and decline to engage with their peers sexually. Moeletsi’s participation in Silver Ring Thing in part reflected pressing material concerns, but it was also driven by a broader desire to transform life in the township of Khayelitsha. Indeed, despite the financial consequences, he left Silver Ring Thing after working there for some time, disenchanted with what he saw as an ineffectual response to the HIV/AIDS epidemic in his community. Once again, Moeletsi was forced to leave the township and return to the Eastern Cape. His eventual return was marked by the start of a position with TAC, an arrangement that was ongoing when we met.

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And then I come back to Cape Town, and I get involved with TAC. But before, with TAC, I don’t understand exactly what they are doing, in terms of, when you are done with school you can come and be a volunteer and work with the staff. Because I did start it in school, orientation and stuff, to know what they do about HIV and STI. . . . So I did it before, to come and do HIV/AIDS education in school. But I didn’t know that I can work for them, doing this voluntary work like I am doing now. So I only knew after I resigned from this Silver Ring Thing. Previously involved with TAC during his secondary studies, Moeletsi returned to Khayelitsha and became involved with the organization, eventually securing a paid position. He had taken a chance when he resigned from Silver Ring Thing, but the gamble had paid off. Moeletsi’s two-room shack and financial independence were a testament to his perseverance, but his circumstances were far from typical. None of Moeletsi’s classmate friends from secondary school had been able to find work since they had finished their studies. Those who had stayed in Khayelitsha were struggling to make ends meet, while others had gone back to the Eastern Cape to live with their families. The challenge of surviving in the township was tangible for Moeletsi; it was present in all his efforts at self-sufficiency. Moeletsi had been able, through family support and perseverance, to avoid the direct impact of rampant poverty and unemployment. But he was well aware of these problems, stating that in Khayelitsha there is crime and hopelessness and that it can be a “horrible” place to live. Matamela, a leading TAC member who had also grown up on the Cape Flats, echoed Moeletsi’s sentiments. “My friend, Khayelitsha is difficult because you can’t be employed, you are unemployable. You don’t escape. You have nothing. You don’t know how to use a computer. You don’t have a driver’s license. There is nothing. You are not educated. There is no hope. There are no alternatives in Khayelitsha. There is no training to become an electrician, no aid to become a plumber. And they come to Khayelitsha in droves, hoping to find work. But the reality? There is no work. That’s the problem with the community of Khayelitsha.” Matamela painted a challenging picture of the socioeconomic dynamics within which the epidemic was flourishing and driven by the confluence of unemployment, a lack of education, insufficient access to social support, and a growing sense of hopelessness. In this context, the fight over HIV/AIDS treatment was more than a debate on the causal relation between HIV and AIDS, but a matter of life and death.

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Matamela (whose background was discussed in the Introduction) remained committed to fighting the epidemic and helping the people of the Cape Flats despite what he saw as a very difficult socioeconomic situation. The challenge that he, Moeletsi, and other TAC members in Khayelitsha faced was to engage people who sought to ameliorate the impact of HIV/AIDS on their lives but had come to mistrust the efficacy of ARVs. Leading ANC members had undermined the public’s trust in these drugs, which sustained people’s lives once they were infected with HIV. The impact of AIDS-dissident efforts was tangible, as Matamela noted that even TAC members, who had received extensive education on the science linking HIV and AIDS, harbored lingering doubts. But what was the broader impact of dissident messages and obfuscations, in South Africa and in Khayelitsha? On this point, Matamela left little to the imagination: The impact cannot be measured. You can only measure that by the number of people who have died from that confusion. Thousands, I mean, millions of people have died. You have people who are starting to say, especially in 2004 and 2005, the minister of health is saying that ARVs are toxic: “I can’t take drugs.” There are people who are saying: “I’ve being told that vitamins are best, so I’d rather use vitamins.” We have people saying that “I’m eating healthily, I’m eating a balanced diet, so there is no need for me to go on therapy to treat AIDS.” We have people telling us that “There is nothing like HIV, because the president is saying that there is no HIV.” In a community where nearly one in three pregnant women were HIVpositive, the potential impact of AIDS dissidence was hard to measure. Some days I would walk with TAC activists on their way to a local clinic where they provided counseling and support to those taking an HIV test or beginning an ARV treatment regimen. I would count as we passed township residents going to the nearby shopping center, imagining that each third person was HIV positive. Clearly, this was an anecdotal exercise, speculative and nothing more, but it quickly left me feeling overwhelmed at the scope of the epidemic in Khayelitsha. How many of the people that I passed in the street had been tested for HIV and knew their status? How many of them questioned whether they should receive HIV/AIDS treatment? How did debates on treatment being carried out in the commanding heights of national institutions manifest here, on the ground in Khayelitsha?

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As I learned, AIDS dissidence was far from a theoretical consideration, as poor and working-class black South African residents served as test subjects for an unproven vitamin-based HIV/AIDS treatment, leading to their deaths. In Khayelitsha, people were recruited by a local alliance of AIDS dissidents to discontinue ART-based HIV/AIDS treatment and to “cure” their illness by ingesting nutritional supplements. By following Moeletsi and other HIV/ AIDS activists throughout the township I learned how AIDS dissidence had filtered through to the local level through a complex set of political alliances and local institutional dynamics. Navigating public sector clinics and community meetings, I came to understand how the legacies of the apartheid era continued to influence how post-apartheid politics unfolded and the extent to which AIDS dissidence influenced local health institutions.

An Unequal History: Contextualizing HIV/AIDS and Public Health in Khayelitsha The negotiated political transition left Cape Town’s uneven social, political, and economic geography relatively intact, and the city continued to exemplify the deep divisions inherited from the colonial and apartheid periods. The most striking of these continuities was the spatial separation of the city’s inhabitants according to racial categories, with the uneven built environment mirroring the ongoing segregation of the populace. Areas of the city that were formerly white-only neighborhoods were equipped with well-maintained roads, schools, and hospitals. The same cannot be said for the townships of the Cape Flats, where living conditions facilitated the spread of pathogens via chronic material deprivation, inadequate housing, and insufficient access to health care. A drive down Landsdowne Road led one through the series of townships that make up the Cape Flats, where differences in the quality of housing and standard of living between racial groups were inescapable. From the crumbling council houses of Hanover Park, inhabited primarily by “coloured” Capetonians, to the mazes of shacks in Khayelitsha, populated predominantly by Xhosa-speaking black South Africans, the townships of the Cape Flats made visible the fact that inequality in resource allocation and infrastructural development continues to inform health and everyday life in the post-apartheid era. My experiences with Moeletsi and other HIV/AIDS activists reinforced the importance of history for understanding the social dynamics driving

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local politics and the HIV/AIDS epidemic in Khayelitsha. Officially established in 1983, Khayelitsha was first settled by black South Africans seeking refuge from the political violence in the Crossroads settlement in the mid1980s.2 That violence can be traced to intensified efforts by the National Party to “create order” within black urban society following the Soweto Uprising in 1976. The apartheid state’s primary targets were black townships and informal settlements, many of which served as a source of strength for the United Democratic Front, a leading organization of the anti-apartheid movement.3 The UDF organized communities within the Crossroads settlement to resist forced removals by the state and expand the base of the anti-apartheid movement. In response, the apartheid state allied with community leaders who had been deposed by the anti-apartheid movement in Crossroads, and together they carried out a series of parastate attacks against UDF members. Following the conflict, government officials announced that black Capetonians residing informally in the city could build shacks on plots in the area today known as Site C in Khayelitsha (Cook 1986). Black South Africans fleeing state-sponsored violence in Crossroads and other informal areas moved to Khayelitsha, which was envisioned by state administrators as a catchment zone for the growing numbers of Xhosaspeaking people moving to Cape Town from the Transkei Bantustan in the early 1980s.4 The original design for Khayelitsha proposed that 250,000 black South Africans could reside in an area just under fifteen square miles. The first building phase for Khayelitsha developed housing for eight hundred contract workers, continuing a pattern of providing hostel accommodation for single male migrant laborers that facilitated future repatriation to rural customary areas. The formalization of Khayelitsha as a labor reserve brought Cape Town closer to the ideal model of the apartheid city, as it “consolidate[d] black urban residents into a single, peripherally located residential area” (Cook 1986). In addition to its spatial separation from central Cape Town, Khayelitsha was designed as a concentrated area with plots sizes only 35 percent of the size recommended for townships in the 1950s.5 The increasing density of the urban townships over time is demonstrated by the fact that Khayelitsha currently boasts one million residents today (Brunn and Wilson 2013). Unsurprisingly, the “separateness” that the apartheid system was designed to produce did not lead to equality, particularly with respect to the provision of health services. The concentration of black South Africans into racially designated spaces produced intermittent health crises over the course of the twentieth century, including syphilis and tuberculosis outbreaks. The HIV/

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AIDS epidemic built upon existing pathways of disease transmission created by the migration of laborers and entered the bodies of black South Africans whose immune systems had been compromised by the socioeconomic conditions encountered in the rural Bantustans and urban townships. The perspective of a former member of the Khayelitsha Development Forum on how these historical trends manifested within the township is instructive: “In the aftermath of apartheid there was only one day hospital in Khayelitsha that was intended to serve a population of 500,000.6 There were also only two high schools at that time with the balance as primary schools. There are now four high schools in Khayelitsha. Since levels of education and opportunity were so low and there was only one major police station, Khayelitsha, the biggest township in Cape Town, was dominated by shebeens and crime, which are instruments of social destruction.”7 The lack of health services that Khayelitsha residents faced upon liberation reflects the inequality inherent in the apartheid paradigm of “separateness.” The central areas of Cape Town, which were historically defined as white areas, held numerous hospitals that provided an array of specialized services. In contradistinction, Khayelitsha’s black residents were not provided adequate health services, sufficient access to education, or basic sanitation systems. The “site and service” model that served as the developmental paradigm for townships provided the bare minimum for human habitation: access to a water tap and defined land plots for settlement. The insufficient provision of health resources to Khayelitsha and other black settlements in both urban and rural areas set the stage for the exponential expansion of HIV/AIDS. During the 1990s, HIV/AIDS exploded in South Africa, and Khayelitsha was not immune to its impact; rather, it emerged as the epidemic’s epicenter in the Western Cape Province. While the prevalence of HIV is lower in Cape Town than other major urban centers in South Africa, the distribution of infections within the city corresponds to the sociospatial divisions produced by colonial segregation and apartheid, patterned by differences in race and class. A 2006 antenatal survey found an aggregate HIV prevalence of 11.1 percent for the city, but the areas with the highest HIV prevalence were two black townships: Gugulethu/Nyanga stood at 28.8 percent, and Khayelitsha at 32.7 percent (Western Cape Department of Health 2007). HIV became endemic within communities that lacked access to basic health services, including HIV testing, taking hold in the bodies of people who were not educated on how to protect themselves. Khayelitsha’s experience with HIV/AIDS echoes Didier Fassin’s claim that the epidemic embodies inequality in South

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Africa. Those who have borne the violence of history are the same ones who have primarily succumbed to HIV/AIDS: black South Africans. Khayelitsha is one community among many in South Africa where the abstract violence of history can be observed in specific patterns of illness (Fassin 2007). The growth of HIV/AIDS was accompanied by the development of a global health movement that sought to expand treatment access across the world, the work of which was particularly evident in the township of Khayelitsha. Organizations such as Partners in Health and MSF began developing models for providing HIV/AIDS treatment in resource-constrained settings during the 1990s, following innovations in HIV/AIDS prevention and treatment.8 MSF expanded their organizational focus from addressing acute health crises to developing health models for HIV/AIDS treatment in the late 1990s, with the township of Khayelitsha figuring centrally in this shift (Redfield 2005). Complementing the efforts of the government to expand primary care services in the post-apartheid era, MSF contributed to the development of health infrastructure and services to address South Africa’s dual epidemics of HIV/AIDS and tuberculosis. In Khayelitsha, MSF built and developed three dual-purpose HIV/TB clinics for piloting PMTCT (1999) and initiating ART (2001) at public sector health facilities in conjunction with the Western Cape provincial government. These pilot sites were developed to demonstrate that ART-based HIV/AIDS prevention and treatment could be successfully implemented and administered in public health clinics located in a low-resource setting. The pilots proved that providing care in these communities was possible, which enabled global health programs to expand provision of ART in developing countries. TAC played a role in these pilots, as its members served as HIV/ AIDS counselors who provided treatment literacy and support to those initiating treatment, with the goal of maintaining treatment adherence. The MSF-initiated and TAC-supported clinics proved successful, with patient visits doubling between 2005 and 2007 to reach eighty-seven thousand patient consultations per year (Médecins Sans Frontières et al. 2008). However, during my fieldwork the clinics experienced difficulty in meeting the demand for HIV testing and treatment in the community. Operating at overcapacity led to longer waiting times and difficulties in maintaining access to treatment amid ongoing staffing shortages, particularly for doctors. Community-based HIV/AIDS activists insisted that staffing shortages produced lower rates of treatment adherence, which, they contended, led to drug resistance and higher morbidity rates. Despite these challenges, demand for HIV/AIDS treatment in

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Khayelitsha continued to grow. When I walked past clinics, there would regularly be a line of people waiting for a consultation or a follow-up visit, which I took as an indication of the HIV/AIDS movement’s success. Despite the fact that there were no clear signs of AIDS dissidence at the clinics, its specter loomed large for HIV/AIDS activists in Khayelitsha. For them, AIDS dissidence was not an abstraction, but a central component of HIV/AIDS politics in the township. But it was difficult, if not impossible, for me to see how it manifested there, at least initially. Over the course of the first several months of research in the township, I was confronted with differing and at times contradictory perspectives on the epidemic. Whether I spoke with HIV/AIDS activists, ANC politicians, or clinic staff, the conversation was in some way oriented around the larger political debate on AIDS dissidence, linking back to President Mbeki and Minister of Health Tshabalala-Msimang. I was interested in how these conflicting sets of ideas manifested within social dynamics in Khayelitsha. In order to gain insight into how the fabric of society had been impacted by the politics of HIV/AIDS, I accompanied community-based HIV/AIDS activists who were TAC members, such as Moeletsi, as they moved across the township. Over time, I came to know an HIV/AIDS activist named Siphiwe,9 a Xhosa man in his late twenties who lived in an area of the township called Ukuvula. Following Siphiwe gave me insights into how HIV/AIDS activists navigated the complex world of communitylevel political institutions in confronting the epidemic and how the national agenda of AIDS dissidence manifested at the local level in Khayelitsha.

Siphiwe’s Story: The Local Politics of HIV/AIDS in Khayelitsha I had just parked and was walking toward the entrance of the building where TAC’s district office was located when I first saw Siphiwe in action. A Toyota minibus, the vehicle that serves as the de facto form of transportation for the vast majority of South Africans, was parked in front of the pale-yellow building. Siphiwe was standing in front of the minibus, engaged in a lively debate with other TAC activists about a condom-distribution campaign that he was working on in Khayelitsha. As the conversation became more exuberant, he stepped up into the doorframe of the minibus where the sliding side door stood open. With one hand on the door handle, the other raised in a feigned demonstration of victory, he proclaimed that he was “the condom

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king.” His statement was met with hearty laughter. Siphiwe then slapped the top of the minibus to indicate to the driver that it was time to depart. As the minibus began to pull away, Siphiwe slipped inside and closed the door in one smooth motion. In the weeks that passed, I came to know Siphiwe through my involvement in the day-to-day activities of TAC’s district office in Khayelitsha. He was lively and outgoing and always seemed to have a story to tell. Over time, we became friendly, and through him I met other HIV/AIDS activists who also lived in his area and were involved with TAC. Siphiwe’s neighborhood, Ukuvula,10 was known to be one of the more dangerous areas of the township. As I would learn in the coming months, gangs and the expanses of open field that they controlled were the driving force behind violence in the community. As I did with Moeletsi, I began to visit Siphiwe and his friends at home. On weekends and holidays we would often sit on milk crates outside of Siphiwe’s shack, catching our collective breath after the workweek. Siphiwe had worked with several organizations in Ukuvula around issues of water, community development, and HIV/AIDS over the past decade. While Siphiwe was often outgoing and boisterous at TAC’s district office, I found him to be quiet and often introspective when we spent time together at his shack. As we came to know one another better, I learned that Siphiwe’s life experiences were similar to those of many young Xhosa men in Khayelitsha. His father had left the Eastern Cape in the early 1980s seeking work in the Western Cape. After several years, his father sent for Siphiwe and his siblings, and they joined their father to live in the township of Gugulethu in 1985. His face glowing, Siphiwe recalled his early years in the township of Gugulethu. With an irrepressible smile, he described what it was like to live with his extended family in a single homestead: “Ja,11 those were the good times. To spend time with the family and discuss and chat and see other sisters and brothers of yours, your father’s brother, your cousin, everything. . . . There were [moments of] violence, but if you get a chance to chat as a family, they forget about [such] violence. You just think about now, but you are with family and you wish that you could be in that family and others and not go back to Crossroads, not go back to Nyanga but you can stay there as a family.” He explained how his family had moved from Gugulethu to different parts of Khayelitsha in the mid-1980s. The close kinship ties that marked Siphiwe’s youth faded, as did his smile in describing this period of his life history. Siphiwe now lived with his girlfriend in a small shack in the backyard of a larger home, some distance from his relatives. His living situation reflected

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the new realities faced by young black South African men who lacked the economic means to pay ilobola (bride price) and thereafter formalize their sexual relationships in marriage. Both families were unhappy that the couple was not following tradition, and they would not let the couple live with them. As a result, they lived together in a one-room shack and moved forward in starting a family despite their tenuous economic situation. Although we grew closer, Siphiwe would hold back when I tried to discuss how HIV/AIDS politics operated in Ukuvula. When I pressed him to describe how local social and political institutions such as street committees or area development forums addressed the epidemic, he would sidestep the question. After several attempts, I left the issue alone. I did not want to offend Siphiwe, and it was clear that something had occurred he was not comfortable sharing. The topic remained off-limits until a set of circumstances unfolded that led Siphiwe to share the local challenges he faced in confronting the epidemic in his community. The brief vignette that follows describes the events that brought Siphiwe and me closer and revealed how HIV/AIDS politics were practiced in Ukuvula and across the Cape Flats. I arrived at the Khayelitsha magistrate’s court after the protest had already begun. TAC members and other community activists stood in loosely organized circles that were dispersed across a brick courtyard. They sang protest songs and danced, engaging in the anti-apartheid practice of the toyi toyi, decrying violence against women in the township. The protest circles were united by the cry of a single activist that echoed across the courtyard: “Phansi violence against women, phansi!”12 Those in attendance replied loudly in unison, “Phansi!” The activist, now clearly visible as Matamela, stood and bellowed again: “Down with violence and oppression, down!” The crowd again replied with “Down!” Some held placards that displayed the face of a TAC activist who had been raped and murdered in Ukuvula. Within the courthouse, a hearing was underway regarding the prosecution of gang members accused of carrying out the crime. It was unclear whether there was sufficient evidence to proceed with a trial, and the mood at the protest reflected this uncertainty, with many of those present wearing tense expressions. As the protest continued, various community leaders gave speeches outlining the problem of violence against women in the township. At the edge of the brick courtyard I saw a group of TAC members huddled with Siphiwe. Matamela was among them, and he wore an anxious expression on his face. Usually affable and unflappable, I was surprised to see him so concerned. I walked over to see what was wrong, and after some cajoling, Matamela

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explained that Siphiwe and other TAC members were witnesses in the legal case against the gang members accused of murder. Furthermore, fellow gang members of those charged were at the protest event, milling among the protestors. The expressions of concern, therefore, were related to whether the situation might escalate into violence, as these gang members were known to carry guns. In fact, affiliated gang members had already attacked some TAC activists in Ukuvula as a reprisal for their testimonies, with one having been shot and hospitalized. I offered to drive Siphiwe and the other TAC activists that were witnesses away from the event. At first, Matamela steadfastly refused. But after some insistence, he relented, and I drove away with Siphiwe and other TAC activists who I had befriended over the last few months. I wasn’t sure where to go, but I knew that we had to leave Khayelitsha. In the end I drove Siphiwe and the other Ukuvula-based TAC members to my apartment in the Salt River section of Cape Town, where we waited to hear news of what to do next. We spent the rest of the day at my place until we heard from TAC’s leadership, who instructed the TAC members to stay at the former TAC national office in Muizenberg, one of Cape Town’s southern suburbs. I drove them over to the impromptu safe house, and Siphiwe and his fellow activists made do as best they could in the empty building. A few months earlier, it had been a bustling center of activity, with people busily working among desks stacked with the papers, fliers, and pamphlets that were part of TAC’s unceasing campaign to secure access to treatment. Now the house was a hollow shell, temporarily occupied by those displaced by the threat of violence. Over the next few weeks, I assisted Siphiwe and the other relocated Ukuvula-based HIV/AIDS activists with their day-to-day needs to the extent that I could. Moving out of their communities was a trying experience for them, but the most pressing of their needs was food. In the southern suburb of Muizenburg, their TAC stipends did not cover their everyday needs, and Siphiwe repeatedly expressed his disbelief at food prices outside the township. I offered what assistance I could, often bringing bread and other nonperishable foods. While we had been friendly for some time, my active support for the group seemed to win over Siphiwe’s trust. One evening, I asked him if we could speak more about politics in Ukuvula, and he agreed. What Siphiwe told me that night opened my eyes to the ways that AIDS dissidence manifested in Khayelitsha. We walked downstairs from the makeshift bedrooms that had formerly served as offices, deciding to talk together in the one room that had working

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lights. Siphiwe and I sat against adjacent walls, using pieces of leftover cardboard as cushions, and the single bulb cast shadows from the center of the room. As I placed my recorder on the ground, its hard plastic exterior rattled against the floor tiles, and the sound echoed throughout the empty room. We began by discussing the ongoing court case and why he had been forced to move out of Ukuvula before shifting to the topic of community politics. With a pained expression on his face, he described how the members of his community had not supported him after gang members had intimidated him. Theodore Powers. So let me ask you a very direct question. What do you think is the reason that they are just acting like they don’t care? Do you think it has anything to do with the fact that they would think that you are HIV positive? Siphiwe. You see, SANCO is a component of [the] ANC, and SANCO is known to be supportive of [the] ANC. But it is supposed to be a nonpolitical organization. CBOs, NGOs, churchgoers, every organization in the community should affiliate along with SANCO and should be the same [as] SANCO. But now it’s [the] ANC, and they see TAC as an organization that is protesting against [the] government or marching against [the] government or posing a threat to the developments they want to put in place. So I think that was their reason. And two is that if they [see] the t-shirt of HIV positive they think that you are going to crush the minister of health. Asking Siphiwe why he thought community members had not been supportive, I expected that he would indicate that they feared for their safety. Instead, Siphiwe turned his focus to the ANC and SANCO, a national body that represents the organizations that had coordinated black urban selfgovernance during late apartheid. When I first heard Siphiwe make this point, I thought that he had mistakenly misused one term for the other: community for SANCO, and SANCO for the ANC. Later in the conversation, I pushed Siphiwe a bit further on the relationship between SANCO, the ANC, and the community to try and understand why he had used these terms interchangeably. He explained that SANCO, the institution that arguably operated as the de facto government in Khayelitsha during late apartheid, continued to maintain considerable influence in the township:

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Theodore Powers. So what effect does SANCO have on the community? I mean, do they have a big influence on what people think and the way that they act? Siphiwe. They have a big influence on the people in the community. Theodore Powers. How do they have an influence? Siphiwe. They are the one that is bringing development. If there is anything that is going to take place or be built in that area, it should start through their meetings. Theodore Powers. So, it’s through SANCO? Siphiwe. Ja, and they should agree as SANCO members before they go—there’s an exco [executive committee] meeting, and they should agree at that exco meeting before they call a general meeting for the whole area to understand what is going on, to tell the community. That they should agree, if they want that they will agree, if they don’t want that then they are not going to agree, then they are just going to turn that down. Theodore Powers. But it’s within SANCO structures that they decide that? Siphiwe. Ja. They don’t decide that with everyone in the community. They will decide that. You can’t just go there and be a speaker. You have to consult SANCO, and if SANCO is happy with what you are going to do, they are going to say it’s fine, build it, or do it. And if they are not happy, they will point you to that direction, and point you to that direction, and point you to that direction, and you end up losing. As I learned in further conversations with Siphiwe, many of Khayelitsha’s area development forums and street committees, and therefore local politics, were under the day-to-day influence of SANCO members. Community initiatives in Ukuvula, be they related to HIV/AIDS or housing, were funneled through the local structures of SANCO. SANCO was formed in 1992 as the civics movement sought to exert influence on the negotiated transition out of apartheid. During the mid-1980s, local civic structures, many of which were tied to the UDF, challenged the leadership structures, or village councils, that came about as a result of the Black Local Authorities Act of 1982 (Cook 1986). Such leadership structures were viewed as illegitimate, were ineffective in governing the townships, and often served as an extension of the intelligence services for the apartheid

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state. The civic structures worked to replace these structures with street committees, area forums, and township-wide coordinating bodies, all of which served as the basis of social organization in black townships during late apartheid. While the organizational components of the anti-apartheid movement were generally disbanded after the ANC was “unbanned” in 1990, the civic organizations were merged into a national-corporatist organizational structure—SANCO—in order to influence policy development for urban planning and local government. They were quite effective to this end (Heller 2003). After having played an important role in defeating the apartheid regime, the civics movement was faced with a period of uncertainty following the return of the ANC and SACP. It was unclear whether institutions that had been developed for community self-governance during late apartheid should continue to operate as autonomous political structures in the post-apartheid era. While many leaders from the civics movement were incorporated into the ANC leadership during the political transition, remaining members united to form SANCO. This period saw SANCO leaders such as Winnie MadikizelaMandela move into the ANC leadership, regional branches secede from the national organization, and discussions about becoming a political party held at the national level (Zuern 2006). And as donors turned to support the ANC during the negotiated political transition, SANCO ran into financial difficulty (Seekings 1996, 1997). After this period of organizational and financial uncertainty, SANCO reemerged via a new alliance with the ruling party, and senior ANC ministers took up leadership roles within the organization, demonstrating the re-established ties. This relationship grew stronger as new social movement organizations such as the Anti-Privatization Forum and Soweto Electricity Crisis Committee challenged the ANC policy of privatization and cost recovery for basic services in townships following the implementation of the GEAR macroeconomic policy. Elke Zuern writes: “As the ANC sought to revive its branches and its connection to township residents in the wake of growing discontent and the rise of new social movements challenging the government, it was clearly reaching out to SANCO for help. In the run-up to the next elections, the ANC sought SANCO’s support for door-to-door community campaigns in return for greater acknowledgement of SANCO’s role as an alliance partner” (2006, 189). Zuern argues, however, that this alliance is a tenuous one, with SANCO branches serving as intermediaries between local government and the community (Zuern 2002). SANCO assists the ANC in pursuing its goals “by

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channeling and co-opting” popular demands at the local level (Zuern 2006). Given its stated membership of 6.3 million people in 4,300 branches, SANCO’s ability to influence local-level politics should not be underestimated, and according to Siphiwe, its capacity was considerable in Khayelitsha. In Khayelitsha, SANCO’s role as intermediary between the ruling party and local communities did not focus on water or electricity, but on HIV/ AIDS. The organization played a central role in disseminating an alternative HIV/AIDS therapy in the townships of Khayelitsha and Nyanga (Thom and Bodibe 2005), with SANCO members serving as liaisons between community members and the Dr. Rath Health Foundation, which claimed its vitamins could cure HIV/AIDS. With the support of SANCO members, the Rath Foundation recruited people living with HIV/AIDS already on ART to discontinue treatment and enroll in a “trial” testing a scientifically unproven vitamin-based regimen (Sidley 2005). SANCO members also staffed the makeshift clinic where the vitamins were distributed (Geffen 2010). While numbers are hard to come by, community-based HIV/AIDS activists working in Khayelitsha claimed that many of those who had stopped ART and switched to the vitamin regime had died. Notably, the Rath treatment trial did not receive institutional approval for human subjects research. Nevertheless, based on the unsanctioned “trial”, the Rath Foundation and SANCO coauthored and copublished a book in 2016 entitled End AIDS! Break the Chains of Pharmaceutical Colonialism. Siphiwe’s description of SANCO’s influence in Ukuvula points to the organizational and institutional mechanisms through which ideas and practices associated with AIDS dissidence were disseminated in Khayelitsha, and it shows how national-level politics filtered down and influenced local communities. SANCO’s influence within local political institutions had tangible effects on Siphiwe’s attempts to educate his community about HIV/AIDS. Several weeks after our conversation in the safe house, I drove back to Ukuvula to further study the political geography of HIV/AIDS and community development with Siphiwe. We drove around the area while Siphiwe discussed the historical roots of community-development projects and the influence of the ruling party and donors on various initiatives. At one point we sat in the parking lot of a new shopping center, which included a new community center. It was still early in the day, but the area was already buzzing with activity. Siphiwe indicated that the shopping center had quickly become the central hub of activity in Ukuvula and that the community center was a major reason for that. He also described how he and other community-based HIV/

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AIDS activists had attempted to use the community center to educate the community about the epidemic and had reserved the venue in advance. However, on the day of the event, they had arrived there only to find their posters and pamphlets destroyed. Siphiwe shook his head with exasperation as he recounted the story, clearly still upset about what had occurred. In the end he canceled the day’s event, but soon after he looked into the reason that the posters and pamphlets had been removed. He spoke with SANCO representatives, who indicated that his materials were removed due to the aggressive stance taken in the printed literature toward Minister of Health Tshabalala-Msimang, a noted AIDS dissident. Given the issue-based alliances that SANCO branches have developed with the ANC, maintaining solidarity with an important figure in the ruling party is unsurprising. However, the closure of the community center to HIV/AIDS activists was not an isolated incident. Siphiwe could no longer access the community center for activities or events, whether they related to HIV/AIDS or not. This restriction was significant given the central location of the community center and the fact that it was the only large meeting space available in the community at the time. A lack of access to this space meant that Siphiwe’s efforts to address the HIV/AIDS epidemic in Ukuvula were largely limited to interpersonal interactions in and around the local HIV/AIDS clinic. SANCO influence also affected Siphiwe’s ability to access local political institutions in Ukuvula. Ward development forums are important spaces for local political debate in South Africa’s townships. They are established for each political ward, the smallest unit of political representation in South Africa, and are cochaired by a community representative and a ward councilor.13 The ward development forum, which Siphiwe described as dominated by SANCO, was vital for planning activities in Ukuvula. Without approval from the ward development forum, it was difficult to garner community support for an event. Siphiwe described to me how, on two occasions, he had scheduled meetings with a local ANC councilor and SANCO members on developing a plan for educating the community about HIV/ AIDS. However, when he arrived at the agreed-upon location at the scheduled time, no one else was there. Siphiwe explained, “They will point you to that direction, and point you to that direction, and point you to that direction, and you end up losing.” It is thus not coincidental that Siphiwe spoke the word “SANCO” in place of “community,” for it is SANCO that influenced the development of his community through their presence in

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local-level political and social institutions, along with local political representatives affiliated with the ANC. Siphiwe’s experiences in Ukuvula underscore how an NGO, in this case a local SANCO branch, was able to limit the impact of community HIV/ AIDS initiatives. An AIDS-dissident alliance between SANCO and the ANC was able to curtail activities organized by Siphiwe and other TAC-affiliated HIV/AIDS activists. Taken in light of SANCO’s active participation in the Rath Foundation’s vitamin trial, Siphiwe’s experiences point to a pattern of obstructing the HIV/AIDS movement’s political activities. But to what extent were these dynamics particular to Ukuvula? Were similar activities taking place in other areas across the Cape Flats? These questions drove me to investigate the local dynamics of AIDS dissidence further, to locate where efforts had been made to challenge the treatment access agenda of the HIV/AIDS movement, and which organizations had undertaken them.

AIDS Dissidence and the Local HIV/AIDS Response Across the Cape Flats Expanding my research on AIDS dissidence beyond Ukuvula necessitated that I accompany HIV/AIDS activists who worked across and between communities on the Cape Flats to discover how national political debates on the epidemic were manifesting locally. Through participant observation with TAC’s provincial office, I attended meetings across the city of Cape Town, including the townships. This included observing several gatherings of local HIV/AIDS coordinating committees to understand how these institutions operated and influenced treatment access. These entities, MSATs, are subdistrict health institutions created to align the work of NGOs and CBOs with HIV/AIDS policy. Given that South African HIV/AIDS policies have included the input of HIV/AIDS activists throughout the post-apartheid era, policy guidelines and goals extended to the work of NGOs and CBOs. While provincial health departments oversaw public sector clinics, MSATs were the local health institutions that coordinated the community-based response, enabling HIV/AIDS policy to touch the ground. MSATs were established when the Western Cape Province received a grant from the Global Fund in 2003. The initial purpose of the subdistrict institutions was to monitor and evaluate the disbursement of grant funds to NGOs and CBOs in each of Cape Town’s eight health subdistricts. Generally,

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MSATs meet monthly and have an executive committee of five to ten individuals and twenty to thirty active volunteer members (Smith 2007). Despite the important goal of coordinating the community response in the fight against the epidemic, MSATs operate on shoestring budgets. The annual budget for each MSAT is ZAR 15,000, or approximately USD 1,984,14 which is primarily used for administrative costs and awareness-raising activities (Smith 2007). With a population of approximately four hundred thousand per subdistrict across Cape Town, these community-coordinating mechanisms receive less than half a cent per capita in funding. As such, MSATs were underfunded, overstretched, and primarily a mechanism for monitoring the nongovernmental response to the epidemic. The majority of MSAT leaders that I spoke with were frustrated with this state of affairs, but the political issues faced by MSATs extended well beyond funding and capacity. The local coordinating institution was a site of political contestation between organizations adopting the AIDS-dissident position and those supporting access to HIV/AIDS treatment. The Klipfontein MSAT was one such case. There, a local branch of the ANC Women’s League attempted to shift the MSAT’s focus toward scientifically unproven alternative HIV/AIDS treatment. Michael,15 a member of the Klipfontein MSAT, described how these events unfolded during an interview: Michael. We found that locally, where we had this foundation, he came with an alternative to ARVs [antiretroviral drugs] in our area. They wanted to infiltrate MSATs and I mean, I was in Gugulethu, there was an office setup politically aligned to drive this process. People from the League, they’ve operated, they’re still operating this office. They were part of the MSAT. They tried to bring it into the MSAT and we said, “No, we cannot do that.” Theodore Powers. But it’s SANCO? Michael. No. Theodore Powers. Is it NAPWA? Michael. No, it’s people from [the] Women’s League. There’s a councilor driving this process. People from the Women’s League. Rather than SANCO, in Klipfontein a branch of the ANC Women’s League attempted to influence the MSAT to take up alternative treatment for HIV/AIDS as part of its mandate. In this case, a formal political representative and ANC branch were directly involved in attempting to redirect

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the MSAT’s policy focus. The Klipfontein health district encompassed areas of the Cape Flats that included historically black and “coloured” areas. While Gugulethu and Nyanga were black South African townships, the health subdistrict included areas that were designated for “coloured” South Africans under apartheid, such as Mannenberg and Hanover Park. But for Michael and TAC members who worked in these areas, the question of AIDS dissidence was not about race or ethnicity, but life and death. Here again, the political legacy of the anti-apartheid movement was central to the success of the HIV/AIDS movement. The nonracialist political principle adopted by HIV/AIDS activists and local health activists provided a common platform for uniting against attempts to extend the AIDS-dissident agenda into local health institutions. After learning of the local politics of HIV/AIDS at the Klipfontein MSAT, I returned to Khayelitsha to determine whether there had been attempts to redirect the local coordinating institution toward an AIDS-dissident platform there as well. I met with leading members of the Khayelitsha MSAT, who described how they were unable to fully carry out their work due to what they described as a “fracture” between the MSAT and the Khayelitsha Health Forum. According to MSAT leaders, this political divide was produced when a leading SANCO member was elected as chairperson of the township-wide Health Forum. The chairperson took an oppositional stance toward the MSAT, rendering the activities of NGOs and CBOs in Khayelitsha somewhat opaque to the coordinating institution. MSAT members described how the SANCO-aligned chairperson was able to “take over” the Health Forum and limit the scope of their work. According to MSAT members, the chairperson had been able to exert influence within the Health Forum due to close ties to notable political figures and a role in the anti-apartheid struggle, characteristics that one would associate with SANCO members, given their central role in the anti-apartheid movement. Members of the Khayelitsha MSAT were in agreement that the key to coordinating NGOs and CBOs in their subdistrict was securing the “buy-in” of the chairperson. Thus, political resistance from a SANCO leader undermined the management of HIV/AIDS initiatives in Khayelitsha. This is significant because of the policy function of the MSATs, which is to align the activities of NGOs and CBOs to that of national and provincial HIV/AIDS policies, including the NSP. The Khayelitsha MSAT was unable to effectively monitor, evaluate, and coordinate community-oriented HIV/AIDS initiatives. The task then fell to the Khayelitsha Health Forum. As such, SANCO

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leadership redirected the institutional location of community HIV/AIDS program coordination from the MSAT to the Khayelitsha Health Forum and, by extension, to SANCO. At the same time, the Rath Foundation “trial” was used to further AIDS dissidence beyond the historically disenfranchised communities of the Cape Flats.

Rippling Effects: The Rath-SANCO Trial and the Circulation of AIDS Dissidence The results of Rath-SANCO “trial” became the basis for further efforts to extend the AIDS-dissident platform across South Africa. Senior ANC members such as the minister of health, the director general of health, and the president of the Medical Research Council, all of whom were purportedly members of the ANC’s AIDS-dissident faction, are said to have supported the work of the Rath Foundation (Geffen 2010). Despite not having taken the necessary step of securing human subjects research clearance for carrying out the trial, the Rath Foundation was given an audience in state institutions to present its findings from the pilot study in Khayelitsha and Nyanga. Research on the effects of the vitamin-based regimen was presented to the National Health Council, a state forum comprised of provincial health ministers and the minister of health (Geffen 2010). Created for the purpose of harmonizing health policy across the provinces, the National Health Council sets health priorities for all provinces and coordinates the activities of provincial health ministries. The National Health Council is therefore an important site for disseminating information to ANC members controlling state health institutions. From this privileged position, the Rath-SANCO partnership furthered the AIDS-dissident agenda and facilitated the promulgation of alternative and scientifically unproven HIV/AIDS treatment elsewhere in South Africa. This was particularly the case in KwaZulu-Natal Province, where Provincial Minister of Health Neliswa “Peggy” Ngonyeni purportedly approached clinics to pilot a scientifically unproven traditional medicine called Ubhejane (Thom 2013). A TAC activist who had met with Ngonyeni recalled how the provincial minister of health declared that she knew “the truth” about HIV/ AIDS and pointed to the Rath-SANCO book while doing so. The book was also passed out to attendees of an HIV information workshop in Durban attended by Ngonyeni (Cullinan and Lombard 2008). When the HIV/AIDS

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activist recalled this incident to me, his face was ashen and drawn. The experience pained him, and understandably so. The people whose lives would be affected by these actions were not abstractions, such as the “South African poor” or “black township residents,” but friends and colleagues. In response, as with other initiatives associated with the AIDS-dissident faction, the HIV/AIDS movement led an alliance to counteract the effects of these actions that utilized the South African courts system. Along with the South African Medical Association, TAC led a court case against the Rath Foundation to halt their activities in the Western Cape. While the Cape High Court eventually ruled in TAC’s favor, the clinical trials appeared to have served their purpose: members of the ANC’s AIDS-dissident faction had leveraged the Rath-SANCO activities to further their political agenda in other provinces. The partnership between SANCO and Rath therefore had broader effects on health institutions across the country. While it is difficult to know the full degree of the local and broader impacts of the illegal clinical trial, we can conclude that local-level partnerships and the information they disseminated served to extend the national political program of the ANC’s AIDS-dissident faction. The politics of HIV/AIDS in Khayelitsha, therefore, was shaped by challenging material circumstances, historically particular political conditions, and the larger political struggle between the South African HIV/AIDS movement and the ANC’s AIDS-dissident faction. Rather than mirroring political dynamics at the national or provincial levels, HIV/AIDS politics in Khayelitsha operated according to the array of actors, organizations, and institutions that converged in the township. The particular actors and organizations involved influenced the local politics of the epidemic in unpredictable ways. The local manifestation of HIV/AIDS politics makes clear that policy processes are highly differentiated across the levels of society, with TAC’s work to develop national policy for treatment access running up against an AIDSdissident alliance. The local politics of the epidemic extended beyond the formal sphere of state institutions and encompassed social institutions that had been developed to enable self-governance during the late apartheid era, such as street committees and township-wide forums. Efforts by AIDS dissidents to limit community health education and redirect local HIV/AIDS policy also focused on the MSATs, marking these transnationally funded institutions as hot spots for local HIV/AIDS politics. Thus, while operating according to a dynamic set by local actors and organizations, the local politics of the epidemic nonetheless

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gravitated toward local institutions where political struggle intensified and HIV/AIDS policy was negotiated. In addition to highlighting the everyday material challenges and political struggle faced by HIV/AIDS activists in the campaign for treatment access, these political dynamics also illuminate the role of alliances and NGOs in post-apartheid governance.

CHAPTER 6

People Are the State Activism, Access, and Transformation

As my fieldwork came to a close in 2008, the fight for treatment access remained in a state of uncertainty, with no resolution to the political struggle between HIV/AIDS activists and AIDS dissidents. The transformation of policy and national health institutions, largely achieved through the efforts of HIV/AIDS activists, was limited by the continued influence of AIDS dissidents in national government. The HIV/AIDS movement’s interventions to expand treatment access, particularly in restructuring SANAC and helping develop the NSP, were undermined by the minister of health’s return to office. HIV/AIDS activists were aware of the constraints within which they operated, and they were prepared to continue the fight for treatment access regardless of the obstacles that stood in their way. After all, the campaign had lasted for a decade already. And so activists steeled themselves for the next phase. I spoke with Philip,1 a leading member of the HIV/AIDS movement, about this state of affairs. Philip had been deeply involved in the antiapartheid movement and played a role in SANAC, so his perspective was important for understanding the HIV/AIDS movement’s direction and planning process. At the time, I was interested in learning more about the longterm expectations of HIV/AIDS activists, as resurgent AIDS dissidence had undermined the treatment access campaign and put SANAC’s autonomy under question. I queried Philip about the political and economic limits to SANAC and whether treatment access could be achieved with political, institutional, and economic impediments standing in the way. Philip, calmly and coolly, stated that Tshabalala-Msimang and Mbeki couldn’t stay in office forever. They, like all political figures, would leave their positions at some point.

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The institutional and political changes achieved by the HIV/AIDS movement would be enacted when AIDS dissidents left office, if not earlier. Philip certainly knew more about the inner workings of national politics than I did, but no one foresaw that South Africa’s political climate would change significantly just a few months later. Seemingly overnight, the obstacles that had stood in the movement’s way were removed, and the goal of near-universal treatment access seemed possible. The resurgence of AIDS dissidence proved to be short lived, but it was not the HIV/AIDS movement that ended it. Rather, lingering political tensions within the ANC led to decisive changes in national government. The writing had been on the wall for the Mbeki presidency since the ANC’s 2007 National Conference, when conference delegates spurned Mbeki’s attempts to stand for a third term as party leader. Many feared he would establish a shadow presidency by installing another party member to serve as president of South Africa who would answer to him. This strategy was not unconstitutional according to the letter of the law, as Mbeki would not serve more than two terms as president, and he could continue to control policy from afar. ANC members rejected Mbeki and elected former deputy president Jacob Zuma as party leader on the back of strong COSATU support, despite lingering corruption charges. Tensions that had simmered within the governing alliance since the national conference reached a breaking point on September 20, 2008, when Mbeki was pressured into resigning from office. Newly elected ANC deputy president Kgalema Motlanthe was voted in by parliament as acting president of South Africa, bringing the Mbeki era to a close. A former MK operative who had previously served as general secretary for the National Union of Mineworkers, historically South Africa’s most powerful trade union, Motlanthe moved quickly to address AIDS dissidence in national institutions. On his first day as acting president, Motlanthe recalled Minister of Health Dr. Manto Tshabalala-Msimang to serve as minister at large within the administration. ANC member and former anti-apartheid activist Barbara Hogan was appointed as minister of health, replacing the noted AIDS dissident. Hogan was one of only a few Members of Parliament who had publicly stood against her party’s leadership and supported the HIV/ AIDS movement. For TAC activist Zackie Achmat, her backing for the campaign for treatment access “gave us hope when it was dark” (Kapp 2009). After her appointment, Hogan distanced herself from Tshabalala-Msimang’s obfuscating views on the epidemic, stating that AIDS dissidence was “completely over in South Africa” (Dugger 2008).

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Hogan strengthened the restructured SANAC with one of her first policy decisions, committing ZAR 932 million (USD 94 million) to fund the hybrid national health institution (Thom 2008). With the stroke of a pen, she addressed the financial constraints that had limited SANAC’s work since its inception. The removal of AIDS dissidents from national government also enabled a new configuration for SANAC’s administrative support. Support systems for SANAC’s day-to-day operations were reassigned from the Department of Health to the Development Bank of Southern Africa, effectively limiting the ability of staff in the Department of Health to influence SANAC activities (Khumalo and Berger 2008). If any institutional remnants of AIDS dissidence remained, they would be unable to undermine the campaign for treatment access. The post-Mbeki era also saw the international community step in to support SANAC, providing it with donor capital and expert advice to drive the campaign for treatment access forward. In late 2008 the United Kingdom donated GBP 15 million prior to World AIDS Day for South Africa’s new PMTCT policy, supporting implementation of the updated SANAC guidelines created by the HIV/AIDS movement (Watts 2008). British funding enabled additional administrative support for SANAC, addressing concerns expressed by civil society delegates regarding the workload involved in coordinating their sectors. The US Centers for Disease Control and Prevention assisted the South African response by providing support for PMTCT expansion and subsequently supporting SANAC operations after 2010 (CDC 2013). After AIDS dissidents were removed from important national posts, near-universal public sector treatment access was finally achieved, attributed to the combination of new leadership in the Department of Health, HIV/ AIDS activists’ continued work within SANAC, and international support. In June 2013, nearly fifteen years after the fight for treatment access had begun, Minister of Health Aaron Motsoaledi announced that South Africa was providing public sector treatment to 80 percent of women and 65 percent of men and children who required ART (SANAC 2013). The expansion of HIV/AIDS treatment to near-universal levels is a remarkable achievement, particularly in a country that had stringently limited access to treatment before 2004. Treatment access had expanded with the NSP’s development and SANAC’s restructuring, but it increased further with the removal of AIDS dissidents from national office, increasing by 250 percent for adults and 150 percent for children by the end of 2009 (Carlson 2010). While the ANC-led South African government moved swiftly to claim credit for expanded public sector

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treatment access in an attempt to move past the political legacy of AIDS dissidence, this achievement would not have been possible without the tireless work of the South African HIV/AIDS movement. While operating within a context of political, economic, and institutional constraint, the HIV/AIDS movement led the development of the world’s most comprehensive public sector HIV/AIDS treatment program. After a decade of contentious conflict, second-wave HIV/AIDS activism achieved its central aim: to establish a rights-based public health response to the epidemic that included ART. Based upon the terms set by second-wave HIV/AIDS activists, the campaign for treatment access transformation is an undeniable success story. Through negotiation with—and direct action against—the ANC, the HIV/AIDS movement transformed the capacity of the South African state to sustain life. Doing so required that the HIV/AIDS movement work within SANAC to transform policy, restructure institutions, and expand treatment access by leveraging a set of political principles that also influenced the rise of AIDS dissidence.

Common Roots, Conflicting Agendas: Political Principles and HIV/AIDS Politics In the face of daunting constraints, the HIV/AIDS movement developed a broad social coalition, created alliances with political elites, transformed national HIV/ AIDS policy, and constructed SANAC, a hybrid national health institution that encouraged broad and substantive input on national HIV/AIDS policy. Though focused on transforming national policy and state institutions, the campaign to secure public sector HIV/AIDS treatment access transcended these spheres, reconfiguring state-society relations and state effects in post-apartheid South Africa. HIV/AIDS activists did so by drawing on political principles developed in response to white minority rule, leveraging institutional innovations created by first-wave HIV/AIDS activists, and organizing the support of black urban communities. However, as this book has shown, AIDS dissidents and HIV/ AIDS activists built on a shared history of anti-apartheid political struggle and thus held similar political principles. Tracing the political principles associated with the anti-apartheid movement to post-apartheid HIV/AIDS politics illuminates how different groups of people went about changing post-apartheid state-society relations in South Africa, and how a social movement was able to transform the social effects produced by the state.

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The HIV/AIDS movement developed a broad alliance that sought to increase access to scientifically proven, ART-based HIV/AIDS treatment based on the foundational principle of social justice. Put differently, the movement mobilized people and organizations to challenge the injustice of predominantly black poor and working-class South Africans dying of HIV/ AIDS, while primarily white upper- and middle-class South Africans had access to HIV/AIDS treatment via the private health sector, albeit at significant cost. Challenging unequal access to resources along racial lines, HIV/ AIDS activists carried forward the demand for equality that had been articulated by the black liberation movement and carried forward through the colonial and apartheid eras. Like the anti-apartheid movement, the HIV/ AIDS movement mobilized a coalition that extended beyond South Africa’s borders, and these transnational networks included HIV/AIDS activists, doctors, health practitioners, and scientists, who all critiqued unequal access to HIV/AIDS treatment and rejected AIDS dissidence. The HIV/AIDS movement also expanded the community involved in HIV/AIDS policy development by transforming SANAC to include civil society, reflecting a different vision of how the state should operate. Broad-based consultation for policy development is an important continuity in the political practices and organizing principles of the anti-apartheid movement and the strategies employed by second-wave HIV/AIDS activists. For example, the Freedom Charter was developed based on broad-based consultation. In addition, the urban civics, the UDF, and the Mass Democratic Movement were organized around consensus-based decision-making. The inclusion of consultative mechanisms within South African state institutions was central to the HIV/AIDS movement’s ability to transform the state from within and expand public sector HIV/AIDS treatment.2 However, SANAC was not the only consultative institution developed during the post-apartheid era.3 The creation of consultative policy institutions during the negotiated political transition was vital to the success of the HIV/AIDS movement, as the National Economic Development and Labour Council (NEDLAC) proved to be an important source of support for HIV/AIDS activists in 2002, when the HIV/ AIDS movement was able to negotiate an HIV/AIDS treatment plan between labor and the private sector in the institution.4 While the ruling party rejected it at the time, the “NEDLAC Plan” served as a model for the first national policy to include ART: the Comprehensive Treatment Plan (2003). The HIV/AIDS movement also invoked the principle of alliance building by developing networks of support with political elites, NGOs, CBOs,

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and communities infected and affected by HIV/AIDS across South African society. The movement’s success in developing alliances with state elites was directly related to the struggle experience of leading activists and the interpersonal ties this shared history entailed. Clearly, these relationships were not accessible to all, particularly not to those who became involved in the movement due to the epidemic’s post-apartheid impact on black urban communities, many of whom were younger and primarily women. The inherently elite, and gendered, character of these relationships echoes the MarxistLeninist character of African liberation movements during the twentieth century, which were typified by a vanguard of elite revolutionaries leading colonized societies to independence (Seekings 2000). The vanguard of the HIV/AIDS movement, which was disproportionately comprised of TAC activists, invoked the ethos, practices, and cultural sensibilities associated with the anti-apartheid movement to build alliances within the ruling coalition, expand the policy input of people living with HIV/AIDS, change the structure of national health institutions, and expand access to life-sustaining HIV/AIDS treatment. In these aims, the principles of social justice, collective welfare, consultative decision-making, and policy based on human need are evident. Rather than adhere to the principle of centralized political power, the South African HIV/AIDS movement sought to expand the political influence of poor and working-class communities. As they engaged with both political elites and poor communities, secondwave HIV/AIDS activists invoked the principle of nonviolence as part of the campaign for treatment access. Nonviolent civil disobedience has been utilized as a political practice in several societies, with the civil rights campaign in the United States and the independence movement in India serving as notable examples. However, this principle and practice has an established history in South Africa as well, where it was advocated for by the ANC’s “young Turks” of Mandela, Tambo, and Sisulu, who led civil disobedience against the expansion of pass laws in the 1950s. First-wave HIV/AIDS activists largely worked within, and influenced the trajectory of, the negotiations that led to South Africa’s first democratic constitution, but they did not rely on civil disobedience to do so. In contrast, second-wave HIV/AIDS activists broke the law in nonviolent ways to support their campaign for treatment access, highlighting a clear continuity with the internal anti-apartheid movement from the 1950s onward. The HIV/AIDS movement also embraced the principle of nonracialism as part of its campaigns, which enabled activists to build a broad coalition

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that transgressed the lines of race and class. Nonracialism was an important organizing principle for the anti-apartheid movement, as evidenced by the Freedom Charter, and was particularly significant for cohesion within the Mass Democratic Movement during the late apartheid era. As the leading edge and radical heart of second-wave HIV/AIDS activism, TAC carried forward the principle of nonracialism and placed it at the center of the campaign for treatment access. Even a cursory glance at TAC’s leadership underscores that the member-based organization drew from across the ethnic divides that had historically separated South African peoples. Just as it was for the antiapartheid movement, the principle of nonracialism served as a unifying concept for the broad-based campaign to secure the right to health and treatment access for people living with HIV/AIDS. While AIDS dissidents and HIV/AIDS activists have overlapping histories of involvement in the anti-apartheid movement, the rivals invoked similar principles to different ends in the struggle over treatment access. But both political blocs adopted critical stances toward unequal access to medicines, and TAC supported the ruling party’s efforts to provide access to lower-cost medicines, initially working with ANC leaders on this campaign. In 1997 the ANC passed the Medicines Act, which enabled South Africa to access cheaper generic pharmaceutical drugs. As Mandisa Mbali (2013) has discussed at length, Northern pharmaceutical corporations and the US government actively pressured the South African government to abandon the law.5 In response, both HIV/AIDS activists and ANC leaders united in their rejection of global inequality and the power of multinational pharmaceutical corporations. AIDS dissidents also sought to empower the historically oppressed, carrying forward the agenda of the black liberation movement in South Africa, just as HIV/AIDS activists sought to create a more just and equal society. Indeed, the concept of an “African Renaissance” was a central feature of Mbeki’s political agenda, which imagined the South African future in terms of indigenous languages, human capabilities, and universal citizenship contributing to dramatic shifts in class structure, scientific knowledge, and social development. Mbeki’s goal was constructed against afro-pessimistic visions of the continent and unequal global power relations, thus mirroring the ANC challenge to international pricing systems for medicines. However, Mbeki pursued different ends in the name of this African Renaissance, leveraging the language of the anti-apartheid struggle to question HIV/AIDS science and treatment efficacy rather than to cultivate a scientific and cultural revolution in postapartheid South Africa.

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Another a significant point of divergence between the two rivals can be seen in the principle of African nationalism, as seen through the AIDSdissident embrace of “African solutions” to the HIV/AIDS epidemic. Throughout the period of minority white rule in South Africa, strands of the black liberation movement maintained African nationalist positions, including the ANC and PAC. In the 1950s, African nationalism led to a fracture within the ANC, when the party expanded its alliance to include other multiethnic organizations opposed to apartheid. An African nationalist faction left the ANC and became the PAC under the leadership of Robert Sobukwe. The PAC took the African nationalist platform forward, while the ANC and the internal anti-apartheid movement embraced the principle of nonracialism. AIDS dissidence, therefore, marked a break with the political principles championed by the ANC since the 1950s, but it still traced its roots to the black liberation movement in South Africa. The political approach employed by AIDS dissidents also built upon hierarchical decision-making, with power wielded by those controlling national and provincial health institutions. The centralization of political authority within the party elite is evidenced by the Presidential Advisory Committee on HIV/AIDS, the composition and character of the first and second iterations of SANAC, and the management of the Department of Health under the leadership of Dr. Manto Tshabalala-Msimang. The power of AIDS dissidents depended largely on their capacity to control national health institutions and their ability to limit public sector access to HIV/AIDS treatment. On its surface, such an approach would seem to diverge from the principles of the consultative decision-making process associated with the anti-apartheid movement and, to an extent, the ANC. However, there are also clear continuities with the centralization of authority in party leadership while in exile, when Mbeki was centrally involved in ANC operations (O’Malley 2007). Political centralism was a life-and-death matter for ANC members in exile, and with AIDS dissidence the historical legacy of that period was carried forward, as a small group of party elites controlled decision-making processes. The political principles invoked by AIDS dissidents also reflect shifts in the ruling party’s political positioning in the post-apartheid era. The ANC adopted centralized political decision-making on important issues with wide-ranging impacts, such as the adoption of GEAR. The development of race-based programs, such as Black Economic Empowerment (BEE), highlights another point when AIDS-dissident politics shifted in concert with the ANC’s post-apartheid policies. BEE created a politically connected black elite

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by negotiating large stock transfers from powerful South African corporations as part of a larger program of state-led redistribution designed by the ANC.6 However, BEE reinforced the racial categories that had been utilized by the colonial and apartheid states to produce racial inequality via political means. In this way, the ANC broke with the principle of nonracialism during the post-apartheid era, while the HIV/AIDS movement built on it to unite people and win the campaign for treatment access. The policies adopted by the ruling ANC during the post-apartheid era have not simply diverged from the party’s past practices but have articulated with a social context deeply marked by centuries of colonial violence and racial segregation. Particularly notable for the analysis put forward in this book is that the dynamics of race served to reinforce state power during negotiations over HIV/AIDS policy in the Western Cape Province. While this finding is not particularly surprising given South Africa’s history of racial inequality, it does run counter to assumptions regarding the role of the state in the postapartheid era. There is a broadly held position that the state has counteracted the socioeconomic impact of racial inequality in South African society through state-led programs and interventions since the ANC rose to power in 1994. On this point, Jeremy Seekings and Nicoli Nattrass (2005) and James Ferguson (2015) offer useful analyses for understanding the broader social and political dynamics that have framed state-led redistribution during the post-apartheid era. However, my research on South African HIV/AIDS politics underscores that, contrary to this expectation, sociopolitical dynamics on the margins of the state were deeply marked by continued racism, which, in turn, served to support state-led processes relative to HIV/AIDS policy development. In short, my analysis highlights that broadly held assumptions about race and the South African state contradict social experiences of racism in South Africa. Here, the pathways forged by HIV/AIDS activists highlight that popularly held assumptions regarding race do not provide a useful analytical measure for understanding life experiences or the state’s impact on society (Jackson 2001).

AIDS Activism, Sociality, and the State The political history of South Africa’s HIV/AIDS epidemic underscores that HIV/AIDS activists and AIDS dissidents carried forward social and political principles developed by the extended campaign for black liberation to

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transform the state, but toward different ends. Differing modes of social life and political practice can manifest within a historically particular setting, and not all variants of social life easily cohere with the vision of society upon which state policies and institutional practices rest. There is, therefore, at times a distance between particular forms of social life and the institutional practices of the state. Indeed, the experiences and challenges faced by people living with HIV/AIDS stood in tension with the AIDS-dissident agenda of limiting access to HIV/AIDS treatment through control of state health institutions. Taking up this point, Marcel Mauss argued that solidarity and broader social formations are projections of the social dynamics that frame individual experience (2015 [1925]). In this case, the social solidarity of the HIV/ AIDS movement grew out of shared classifications that derived from activists’ lived experience of treatment inaccessibility, which they interpreted as an injustice. As with Durkheim’s theorization of religious practice and society, these shared experiences resonate with, and draw their power from, the people that constitute society rather than from state institutions (Durkheim 1915; Douglas 1986). Mauss sees social change as an extension of experience and self-expression that expands out toward society in the form of social groups and organizations, offering an important counterpoint to theories of social change predicated on historical rupture or top-down state processes controlled by elites. Mauss’s theorization can be extended to make a broader conceptual and political claim: different variants of social life in a pluralistic society are reflected in a state’s institutional form. Different social and political principles, Mauss suggests, may be incorporated into the formal political sphere, allowing state institutions to be reformed to reflect the experiences of, and political principles developed by, multiple social groups. Thus, his analysis underscores the possibility of “building new groups and institutions alongside and on top of the old ones” (Hart 2009). This conceptualization of state and society is useful for understanding the campaign for HIV/AIDS treatment access, which brought the experiences of people living with HIV/AIDS into the state. As policies changed to reflect these experiences, for example with PMTCT, the abstract principles according to which state institutions operated converged with South African social life, reflecting the experiences of communities infected and affected by the epidemic.7 However, the adoption and dissemination of a particular set of political principles by the state is never given, and the process through which they move forward over time is not linear but multifaceted and complex.

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After all, it is through the work of people that political principles are carried forward over time, and it is through their work that interpersonal networks, organizations, and institutions come into being. This book has mapped the connections between waves of South African HIV/AIDS activism, embodied in interpersonal relationships and organizational ties, that transported social movement knowledge and practices over time and across space. Analyzing the transmission of knowledge and practices through interpersonal relationships offers a complementary approach to contemporary anthropological theories of social movements that developed alongside the alterglobalization movement of the late 1990s, which challenged existing perspectives on social movements as activists and campaigns took on a transnational character (Edelman 2001; Edelman and Haugerud 2005; Nash 2005). These accounts emphasize the important roles of transnational networks and new forms of internet-based communication for the tactics and strategies employed by activists (Maskovsky 2003; Juris 2005; Gautney 2009a, 2009b; Juris and Khasnabish 2013). Understanding South African HIV/AIDS politics would not be possible without accounting for transnational influences, as this book has shown. The ANC’s AIDS dissidents were deeply influenced by heterodox HIV/AIDS researchers and organizations from the United States and Europe. South African HIV/AIDS activism relied on transnational networks of activists at several key junctures, with international solidarity helping to isolate AIDS dissidents within the ANC. However, rather than assume that transnational forces played the decisive role in how the campaign for treatment access unfolded, I have shown the significance of historical relationships, tracing them to several segments of the anti-apartheid movement. The HIV/AIDS movement’s engagement with the South African state in the campaign for treatment access, and its success in doing so, is an important example to consider alongside other contemporary social movements. Recent research on social movements such as Occupy Wall Street underscores a shift toward “horizontal” dynamics in decision-making structures, a dynamic previously associated with social justice organizing in Europe and South America (Juris 2008, 2012; Sitrin 2012a). Indeed, a significant example of social movements adopting nonhierarchical self-governance comes from postcrisis Argentina, where “horizontality” emerged in the associations created to meet the material needs of the working-class communities in the aftermath of financial crisis (Sitrin 2006, 2012b; Vietra 2010). These influential examples have been accompanied by the concept of “prefiguration,” or modeling the politics one wishes to see in the world within one’s own organizational

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networks (Maeckelbergh 2011; Yates 2015). People within these movements are living the politics of the world they aim to create, and they are doing so without formally engaging with the state. While advocating for social justice, the South African HIV/AIDS movement has internal politics that are significantly different from the growing tendency toward prefiguration among contemporary social justice movements. TAC and other organizations in the HIV/AIDS movement brought forward political principles developed by the struggle for black liberation that include broad-based consultative decision-making, which proved significant for the eventual success of the campaign for HIV/AIDS treatment. Consultative decision-making was based on universal democratic participation, but it did not challenge organizational hierarchy. TAC in particular was influenced by the Marxist-Leninist models of twentieth century socialist revolution, and it had a top-heavy structure for organizational decision-making. While consultative decision-making processes within the organization were democratic and inclusive, it is clear that leading members, mostly men, played an outsized role in determining TAC’s agenda.8 Viewed more broadly, TAC was the vanguard of the HIV/AIDS movement and had a disproportionate impact on the movement’s goals and direction when compared to other organizations. While organizing communities and enabling people living with HIV/AIDS to substantively affect policy and treatment access, the HIV/AIDS movement did not fundamentally challenge organizational and institutional hierarchies within its campaign for treatment access. To the contrary, the HIV/AIDS movement’s success was contingent upon high-level engagement with ANC elites and “occupying” the state. Rather than developing a politics of the world to come within their organizational networks, the HIV/AIDS movement sought to change the state from within and redirect it to achieve their ends. It is of some general interest how a social movement could leverage the power of international institutions, domestic political pressures, and transnational donor capital to achieve this goal.9 That story is told here, and it is one that was contingent upon a set of historically particular social, political, economic, institutional, and cultural conditions that may prove difficult to duplicate elsewhere. Nonetheless, the history of South African HIV/AIDS activism offers a significant example of how social movements might go about transforming the state in order create a more just society. In South Africa today, millions of lives are now sustained by the world’s largest public sector HIV/AIDS treatment program. That is no accident, but rather the result of people dedicating their lives to achieving that

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outcome. HIV/AIDS activists’ success provides a useful case for rethinking contemporary anthropological theories of the state.

People, the State, and Transnationalism Anthropological research on the state has analyzed the diverse manifestations of administrative authority in societies across the world, underscoring the particularity of supposedly universal conceptions of hierarchy, policy, and institutions associated with Western societies. Foundational accounts have rejected economic determinism and underscored the difficulty of studying the state, and more recent theorizations have shown that modern states exert power via the internalization of various forms of discipline. They have also illuminated how states produce social effects, such as the imagined hierarchies associated with state authority (Poulantzas 1978; Abrams 1988 [1977]; Foucault 1991; Mitchell 1991; Scott 1998). Such accounts underscore that the power and authority ascribed to the state can take many forms, such as the local authority of a mayor, and that the performance of state power carries with it an abundance of symbolic imagery, which is at times expressed through the charismatic behavior of state officials (Weber 1946 [1919]; Geertz 1983; Verdery 2002). A broad body of anthropological literature has adopted these approaches to studying the state, highlighting the changing social, political, economic, and cultural dynamics associated with the transition to modernity and the rise of neoliberal globalization. In these concluding pages, I discuss several influential approaches to highlight how the history of South African HIV/AIDS politics necessitates a methodological and conceptual reconsideration of how the state is studied and understood. Contemporary analyses of the state owe much to Michel Foucault’s work, which opened new areas of inquiry into the exercise of power. Foucault (1991) argues that a central aspect of modernity is a change from the governance of households to the population, which necessitated a shift away from the state’s use of negative forms of power (such as violence) toward techniques of governance based on the internalization of state authority. Foucault posits that modern states create social order through “disciplines” that are internalized by populations, producing a self-governing society organized around a normative ethos. However, this perspective assumes that a far-reaching bureaucratic apparatus monitors the population, an assumption that may not hold in postcolonial societies. While colonial expansion was predicated on ordering

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principles that emanated from the European enlightenment, which brought with them particular conceptions of race, hierarchy, and power, the extension of state institutions in the South African context unfolded in uneven ways (Comaroff and Comaroff 1991). Certainly, the state had limited reach and surveillance capabilities in black rural areas of South Africa, where the power of traditional authorities held sway. Furthermore, Foucault’s decentralized conception of power, which envisioned social hierarchies as reinforced via capillary means, relies on a unified conception of authority, or the presence of one clear form of authority within a delimited territory. However, rural traditional authorities and intermittent forms of self-organization in black urban areas demonstrate that this assumption does not hold across South African history or during the post-apartheid era (Buur 2005). South Africa remains a politically segmented society, with political authority divided between traditional authorities and the modern state. In addition, Foucault’s work relies on a hierarchical conceptualization of discursive power—that discourses are generated by and reflect power relations in society and their subsequent internalization reproduces society as it is constituted, hierarchies and all. The history of South African HIV/AIDS activism contradicts this premise. Indeed, the social and political principles carried forward by HIV/AIDS activists reflected a history of struggle for black liberation, not minority white rule and the politicoeconomic relations on which it was based. Rather than reproduce class structure and power relations, the HIV/ AIDS movement transformed the state to sustain the lives of those historically deemed surplus to South African society (Platzky and Walker 1985). Building on Foucault’s insights, scholars have argued that state apparatuses produce “state effects,” where the state, operating as a “mythicized abstraction,” produces effects that are internalized by people, such as the hierarchy postulated to exist between state and society (Ferguson and Gupta 2002). In particular, Timothy Mitchell (1999) eschews Foucault’s decentralized and polyvalent notion of biopolitics by emphasizing government’s role in producing conceptions of the state, citizenship, and hierarchy. Examining state effects thus recenters the focus on the state, rather than the multiplex ways that discourse is constructed and operates in capillary form to reinforce social hierarchy. However, focusing on effects assumes a unitary manifestation of state power that privileges the power of elites to produce modes of understanding that are internalized by the population at large. As the history of South African HIV/AIDS politics underscores, the state is made up of people who bring different political agendas into its institutions,

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which then are used to amplify these visions, buttressed by state authority and its roles in producing social order—both imagined and real. These conceptions can reproduce social hierarchies, but they can also transform society. In addition, ideas of the state and power—and the social effects that they produce— can vary within the state, as different entities can adopt different positions on important issues such as HIV/AIDS. This was the case in South Africa, as the Treasury supported the treatment access agenda through national budgetary processes, while AIDS dissidents worked to limit the impact of these interventions within the Department of Health. The state is not monolithic, and accordingly, neither are state effects or the people and organizations that influence how states, policies, and power relations articulate in societies. Scholars analyzing the shifting and contingent character of elite power and its impact on the state have often deployed the concept of hegemony, which embraces the fractured and contingent character of elite alliances and state power. Antonio Gramsci’s conception of hegemony exposes the shifting and unstable terrain on which elite alliances are based and the coalitions of actors and organizations that inform how state power is exercised (Gramsci 1971; Crehan 2002). However, Gramsci’s conception of hegemony is based on a notion of the state and society that is inherently national, rather than transnational, as it manifests through “the development of technocratic programs and institutions that govern by virtue of routines, internal bureaucratic logics, and allotted resources” (Hansen and Stepputat 2001). In this formulation, the enactment of hegemony is linked to the power of state institutions as its means for expression. Consent and conformity within a society are secured based on recourse to a shared repository of symbols, practices, and ideas associated with state authority, which are leveraged to reify elite power in society. In short, the state, society, and class are framed as operating within a contained, Cartesian notion of space, where political, economic, and cultural forces are manipulated by elite alliances to maintain power. As HIV/AIDS politics exemplifies, transnational forms of influence have a decisive effect on political dynamics across all levels of South African society. When adopting a transnational perspective, it becomes difficult, if not impossible, to characterize the ANC’s AIDS-dissident faction as hegemonic, even if its adherents within the ruling party held positions where they wielded state power. If anything, the HIV/AIDS movement and its treatment access agenda cohered with transnational biomedical conceptions, which reflected the power of global health institutions and were backed by large quantities of transnational donor capital. The concept of hegemony thus is ill suited for

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analyzing the history of South African HIV/AIDS politics, given the complexity introduced by transnational dynamics. Recent research on the relationship between power, governance, and citizenship has increasingly turned to the concept of sovereignty to analyze how state power is exercised in the modern world. Characterizing sovereignty as a “tentative and always emergent form of authority grounded in violence” that is “performed and designed to generate loyalty, fear and legitimacy,” this line of inquiry highlights the power of the state to produce death and the conditions of bare life (Hansen and Stepputat 2006). This work builds on Giorgio Agamben’s (1998, 2005) theorization of sovereignty as the power to either include or exclude populations from the realm of rights and citizenship through states of exception and, based upon this legal suspension of law, construct a moral and social order. In addition, Achille Mbembe (2003) frames politics as the “work of death,” and sovereignty is exercised as the “right to kill.” That AIDS dissidents relied on control of state institutions and had the power to determine who would live and who would die underscores the importance of the sovereignty concept for South African HIV/AIDS politics. However, Agamben’s theorization of sovereignty has been critiqued in recent anthropological work for its conceptualization of elite power, transnationalism, and agency. By positing the expansion of executive and/or sovereign power in times of crisis, Agamben’s conception of sovereignty characterizes power as a union of state institutions and elites, which, as Gramsci emphasized, is often fractured and riven with tension. Furthermore, conceptualizing the state as an extension of elite power underestimates the influence of those who operate on its margins. As the case of South African HIV/AIDS activism highlights, it is not only those controlling the executive branch who play decisive roles in producing state effects. This mode of analysis also entails a notion of state authority predicated on territorial sovereignty, a conception that, relative to the modern state, has seldom held true across the Global South, where NGOs play increasingly large roles mitigating conditions of bare life (Jackson 1990; Keene 2002; Anghie 2004; Ong 2006). In part, this line of analysis reflects the intellectual roots of sovereignty theory, which can be traced to monarchical and fascist modes of political organization across European history (Schmitt 1985; Machiavelli 2005 [1922]). Given these emphases, it is unsurprising that in studies of state sovereignty poor and working-class people are perceived as having little to no power to influence the politics of life and death. However, “radical despair” may be unwarranted, as these insights do not hold true relative to South African

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HIV/AIDS politics (Mazower 2008). The HIV/AIDS movement transformed the politics of bare life for people living with HIV/AIDS, who, in effect, were sentenced to premature death due to limited access to HIV/AIDS treatment. Rather than an example of the power of the state to produce death among a society’s people, HIV/AIDS activism shows that it is possible for a social movement to transform these dynamics by working within the state and renovating state effects to sustain life. HIV/AIDS activists’ ability to influence national politics reflects contemporary political trends across the Global South, where changing social, political, and economic conditions accompanying neoliberal globalization have undermined local politics, reasserted imperial morality, diversified regulatory authority, sparked a rise in technocratic forms of governance, and transformed state institutions (Ferguson 1990; Heller 2003; Roitman 2004; Susser 2009). A diversification of state power has been accompanied by a shift in anthropological research to the margins of the state, where those who lack political and economic influence exert agency via subtle strategies of resistance (Scott 1985; Comaroff 1985; Das and Poole 2004). Such accounts have shifted away from the formal exercise of authority to the social mechanisms through which lives are sustained and livelihoods secured amid precarious social and political circumstances, such as local mechanisms for self-reliance and the expansion of NGOs and CBOs. In addition, anthropological perspectives on states in the Global South highlight the growing role of NGOs and social movements in the formal political sphere, a trend that is exemplified with the campaign for HIV/AIDS treatment in South Africa (Ferguson 2006). While anthropological scholarship on the state has brought critical insight to the exercise of power in the contemporary world, it adopts certain assumptions regarding hierarchy, agency, and power that do not reflect the history of South African HIV/AIDS politics. The HIV/AIDS movement leveraged political principles and social movement knowledge and practices developed during the campaign for black liberation in South Africa rather than reproducing conceptions of the state and hierarchy that sustained elite power. While transnational biomedical norms were leveraged to do this and, in the process, HIV/AIDS activists contributed in some ways to their own exploitation, they did so using political principles and practices that were historically particular to South Africa (Comaroff 2007). They did so in part by cultivating allies within the state elite, where AIDS dissidence led to fractures within the ruling alliance. These fissures were exploited by HIV/AIDS activists to get the treatment access agenda reflected in state policy and in the composition of

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national health institutions. However, this relied on leveraging the power of donor capital available through global health institutions and international organizations. As a result, the state and policy were transformed to incorporate a wider array of representation relative to HIV/AIDS, and the result was a massive expansion of HIV/AIDS treatment access in South Africa. In order to study the campaign, which unfolded differentially at different levels of the state, it was necessary to set aside preconceived notions of the state, power, and hierarchy in order to accurately represent South African HIV/AIDS politics. That required that I follow HIV/AIDS activists to learn how these dynamics unfolded in lived experience, socially, spatially, and politically. Discarding preconceived notions of hierarchy and power allowed a different understanding of the state to emerge, one where people stood at the center of the institutional processes that were transformed to sustain life in South Africa.

Pathways to Power: HIV/AIDS Activism and Treatment Access in South Africa This book analyzed the process through which the HIV/AIDS response was transformed by following the pathways of HIV/AIDS activists, locating points of intersection for people involved with HIV/AIDS policy development, and studying hot spots for HIV/AIDS politics. Rather than presume that policy process and HIV/AIDS politics were based in state health institutions and controlled by state elites, I examined the local political formations that came together around particular hot spots and determined outcomes for treatment access. Based on these ethnographic foundations, a picture of the South African state emerged over time, one that showed how a diverse group of people drove policy and state effects, underscoring that assumptions of elite power and state hierarchy may not hold in all instances. The localized political formations that produced HIV/AIDS politics, policy, and treatment access levels were constituted by a local array of actors and organizations that gravitated toward, but were not reducible to, state health institutions. At the national level, SANAC was transformed into a hybrid state-and-civil-society institution, which enabled the HIV/AIDS movement to utilize lived experience to inform new national policy norms for PMTCT. It also extended the domain for policy development beyond the realm of formal state institutions and into the interpersonal networks that constituted the

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HIV/AIDS movement. State elites associated with the dissident faction maintained control over the Department of Health and the presidency, and they were able to undermine the HIV/AIDS movement’s treatment access agenda through their positions of power within these state bodies. However, their institutional power was mediated by HIV/AIDS activists’ ability to develop alliances with competing factions within the ruling alliance, which eventually enabled the restructuring of national health institutions and activist oversight of the Department of Health. In sum, political actors who were not members of the state elite fundamentally transformed the institutional dynamics that set the level of public sector treatment access in South Africa. South African HIV/AIDS politics shows that the formal political process was not reducible to the state or elites but must be conceptualized as encompassing an array of people and organizations, many of which were part of the HIV/AIDS movement. Just as the power relations that hold together hegemonic alliances are tenuous and subject to change, so too are the groups of people in state institutions who influence political process and policy development. Indeed, the policy process at the provincial level showed the capacity of nonstate actors to influence formal politics in ways that were not supportive of the treatment access agenda. There, WC-Nacosa redirected the PSP policy consultations toward a reapplication process for Global Fund support, undermining the policy process initiated by the HIV/AIDS movement at the national level. WC-Nacosa maintained a close working relationship with state administrators and leveraged that relationship to reposition itself as an intermediary between transnational donor capital and communitybased organizations addressing the epidemic in the Western Cape, and in the process it influenced policy outcomes at the provincial level. By following TAC activists, WC-Nacosa members, and state health administrators I was allowed to witness how this social process unfolded in real time as I traversed the Western Cape and identified the sociopolitical zones where their pathways converged. These and other actors and organizations came together and influenced the PSP policy process, and their overlapping activities unveiled power dynamics within these local political formations. Sociopolitical dynamics within these hot spots reflected the people and organizations working to combat HIV/AIDS in each health district, the political histories of these regions, and the ongoing legacy of institutionalized racism in South Africa. The pathways produced by people operating at the margins of the state were often fleeting and visible only to those also participating in a given policy consultation. But not all pathways were invisible and ephemeral,

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as the participation of state administrators was often denoted in policy documents, the composition of which they wield influence over. It is seldom the case that the participation of nonstate actors in policy processes is as visible. As Tim Ingold’s work shows, the selective recognition of policy participants leads to the development of fixed forms, in this case policy, which may not be representative of the social process through which they are constituted (2008). Studying the state by following different groups of people, including those at its margins, thus challenges the assumptions of power and hierarchy that lie at the core of contemporary anthropological debates on the state. For example, the method of following and the focus on intersections and hot spots together shed light onto the activities of people whose experiences and input might otherwise be lost. Putting people at the center of states enables analyses that do not presume to know who matters in how power and policy processes work. Indeed, the campaign for treatment access reveals that the tendency to analyze broad institutional trends and forces underestimates an important factor: people. This book highlights that it is people working within the state that control how government institutions operate and produce effects that impact society. Rather than impersonal institutions that reflect normative criteria, the campaign for HIV/AIDS treatment access in South Africa makes clear that people are the state. This insight derives through an examination of lived experiences to see how power is expressed through the state and to understanding the working of the state amid the transnational forces associated with neoliberal globalization. Instead of adopting hierarchical notions of the state or society, I have studied people as the state. Thus, the hot spots approach shows how state actors and those operating at the margins interacted by examining points of convergence in their pathways and analyzing how power dynamics within localized political formations that formed at these intersections produced divergent outcomes for HIV/AIDS policy process at the national, provincial, and township levels. However, social processes at different institutional levels operated autonomously, to a degree, and were contingent on the particular array of people, organizations, and institutions that aggregated and produced a localized political formation. Local political dynamics in Khayelitsha underscored this point. There AIDS dissidence did not manifest through state health administrators, as was the case within national institutions. Instead, it was the Rath-SANCO alliance and a local branch of the ANC Women’s League that advocated for AIDS-dissident ideas and practices within communities across

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the Cape Flats. These dynamics were linked to the national level, but they were not reducible to the way that dissident politics manifested in SANAC. Instead of a faction of political elites that relied on state institutions to exert power, in Khayelitsha, SANCO members controlled local political institutions, but they were unable to undermine the treatment access agenda due to the HIV/AIDS movement’s sustained activism. Indeed, the hierarchical assumption that local health institutions would reflect the political agenda of national policy actors, in this case AIDS dissidents, was not supported. As the book has illustrated, the campaign that achieved near-universal HIV/AIDS treatment access required that HIV/AIDS activists move across institutional levels and work within state health institutions to transform policy and the public health response to the epidemic. Understanding how this sociopolitical process unfolded across space and time required the application of the pathways, intersections, and hot spots approach, which led to research findings that challenge the presumed links among state actors, state institutions, and policy development. In sum, adopting the hot spots approach allowed me to observe a more diverse set of field sites, actors, and outcomes. The book thus highlights the limitations of anthropological research based on elite conceptions of state power and the benefits of orienting anthropological research toward the pathways, intersections, and hot spots that emerge from ethnographic analysis with different actors and organizations. The hot spots approach also underscores that transnational political, economic, and cultural influence on South African HIV/AIDS politics was channeled through and also fundamentally transformed by historically particular social, cultural, political, and economic dynamics. The findings cast a critical light on existing theories of transnational influence, which tether global influences to local outcomes without sufficiently considering the influence of intermediary actors and organizations. Political processes manifested differently at the institutional levels of the South African state, exhibiting both overlapping and autonomous characteristics. These findings underscore that the localized political formations at each level required ethnographic inquiry and critical analysis in order to understand how actions and outcomes unfolded in, and were influenced by, particular social, political, economic, and material circumstances. While the HIV/AIDS movement overcame the institutional power of the ANC’s AIDS-dissident faction and led the development of the world’s largest public sector HIV/AIDS treatment program, lingering challenges remain in the fight to end the South African epidemic. The annual rate of infection

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remains stubbornly high in South Africa, leading to growing numbers of people living with HIV/AIDS, as those infected are benefiting from the lifeextending effects of treatment. Given the epidemic’s continued growth, it is necessary to question triumphalist claims of “winning” the fight against HIV/ AIDS in South Africa and instead consider the extent of social change produced by the campaign for treatment access. Were the transformative effects of the campaign for treatment access limited to state health institutions and policy norms? To what extent did HIV/AIDS activism change the social conditions that concentrate illness, disease, and poverty among the black South African population, if at all? What can be learned from the history of South African HIV/AIDS politics for understanding the limits of social change in postcolonial African societies? While these questions remain to be answered, it is clear that the campaign for treatment access has not marked the end of HIV/AIDS in South Africa.

AF TERWORD

After Treatment Access An Epidemic Unresolved

The only freedom that we have in South Africa is the thing of the pass. We are no longer carrying the pass or don’t pass when you are walking on the street. And you can stand, you can stay, you can walk, you can talk with a white guy. Firstly, that government of apartheid, that wasn’t happening. That’s the only freedom that we have. On the other hand, we don’t have freedom. We tend to say, we do have freedom, but our freedom is being vandalized or is being misused by the other guys that are up there in the government constitutions. So, I for one, I don’t have freedom and I don’t know what to celebrate. As much as I celebrate that I am free in terms of walking, I can walk everywhere I want, and I can talk with whom I want; that is the only freedom that I have.

Bongani,1 an HIV/AIDS activist from Ukuvula, offered a damning characterization of social change in South Africa during the course of a conversation we had nearly two decades after the negotiated political transition. What he said echoed statements that I had heard from HIV/AIDS activists and community residents alike in Khayelitsha, which were that their lives had not fundamentally changed since apartheid and that, for some, the situation had worsened. Initially, the statement was shocking to hear, as it was hard to believe that those who had won their political freedom after more than three centuries of white

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minority rule would see their victory as hollow. But so it was, and continues to be, for many living in the grueling socioeconomic conditions that typify the black South African post-apartheid township. Thus, while the HIV/AIDS movement eventually emerged as triumphant in the struggle over treatment access, many poor and working-class South Africans, including those involved in the movement, saw the victory as not having addressed the fundamental conditions that structured their lives and drove HIV/AIDS infection. In addressing the post-apartheid situation, Bongani described the transition to democracy as one that had been devoid of the transformative elements that could have changed South African society. What was it that Bongani yearned for? What would real freedom look like for Bongani and his fellow township dwellers? What does the limited social transformation described by Bongani mean for the campaign for treatment access and the ANC’s postapartheid governing strategies? What might we learn about post-apartheid South Africa from earlier debates on postcolonial transition across the African continent? In order to address these questions, I will return to debates on Africa liberation before linking these perspectives to social, political, and economic conditions in post-apartheid South Africa that are driving the continued expansion of the HIV/AIDS epidemic.

African Liberation and Social Transformation Over fifty years after its publication, Frantz Fanon’s (2004 [1961]) work retains its relevancy for the analysis of postcolonial African societies. As a scholar who engaged directly with colonial violence and the anticolonial movements that liberated African societies, Fanon analyzed the legacies and pitfalls of revolutionary movements in the African context.2 Subsequent scholars have taken forward Fanon’s insights on postcolonial elites, the political economy of the postcolonial state, and the role of violence in postcolonial governance, shedding light onto the social, political, and economic dynamics of contemporary African societies (Burawoy 1972; Bayart 1993; Mbembe 2001; Cooper 2002). Here I will return to Fanon’s foundational work to think through the legacy of the anti-apartheid movement for post-apartheid HIV/AIDS politics and social change in South Africa. One characteristic that has given Fanon’s work its timeless character is his incisive analysis into the unresolved contradictions that were carried forward through the form and composition of anticolonial movements. First,

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and perhaps most significantly, Fanon makes the case that African liberation movements in the 1950s and 1960s failed to sufficiently analyze the structure of the colonial economy in charting postcolonial developmental strategies. For Fanon, the colonial state played an intermediary role, siphoning value off of an export-oriented economy that relied on the complicity of African elites drawn from rural traditional leaders and urban administrators. The nature of the colonial economy as fundamentally externally oriented depended on a state form that served as a “gatekeeper” for the interests of the European colonial economic enterprise, which was reflected in its institutional form (Cooper 2002). Fanon contended that in order to liberate African societies from the legacy of European colonization, a broader transformation in the structure of the colonial economy and the form of the African state was necessary. Rather than serve as a proxy for European colonial interests, the postcolonial state would necessarily be renovated to serve the needs of historically marginalized African peoples. On this point, Fanon relied heavily on his experiences during the Algerian war for liberation from France (1954–1962). There, in the liberated zones of the country, he experienced an economy redirected away from export-oriented activity and toward the needs of Algerian people, where predatory middlemen were relieved of their duties, and different forms of socioeconomic organization emerged. In Fanon’s experience, the liberated Algerian people defined the needs of their community and transformed economic relations and representative political structures accordingly. Therefore, his position on transforming formerly colonized African societies involved putting people’s material needs and ideas of how society and economy should be organized at the center of the postcolonial project.3 Here the values and community-oriented practices that had sustained communities during the anticolonial struggle took center stage as the foundation upon which a new society would be built. The leaders of the African decolonization movements were the primary obstacles to postcolonial transformations of this kind, in Fanon’s perspective. In a critique that was targeted squarely at anticolonial leadership in West Africa, Fanon made the case that national liberation movements were thoroughly immersed in European thought and culture and, as a result, were unable to see outside of colonial constructions of state and economy that animated debates on postcolonial social change.4 The issue with ceding leadership to those who approached the governance of African societies through a Eurocentric lens, for Fanon, was that the forms of self-governance

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and economic reorganization that emerged during the anticolonial struggle would then be seen as dysfunctional, backward, and impractical. Furthermore, the external orientation of economic relations would appear normative to those immersed in European modes of thought, thus precluding a broader transformation of economies toward the needs and interests of African people. Finally, and perhaps most incisively, Fanon foresaw that those who had internalized European modes of thought would adopt cultural tastes and modes of consumption associated with the former colonial elite and easily turn against the newly liberated African citizenry should they become disenchanted with the pace of postcolonial social transformation. For Fanon, educated African elites who saw European culture as superior to African societies would also see Africans as being inferior to their European counterparts and, perhaps, those who had become conversant in their social, cultural, political, and economic norms. For Fanon, then, the anticolonial revolutions of the 1950s and 1960s were incomplete, as the political and economic infrastructure developed during the colonial period remained largely unchanged in Africa. The postcolonial elite simply replaced the colonial elite as an intermediary class, adopting the cultural norms and consumption patterns of their former colonizers. Attempts to fundamentally alter the trajectory of postcolonial societies would be met with violence, and, despite transformations in the composition of national leadership the politics of extraversion that had characterized earlier regimes would be replicated (Bayart 1993). Fanon’s rather dour perspective on the path-dependent character of African societies has unfortunately proven somewhat prescient for understanding the postcolonial period. There are, of course, important political histories that deviate from Fanon’s vision of colonial continuity. Attempts to fundamentally transform postcolonial political and economic relations can be seen in Lumumba’s Congo, Kaunda’s Zambia, Nyerere’s Tanzania, and Sankara’s Burkina Faso. Each of these examples offers a different case study in postcolonial social transformation unfolding in a manner reminiscent of Fanon’s vision. Notably, the assassination of political leaders curtailed the postcolonial transformation in two of the four cases, with Western political and economic interests rumored to be involved. Indeed, the unraveling of postcolonial transformation cannot be laid at the feet of African leaders and revolutionary movements only but must also include the impact of transnational interventions led by the International Monetary Fund and other international incursions that precluded the possibilities of postcolonial transformation.

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A Society Transformed? The Political Economy of Post-Apartheid South Africa Post-apartheid South Africa offers another example to investigate how postcolonial social transformation has unfolded in the African context. Despite the promise of the negotiated transition to democracy, the socioeconomic conditions experienced by the majority of South Africans remain largely unchanged, as Bongani emphatically explained. Two decades into South Africa’s democratic period, the socioeconomic transformation that many had anticipated has yet to occur, as rampant poverty resulting from colonization, segregation, and apartheid continues to plague South African society. In a country with a population of fifty-three million people, 45 percent of the South African population lives on less than two US dollars a day, while more than ten million people live on less than one US dollar per day (Mayosi and Benatar 2014). Indeed, the life experiences of Bongani and his fellow township residents are not the only source of evidence for increasing levels of social inequality during the post-apartheid era. Proof of growing inequality can also be found with the GINI coefficient, which increased from 0.6 in 1995 to nearly 0.7 in 2009 (Mayosi and Benatar 2014). Class lines continue to follow the racial cleavages produced by South African history, as approximately 90 percent of South Africans living in poverty are black (Leibbrandt et al. 2011). Clearly, the material conditions endured by poor and working class black South Africans have not been sufficiently addressed by the ANC’s post-apartheid socioeconomic policies. While the negotiated political transition provided for political and socioeconomic rights, the core features of the South African economy have remained in place, with social inequality exacerbated by austerity and neoliberal macroeconomic policies. White South Africans continued to disproportionately own the land, businesses, and homes that resulted from the expropriation of these resources from black South Africans during the periods of colonial settlement, unified white rule, and apartheid. The abandonment of the RDP for GEAR’s neoliberal austerity has undoubtedly contributed to continuity in the way that resources are allocated in South African society. While the RDP sought to actively transform South African society through redistribution, GEAR maintained the core features of the South African economy in order to slowly redistribute resources across society via the state. Fanon’s concerns about the consequences of incomplete economic transformation loom large here.

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From a purely economic perspective, Fanon’s dire warnings of the endgame of insufficient postcolonial socioeconomic transformation appear to cohere with the experience of poor and working-class communities in postapartheid South Africa. However, the ANC-led transformation of the South African state into a mechanism for redistribution complicates the picture. The ANC has attempted to soften the impact of continued social inequality through the development of a large-scale social grants program. Starting in 2003, the ANC oversaw the expansion of a social grants program that included state support for pensioners, children, and the disabled (Ferguson 2015). The number of South Africans qualifying for social grants has more than doubled within a decade, and by 2014 there were 16.4 million people on social grants (Holmes 2014). It is estimated that 17.5 million people, or nearly a third of the South African population, will be on social grants by 2018 (Mutheiwana 2015). Certainly, there have been serious attempts at redistributing resources via a state apparatus that had previously focused on South Africa’s white citizenry. The expansion of state-provisioned social support can be traced in part to employment conditions in post-apartheid South Africa. According to the expanded definition of unemployment, 35 percent of working-age South Africans are unable to find work, youth unemployment stands at 50 percent, and unemployment in the townships sits at 60 percent (Statistics South Africa 2014; Mahajan 2014). Therefore, redistribution, substantial as it has been, has not fundamentally transformed the socioeconomic conditions experienced by the poor and working classes but has created a means of subsistence for historically disenfranchised black South Africans, who have been left behind amid South Africa’s reincorporation into the global economy. Indeed, the ANC has transformed the state, but the broader social and economic patterns that have characterized South African society since the onset of settler colonialism have continued, albeit in different form. The ANC’s expansion of redistribution via social grants and other programs has not fundamentally reconfigured the social processes producing inequality in South Africa, and it has been accompanied by a culture of selfenrichment for the elite within the ruling party. While the South African economy has grown based on neoliberal macroeconomic policy, these gains have been primarily measured in gross domestic product (GDP) and corporate profit rates rather than employment. Economic expansion without commensurate gains in employment has resulted in increasing levels of “informal” economic activity in society as people attempt to garner whatever resources they

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can to survive. In the absence of growing employment opportunities, the ANC has employed its own within the state, with government positions serving as a means of supporting the party and its members (Picard 2005; Feinstein 2009). There have also been several allegations of large-scale corruption by ANC leaders, including a ZAR 70 billion arms deal and the sale of South Africa’s strategic oil reserves (Feinstein 2011; Hogg 2016). Clearly, a lack of socioeconomic transformation appears to have led some ANC members to utilize the state as a means of accessing resources, either for individual or party benefit. The decentralized South African state, which has many public services provided by private contractors, has also operated as a site for accumulation through its awarding of contracts. Politically linked bids to government contracts have created a new class of “tenderpreneurs,” those that seek to accumulate capital by securing government tenders and subsequently providing suboptimal services, with the difference being pocketed by those linked to the bid (Kings 2014; Hartley 2016). Former ANC politician Julius Malema, among others, reportedly benefited from irregular tenders prior to his ouster from the ruling party (News24 2012). These tendencies within the ruling party, which do not hold for all its members, nevertheless highlight patterns of accumulation via political ties that undermine the transformative capacity of social transformation, the core of the ANC’s post-apartheid agenda. Those most impacted by a rising culture of self-enrichment in the ANC are historically disenfranchised communities across South Africa. In these predominantly black and poor areas, many of which are located along the urban periphery, the social services long waited for are arriving via private subcontractors who, in tandem with government officials, are providing poor quality services, leading to rising numbers of urban protests (Von Holdt et al. 2011). The stark divide between those affiliated with the ruling party and those working to survive and subsist in the post-apartheid township was something that I saw every day during my work across the Cape Flats. But the contrast was particularly striking during a research trip in 2016, when I attended the International AIDS Conference in the city of Durban after several weeks of fieldwork in Khayelitsha. That day, I sat in Habour Park, a small, picturesque urban esplanade situated next to a large colonial building that holds the Durban Art Gallery and the Durban Natural History Museum. I sat there, thankfully basking in the midwinter sun, warming myself as I waited for a march led by HIV/AIDS activists to arrive. As I did so, I noticed a fleet of shining new black Mercedes-Benz sedans, gleaming with authority, pull up and park in front of the art museum. Shortly after, a delegation of ANC leaders

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streamed out of the cars, heading into the building to receive those protesting the state of South Africa’s health system and the tenuous state of its HIV/AIDS response. I was asked to move from my perch by several plainclothes members of the police services, and I struck up a conversation with a young Zulu man named Nkandla as I shifted into a different section of the park.5 Nkandla was studying information technology at a technical college nearby, and he had stopped off at the park before heading back to the township he called home, KwaMashu. In his early twenties, Nkandla hoped to use his studies to gain a job and escape the harsh realities he faced in his community. His other friends, he indicated, had all dropped out of school and turned to drugs and alcohol, having lost hope of a better future. Nyaope—a mix of heroin, marijuana, ARVs, and other additives—was one of the vices that Nkandla’s classmates had fallen into and one that would create resistance to first-line medicines if they became infected with HIV. As we spoke, the similarity between Bongani’s and Nkandla’s experiences struck me, particularly how they continued to fight to survive and thrive despite obstacles that their peers saw as insurmountable. I pointed to the silver Mercedes-Benz sedans and asked Nkandla what he thought of them. His face tightened as he answered, telling me that they—the ANC—only cared about themselves, not the people who were struggling. I did not push Nkandla to elaborate further on his assessment, but I wondered who else other young men in his position might blame for the socioeconomic conditions they negotiated. As social transformation has sputtered and socioeconomic inequality persisted, many young black South African men have turned their attention toward African migrants who have settled in the country. Xenophobic violence has been one response to a society untransformed, with nearly twenty thousand people displaced across the country in 2008 by an outburst that shook the nation. TAC members led the response to xenophobic violence in Khayelitsha at that time, using their organizational resources to pick up Africans of foreign origin and place them in sanctuaries across the township. I spent time at these facilities, where the migrants, many of whom were Zimbabwean, had lost all their belongings and feared for their lives. Some had defaulted on HIV/AIDS treatment as a result of the violence and now faced their final days, too sick to recover amid the damp winter rains. Xenophobic violence subsequently wracked the city of Durban in 2015, with five people dying following Zulu king Goodwill Zwelithini kaBhekuzulu’s call for all foreigners to return home so that black South Africans could find work. These events carry forward the trauma of South Africa’s past, but one that is now

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enacted upon Africans from across the continent who seek their fortunes in the post-apartheid demos. A lack of socioeconomic transformation and a rising culture of selfenrichment mirror what Fanon witnessed across West Africa in the 1960s, where the limits to national movements for liberation were laid bare by a wave of postcolonial xenophobic violence. Therefore, Fanon’s critical intervention on the characteristics of postcolonial African societies, which emphasizes the limits to social transformation, appears to find resonance with social dynamics unfolding in post-apartheid South Africa. That this has been the case requires a reconsideration of the paths pursued by both the ANC and the South African HIV/AIDS movement, which have been predicated on leveraging political principles associated with the anti-apartheid movement to produce social change.

HIV/AIDS, Human Rights, and the Social Determinants of Health in South Africa The HIV/AIDS movement and the ANC have both pursued transformative social change based on political principles developed by black South Africans in response to white minority rule. While the ANC’s AIDS-dissident faction pursued a political strategy to limit access to HIV/AIDS treatment in South Africa, its members did so by building on a similar repository of political ideals, though leveraging them to different ends. That the politics of the antiapartheid movement and black urban social formations served as the foundation from which treatment access and social redistribution sprang offers another means through which to analyze Fanon’s insights on the postcolonial African state. More to the point, post-apartheid HIV/AIDS politics offers a way to gauge whether social change predicated on liberal constitutional foundations and socioeconomic rights can transform the broader socioeconomic conditions faced by the poor and working classes in postcolonial Africa, which drive the growth of infectious disease epidemics such as HIV/AIDS. The historical and ethnographic analysis of the HIV/AIDS movement that I have presented underscores the complex ways that anti-apartheid political principles influenced the trajectory of state restructuring following the political transition out of apartheid. I have argued that the HIV/AIDS movement transformed state effects to sustain the lives of people living with HIV/AIDS by embracing the political principles of the anti-apartheid campaign and

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activating the socioeconomic rights ensconced in the post-apartheid constitution. Relative to Fanon’s perspective on decolonization, which emphasizes control of the postcolonial state, the HIV/AIDS movement was successful in producing social change despite not directly controlling the post-apartheid state apparatus. Therefore, the history of South African HIV/AIDS activism points to the possibility that social movements and other nonstate entities have the capacity to carry forward the political principles that drove African liberation and influence postcolonial social change. The centrality of South African HIV/AIDS activism in carrying forward the political principles of the anti-apartheid movement and transforming the state to provide HIV/AIDS treatment provides a useful point of engagement with Fanon’s work. Certainly, both waves of HIV/AIDS activism contributed to the form and character of the post-apartheid state, leading to the inclusion of rights-based HIV/AIDS policy and constitutional protection against sexual discrimination, among other measures. Given that they are central to postapartheid HIV/AIDS politics and the state-society relation, it may be useful to broaden the conceptualization of the potential avenues for the mobilization and postcolonial manifestation of revolutionary social practices and principles to include social movements and NGOs. The history of HIV/AIDS activism underlines that the political principles of the anticolonial movement do not operate and manifest through the state elite alone but through an array of social avenues, some of which may hold the potential to enact the social change envisioned by Fanon. Therefore, it may be necessary to expand our understanding of the transformative principles Fanon was concerned with, as post-apartheid HIV/AIDS politics indicates that they circulate through interpersonal and organizational networks over time and space and are not confined to the state-centric postcolonial elite. However, as I have outlined here, the transformative capacity of the South African HIV/AIDS movement should not be overstated. In particular, I have highlighted that it was necessary for second-wave HIV/AIDS activists to occupy the state to expand public sector treatment access in South Africa. Indeed, South African state health institutions were central to the restriction and subsequent expansion of public sector access to ARV-based HIV/ AIDS treatment. That the success of the TAC-led second-wave HIV/AIDS activism required engagement with and occupation of the South African state necessitates a reassessment of how one might nuance perspectives on postcolonial social transformation that rely on binaristic conceptualizations of the state-society relation. Furthermore, the history of South African HIV/

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AIDS activism raises the question of sustainability relative to social movements, particularly for how they might sustain broad-based campaigns and organizational integrity after their goals have been achieved. Certainly, the question remains whether social movements that depend on transnational donor capital can continue their campaigns without the sort of state-led social transformation envisioned by scholars of African liberation. While social movements may serve as a critical avenue for carrying forward the values and political principles around which postcolonial African societies might be transformed, Fanon emphasized that the postcolonial state alone held the capacity to carry out broad social transformation. Indeed, despite its success, the HIV/AIDS movement has subsequently faded from prominence in South African politics. To some degree, such an outcome is to be expected; after all, the primary aim of the second-wave HIV/AIDS activism was treatment access, which was achieved. TAC continues to lead efforts to maintain the public sector treatment access that was so long fought for, including campaigns focused on drug procurement, the status of the health system, and the protection of health sector personnel. Despite the efforts of TAC activists to continue the fight to end HIV/AIDS in a country has the world’s largest epidemic, South Africa has slowly receded from the international spotlight. It seems that now, after the fight for treatment access has been won, transnational networks of solidarity are less focused on South Africa, and with that, the flow of transnational donor capital has slowed. The decline in transnational donor support for the HIV/AIDS movement might have been expected after the campaign for treatment access was won, but it is also part of a broader pattern of declining donor support following the 2008 global financial crisis. Within this environment, TAC and other organizations focused on the dynamics of health and society in South Africa have been sustained at lower levels of staffing and community mobilization. Certainly, declining donor support for the HIV/AIDS movement has limited its activities and influence within South Africa. The capricious character of donor support on which social movements depend underscores that Fanon’s emphasis on the postcolonial state was not necessarily misplaced.

Is HIV/AIDS Ending in South Africa? Despite the HIV/AIDS movement’s success, lingering challenges remain in the fight to end the epidemic in South Africa, including growing numbers of

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people living with HIV/AIDS driven by a relatively stable level of new HIV infections each year. As Bongani emphasized, the political economy of postapartheid South Africa and its effects on poor and working class black South African communities stand as the primary challenges to ending the HIV/ AIDS epidemic. The dynamics of society that are driving infection grow out of the material challenges experienced by many black South Africans and mark a point of continuity with earlier epidemics that were concentrated within the country’s black population, such as syphilis and tuberculosis. Despite the political freedoms won and the socioeconomic rights ensconced in the post-apartheid constitution, many still see themselves as trapped by their socioeconomic conditions, which some argue have worsened during the post-apartheid era. And while the HIV/AIDS movement created the conditions for sustaining lives, people must secure their survival, with or without treatment access in the context of material privation. The HIV/AIDS movement, therefore, succeeded in transforming the state to sustain the lives of people living with HIV/AIDS, just as the ANC has with the expansion of social programs, but in doing so, neither have managed to fundamentally transform the socioeconomic dynamics that drive HIV infection in South Africa. Rather than a triumphant overcoming of the odds, the story of the South African HIV/AIDS epidemic is clouded by current social, economic, and epidemiological trends. The number of people living with HIV/AIDS in South Africa has now surpassed seven million, and it continues to grow by the day. As Mark Hunter (2010) outlines, the factors driving the epidemic are everyday material concerns, such as insufficient access to food and shelter, which lead to the development of multiple, concurrent sexual partnerships. Emphasizing the role of resources in romantic relationships, Hunter highlights how “provider love” dovetails with traditional resource transfers associated with marriage and social reproduction across Southern Africa, in the form of ilobola, and how concurrent relationships offer a means of provisioning for loved ones in a situation of pressing material needs. Given these factors, it should not be surprising that young women are disproportionately exposed to and infected with HIV, as they undertake measures to ensure the survival of others in addition to themselves. The history of South African HIV/AIDS politics points to the limits of the post-apartheid political compromise, as those who bore the brunt of poverty and illness, black South Africans, continue to do so today just as they did in the past. The adoption of one of the world’s most progressive constitutions

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should not be underestimated, particularly given the centrality of socioeconomic rights for the extended campaign for treatment access, but these have not provided the means for a broad-based socioeconomic transformation. Indeed, both the HIV/AIDS movement and the ANC have mobilized state institutions to transform the conditions of life for South Africa’s black majority, but thus far, they have been unsuccessful in their attempts to do so. Perhaps the most pressing evidence of this is that the socioeconomic conditions that drive HIV/AIDS infection continue, and with them, the slow and steady expansion of the epidemic continues, unabated. The transformation of the state, even to a progressive rights-based democratic system, has not been a sufficient condition to transform the lives of poor and working-class South Africans and, with that, the trajectory of the HIV/AIDS epidemic. Despite the unrelenting expansion of the South African HIV/AIDS epidemic, a new narrative on the global HIV/AIDS epidemic has begun to circulate transnationally in the aftermath of increasing treatment access for people living with HIV/AIDS. Michel Sidibé, the executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS), has been at the forefront of this tendency, arguing that the world now has the necessary tools to end the global HIV/AIDS epidemic (Sidibé et al. 2014). Building on this rhetoric, a UNAIDS-Lancet commission set out a plan to end the global HIV/ AIDS epidemic in 2015. Leading scientists and administrators from key institutions argued that the epidemic’s status as a major public health threat could be brought under control by 2030 if existing technologies and interventions were actively scaled up, including treatment access (Piot et al. 2015). The “end AIDS” rhetoric has remained at the center of debates within international policy discussions subsequently, serving as the rationale for continuing to expand testing, treatment access, and viral load suppression to reach the 90-90-90 target (Sidibé et al. 2016). However, as this history of South African HIV/AIDS politics underscores, treatment access has not been a sufficient condition for ending the epidemic. Thus, while outlining the success of the HIV/AIDS movement in the campaign for treatment access, it is also necessary to frame treatment access as but one of the many challenges that poor and working-class South Africans face in navigating their survival. Certainly, the second wave of South African HIV/AIDS activism achieved its central aim: to establish a rights-based public sector response to the epidemic that included ART. In the terms set by second-wave HIV/AIDS activists, the campaign for treatment access transformation is an undeniable success story. In negotiation with—and direct

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action against—multinational pharmaceutical corporations and the ANC, the HIV/AIDS movement transformed the capacity of the South African state to sustain life. But the campaign for treatment access and its aftermath highlight that treatment access manifests within a particular political, economic, and institutional situation, which carries forward many of the defining features that have driven and concentrated illness and infections among black South Africans. While South Africa now has the world’s most comprehensive public sector HIV/AIDS treatment program, an effort driven in large part by the HIV/AIDS movement, the health system that sustains the lives of people living with HIV/AIDS floats upon a sea of poverty and illness, which the South African state appears unable to fully address or transform. In the absence of a cure, ending HIV/AIDS in South Africa may require the broad socioeconomic transformation envisioned by Fanon, which offers a sobering riposte to triumphalist claims of an “end to AIDS” circulating within international health institutions and, most tragically, within communities infected and affected by the epidemic.

NOTES

Introduction 1. A pseudonym has been utilized to protect the identity of the research participant. 2. Structural adjustment programs were a central component of the broader dissemination of neoliberal politicoeconomic principles. The core policy principles associated with structural adjustment include—but are not limited to—the privatization of state assets, the liberalization of the economy, and the deregulation of markets. 3. On this point, see Harvey (1989); Glick-Schiller et al. (1995); Castells (1996). Kearney (1995) offers a different perspective on the issue, questioning the efficacy of dividing the world into discrete regions, given the increasing dynamics of transnational interconnectivity that typify the contemporary global era. 4. Utilizing the concept of scale to describe sociocultural process across multiple levels may introduce unwarranted assumptions. Scale is a quantitative concept, a metric that increases or decreases the scope of analysis. Analyzing sociocultural dynamics using the concept of scale assumes that actions manifesting at a smaller scale are subsumed within those operating at a larger scale. Thus, in addition to asserting unity, Tsing’s analysis assumes hierarchy. As others have noted relative to the state, the association of hierarchy within state institutions produces the effect of vertical encompassment, or of presuming hierarchy where none may exist (Ferguson and Gupta 2002). Arguably, there is a similar entailment in the application of the scale concept to sociocultural dynamics, as scalar units are often linked to institutional levels of government. 5. George Marcus (1995) traces the roots of the former back to Malinowski’s (2014 [1922]) seminal Argonauts of the Western Pacific, in which “following” the physical movements of prominent men played an important role in understanding the significance of the kula ring. 6. Both of the approaches developed in the anthropology of policy subfield owe much to Marcus’s (1995) theorization of “following.” The “following the policy” approach dovetails closely with “following the conflict,” while the “studying-through” approach closely corresponds to “following the people.” 7. As Marcus (1995) underscores, the social situational approach associated with the extended case method is a useful way to analyze data produced by multi-sited research (see also Van Velson 1979). Associated with the Manchester school of anthropology, the social situational approach analyzes the “underlying system of relationships” in a given ethnographic encounter (Gluckman 1940, 11). Michael Burawoy (1991) extends this claim by arguing that this approach offers a useful method to connect the micro and macro sociocultural processes that one encounters in the contemporary phase of global integration (274). 8. The “hot spots” terminology has been used to describe biodiversity-conservation projects, the growth of infectious disease, and social science research (Myers et al. 2000; Jones et al.

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2008; Neimark and Schroeder 2009; Paige et al. 2015). For application of the term in anthropology, see Allison and Piot (2015); Brown and Kelly (2014). 9. While the movement of research participants transcended the different institutional levels around which political activity cohered into hot spots, I cluster observations and interview data into an analysis that is framed around the national, provincial, and local levels.

Chapter 1 1. As John L. Comaroff (1989) notes, protestant missionaries were often in tension with the dominant classes of the British Empire, seeing themselves as “friends of the native,” which highlights fractured and multiplex dynamics within the colonial encounter (663). 2. Precolonial South African social formations include the development of politically centralized hierarchical societies that controlled long-distance trade, such as with Mapungubwe, a centralized kingdom located near the Limpopo River System that existed from 1000 to 1250 ce (Switzer 1993, 29). 3. The term “Khoisan” is a compound terminology that encompasses San hunter-gatherer groups and Khoi-Khoi pastoralists. 4. In describing European expansion, Jean and John Comaroff described this process as a genocidal “war of extermination” waged by Dutch settlers against the Khoisan (1991, 96). As Switzer (1993, 41) notes, this process occurred in the latter half of the seventeenth century. 5. Sexual unions between European settlers and indigenous women led to the emergence of the “Cape coloured” designation to refer to their offspring (Crais 1992, 45). 6. It should be noted that alongside the forcible use of Khoisan people as laborers, slaves began to be imported to the Cape Colony by 1658, as settler farming depended on slave labor (Crais 1992, 32, 45). 7. Based on oral histories, it is estimated that Xhosa chiefdoms arose in the Eastern Cape between the twelfth and fifteenth centuries and that there was relatively continuous contact between Dutch settlers and Xhosa people from the 1770s onward in areas near Port Elizabeth (Switzer 1993, 33–34). 8. The Xhosa polity was a segmentary state that contained a number of autonomous chiefdoms within it. These were politically controlled by chiefs from a royal lineage and the heads of aligned lineages in the royal clan (Switzer 1993, 34–35). 9. Central to the Zulu polity’s capability to resist European conquest were village-based and regionally linked age sets, which enabled large-scale mobilization of military regiments across a diverse cultural and geographic landscape. 10. Infectious-disease response also reflected protoracial policies. In 1755, a smallpox outbreak in the Cape Colony killed 963 settlers and one thousand slaves, and the temporary hospitals set up to isolate the sick were divided along racial lines (De Beer 1986, 16–17). 11. The civilian commandos began in the early eighteenth century in response to the resistance from Khoisan peoples to European encroachment (Crais 1992, 42). 12. The British colonial administration was restructured in the 1820s to isolate the civil service from the patronage system that had characterized Dutch colonial rule (Switzer 1993, 82). 13. The Hottentot Proclamation, which was enacted by measures in 1809 and 1812, compelled Khoisan peoples to work for colonists and their children to serve as apprentices for a ten-year period, which could last until they had reached twenty-five years of age (Switzer 1993, 83). See also Lester (1996, 28). 14. In 1807 slaves were prohibited from being imported into the Cape Colony, and in 1834 slavery was abolished (Crais 1992, 61).

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15. The Great Trek began in 1834 and would continue over the next two decades, with approximately fifteen thousand Afrikaners moving into the South African hinterland during this time (Switzer 1993, 85). 16. Alongside abolition, the Cape Colony established the nonracial 1853 Cape franchise, which limited voting based on a GBP 25 property qualification while the imperial governor retained some financial and all executive power (Crais 1992, 192). 17. The Cape-Xhosa wars, of which there were nine in total, were fought over a hundredyear period between 1779 and 1878 over settler demand for African land and labor (Switzer 1993, 52). 18. Trade between Xhosa and Europeans shifted over time toward settler coercion, leading to violence (Crais 1992, 48). However, it should be noted that indigenous black peasant producers were supplying raw materials for British merchants and contributed to the development of a domestic consumer market by the mid-nineteenth century (Marks and Trapido 1987, 5). 19. The segmentary Xhosa state was undermined in the 1840s and 1850s due to a loss of territory, colonial war, and the cattle-killing crisis (Switzer 1993, 87). 20. The Nongqawuse story is rooted in precolonial cosmology and highlights the historically significant role of diviners in Xhosa-speaking social formations (Crais 1992, 204–7). 21. The 1834–1835 Xhosa War led to the conquest of Xhosa lands by the British and the sale of conquered territory to British settlers, a boom in wool production, and the migration of dispossessed Xhosa people into the Cape Colony as wage laborers (Crais 1992, 117–18). 22. As Jean Comaroff (1993) has shown, medical missionaries played a central role in constructing the African “native” as diseased and a source of contagion. But as they settled the colonial frontier and enabled the establishment of the colonial state, their role as healers was displaced by public health concerns that focused on hygiene and securing the labor of African people, each supporting the other in their efforts (306). 23. British Protestant missionaries had reached the Xhosa prior to the mid-nineteenth century, in the 1820s, building missions on land allocated by local chiefs (Switzer 1993, 113). 24. Presbyterians established a boarding school at Lovedale Mission in 1841 and encouraged children of settlers and missionaries to attend the school along with Xhosa youth (Switzer 1993, 129). 25. Etherington (2014) argues that the history of southern African is not one where European settlers swept away indigenous people in a genocidal wave of colonial violence, as in the United States and Australia, but one where African social formations largely held their ground until the mid-nineteenth century, adapting to the new technologies introduced by settler colonists (1). 26. The Cape and Natal colonies had medical institutions that mirrored those of Britain in the nineteenth century, but they were reserved for settler populations. For example, the 1893 Hospitals Act in the Cape Colony led to more hospital facilities being built in smaller towns and subsidized by the Cape government (WHO 1983, 87). 27. Etherington (2014) rejects the mfecane hypothesis, following Cobbing (1988), who posits that the slave trade and increased raiding were important factors in social disruption but that this was not a novel process initiated by Zulu expansion. Relatedly, Etherington argues that the scale of violence in southeast Africa during the nineteenth century has been exaggerated and that the open grasslands of the highveld were likely always sparsely populated, rather than having been depopulated during the mfecane (Etherington 2014, xx–xxii). 28. Approximately 1,500 trekboers were issued grazing permits in the eastern reaches of the Cape Colony in 1703. These migrating stock farmers controlled large tracts of land beyond the control of the Dutch colonial polity (Switzer 1993, 41–42).

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29. As Clifton Crais (2003) outlines, the cultural and political technologies that were deployed to subjugate indigenous peoples were formed through encounters between colonial bureaucrats and African social formations, a crosscultural encounter where the categories for mutual understanding were actively constructed, rather than a process where a premade set of governing techniques and tools were applied to African peoples. 30. The rinderpest outbreak started in the horn of Africa, in Somaliland in 1889, and by 1892 it had shifted to Zambia before spreading to Cape Town by 1897. The outbreak was the flash point for a series of political uprisings where African social formations attempted to overthrow colonial rule, as occurred in Lesotho against the British, for example. However, as Charles Van Onselen emphasizes, rinderpest also led to political tension and opportunism within and between African societies (1972, 473, 479). 31. As Shula Marks (1986) outlines, traditional authorities helped to “manufacture consent” among black South African people in tandem with the exercise of state violence (39). 32. In the 1930s and 1940s, it was estimated that 75 percent of black South Africans in the Transkei, a Xhosa reserve, were infected with tuberculosis (WHO 1983, 90; see also Kark 2003; Packard 1989). 33. Within the migrant-labor system, mining houses backed by the state set low wages, and the cost of social reproduction was borne by the family in the rural reserves, who would also bear the cost of welfare and illness for the worker in old age (WHO 1983, 79). However, higher wages and cash-payment systems in the mines created a labor shortage for farmers in the Afrikaner republics and, perhaps more significantly, deprived Afrikaner settlers of skilled agricultural laborers (Delius 1983). 34. As Alan Jeeves (1975) outlines, the rise of the mining industry relied on the support of the South African state to coerce black South African laborers into mining employment and to coordinate conflict between mining houses. Mining policies were developed through collaboration rather than domination of state or capitalist elites over the others (4–5). 35. Shula Marks and Stanley Trapido (1979) argue that the restructuring of the South African state in the late nineteenth century aimed to reinforce class relations that supported the establishment of a mining-based capitalist society. In addition, they contend that this period must be contextualized within the logic of empire, rather than individual personalities or aims, as securing long-term interests in the South African mines was of critical geopolitical significance to the British Empire (52–54). 36. The Native Affairs Act (1920) led to the establishment of a Native Affairs Commission, which expanded the Glen Gray system of African local government and established “native advisory boards” in urban areas (Rich 1996, 29). 37. Only 15 percent of the Xhosa population living in the Ciskei Bantustan had land suitable for farming, and of that, only 6 percent of residents lived on plots large enough for subsistence agriculture (De Beer 1986, 52; see also WHO 1983, 154). 38. The South African Native National Congress saw the Natives Land Act as a social and economic revolution that threatened the achievements of the last century, particularly for the mission-educated black South African elite (Rich 1996, 18). 39. As Paul Rich (1996) notes, the Cape colonial government supported the development of a small class of freeholding African farmers to qualify for voting rights, a strategy that was supported by missionaries. The enfranchised black African “elite” participated in Cape politics, though with limited impact, leading to the belief that the twentieth century would see an end to racial segregation in South Africa (Rich 1996, 62).

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40. As Clifton Crais (2006) notes, the 1920s were a key phase for the development of segregation via the 1920 Native Affairs Act and the 1927 Native Administration Act (721). 41. In the late 1920s, it is estimated that one in five Afrikaners were “poor whites,” with the health and welfare of poor and working-class whites and blacks not dissimilar during this time period (WHO 1983, 80). 42. Wages from working in the South African mines were lower in 1911 than they had been in the 1890s, highlighting the capacity of the capital-state alliance to lower labor costs in the aftermath of the South African War (WHO 1983, 79). 43. As Owen Crankshaw (2005) notes, the historical period leading up to apartheid was marked by racial discrimination against black South Africans and class differences among the black South African population, which manifested via variable housing conditions and “different urban rights to middle class and working class people” (354). 44. While the black urban population grew, the 1923 Natives (Urban Areas) Act denied the right of black South Africans to own property in urban areas (Rich 1996, 30). 45. Andrew Spiegel (1995) notes that household composition in black urban areas was influenced by material pressures and a moral economy of generalized reciprocity that drove people to enact an individualized instrumentalism for domestic relations amid fluidity in the composition of urban households dating from the 1930s (91). 46. Despite growing black urban areas, government attempts to codify racial inequality continued. As Josette Cole (1987) describes, the Urban Areas Act (1923) formalized that black South Africans were only allowed to reside in urban areas for the purpose of work. However, the vast majority of black South African resisted the attempt at centralized surveillance, and by 1926 only 12 percent of private-sector laborers had registered in accordance with the act (5). 47. In 1935, Mpanza formed the Sofasonke Party, whose name means “let us die together,” and led the development of an informal settlement of twenty thousand people in the Orlando area of present-day Soweto (Callinicos 1993, 37). 48. As Shula Marks (1978) notes, traditional leaders were central elements of colonial South Africa, and traditional authority was viewed as the linchpin for maintaining social order. 49. During the 1940s, in the face of rising militancy, the state extended social welfare provisions to black South Africans including pensions for the aged and blind and a feeding scheme for schoolchildren (WHO 1983, 81). 50. The 1940s saw the expansion of black urban employment, trade unions, and growing political activity, and the African urban population doubled between 1939 and 1952 (Lodge 1983, 1, 11). 51. Dr. H. Gluckman, then MP for Yeoville in Johannesburg, proposed a commission to investigate the best measures to ensure the health of all South Africa’s population, which led to the National Health Services Commission, also known as the Gluckman Commission (1942– 1944) (De Beer 1986, 15). 52. As Charles Simkins (1983) notes, the percentage of the black population living in rural Bantustans expanded from 39.1 percent in 1960 to 52.7 percent in 1980 because of forced removals and growing densification (Simkins 1983) 53. As Colin Murray (1987) emphasizes, the rural reserves became dense “slums” due to forced removals and the displacement of black South Africans from urban areas during apartheid, which also transferred political conflicts from urban to rural areas. The process was also accompanied by the diversion of state spending to the Bantustans and a deliberate end to housing development for black South Africans in urban areas (313–14).

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54. This wave of political resistance built on earlier practices developed in black urban social formations. For example, rising costs for staple foods and transportation during the 1940s were met by political action, such as the Alexandra bus boycotts of 1940 and 1945 or the Johannesburg squatters movement of 1994 and 1947 (Lodge 1983, 12). 55. Based on coordinated civil disobedience in urban centers across South Africa, the Defiance Campaign consisted of black South Africans committing minor offenses such as using white facilities at post offices and violating curfew and pass laws. While associated with the ANC, the Defiance Campaign also incorporated the South African Indian Congress and the Franchise Action Committee (Lodge 1983, 43). 56. However, the inclusive and nonracialist platform advocated for via the Freedom Charter alienated those within the ANC that maintained an African nationalist position. Led by Robert Sobukwe, ANC members that advocated for a solely black South African campaign against apartheid separated from the party and formed the Pan-Africanist Congress. 57. Not all of South Africa’s isolation was voluntary. Following the Rivonia Trials major international sporting bodies removed South Africa from their lists of members, effectively banning the country from formal participation in international sporting events. 58. It should be noted that Biko and Ramphele were life partners and also played leading roles as BCM activists. 59. As Ramphele (1993) underscores, barriers to accessing public sector health services included long lines and user fees (43–44). 60. Alongside the militarization of the state, the National Party pursued reformist policies during the 1970s, which were pushed for by economic actors and organizations and had their roots in earlier liberal policies in South Africa (Stadler 1987, 4). For a detailed analysis of the expansion of the nursing sector to include black South African workers, see Marks (1994). 61. Both urban and rural households were increasingly in flux by the 1980s, as women and children began moving back and forth from rural areas to cities, a development that grew out of uncertainty regarding migrant-labor earnings (Sharp 1987; Spiegel 1987). 62. Civic associations built on earlier organizational forms, such as residential representative bodies, and deployed strategies that included boycotts, strikes, stay-away campaigns, and civil disobedience (Bundy 2000, 27). 63. The UDF was publicly launched on August 20, 1983, in a community hall in Cape Town, however, 1,500 delegates and representatives from more than five hundred organizations formed the organization in a meeting prior to that event (Seekings 2000, 1–2).

Chapter 2 1. The policy-development capacity of the NPPHCN proved to be particularly influential during the negotiated political transition. See also NPPHCN (1986). 2. During this period Toms also established the Students’ Health and Welfare Centres Organisation, which reestablished health services to residents of the Cape townships via mobile units following the closure of the Crossroads clinic by the apartheid state. 3. For example, Toms presented at TAC’s Western Cape Provincial Congress on the future of HIV/AIDS programs in Cape Town in 2008. 4. The organization demonstrates the links between the human rights-oriented response to state violence during late apartheid and the first wave of South African HIV/AIDS activism. 5. The strategies employed to secure social, political, and economic autonomy varied across the continent. Two notable examples can be found in the Ujamaa (a Swahili word for “extended

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family”) approach taken in Tanzania and the African humanist path followed in Zambia. On Ujamaa, the work of Goran Hyden (1980) is particularly useful. Michael Burawoy (1972) offers a detailed account of how “Zambianization” unfolded as a social process. 6. The RDP was based upon the principle of “growth through redistribution,” rather than the “redistribution through growth” approach that had been proposed by both the South African business sector and international organizations. 7. At the time, this equated to nearly USD 7 billion. 8. Of the ZAR 21.7 billion invested in 1995, 42 percent was short-term. Of the remaining long-term capital investment, more than half involved nonresident purchases of securities, which are defined as long-term but in practice can often be very volatile (see Lowell et al. 1998, 45). 9. At the time, ZAR 20 million amounted to approximately USD 4 million. See also Fassin (2007, 37). 10. The implementation of the policy was also contingent upon the continued participation of the professional and voluntary associations that made up the National AIDS Coordinating Committee of South Africa. On this point, see Schneider and Stein (1997, 2001). 11. Despite the impact of these scandals on the HIV/AIDS alliance, activists continued to work with the ANC to push the HIV/AIDS response forward. Through the adoption of the Medicines and Related Substances Control Amendment Act (1997), the ANC asserted the right to acquire generic medicines to address the HIV/AIDS epidemic (Nattrass 2007, 50). Citing the World Trade Organization’s Trade-Related Aspects of Intellectual Property Rights agreement, forty-two pharmaceutical corporations sued the South African government to prevent the implementation of the Medicines Act. The United States government also threatened to put South Africa on a watch list for potential sanctions and lodged a complaint with the World Trade Organization (Fassin 2007, 68). During the ensuing legal action, United States vice president Al Gore actively pressured the ANC to accept a deal on reduced prices for antiretroviral drugs (Gevisser 2007, 739). Alongside the ANC’s legal challenge to global pharmaceutical corporations, the HIV/AIDS movement mounted a campaign of direct action and civil disobedience against the pricing system for AIDS drugs. TAC led a campaign to “name and shame” global pharmaceutical corporations to provide antiretroviral drugs at affordable prices, activating transnational networks of HIV/AIDS activists to pressure the United States into dropping its threats against the South African government. Its high point was the civil disobedience action led by TAC activist Zackie Achmat, who illegally imported five thousand fluconazole pills in October 2000 from Thailand, where they were generically produced (Robins 2004). The cost of one pill in Thailand at this time was ZAR 1.78 (USD 0.25), while in South Africa it cost ZAR 124.84 (USD 18.10) (Soal 2000). 12. At the time, this constituted nearly USD 3 million. 13. The Virodene scandal also provided ammunition to the ANC’s political opposition, with members of parliament attacking the Ministry of Health for their mismanagement and support for ethically questionable clinical trials (Fassin 2007, 44). In a harbinger of the politics to come, it emerged that a leading critic in the political opposition had received financial support from pharmaceutical companies, a fact quickly seized upon by members of the ANC. On this point, see Fassin (2007, 39). 14. As indicated by the institution’s name, the Medicines Control Council regulates the approval of medicines in South Africa. 15. In order to qualify for funding from the Global Fund and to be designated as the organization to oversee the disbursement of funds, SANAC’s composition had to include greater

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representation from civil society. SANAC’s expansion was required by the Global Fund for it to be listed as South Africa’s country coordinating mechanism for overseeing the disbursement of funding. However, the development of national coordinating institutions to include broader representation was promoted by the Joint United Nations Programme on HIV/AIDS and the United Nations High Commissioner for Human Rights following the success of a similar institutional configuration in cutting HIV/AIDS prevalence in Uganda. On this point, see Papadakis (2006). 16. The quote has been slightly edited to obscure the gender of the research participant and to ensure anonymity. 17. Here, the research participant is referring to the minister of health, Dr. Manto Tshabalala-Msimang. 18. The name of the sector has been omitted to maintain the research participant’s anonymity. 19. To date, Dubula has served as the general secretary of TAC, as the national representative for people living with HIV/AIDS at SANAC, and as a commissioner for the UNAIDS High Level HIV Prevention Commission. She is an advisor to national government on medicines procurement and delivery and serves on the board of directors for several social justice oriented nongovernmental organizations. As a leading HIV/AIDS activist, Dubula represents the shifting demographics of HIV/AIDS activism that emerged during the second wave. 20. Reflecting the patriarchal character of South African society, gender imbalances remain an issue within TAC, particularly with respect to leadership positions. However, the rise of black South African women to important positions within the HIV/AIDS movement and state and international institutions is an important legacy of second-wave HIV/AIDS activism.

Chapter 3 1. A pseudonym has been utilized to protect the identity of the research participant. 2. The name of the newspaper is withheld in order to maintain anonymity. 3. Taken in isolation, these developments might appear to be government officials simply dismissing the inputs of HIV/AIDS activists and appointing themselves as heads of relevant committees. But the broader context reveals a correlation between institutional intransigence within SANAC and limited access to HIV/AIDS treatment in the South African public health sector. 4. In terms of contextualizing Francis’s statement, it is important to first note that the process of developing and negotiating the adoption of the NSP was channeled through SANAC. Since SANAC was responsible for HIV/AIDS policy development, the process of developing, implementing, and overseeing the NSP is one that cannot be extricated from the restructured national health institution. 5. A pseudonym has been utilized to protect the identity of the research participant. 6. Based upon an average South African rand / US dollar exchange rate of ZAR 7.56 / USD 1 for 2008, this amounted to approximately USD 3.97 million. 7. Based upon an average South African rand / US dollar exchange rate of ZAR 7.56 / USD 1 for 2008, this amounted to approximately USD 833,333. 8. A pseudonym has been utilized to protect the identity of the research participant. 9. As Steven pointed out, HAART only became available in the South African public health sector in 2004, following the development of a comprehensive HIV/AIDS treatment plan that impacted pregnant women, so there were changes to policy but none that focused specifically on PMTCT.

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10. In South Africa’s quasi-federal political system, national institutions develop policy norms while provincial institutions develop implementation strategies based on them (Friedman and Kihato 2004). 11. A pseudonym has been utilized to protect the identity of the research participant. 12. Thus, the HIV/AIDS movement appropriated biomedical knowledge in order to support their political goals within South Africa—a campaign that was buttressed by transnational actors and international organizations (Comaroff 2007).

Chapter 4 1. St. George’s Cathedral operated as a central node of the anti-apartheid campaign in the Western Cape and Cape Town during the 1980s. 2. Coverage of Madlala-Routledge’s abrupt sacking was also discussed in international news outlets, including the New York Times, and leading academic journals, such as the Lancet. 3. A pseudonym has been utilized to protect the identity of the research participant. 4. A pseudonym has been utilized to protect the identity of the research participant. 5. As outlined in Chapter 2, at this time the ANC’s AIDS-dissident faction had taken the position that ART was poisonous and had to be tested in Africa prior to being included in the public sector response to the epidemic. 6. The ANC managed to successfully wrest control of the Western Cape province in the 2004 elections through a political alliance with New National Party leadership. As the political fortunes of the New National Party waned, party leadership negotiated an alliance with the ANC that secured political control for the ruling party in the Western Cape. As a result of the alliance, the New National Party voted to disband itself and was consolidated into the ANC during the controversial “floor crossing” period in August 2005. As a result, political figures who had once worked within the apartheid state were now ANC members. 7. Uys had cut his teeth as a politician in the National Party in the mid-1980s in the Cape Town suburb of Kuils River and retained his position after the political transition as part of the New National Party. A career politician, Uys fulfilled several roles on the Cape Metropolitan Council and in the National Assembly before assuming his role as provincial health minister. 8. A pseudonym has been utilized to protect the identity of the research participant. 9. The unapproved trial and its effects on local politics in Khayelitsha are discussed further in Chapter 5. 10. “Khayelitsha” is an IsiXhosa word that roughly translates to “new home.” 11. A pseudonym has been utilized to protect the identity of the research participant. 12. A pseudonym has been utilized to protect the identity of the research participant. 13. A pseudonym has been utilized to protect the identity of the research participant. 14. A pseudonym has been utilized to protect the identity of the research participant. 15. A pseudonym has been utilized to protect the identity of the research participant. 16. The quotation has been reconstructed based on my research notes from the meeting. 17. MSATs, which will be analyzed in depth in Chapter 5, are coordinating institutions that gathered information on the activities of community-based organizations addressing the HIV/ AIDS epidemic in each of Cape Town’s health subdistricts. 18. The quotation has been reconstructed based on my research notes from the meeting. 19. A pseudonym has been utilized to protect the identity of the research participant. 20. The MSATs served as local coordinating structures for the nonstate community-based HIV/AIDS response. Located in each health subdistrict for the Cape Metropole district, the

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institutions were supported by funding from both the South African state and the Global Fund. The MSATs are discussed in greater depth in Chapter 5. 21. The quotation has been reconstructed based on my research notes from the meeting. 22. The quotation has been reconstructed based on my research notes from the meeting. 23. The quotation has been reconstructed based on my research notes from the meeting. 24. Our conversation presaged a critical assessment of the NSP-PSP policy process published by the ALN in the organization’s journal, AIDS Legal Quarterly (Van der Schaaf 2008). 25. The quotation has been reconstructed based on my research notes from the meeting. 26. The quotation has been reconstructed based on my research notes from the meeting. 27. The quotation has been reconstructed based on my research notes from the meeting. 28. Although I regularly used my computer to access the internet I was unable to find the “interactive” mechanism on the WC-Nacosa website for submissions to the PSP process. I informed members of the organization of this at the West Coast consultative meeting held in Piketberg on April 17, 2008. At that time, they informed me that they had not yet received feedback from any of the policy consultations through their website.

Chapter 5 1. A pseudonym has been utilized to protect the identity of the research participant. 2. The announcement ended the Western Cape’s designation as a Coloured Labour Preference Area, which entailed strict controls and sharp limits on the numbers of black South Africans who could legally seek work and residence in the province (Cook 1986). 3. Squatter camps had been subject to increased abuse from local authorities following the passage of amendments to the Prevention of Illegal Squatting Act in 1976, 1977, and 1980 (Cook 1986). 4. It is important to situate this depiction of population migration within the late apartheid period. It fed into existing fears of “black peril” (swart gevaar) and urban unrest aimed at toppling the state. 5. Khayelitsha’s establishment was accompanied by the decision to cancel the planned provision of services to other squatter areas in Cape Town, enacting the logic of racial containment that was typical of apartheid urban planning (Cook 1986). 6. A “day hospital” provides a community with a trauma ward, a maternity-and-obstetrics ward, a pharmacy, and access to primary care services. 7. This quotation was reconstituted on the basis of interview notes taken by the author. A shebeen is a name for a bar or pub in a township that does not have a formal government license to serve alcohol. Since it was illegal for Africans to brew their own beer or produce their own spirits under apartheid, maintaining a shebeen was an act of defiance. Notably, many shebeens were owned and operated by women who oversaw the brewing of traditional African beer. 8. Partners in Health initially focused their work on tuberculosis and HIV/AIDS in rural Haiti, carrying out pioneering work on community-oriented care that led to sharp improvements in uptake and adherence to tuberculosis and HIV/AIDS treatment regimens. 9. A pseudonym has been utilized to protect the identity of the research participant. 10. Ukuvula is a pseudonym for the area of Khayelitsha where Siphiwe lived. The name of the area has been changed to protect Siphiwe’s identity. 11. Ja translates to “yes” in Afrikaans, but it is utilized by South Africans across ethnic groups 12. Phansi is an isiXhosa word that roughly translates to “down.”

Notes to Pages 151–167

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13. In South Africa’s post-apartheid system of political representation, people vote for political parties rather than for particular candidates. Ward councilors and other political representatives are named by their parties to particular posts rather than directly standing for office in a given ward, district, or province. 14. These calculations are based upon an average South African rand / US dollar exchange rate of ZAR 7.56 / USD 1 for 2008. 15. A pseudonym has been utilized to protect the identity of the research participant.

Chapter 6 1. A pseudonym has been utilized to protect the identity of the research participant. 2. Kumiko Makino (2009) emphasizes that the government’s openness to policy input from NGOs and the HIV/AIDS movement was a significant factor in the success of the campaign for treatment access. Whether one takes the positive liberties framework of South Africa’s constitution or the rights-based approach to HIV/AIDS, these outcomes were the direct result of extended negotiations during the political transition, and they were carried forward through the alliancebuilding tactics of second-wave HIV/AIDS activism that enabled the HIV/AIDS movement to work within the state. Indeed, first-wave HIV/AIDS activists created the rights-based approach, organizations, and policies that enabled the HIV/AIDS movement’s subsequent success. 3. The Integrated Development Planning (IDP) process is another key example of postapartheid policy and institutions being modeled on consultative decision-making processes developed during the late apartheid era. Growing out of the political precedents set by urban civics organizations in Alexandra township during late apartheid, the IDP process emphasizes broad-based consultation with communities in order to develop comprehensive communitydevelopment strategies. The IDP became a required aspect of urban planning with the Local Government: Municipal Systems Act (2000), concretizing consultative and democratic principles as national law in South Africa. 4. Created in 1995, NEDLAC is a hybrid civil-society-and-government institution modeled on consultations that occurred between political and economic actors, organizations, and institutions during the negotiated political transition. NEDLAC serves as an important venue for the resolution of pressing socioeconomic challenges in post-apartheid South Africa, and it was modeled on political practices developed during the late apartheid era. 5. Court cases were filed against the South African government by “big pharma” and the threat of sanctions was broached as the US interpreted the act as contravening the “trade-related aspects of intellectual property and services” clause of the World Trade Organization. 6. The ANC also implemented Broad-Based Black Economic Empowerment (BBBEE), which facilitated asset transfers to historically disenfranchised communities. See also Freund (2007) 7. Historical debates on the rise of capitalism are relevant here. In contradistinction to Marx’s (1977 [1867]) emphasis on the industrial process, Polanyi (2001) theorizes the rise of capitalism as facilitated via the development of a supportive institutional framework. In his view, the emergence of capitalism was contingent on the development of an institutional environment that could sustain social reproduction amid the dislocation produced by a transformation in the mode of production. For Polanyi, the institutions of the state worked in concert with the “forms of integration” through which social reproduction occurred. On this point, Polanyi (1977, 36) was primary concerned with the way in which reciprocity, redistribution, and exchange governed economic life.

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8. Unequal gender dynamics within TAC are a long-standing point of critique of the organization. Despite forming the majority of the organization’s members, women were historically underrepresented in leadership positions (Friedman and Mottiar 2004). Participant observation with TAC reflected these observations, to a degree, as leadership varied at different levels of the organization. While the organization’s national leadership was primarily male when I began my research, following the 2008 national elections TAC’s leaders were two women: Nonkosi Khumalo and Vuyiseka Dubula. In addition, the leaders of the Western Cape provincial office, where I carried out extensive fieldwork, were women. Men held leadership positions at the district office based at Site B in Khayelitsha. Thus, rather than a simple bifurcation of male leaders and female members, the actual situation was more complex. 9. The ANC defined its political interests in relation to transnational forces, with the opinion of biomedical experts within international scientific forums proving significant following the 2006 International AIDS Conference in Toronto. Certainly, the position of the ruling party on HIV/AIDS treatment has oscillated over time. The story outlined in this book reveals many shifts and countercurrents in this respect. It was presumably only after moderate elements of the ANC and the other members of the ruling alliance saw the continued exclusion of TAC and other HIV/AIDS organizations as a threat to their own power that they were incorporated into SANAC and offered the means to transform treatment access in South Africa’s public health sector.

Afterword 1. A pseudonym has been utilized to protect the identity of the research participant. 2. As Martin (1970) and Rabaka (2011) note, Fanon’s theories grew out of the thought of Hegel, Marx, Sartre, and Césaire, and they were predicated on a transformation or “stretching” of Marx’s thought to address the colonial situation. 3. Fanon’s emphasis on transformation through the pursuit of freedom has led some to describe his thought as “metamorphic” (Mbembe 2012). 4. As Nigel Gibson (2011) outlines, Steve Biko and others carried forward Fanon’s thought in South Africa through their work with the Black Consciousness Movement. In addition, Gibson argues that new social movements such as Abahlali baseMjondolo have developed forms of political practice aimed at cultivating humanity based on the principles of Ubuntu philosophy, which underscores the revolutionary potential of Fanon’s thought for transforming South African society. 5. A pseudonym has been utilized to protect the identity of the research participant.

REFERENCES

Abdullah, Fareed. 2004. “The Complexities of Implementing Antiretroviral Treatment in the Western Cape Province of South Africa.” Development Update 5 (3): 245–64. Abrams, Philip. 1988 [1977]. “Notes on the Difficulty of Studying the State.” Journal of Historical Sociology 1 (1): 58–89. Achmat, Zackie. 1995. “My Childhood as an Adult Molester: A Salt River Moffie.” In Defiant Desire: Gay and Lesbian Lives in South Africa, edited by Mark Gevisser and Edwin Cameron, 325–47. New York: Routledge. Achmat, Zackie, and Edwin Cameron. 1995. “Judges and Policy on AIDS: Prisons and Medical Ethics.” South African Law Journal 112 (1): 1–9. Agamben, Giorgio. 1998. Homo Sacer: Sovereign Power and Bare life. Palo Alto: Stanford University Press. Agamben, Giorgio. 2005. State of Exception. Chicago: University of Chicago Press. Allison, Anne, and Charles Piot. 2015. “Editing the Times.” Cultural Anthropology 30 (4): 525–30. Altman, Denis. 2001. Global Sex. Chicago: University of Chicago Press. Altman, Lawrence K. 2006. “U.N. Official Assails South Africa on its Response to AIDS.” New York Times, August 19, 2006. Anghie, Antony. 2004. Imperialism, Sovereignty, and the Making of International Law. Cambridge: Cambridge University Press. Annas, George. 2003. “The Right to Health and the Nevirapine Case in South Africa.” New England Journal of Medicine 38 (8): 750–54. Appadurai, Arjun. 1990. “Disjuncture and Difference in the Global Cultural Economy.” Theory, Culture, and Society 7 (2): 295–310. Aron, Janine, and Ibrahim Elbadawi. 1999. “Reflections on the South African Rand Crisis of 1996 and Its Consequences.” CSAE Working Paper Series 1999–2013. Centre for the Study of African Economies. Oxford: University of Oxford. Asad, Talal. 1973. “Introduction.” In  Anthropology & the Colonial Encounter, edited by Talal Asad, 9–21. London: Ithaca Press. Ashforth, Adam. 2005. Witchcraft, Violence, and Democracy in South Africa. Chicago: University of Chicago Press. Baer, Hans, Merrill Singer, and Ida Susser. 2003. Medical Anthropology and the World System. New York: Praeger. Baker-Cristales, Beth. 2008. “Magical Pursuits: Legitimacy and Representation in a Transnational Political Field.” American Anthropologist 110 (3): 349–59.

208

References

Bank, Andrew. 2013. Introduction to Inside African Anthropology: Monica Wilson and Her Interpreters, edited by Andrew Bank and Leslie J. Bank, 1–36. New York: Cambridge University Press. Barth, Frederik. 1998 [1969]. Ethnic Groups and Boundaries: The Social Organization of Cultural Difference. Long Grove: Waveland. Bateman, Chris. 2008. “Ivan Toms: A Selfless Model of Social Conscience.” South African Medical Journal 98 (5): 338–40. Bayart, Jean-François. 1993. The State in Africa: The Politics of the Belly. Translated by Mary Harper, Christopher Harrison, and Elizabeth Harrison. New York: Longman. BBC News. 2014. “HIV Drugs ‘Boost South African Life Expectancy.’” August 1, 2014. http:// www.bbc.com/news/world-africa-28592255. Bear, Laura. 2016. Navigating Austerity: Currents of Debt Along a South Asian River. Stanford: Stanford University Press. Benatar, Solomon R. 2001. “South Africa’s Transition in a Globalizing World: HIV/AIDS as a Window and a Mirror.” International Affairs 77 (2): 347–75. Beresford, Belinda. 2007. “Baby Mortality Bombshell: MRC Report Says One in Five Infant Deaths Is Avoidable.” Mail & Guardian, August 17, 2007. Bernal, Victoria, and Inderpal Grewal. 2014. “Introduction: The NGO Form: Feminist Struggles, States, and Neoliberalism.” In Theorizing NGOs: States, Feminisms, and Neoliberalism, edited by Victoria Bernal and Inderpal Grewal, 1–18. Durham: Duke University Press. Bernard, H. Russell. 2011. Research Methods in Anthropology. 5th ed. Lanham: Altamira. Biehl, João. 2007. “Pharmaceuticalization: AIDS Treatment and Global Health Politics.” Anthropological Quarterly 80 (4): 1083–1126. Biehl, João. 2008. “Drugs for All: The Future of Global AIDS Treatment.” Medical Anthropology 27 (2): 99–105. Biehl, João. 2016. “Theorizing Global Health.” Medicine, Anthropology, Theory 3 (2): 127–42. Biehl, João, and Adriana Petryna. 2014. “Peopling Global Health.” Saúde e Sociedade 23 (2): 376–89. Boehringer Ingelheim Pharmaceuticals. 2000. “Boehringer Ingelheim Offers VIRAMUNE (Nevirapine) Free of Charge to Developing Economies for the Prevention of HIV-1 Motherto-Child Transmission.” July 7, 2000. Bond, Patrick. 1999a. A Case for Capital Controls. Paper commissioned by the Nedlac Labour Caucus. Johannesburg: University of Witwatersrand. Bond, Patrick. 1999b. “Global Economic Crisis: A View from South Africa.” Journal of WorldSystems Research 5 (2): 413–55. Bond, Patrick. 2003. Against Global Apartheid: South Africa Meets the World Bank, IMF and International Finance. Cape Town: University of Cape Town Press. Bond, Patrick. 2004. Talk Left, Walk Right: South Africa’s Frustrated Global Reforms. Durban: University of KwaZulu-Natal Press. Bonner, Philip. 1990. “The Politics of Black Squatter Movements on the Rand, 1944–1952.” Radical History Review 46 (7): 89–115. Brown, Hannah, and Ann H. Kelly. 2014. “Material Proximities and Hotspots: Toward an Anthropology of Viral Hemorrhagic Fevers.” Medical Anthropology Quarterly 28 (2): 280–303. Brunn, Stanley D., and Matthew W. Wilson. 2013. “Cape Town’s Million Plus Black Township of Khayelitsha: Terrae Incognitae and the Geographies and Cartographies of Silence.” Habitat International 39: 284–94.

References

209

Bundy, Colin. 1979. The Rise and Fall of the South African Peasantry. Berkeley: University of California Press. Bundy, Colin. 2000. “Survival and Resistance: Township Organizations and Non-Violent Direct Action in Twentieth Century South Africa.” In From Comrades to Citizens, edited by Glenn Adler and Jonny Steinberg, 26–51. London: Palgrave Macmillan. Burawoy, Michael. 1972. The Colour of Class on the Copper Mines: From African Advancement to Zambianization. Berkeley: University of California Press. Burawoy, Michael. 1991. “The Extended Case Method.” In Ethnography Unbound: Power and Resistance in the Modern Metropolis, edited by Michael Burawoy et al., 271–90. Berkeley: University of California Press. Butler, Anthony. 2005. “South Africa’s HIV/AIDS Policy, 1994–2004: How Can It Be Explained?” African Affairs 104 (417): 591–614. Buur, Lars. 2005. “The Sovereign Outsourced: Local Justice and Violence in Port Elizabeth.” In Sovereign Bodies: Citizens, Migrants, and States in the Postcolonial World, edited by Thomas Blom Hansen and Finn Stepputat, 218–38. Princeton: Princeton University Press. Callinicos, Luli. 1993. A Place in the City: The Rand on the Eve of Apartheid. Braamfontein: Ravan. Carlson, Cindy et al. 2010. “NSP Mid-Term Review.” Pretoria: South African National AIDS Council. Castells, Manuel. 1996. The Rise of the Network Society. The Information Age: Economy, Society and Culture, vol. 1. New York: Blackwell. CDC (Centers for Disease Control and Prevention). 2013. “Our Progress in South Africa.” Last reviewed May 23, 2013. http://www.cdc.gov/globalhealth/countries/southafrica/progress/. Chigwedere, Pride, George Seage III, Sofia Gruskin, Tun-Hou Lee, and Myron Essex. 2008. “Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa.” Journal of Acquired Immune Deficiency Syndrome 49 (4): 410–15. Chikane, Frank. 2013. The Things That Could Not Be Said: From A(ids) to Z(imbabwe). Johannesburg: Picador. Cobbing, Julian. 1988. “The Mfecane as Alibi: Thoughts on Dithakong and Mbolompo.” Journal of African History 29 (3): 487–519. Cock, Jacklyn. 2003. “Engendering Gay and Lesbian Rights: The Equality Clause in the South African Constitution.” Women’s Studies International Forum 26 (1): 35–45. Cole, Josette. 1987. Crossroads: The Politics of Reform and Repression, 1976–1986. Johannesburg: Ravan. Comaroff, Jean. 1985. Body of Power, Spirit of Resistance: The Culture and History of a South African People. Chicago: University of Chicago Press. Comaroff, Jean. 1993. “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body.” In Knowledge, Power, and Practice: The Anthropology of Medicine and Everyday Life, edited by Margaret Lock and Shirley Lindenbaum, 305–29. Berkeley: University of California Press. Comaroff, Jean. 2007. “Beyond Bare Life: AIDS, (Bio)Politics, and the Neoliberal Order.” Public Culture 19 (1): 197–219. Comaroff, Jean, and John L. Comaroff. 1991. Of Revelation and Revolution: Christianity, Colonialism, and Consciousness in South Africa. Chicago: University of Chicago Press. Comaroff, Jean, and John L. Comaroff. 2001. “Millenial Capitalism: First Thoughts on a Second Coming.” In Millenial Capitalism and the Culture of Neoliberalism, edited by Jean Comaroff and John L. Comaroff, 1–56. Durham: Duke University Press.

210

References

Comaroff, John L. 1989. “Images of Empire, Contests of Conscience: Models of Colonial Domination in South Africa.” American Ethnologist 16 (4): 661–85. Congress of South African Trade Unions. 2003. “Cosatu and the Treatment Action Campaign.” Cosatu Press Statements. March 30, 2003. http://www.cosatu.org.za/show.php?ID=976. Cook, Gillian P. 1986. “Khayelitsha: Policy Change or Crisis Response?” Transactions of the Institute of British Geographers 11 (1): 57–66. Cooper, Frederick. 2002. Africa Since 1940: The Past of the Present. New York: Cambridge. Coplan, David. 1985. In Township Tonight! South Africa’s Black City Music and Theatre. New York: Longman. Crais, Clifton C. 1992. White Supremacy and Black Resistance in Pre-Industrial South Africa: The Making of the Colonial Order in the Eastern Cape, 1770–1865. New York: Cambridge University Press. Crais, Clifton C. 2003. “Chiefs and Bureaucrats in the Making of Empire: A Drama from the Transkei, South Africa, October 1880.” American Historical Review 108 (4): 1034–56. Crais, Clifton C. 2006. “Custom and the Politics of Sovereignty in South Africa.” Journal of Social History 39 (3): 721–40. Crankshaw, Owen. 2005. “Class, Race and Residence in Black Johannesburg, 1923–1970.” Journal of Historical Sociology 18 (4): 353–93. Crehan, Kate. 2002. Gramsci: Culture and Anthropology. Berkeley: University of California Press. Crewe, Mary. 1992. AIDS in South Africa: The Myth and the Reality. London: Penguin Books. Croucher, Sheila. 2002. “South Africa’s Democratisation and the Politics of Gay Liberation.” Journal of Southern African Studies 28 (2): 315–30. Croucher, Sheila. 2011. “South Africa: Opportunities Seized in the Post-Apartheid Era.” In The Lesbian and Gay Movement and the State: Comparative Insights into a Transformed Relationship, edited by Manon Tremblay, David Paternotte, and Carol Johnson, 153–66. New York: Routledge. Cullinan, Kerry, and Anso Thom. 2005. “Official Nod for Voodoo Trials?” Mail & Guardian, October 28, 2005. Cullinan, Kerry, and Anne-Marie Lombard. 2008. “Health Chiefs Back Quackery to Treat HIV.” Sunday Times, May 18, 2008. Das, Veena, and Deborah Poole. 2004. “State and Its Margins: Comparative Ethnographies.” In Anthropology at the Margins of the State, edited by Veena Das and Deborah Poole, 3–34. Sante Fe: School of American Research. Davis, R. Hunt. 1976. “Charles T. Loram and an American Model for African Education in South Africa.” African Studies Review 19 (2): 87–100. De Beer, Cedric. 1986. The South African Disease: Apartheid Health and Health Services. London: Catholic Institute for International Relations. Decoteau, Claire. 2013. Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in PostApartheid South Africa. Chicago: University of Chicago Press. Deedat, Hameda, and Eddie Cottle. 2002. “Cost Recovery and Prepaid Water Meters: A Case Study in Madlebe, KZN.” In Cost Recovery and the Crisis of Service Delivery in South Africa, edited by David McDonald and John Pape, 81–97. South Africa: Rural Development Services Network. Delius, Peter. 1983. The Land Belongs to Us: The Pedi Polity, the Boers, and the British in Nineteenth-Century Transvaal. Berkeley: University of California Press.

References

211

Desai, Ashwin. 2002. We Are the Poors: Community Struggles in Post-Apartheid South Africa. New York: Monthly Review Press. Desai, Ashwin, and Richard Pithouse. 2004. “‘What Stank in the Past Is the Present’s Perfume’: Dispossession, Resistance and Regression in Mandela Park.” South Atlantic Quarterly 103 (4): 841–75. Douglas, Mary. 1986. How Institutions Think. Syracuse: Syracuse University Press. Dressler, William W., Kathryn S. Oths, and Clarence C. Gravlee. 2005. “Race and Ethnicity in Public Health Research: Models to Explain Health Disparities.” Annual Review of Anthropology 34: 231–52. Du Plessis, Max. 2007. “Professor John Dugard: A South African Perspective.” Leiden Journal of International Law 20 (4): 955–64. Dubow, Saul. 1995. Scientific Racism in Modern South Africa. New York: Cambridge University Press. Dugger, Celia. 2008. “Study Cites Toll of AIDS Policy in South Africa.” New York Times, November 25, 2008. Duménil, Gérard, and Dominic Lévy. 2005. “The Neoliberal (Counter-) Revolution.” In Neoliberalism: A Critical Reader, edited by Alfredo Saad-Filho and Deborah Johnston, 9–20. Ann Arbor: Pluto. The Durban Declaration. 2000. “The Durban Declaration.” Nature 406: 15–16. Durkheim, Emile. 1915. The Elementary Forms of Religious Life. London: George Allen. Edelman Marc. 2001. “Social Movements: Changing Paradigms and Forms of Politics.” Annual Review of Anthropology 30: 285–317. Edelman, Marc, and Angelique Haugerud. 2005. “Introduction: The Anthropology of Development and Globalization.” In The Anthropology of Development and Globalization: From Classical Political Economy to Contemporary Neoliberalism, edited by Marc Edelman and Angelique Haugerud, 1–74. Malden: Blackwell. Eisenstein, Hester. 2010. Feminism Seduced: How Global Elites Use Women’s Labor and Ideas to Exploit the World. Boulder: Paradigm. Epstein, A. L. 1958. Politics In An Urban African Community. Manchester: Manchester University Press. Etherington, Norman. 1988. “Natal’s Black Rape Scare of the 1870s.” Journal of Southern African Studies 15 (1): 36–53. Etherington, Norman. 2014. The Great Treks: The Transformation of Southern Africa 1815–1854. New York: Routledge. Falzon, Marc-Anthony. 2009. Introduction to Multi-Sited Ethnography: Theory, Praxis and Locality in Contemporary Research, edited by Marc-Anthony Falzon, 1–24. Surrey: Ashgate. Fanon, Frantz. 2004 [1961]. The Wretched of the Earth. New York: Grove. Farmer, Paul. 1992. AIDS and Accusation: Haiti and the Geography of Blame. Berkeley: University of California Press. Farmer, Paul. 2004. “An Anthropology of Structural Violence.” Current Anthropology 45 (3): 305–325. Fassin, Didier. 2007. When Bodies Remember: Experiences and Politics of AIDS in South Africa. Berkeley: University of California Press. Feinstein, Andrew. 2009. After the Party: Corruption, the ANC, and South Africa’s Uncertain Future. New York: Verso. Feinstein, Andrew. 2011. The Shadow World: Inside the Global Arms Trade. New York: Macmillan.

212

References

Feinstein, Charles. 2005. An Economic History of South Africa: Conquest, Discrimination, and Development. New York: Cambridge University Press. Feldman, Gregory. 2005. “Culture, State and Security in Europe: The Case of Citizenship and Immigration Policy in Estonia.” American Ethnologist 32 (4): 676–95. Ferguson, James. 1990. The Anti-Politics Machine: “Development,” Depoliticization, and Bureaucratic Power in Lesotho. Cambridge: Cambridge University Press. Ferguson, James. 1999. Expectations of Modernity: Myths and Meanings of Urban Life on the Zambian Copperbelt. Berkeley: University of California Press. Ferguson, James. 2006. Global Shadows: Africa in the Neoliberal World Order. Durham: Duke University Press. Ferguson, James. 2015. Give a Man a Fish: Reflections on the New Politics of Distribution. Durham: Duke University Press. Ferguson, James, and Akhil Gupta. 1997. “Culture, Power and Place: Ethnography at the End of an Era.” In Culture, Power and Place: Explorations in Critical Anthropology, edited by James Ferguson and Akhil Gupta, 1–32. Durham: Duke University Press. Ferguson, James, and Akhil Gupta. 2002. “Spatializing States: Towards an Ethnography of Neoliberal Governmentality.” American Ethnologist 29 (4): 981–1002. First, Ruth. 1977. The Mozambican Miner: A Study in the Export of Labour. Centre for African Studies. Maputo: Eduardo Mondlane University. First, Ruth. 1983. Black Gold: The Mozambican Miner, Proletarian and Peasant. New York: St. Martin’s Press. Fischer, Michael. 1999a. “Worlding Cyberspace: Toward a Critical Ethnography in Time, Space and Theory.” In Critical Anthropology Now: Unexpected Contexts, Shifting Constituencies, Changing Agendas, edited by George E. Marcus, 245–304. Sante Fe: School of American Research Press. Fischer, Michael. 1999b. “Emergent Forms of Life: Anthropologies of Late or Postmodernities.” Annual Review of Anthropology 28: 455–78. Fisher, William F. 1997. “Doing Good? The Politics and Antipolitics of NGO Practices.” Annual Review of Anthropology 26 (1): 439–64. Foucault, Michel. 1991. “Governmentality.” In The Foucault Effect: Studies in Governmentality, edited by Graham Burchell, Colin Gordon, and Peter Miller, 87–104. Chicago: University of Chicago Press. Fourie, Peter. 2006. The Political Management of HIV/AIDS in South Africa: One Burden Too Many? New York: Palgrave-MacMillan. Freund, Bill. 2007. “South Africa: The End of Apartheid and the Emergence of the ‘BEE Elite.’” Review of African Political Economy 34 (114): 661–78. Freund, Bill. 2013. “A Ghost from the Past: The South African Developmental State of the 1940s.” Transformation: Critical Perspectives on Southern Africa 81 (1): 86–114. Friedman, Steven and Caroline Kihato. 2004. “South Africa’s Double Reform: Decentralization and the Transition from Apartheid.” In Decentralization, Democratic Governance, and Civil Society in Comparative Perspective, edited by Philip Oxhorn, Joseph S. Tulchin, and Andrew D. Selee, 141–89. Washington, D.C.: Woodrow Wilson Press. Friedman, Steven, and Shauna Mottiar. 2005. “Rewarding Engagement: The Treatment Action Campaign and the Politics of HIV/AIDS.” Politics and Society 33 (4): 511–65. Gautney, Heather. 2009a. “The Globalization Movement and World Social Forum: From Protest to Politics.” In Engaging Social Justice: Critical Studies of 21st Century Transformation, edited by David Fasenfest, 135–60. Leiden: Brill.

References

213

Gautney, Heather. 2009b. Protest and Organization in the Alternative Globalization Era: NGOs, Social Movements, and Political Parties. New York: Palgrave Macmillan. Geertz, Clifford. 1983. Local Knowledge: Further Essays in Interpretive Anthropology. New York: Basic Books. Geffen, Nathan. 2010. Debunking Delusions: The Inside Story of the Treatment Action Campaign. Johannesburg: Jacana. Geiger, H. Jack. 1987. “Community-Oriented Primary Care: The Legacy of Sidney Kark.” American Journal of Public Health 83 (7): 946–47. Geissler, Paul Wenzler. 2014. “The Archipelago of Public Health: Comments on the Landscape of Medical Research in Twenty-First-Century Africa.” In  Making and Unmaking Public Health in Africa: Ethnographic and Historical Perspectives, edited by Ruth J. Prince and Rebecca Marsland, 231–56. Athens: Ohio University Press. Gevissser, Mark. 1999. “Simon Nkoli: South Africa’s First True Renaissance Man.” Poz, July 1, 1999. Gevisser, Mark. 2007. Thabo Mbeki: The Dream Deferred. Johannesburg: Jonathan Ball. Gibson, Nigel C. 2011. Fanonian Practices in South Africa: From Steve Biko to Abahlali baseMjondolo. Scotsville: UKZN Press. Gill, Lesley. 2000. Teetering on the Rim: Global Restructuring, Daily Life and the Armed Retreat of the Bolivian State. New York: Columbia University Press. Glick-Schiller, Nina. 2008. “Beyond Methodological Ethnicity: Local and Transnational Pathways of Immigrant Incorporation.” Willy Brandt Series of Working Papers in International Migration and Ethnic Relations. Malmö: University of Malmö. Glick-Schiller, Nina, Linda Basch, and Cristina Szanton Blanc. 1995. “From Immigrant to Transmigrant: Theorizing Transnational Migration.” Anthropology Quarterly 68 (1): 48–63. Gluckman, Max. 1940. “Analysis of a Social Situation in Modern Zululand.” Bantu Studies 14 (1): 1–30. Gluckman, Max. 1941. The Economy of the Central Barotse Plain. Livingstone: RhodesLivingstone Institute. Gluckman, Max. 1965. Politics, Law and Ritual in Tribal Society. Oxford: Basil Blackwell. Gramsci, Antonio. 1971. Selections from the Prison Notebooks. Translated and edited by Quintin Hoare and Geoffrey Nowell Smith. New York: International. Gray, Andy, and Caron Jack. 2008. “Health Legislation and Policy.” In South African Health Review, edited by Peter Barron and Josianne Roma-Reardon, 31–50. Durban: Health Systems Trust. Grebe, Eduard. 2011. “The Treatment Action Campaign’s Struggle for AIDS Treatment in South Africa: Coalition Building Through Networks.” Journal of Southern African Studies 37 (4): 849–68. Greenhalgh, Susan. 2003. “Planned Births, Unplanned Persons: ‘Population’ in the Making of Chinese Modernity.” American Ethnologist 30 (2): 196–215. Greenhalgh, Susan. 2008. Just One Child. Berkeley: University of California Press. Guay, Laura A. et al. 1999. “Intrapartum and Neonatal Single-Dose Nevirapine Compared with Zidovudine for Prevention of Mother-to-Child Transmission of HIV-1 in Kampala, Uganda: HIVNET 012 Randomised Trial.” Lancet 354 (9181): 795–802. Gumede, William Mervin. 2005. Thabo Mbeki and the Battle for the Soul of the ANC. Cape Town: Zebra. Gupta, Akhil. 1995. “Blurred Boundaries: The Discourse of Corruption, the Culture of Politics, and the Imagined State.” American Ethnologist 22 (2): 375–402.

214

References

Gupta, Akhil. 2012. Red Tape: Bureaucracy, Structural Violence, and Poverty in India. Durham: Duke University Press. Hansen, Thomas Blom, and Finn Stepputat. 2001. “Introduction: States of Imagination.” In States of Imagination: Ethnographic Explorations of the Postcolonial State, edited by Thomas Blom Hansen and Finn Stepputat, 1–38. Durham: Duke University Press. Hansen, Thomas Blom, and Finn Stepputat. 2006. “Sovereignty Revisited.”  Annual Review of Anthropology 35: 295–315. Harrison, Philip. 1992. “The Policies and Politics of Informal Settlement in South Africa: A Historical Perspective.” Africa Insight 22 (1): 14–22 Harrison, Faye V. 2002. “Global Apartheid, Foreign Policy, and Human Rights.”  Souls  4 (3): 48–68. Harrison, Faye V. 2005. “Introduction: Global Perspectives on Human Rights and Interlocking Inequalities of Race, Gender, and Related Dimensions of Power.” In Resisting Racism and Xenophobia: Global Perspectives on Race, Gender, and Human Rights, edited by Faye V. Harrison, 1–34. New York: Rowman Altamira. Harrison, Faye V. 2007. “Everyday Neoliberalism, Diminishing Subsistence Security, and the Criminalization of Survival: Gendered Urban Poverty in Three African Diaspora Contexts.” In  IUAES Inter Congress on Mega-Urbanization, Multi-Ethnic Society, Human Rights and Development, edited by Buddhadeb Chaudhuri and Sumita Chaudhuri, 82–103. New Delhi: Inter-India Publications. Hart, Keith. 2009. “A Human Economy for the Twenty-First Century.” The Memory Bank. November 11, 2009. http://thememorybank.co.uk/2009/11/30/a-human-economy-for-the -twenty-first-century/. Hartley, Windham. 2016. “Cleaning up SA’s R500bn Tender Machine.” Business Day Live. June 29, 2016. Harvey, David. 1989. The Condition of Postmodernity: An Enquiry into the Origins of Cultural Change. Oxford: Blackwell. Harvey, David. 2003. The New Imperialism. New York: Oxford University Press. Harvey, David. 2005. A Brief History of Neoliberalism. New York: Oxford University Press. Heller, Patrick. 2003. “Reclaiming Democratic Spaces: Civics and Politics in Posttransition Johannesburg.” In Emerging Johannesburg: Perspectives on the Postapartheid City, edited by Richard Tomlinson, Robert A. Beauregard, Lindsay Bremner, and Xolela Mangcu, 155–84. New York: Routledge. Heywood, Leslie, and Jennifer Drake. 1997. Introduction to Third Wave Agenda: Being Feminist, Doing Feminism, edited by Leslie Heywood and Jennifer Drake, 1–20. Minneapolis: University of Minnesota. Heywood, Mark, and Morna Cornell. 1998. “Human Rights and AIDS in South Africa: From Right Margin to Left Margin.” Health and Human Rights 2 (4): 61–82. Hibou, Béatrice. 2004. “Introduction: From Privatising the Economy to Privatising the State.” In Privatizing the State, edited by Béatrice Hibou, 1–47. New York: Columbia University Press. Hirsch, Alan. 2005. Season of Hope: Economic Reform Under Mandela and Mbeki. Scottsville: University of KwaZulu-Natal Press. Ho, Karen. 2009. Liquidated: An Ethnography of Wall Street. Durham: Duke University Press. Hogg, Alec. 2016. “Oilgate: How Insiders Stole R1.5bn in Sale of SA’s Strategic Oil Stockpile.” Fin24. August 23, 2016. https://www.fin24.com/BizNews/oilgate-how-insiders-stole-r15bn -in-sale-of-sas-strategic-oil-stockpile-20160823.

References

215

Holmes, Thalia. 2014. “Social Grants Beneficiaries More Than Doubled in 10 Years.” Mail & Guardian, June 19, 2014. Holston, James. 1999. “The Modernist City and the Death of the Street.” In Theorizing the City: The New Urban Anthropology Reader, edited by Setha Lowe, 245–76. New Brunswick: Rutgers University Press. Holston, James. 2008. Insurgent Citizenship: Disjunctions of Democracy and Modernity in Brazil. Princeton: Princeton University Press. Hunter, Mark. 2010. Love in the Time of AIDS: Inequality, Gender, and Rights in South Africa. Bloomington: Indiana University Press. Hyden, Goran. 1980. Beyond Ujamaa in Tanzania: Underdevelopment and an Uncaptured Peasantry. Berkeley: University of California Press. Iliffe, John. 2006. The African AIDS Epidemic: A History. Athens: Ohio University Press. Ingold, Tim. 2008. “Bindings Against Boundaries: Entanglements of Life in an Open World.” Environment and Planning A 40 (8): 1796–810. IOM (Institute of Medicine) et al. 2013. Evaluation of PEPFAR. Washington: National Academies Press. Jackson, John L. 2001. Harlem World: Doing Race and Class in Contemporary Black America. Chicago: University of Chicago Press. Jackson, Robert. 1990. Quasi-States: Sovereignty, International Relations and the Third World. Cambridge: Cambridge University Press. Janzen, Jonathan. 1992. Ngoma: Discourses of Healing in Central and Southern Africa. Berkeley: University of California Press. Jeeves, Alan. 1975. “The Control of Migratory Labour on the South African Gold Mines in the Era of Kruger and Milner.” Journal of Southern African Studies 2 (1): 3–29. Johnson, Leigh F., Margaret T. May, Rob E. Dorrington, Morna Cornell, Andrew Boulle, Matthias Egger, and Mary-Ann Davies. 2017. “Estimating the Impact of Antiretroviral Treatment on Adult Mortality Trends in South Africa: A Mathematical Modelling Study.” PLoS Medicine 14 (12): p.e1002468. Jones, Peris. 2005. “A Test of Governance: Rights-Based Struggles and the Politics of HIV/AIDS Policy in South Africa.” Political Geography 24: 419–47. Jones, Kate E., Nikkita G. Patel, Marc A. Levy, Adam Storeygard, Deborah Balk, John L. Gittleman, and Peter Daszak. 2008. “Global Trends in Emerging Infectious Diseases.” Nature 451 (7181): 990–93. Juris, Jeff. 2005. “Violence Performed and Imagined: Militant Action, the Black Bloc and the Mass Media in Genoa.” Critique of Anthropology 25 (4): 413–32. Juris, Jeff. 2008. “Spaces of Intentionality: Race, Class, and Horizontality at the United States Social Forum.” Mobilization 13 (4): 353–72. Juris, Jeff. 2012. “Reflections on #Occupy Everywhere: Social Media, Public Space and Emerging Logics of Aggregation.” American Ethnologist 39 (2): 259–79. Juris, Jeff, and Alex Khasnabish. 2013. “Introduction: Ethnography and Activism Within Networked Spaces of Transnational Encounter.” In Insurgent Encounters: Transnational Activism, Ethnography, and the Political, edited by Jeff Juris and Alex Khasnabish, 1–38. Durham: Duke University Press. Kahn, Brian, Abdel Senhanji, and Michael Walton. 1992. “South Africa: Macroeconomic Issues for the Transition.” Informal Discussion Papers on the Economy of South Africa. Johannesburg: World Bank Southern Africa Department.

216

References

Kadushin, Charles. 1968. “Power, Influence and Social Circles: A New Methodology for Studying Opinion-Makers.” American Sociological Review 33 (5): 685–99. Kapp, Clare. 2009. “Barbara Hogan: South Africa’s Minister of Health.” The Lancet 373 (9660): 291. Kearney, Michael. 1995. “The Local and the Global: The Anthropology of Globalization and Transnationalism.” Annual Review of Anthropology 24: 547–65. Kardas-Nelson, Mara. 2012. “The Task Is So Big.” NSP Spotlight. October 2, 2012. https://www .spotlightnsp.co.za/2012/10/02/the-task-is-so-big/. Kark, Sidney L. 2003 [1949]. “The Social Pathology of Siphilis in Africans.” International Journal of Epidemiology 32 (2): 181–86. Keene, Edward. 2002. Beyond the Anarchical Society: Grotius, Colonialism, and Order in World Politics. Cambridge: Cambridge University Press. Kingfisher, Catherine. 2013. A Policy Travelogue: Tracing Welfare Reform in Aotearoa / New Zealand and Canada. New York: Berghahn. Kings, Sipho. 2014. “How Officials Are Milking the State.” Mail & Guardian Online, November 21, 2014. https://mg.co.za/article/2014-11-20-how-officials-are-milking-the-state. Kenyon, Chris. 2006. “The Origins, Evolution and Outsourcing of HIV Denialism.” Southern African Journal of HIV Medicine 7 (4): 15–16. Khumalo, Nonkosi, and Jonathan Berger. 2008. “SANAC and the Implementation of the NSP.” In AIDS Law Project: 18-month review: July 2007–December 2008, edited by Jonathan Berger, 65–72. Johannesburg: ALP. Kinser, Amber E. 2004. “Negotiating Spaces For/Through Third Wave Feminism.” NWSA Journal 16 (3): 124–53. Lear, Martha Weinman. 1968. “The Second Feminist Wave.” New York Times Magazine, March 10, 1968. Leclerc-Madlala, Suzanne. 2008. “Age-Disparate and Inter-Generational Sex in Southern Africa: The Dynamics of Hypervulnerability.” AIDS 22 (December 2008): S17–S25. Lendvai, Noémi, and Paul Stubbs. 2007. “Policies as Translation: Situating Transnational Social Policies.” In Policy Reconsidered: Meanings, Politics and Practices, edited by Susan Hodgson and Zoë Irving, 173–89. Bristol: Policy Press. Leibbrandt, Murray, Eva Wegner, and Arden Finn. 2011. “The Policies for Reducing Income Inequality and Poverty in South Africa.” Working Paper Number 64. Cape Town: South Africa Labour and Development Research Unit (SALDRU). Lester, Alan. 1996. From Colonisation to Democracy: A New Historical Geography of South Africa. New York: B. Tauris Publishers. Lévi-Strauss, Claude. 1969 [1949]. The Elementary Structures of Kinship. Boston: Beacon. Levitt, Peggy, and Nina Glick-Schiller. 2004. “Conceptualizing Simultaneity: A Transnational Social Field Perspective on Society.” International Migration Review 38 (145): 595–629. Lewis, David, and David Mosse. 2006. “Theoretical Approaches to Brokerage and Translation in Development.” In Development Brokers and Translators: The Ethnography of Aid and Agencies, edited by David Mosse and David Lewis, 1–26. West Hartford: Kumarian. Lewis, David, and Mark Schuller. 2017. “Engagements with a Productively Unstable Category: Anthropologists and Non-Governmental Organizations. Current Anthropology 58 (5): 634–51. Lodge, Tom. 1983. Black Politics in South Africa Since 1945. New York: Longman. Lowe, Setha. 1996. “Spatializing Culture: The Social Production and Social Construction of Public Space in Costa Rica.” American Ethnologist 23 (4): 861–79.

References

217

Lowell, Julia F., C. Richard Neu, and Daochi Tong. 1998. Financial Crisis and Contagion in Emerging Market Countries. Washington: Rand Corporation. Mabin, Alan. 1992. “Dispossession, Exploitation and Struggle: An Historical Overview of Urbanization in South Africa.” In The Apartheid City and Beyond: Urbanization and Social Change in South Africa, edited by D.M. Smith, 13–24. Johannesburg: University of Witwatersrand Press. Maclennan, Ben. 2006. “Protest leads to arrest of TAC members.” Mail & Guardian. Accessed at http://mg.co. za/article/2006-08-18-protest-leads-to-arrest-of-tac-members on October 2, 2014. Machiavelli, Niccolò. 2005 [1922]. The Prince. New York: Oxford University Press. Maeckelbergh, Marianne. 2011. “Doing Is Believing: Prefiguration as Strategic Practice in the Alterglobalization Movement.” Social Movement Studies 10 (1): 1–20. Magubane, Bernard. 1971. “A Critical Look at the Indices Used to Study Social Change in Colonial Africa.” Current Anthropology 12 (4/5): 419–45. Mahajan, Sandeep. 2014. “Overview.” In Economics of South African Townships, edited by Sandeep Mahajan, 1–30. Washington: International Bank for Reconstruction and Development. Makino, Kumiko. 2009. “Institutional Conditions for Social Movements to Engage in Formal Politics: The Case of AIDS Activism in Post-Apartheid South Africa.” In Protest and Social Movements in the Developing World, Edited by Shinichi Shigetomi and Kumiko Makino, 110–33. Northampton: Edward Elgar. Malinowski, Bronislaw. 2014 [1922]. Argonauts of the Western Pacific: An Account of Native Enterprise and Adventure in the Archipelagoes of Melasian New Guinea. New York: Routledge. Mamdani, Mahmood. 1996. Citizen and Subject: Contemporary Africa and the Legacy of Late Colonialism. Princeton: Princeton University Press. Marais, Hein. 2005. Buckling: The Impact of AIDS in South Africa. Pretoria: Centre for the Study of AIDS and the University of Pretoria. Marcus, George. 1995. “Ethnography of the World System: The Emergence of Multi-Sited Ethnography.” Annual Review of Anthropology 24: 95–117. Marks, Shula. 1978. “Natal, the Zulu Royal Family and the Ideology of Segregation.” Journal of Southern African Studies 4 (2): 172–94. Marks, Shula. 1986. The Ambiguities of Dependence in South Africa: Class, Nationalism, and the State in Twentieth-Century Natal. Baltimore: Johns Hopkins University Press. Marks, Shula. 1994. Divided Sisterhood: Race, Class and Gender in the South African Nursing Profession. New York: Palgrave Macmillan. Marks, Shula. 2002. “An Epidemic Waiting to Happen? The Spread of HIV/AIDS in South Africa in Social and Historical Perspective.” African Studies 61 (1): 13–26. Marks, Shula, and Stanley Trapido. 1979. “Lord Milner and the South African State.” History Workshop, 8: 50–80. Marks, Shula, and Stanley Trapido. 1987. “The Politics of Race, Class, and Nationalism.” In The Politics of Race, Class, and Nationalism in Twentieth Century South Africa, edited by Shula Marks and Stanley Trapido, 1–70. New York: Longman. Martin, Tony. 1970. “Rescuing Fanon from the Critics.” African Studies Review 13 (3): 381–99. Marx, Karl. 1977 [1867]. Capital. Vol. 1. New York: Vintage Books. Maskovsky, Jeff. 2003. “Global Justice in the Post-Industrial City: Beyond the Local/Global Divide.” in Wounded Cities: Reconstruction and Deconstruction in a Globalized World, edited by Jane Schneider and Ida Susser, 149–72. New York: Berg.

218

References

Mauss, Marcel. 2015 [1925]. The Gift: The Form and Reason for Exchange in Archaic Societies. Chicago: HAU Books. Mayer, Philip, and Iona Mayer. 1971 [1961]. Townsmen or Tribesmen: Conservatism and the Process of Urbanization in a South African City. Cape Town: Oxford University Press. Mayer, Philip, ed. 1980. Black Villagers in an Industrial Society: Anthropological Perspectives on Labour Migration in South Africa. Oxford: Oxford University Press. Mayosi, Bongani M., and Solomon R. Benatar. 2014. “Health and Health Care in South Africa—20 Years After Mandela.” New England Journal of Medicine 371 (14): 1344–53. Mazower, Mark. 2008. “Foucault, Agamben: Theory and the Nazis.” Boundary 2 35 (1): 23–34. Mbali, Mandisa. 2013. South African HIV/AIDS Activism and Global Health Politics. New York: Palgrave Macmillan. Mbembe, Achille. 2001. On the Postcolony. Berkeley: University of California Press. Mbembe, Achille. 2003. “Necropolitics.” Translated by Libby Meintjes. Public Culture 15 (1): 11–40. Mbembe, Achille. 2012. “Metamorphic Thought: The Works of Frantz Fanon.” African Studies 71 (1): 19–28. Mbeki, Thabo. 2016. “Mbeki Addresses ‘Aids Denialism’ Criticisms.” Mail & Guardian. March 7, 2016. McDonald, David, and Greg Ruiters. 2005. “Introduction: From to Private (to Public Again?).” In The Age of Commodity: Water Privatization in Southern Africa, edited by David McDonald and Greg Ruiters, 1–12. London: Earthscan. McGregor, Liz. 2009: “Garlic, Olive Oil, Lemons, Beetroot.” In The Virus, Vitamins, and Vegetables: The South African HIV/AIDS Mystery, edited by Kerry Cullinan and Anso Thom, 130–42. Johannesburg: South Africa. McIntyre, Diane, and Michael Thiede. 2007. “Health Care Financing and Expenditure.” In South African Health Review, edited by S. Harrison, R. Bhana, and A. Ntuli, 35–46. Durban: Health Systems Trust. McKay, Ramah. 2017. Medicine in the Meantime: The Work of Care in Mozambique. Durham: Duke University Press. McKinley, Dale T. 1997. The ANC and the Liberation Struggle: A Critical Political Biography. London: Pluto Press. McNeil, Fraser. 2011. AIDS, Politics and Music in South Africa. New York: Cambridge University Press. Médecins Sans Frontières, Western Cape Province Department of Health, City of Cape Town Department of Health, University of Cape Town Infectious Disease Epidemiology Unit. 2008. “Comprehensive TB/HIV Services at Primary Health Care Level Khayelitsha Annual Activity Report 2007a–2008.” Cape Town: MSF. http://www.msf.or.jp/library/pressreport /pdf/2009_hiv01.pdf. Michie, Jonathan, and Vishnu Padayachee. 1998. “Three Years After Apartheid: Growth, Employment and Redistribution?” Cambridge Journal of Economics 22 (5): 623–35. Mintz, Sidney. 1985. Sweetness and Power: The Place of Sugar in the World Economy. New York: Penguin Books. Mitchell, J. Clyde. 1956. The Kalela Dance: Aspects of Social Relationships Among Urban Africans in Northern Rhodesia. Rhodes-Livingstone Papers 27. Manchester: Manchester University Press. Mitchell, Timothy. 1991. The Limits of the State: Beyond Statist Approaches and Their Critics. American Political Science Review 85 (1): 77–96.

References

219

Mitchell, Timothy. 1999. “Society, Economy, and the State Effect.” In State/Culture: StateFormation After the Cultural Turn, edited by George Steinmetz, 76–97. Ithaca: Cornell University Press. Mitchell, Timothy. 2002. Rule of Experts: Egypt, Techno-Politics, Modernity. Berkeley: University of California Press. Mollenkopf, John, and Manuel Castells. 1992. The Dual City: Restructuring New York. New York: Russell Sage Foundation. Moodie, T. Dunbar. 1994. Going for Gold: Men, Mines and Migration. Berkeley: University of California Press. Mosse, David. 2011. “Politics and Ethics: Ethnographies of Expert Knowledge and Professional Identities.” in Policy Worlds: Anthropology and Analysis of Contemporary Power, edited by Cris Shore and Susan Wright, 50–67. New York: Berghahn. Mullings, Leith. 1995. “Households Headed by Women: The Politics of Race, Class, and Gender.” In Conceiving the New World Order: The Global Politics of Reproduction, edited by Faye Ginsberg, 122–39. Berkeley: University of California Press. Mullings, Leith. 2005. “Resistance and Resilience: The Sojourner Syndrome and the Social Context of Reproduction in Central Harlem.” Transforming Anthropology 13 (2): 79–91. Mullings, Leith, and Amy J. Schulz. 2006. “Intersectionality and Health: An Introduction.” In Gender, Race, Class, and Health, edited by Leith Mullings and Amy J. Schulz, 3–20. San Francisco: Jossey-Bass. Mullings, Leith, and Alaka Wali. 2001. Stress and Resilience: The Social Context of Reproduction in Central Harlem. New York: Klewer. Murray, Colin. 1987. “Displaced Urbanization: South Africa’s Rural Slums.” African Affairs 86 (344): 311–29. Musoke, Philipa. 2004. “Recent Advances in Prevention of Mother to Child Transmission (PMTCT) of HIV.” African Health Sciences 4 (3): 144–45. Mutheiwana, Matiba. 2015. “Social Grants to Increase from 1 April.” SABC News, February 25, 2015. Myers, Norman, Russell A. Mittermeier, Cristina G. Mittermeier, Gustavo A.B. da Fonseca, and Jennifer Kent. 2000. “Biodiversity Hotspots for Conservation Priorities.” Nature 403 (6772): 853–58. Naimak, Trudy H. 2006. “Antiretroviral Treatment in the Western Cape: A Success Story Facilitated by the Global Fund.” CSSR Working Paper No. 61. Cape Town: University of Cape Town. Nash, June. 2005. “Introduction: Social Movements and Global Processes.” In Social Movements: An Anthropological Reader, edited by June Nash, 1–26. Malden: Blackwell. Nattrass, Nicoli. 2004. The Moral Economy of AIDS in South Africa. New York: Cambridge University Press. Nattrass, Nicoli. 2007. Mortal Combat: AIDS Denialism and the Struggle for Antiretrovirals in South Africa. Scottsville: UKZN Press. Nattrass, Nicoli. 2008. “AIDS and the Scientific Governance of Medicine in Post-Apartheid South Africa.” African Affairs 107 (427): 157–76. Nattrass, Nicoli, and Nathan Geffen. 2003. “The Cost of HIV Prevention and Treatment Interventions in South Africa.” Centre for Social Science Research. Cape Town: University of Cape Town. Neimark, Benjamin D., and Richard A. Schroeder. 2009. “Hotspot Discourse in Africa: Making Space for Bioprospecting in Madagascar.” African Geographical Review 28 (1): 43–69.

220

References

News24. 2012. “Protector Fingers Malema on Tenders.” October 10, 2012. https://www .news24.com/SouthAfrica/News/Protector-Malema-benefited-improperly-from-tenders -20121010. Niehaus, Isak. 2013. Witchcraft and a Life in the New South Africa. New York: Cambridge University Press. Nguyen, Vinh-Kim. 2005. “Antiretroviral Globalism, Biopolitics, and Therapeutic Citizenship.” In Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems, edited by Aihwa Ong and Stephen Collier, 107–24. New York: Blackwell. Nguyen, Vinh-Kim. 2010. The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS. Durham: Duke University Press. NPPHCN (National Progressive Primary Health Care Network). 1986. Proposal for the Development of a Progressive Primary Health Care Network in South Africa. Durban: National Progressive Primary Health Care Network. O’Malley, Padraig. 2007. Shades of Difference: Mac Maharaj and the Struggle for South Africa. New York: Viking. O’Meara, Dan. 1983. Volkskapitalisme: Class, Capital and Ideology in the Development of Afrikaner Nationalism, 1934–1948. Cambridge: Cambridge University Press. Ong, Aihwa. 2006. Neoliberalism as Exception: Mutations in Citizenship and Sovereignty. Durham: Duke University Press. Oppenheimer, Gerald M., and Ronald Bayer. 2007. Shattered Dreams? An Oral History of the South African HIV/AIDS Epidemic. New York: Oxford University Press. Packard, Randall. 1989. White Plague, Black Labor: Tuberculosis and the Political Economy of Health and Disease in South Africa. Berkeley: University of California Press. Packard, Randall. 2000. “Post-Colonial Medicine.” In Companion to Medicine in the Twentieth Century, edited by Roger Cooter and John V. Pickstone, 97–112. New York: Routledge. Paige, Sarah B., Carly Malavé, Edith Mbabazi, Jonathan Mayer, and Tony L. Goldberg. 2015. “Uncovering Zoonoses Awareness in an Emerging Disease ‘Hotspot.’” Social Science & Medicine 129: 78–86. Papadakis, Konstantinos. 2006. Civil Society, Participatory Governance and Decent Work: The Case of South Africa. Geneva: International Labor Organization. Pape, John, and David A. McDonald. 2002. “Introduction.” In Cost Recovery and the Crisis of Service Delivery in South Africa, edited by David A. McDonald and John Pape, 1–16. Cape Town: HSRC Publishers. Pfeiffer, James. 2003. “International NGOs and Primary Health Care in Mozambique: The Need for a New Model of Collaboration.” Social Science and Medicine 56 (4): 725–38. Pfeiffer, James. 2013. “The struggle for a public sector.” In  When People Come First: Critical Studies in Global Health, edited by João Biehl and Adriana Petryna, 166–81. Princeton: Princeton University Press. Pfeiffer, James, and Rachel Chapman. 2010. “Anthropological Perspectives on Structural Adjustment and Health.” Annual Review of Anthropology 39: 149–65. Picard, Louis A. 2005. The State of the State: Institutional Transformation, Capacity and Political Change in South Africa. Johannesburg: Witwatersrand University Press. Pieterse, Jim. 2016. “Managing Belief in a Hostile World: Experiencing Gifts of the Spirit at a Small Pentecostal Charismatic Church in Pretoria.” Anthropology Southern Africa 39 (1): 1–13. Piot, Peter et al. 2015. “Defeating AIDS—Advancing Global Health.” The Lancet 386 (9989): 171–218.

References

221

Platzky, Laurine, and Cherryl Walker. 1985. The Surplus People: Forced Removals in South Africa. Johannesburg: Ravan. Polanyi, Karl. 1977. The Livelihood of Man. Edited by Harry G. Pearson. New York: Academic Press. Polanyi, Karl. 2001 [1944]. The Great Transformation: The Political and Economic Origins of Our Time. New York: Beacon. Posel, Deborah. 1991. The Making of Apartheid, 1948–1961: Conflict and Compromise. Oxford: Clarendon Press. Posel, Deborah. 2005. “Sex, Death and the Fate of the Nation: Reflections on the Politicization of Sexuality in Post-Apartheid South Africa.” Africa 75 (2): 125–53. Postill, John. 2008. “Localizing the Internet Beyond Communities and Networks.” New Media and Society 10 (3): 413–31. Poulantzas, Nicos. 1978. State, Power, Socialism. Translated by Patrick Camiller. London: NLB. Power, Samantha. 2003. “The AIDS Rebel.” New Yorker. May 19, 2003. Powers, Theodore. 2012. “Institutionalizing Dissent: HIV/AIDS, the Post-Apartheid State, and the Limits of Transnational Governance in South Africa.” Journal of Southern African Studies 38 (3): 531–49 Powers, Theodore. 2016. “HIV/AIDS Policy, Transnational Donor Capital and Localized Political Formations in South Africa.” Human Organization 75 (3): 239–48. Powers, Theodore. 2017a. “Pathways, Intersections, and Hotspots: HIV/AIDS, Interpersonal Networks, and Policy in South Africa.” Medicine, Anthropology, Theory 4 (5): 73–98. Powers, Theodore. 2017b. “Knowledge Practices, Waves and Verticality: Tracing HIV/AIDS Activism from Late Apartheid to the Present in South Africa.” Critique of Anthropology 37 (1): 27–46. Presidential A.I.D.S. Advisory Panel Report (PAAPR). 2001. “Presidential AIDS Advisory Panel Report: A Synthesis Report of the Deliberations by the Panel of Experts Invited by the President of the Republic of South Africa, the Honourable Thabo Mbeki.” Pretoria: Republic of South Africa. Rabaka, Reiland. 2011. “Revolutionary Fanonism: On Frantz Fanon’s Modification of Marxism and Decolonization of Democratic Socialism.” Socialism and Democracy 25 (1): 126–45. Ramphele, Mamphela. 1993. A Bed Called Home: Life in the Migrant Labour Hostels of Cape Town. Cape Town: New Africa Books. Ramphele, Mamphela. 2016. “The Struggle Was Shaken Out of Its Moribund State.” Sunday Times, June 12, 2016. Ranchod, Kirty. 2007. “State-Civil Society Relations in South Africa: Some Lessons from Engagement.” Policy: Issues and Actors 20 (7): 1–23. Ranger, Terence. 1983. “The Invention of Tradition in Colonial Africa.” In The Invention of Tradition, edited by Eric Hobsbawm and Terence Ranger, 211–262. New York: Cambridge University Press. Redfield, Peter. 2005. “Doctors, Borders, and Life in Crisis.”  Cultural Anthropology 20 (3): 328–61. Reed, Joel C. 2018.  Landscapes of Activism: Civil Society, HIV and AIDS Care in Northern Mozambique. New Brunswick: Rutgers University Press. Rich, Paul B. 1996. State Power and Black Politics in South Africa, 1912–51. New York: Macmillan. Robins, Steven. 2004. “‘Long Live Zackie, Long Live’: AIDS Activism, Science and Citizenship After Apartheid.” Journal of Southern African Studies 30 (3): 651–72.

222

References

Robins, Steven. 2005. “AIDS, Science and Citizenship After Apartheid.” In Science and Citizens: Globalisation and the Challenge of Engagement, edited by Melissa Leach, Ian Scoones, and Brian Wynne, 113–30. London: Zed. Robins, Steven. 2005. “From ‘Rights’ to ‘Ritual’: AIDS Activism in South Africa.” American Anthropologist 108 (2): 312–23. Robotham, Donald. 2005. Culture, Society and Economy: Bringing Production Back In. London: Sage. Rodney, Walter. 1972. How Europe Underdeveloped Africa. London: Bogle-L’Ouverture. Roitman, Janet. 2004. Fiscal Disobedience: An Anthropology of Economic Regulation in Central Africa. Princeton: Princeton University Press. SADoH (South African Department of Health). 2008. “Health: Pocket Guide to South Africa for 2008/09.” Pretoria: Republic of South Africa. Sanders, David, and Abdulrahman Sambo. 1991. “AIDS in Africa: The Implications of Economic Recession and Structural Adjustment.” Health Policy and Planning 6 (2): 157–65. Sassen, Saskia. 1990. The Mobility of Labor and Capital: A Study in International Investment and Labor Flow. New York: Cambridge University Press. Schmitt, Carl. 1985 [1922]. Political Theology: Four Chapters on the Concept of Sovereignty. Chicago: University of Chicago Press. Schneider, Helen. 2002. “On the Fault Line: The Politics of AIDS Policy in Contemporary South Africa.” African Studies 61 (1): 145–67. Schneider, Helen, and Joanne Stein. 1997. “From Policy on Paper to Action on the Ground: Contextual Issues Affecting Implementation of the National AIDS Plan in South Africa.” In The South African National STD/HIV/AIDS Review July 4–18, 1997: Comprehensive Report. Pretoria: Medical Research Council. Schneider, Helen, and Joanne Stein. 2001. “Implementing AIDS Policy in Post-Apartheid South Africa.” Social Science and Medicine 52 (5): 723–31. Schneider, Jane, and Ida Susser. 2003. “Wounded Cities: Deconstruction and Reconstruction in a Globalized World.” In Wounded Cities: Deconstruction and Reconstruction in a Globalized World, edited by Jane Schneider and Ida Susser, 1–24. New York: Berg. Schoepf, Brooke G., Claude Schoepf, and Joyce V. Millen. 2000. “Theoretical Therapies, Remote Remedies: SAPs and the Political Ecology of Poverty and Health in Africa.” In Dying for Growth, edited by Jim Yong Kim, Joyce V. Millen, Alec Irwin and John Greshman, 91–125. Monroe: Common Courage. Schuller, Mark. 2009. “Gluing Globalization: NGOs as Intermediaries in Haiti.” PoLAR: Political and Legal Anthropology Review 32 (1): 84–104. Schwartz, Mark, Victor Turner, and Arthur Tuden. 1966. Introduction to Political Anthropology, edited by Mark Schwartz, Victor Turner and Arthur Tuden, 1–42. Chicago: Aldine. Scott, James C. 1985. Weapons of the Weak: Everyday Forms of Peasant Resistance. New Haven: Yale University Press. Scott, James C. 1998. Seeing Like a State: How Certain Schemes to Improve the Social Condition Have Failed. New Haven: Yale University Press. Scully, Pamela. 1995. “Rape, Race, and Colonial Culture: The Sexual Politics of Identity in the Nineteenth-Century Cape Colony, South Africa.” American Historical Review 100 (2): 335–59. Seekings, Jeremy. 1996. “The Decline of South Africa’s Civic Organizations, 1990–1996.” Critical Sociology 22 (3): 135–57.

References

223

Seekings, Jeremy. 1997. “SANCO: Strategic Dilemmas in a Democratic South Africa.” Transformation 34: 1–30. Seekings, Jeremy. 2000. The UDF: A History of the United Democratic Front in South Africa, 1983–1991. Athens: Ohio University Press. Seekings, Jeremy, and Nicoli Nattrass. 2005. Class, Race, and Inequality in South Africa. New Haven: Yale University Press. Sharma, Aradhana. 2006. “Crossbreeding Institutions, Breeding Struggle: Women’s Empowerment, Neoliberal Governmentality, and State (Re)Formation in India.” Cultural Anthropology 21 (1): 60–95. Sharp, John. 1987. “Relocation, Labour Migration, and the Domestic Predicament: Qwaqwa in the 1980s.” In Migrants, Workers, and Social Order, edited by Jeremy Eades, 130–47. London: Tavistock. Sharp, John. 2001. “The Question of Cultural Difference: Anthropological Perspectives in South Africa.” South African Journal of Ethnology 24 (3): 67–74. Sharp, John, and Andrew Spiegel. 1985. “Vulnerability to Impoverishment in South African Rural Areas: The Erosion of Kinship and Neighborhood as Social Resources.” Africa 55 (2): 133–152. Shore, Cris, and Susan Wright. 1997. “Policy: A New Field of Anthropology.” In Anthropology of Policy: Perspectives on Governance and Power, edited by Chris Shore and Susan Wright, 3–42. New York: Routledge. Shore, Cris, and Susan Wright. 2011. “Conceptualising Policy: Technologies of Governance and the Politics of Visibility.” In Policy Worlds: Anthropology and the Analysis of Contemporary Power, edited by Cris Shore, Susan Wright, and Davide Perot, 1–26. New York: Berghahn. Sidibé, Michel, José M. Zuniga, and Julio Montaner. 2014. “Leveraging HIV Treatment to End AIDS, Stop New HIV Infections, and Avoid the Cost of Inaction.” Clinical Infectious Diseases 59 (suppl_1): S3–S6. Sidibé, Michel, Luiz Loures, and Badara Samb. 2016. “The UNAIDS 90-90-90 Target: A Clear Choice for Ending AIDS and for Sustainable Health and Development.” Journal of the International AIDS Society 19 (1): 21133. Sidley, Pat. 2005. “South African Foundation Is Accused of ‘Compromising’ Care of People with HIV and AIDS.” British Medical Journal 331 (7520): 800. Simkins, Charles. 1983. “Four Essays on the Past, Present, and Possible Future of the Distribution of the Black Population of South Africa.” Cape Town: Southern Africa Labour and Development Research Unit. Sitrin, Marina A. 2006. Horizontalism: Voices of Popular Power in Argentina. Oakland: AK. Sitrin, Marina A. 2012a. Everyday Revolutions: Horizontalism and Autonomy in Argentina. London: Zed Books. Sitrin, Marina A. 2012b. “Horizontalism and the Occupy Movements.” Dissent 59 (2): 74–75. Smith, Neil. 1984. Uneven Development: Nature, Capital and the Production of Space. Athens: University of Georgia Press. Smith, Neil. 2002. “New Globalism, New Urbanism: Gentrification as Global Urban Strategy.” Antipode 34 (3): 427–50. Smith, Terence. 2007. Mainstreaming Local Government Responses to HIV/AIDS: A Case Study of the City of Cape Town’s HIV/AIDS/TB Multi-Sectoral Strategy. Cape Town: Isandla Institute. Soal, Judith. 2000. “Rebels Show Smuggled Drugs Cost R100 less.” IOL News. October 17, 2000. http:// www.iol .co.za /news /south -africa /rebels -show -smuggled -drugs -cost -r100 -less -1 .49696.

224

References

South African AIDS Conference. 2013. “National AIDS Conference: Fact Sheet.” Accessed at http://www.gov.za/speeches/2013/AIDS%20conference.pdf on June 27, 2013. SANAC (South African National AIDS Council). 2010. “About Sanac—History.” Accessed at http://www.sanac.org.za/index.php/about-sanac/history on June 6, 2012. SANAC (South African National AIDS Council). 2013. “South Africa’s National Aids Spending Assessment Brief (2007/08–2009/10).” Accessed at http://www.sanac.org.za/resources/aids -spending on July 29, 2013. South African National Civics Organization and the Dr. Rath Foundation Africa. 2016. End AIDS! Break the Chains of Pharmaceutical Colonialism. Accessed on March 31, 2017 at https://www.dr-rath-foundation.org/2017/11/end-aids/ Spiegel, Andrew D. 1987. “Dispersing Dependents: A Response to the Exigencies of Labour Migration in Rural Transkei.” In Migrants, Workers, and Social Order, edited by Jeremy Eades, 113–29. London: Tavistock. Spiegel, Andrew. 1995. “Migration, Urbanisation, and Domestic Fluidity: Reviewing Some South African Examples.” African Anthropology 2 (2): 90–113. Stadler, Alf W. 1979. “Birds in the Cornfield: Squatter Movements in Johannesburg, 1944–1947.” Journal of Southern African Studies 6 (1): 93–123. Stadler, Alf W. 1987. The Political Economy of Modern South Africa. London: Croom Helm. Stals, Chris. 1996a. “Parliamentary Briefing.” February 13, 1996. Stals, Chris. 1996b. “Consequences of South Africa’s Integration in the Global Financial Markets.” Address by governor of the South African Reserve Bank at the Annual Meeting of the French Chamber of Commerce and Industries. April 23, 1996. Johannesburg: South African Reserve Bank. Statistics South Africa. 2014. Mid-Year Population Estimates. Pretoria: Government of South Africa. Steinberg, Jonny. 2008. Three Letter Plague: A Young Man’s Journey Through a Great Epidemic. New York: Vintage. Steinbrook, Robert. 2004. “The AIDS Epidemic in 2004.” New England Journal of Medicine 351: 115–17. Stinson, Kathryn et al. 2014. “Reflections on a Decade of Delivering PMTCT in Khayelitsha, South Africa.” Southern African Journal of HIV Medicine 15 (1): 30–32. Susser, Ida. 1998. “Inequality, Violence, and Gender Relations in a Global City: New York, 1986– 1996.” Identities: Global Studies in Culture and Power 5 (2): 219–47. Susser, Ida. 2009. AIDS, Sex and Culture: Global Politics and Survival in Southern Africa. New York: Wiley-Blackwell. Swanson, Maynard J. 1977. “The Sanitation Syndrome: Bubonic Plague and Urban Native Policy in the Cape Colony, 1900–1909.” Journal of African History 18 (3): 387–410. Switzer, Les. 1993. Power and Resistance in an African Society: The Ciskei Xhosa and the Making of South Africa. Madison: University of Wisconsin Press. Tate, Winifred. 2015. Drugs, Thugs and Diplomats: U.S. Policymaking in Colombia. Stanford: Stanford University Press. Terreblanche, Sampie. 1991. A History of Inequality in South Africa 1652–2002. Scottsville: University of KwaZulu-Natal Press. Thom, Anso. 2005. “Western Cape Leads the Way.” Health-e News. June 6, 2005. https://www .health-e.org.za/2005/06/06/western-cape-leads-the-way/. Thom, Anso. 2008. “SANAC Invigorated by Political Changes.” Health-e News. October 27, 2008. https://www.health-e.org.za/2008/10/27/sanac-invigorated-by-political-changes/.

References

225

Thom, Anso. 2013. “Quack Is Back: Neliswa ‘Peggy’ Ngonyeni, KZN’s AIDS Denialist, Now In Charge of Education.” Daily Maverick, October 14, 2013. http://www.dailymaverick.co.za /article/2013-10-14-quack-is-back-neliswa-peggy-nkonyeni-kzns-aids-denialist-now-in -charge-of-education#.VwE8d6tcvp1. Thom, Anso, and Khopotso Bodibe. 2005. “HIV Patients in Illegal Vitamin Trial.” Sunday Times, September 4, 2005. Thomas, Deborah A., and M. Kamari Clarke. 2013. “Globalization and Race: Structures of Inequality, New Sovereignties, and Citizenship in a Neoliberal Era.” Annual Review of Anthropology 42: 305–25. Thomas, Elizabeth. 2006. “The Local Government Challenge for Healthy Development in Informal Settlements Especially in a Time of HIV/AIDS.” In Informal Settlements: A Perpetual Challenge?, edited by Marie Huchzermeyer, 274–89. Cape Town: University of Cape Town Press. Thornton, Robert. 2008. Unimagined Community: Sex, Networks, and AIDS in Uganda and South Africa. Berkeley: University of California Press. Tollman, Stephen M. 1994. “The Pholela Health Centre—the Origins of Community-Oriented Primary Health Care (COPC).” South African Medical Journal 84 (10): 653–58. TAC (Treatment Action Campaign). 2003. “Dying for Treatment.” TAC Briefing Document on the Civil Disobedience Campaign, March 2003. Cape Town: TAC. TAC (Treatment Action Campaign). 2005. “Joint Civil Society Monitoring Forum: Monitoring the Antiretroviral Rollout.” June 1, 2005. Cape Town: TAC. TAC (Treatment Action Campaign). 2008. “TAC and SAMA versus Mattias Rath and the Government of South Africa.” March 11, 2008. Cape Town: TAC. Trouillot, Michel Rolph, 2001. “The Anthropology of the State in the Age of Globalization: Close Encounters of the Deceptive Kind.” Current Anthropology 42 (1): 125–38. Tsing, Anna. 2000. “The Global Situation.” Cultural Anthropology 15 (3): 327–60. Tsing, Anna. 2005. Friction: An Ethnography of Global Connection. Princeton: Princeton University Press. Turner, Victor. 1957. Schism and Continuity in an African Society. Manchester: Manchester University Press. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2013. Getting to Zero: HIV in Eastern and Southern Africa. Geneva: United Nations. UNAIDS (Joint United Nations Programme on HIV/AIDS) and the WHO (World Health Organization). 2005. AIDS Epidemic Update: December 2005. Geneva: UNAIDS. Vail, Leroy. 1989. “Introduction: Ethnicity in Southern African History.” In The Creation of Tribalism in Southern Africa, edited by Leroy Vail, 1–18. Berkeley: University of California Press. Van Allen, Judith. 1982. “‘Sitting on a Man’: Colonialism and the Lost Political Organization of Igbo Women.” Canadian Journal of African Studies 6 (2): 165–81. Van der Linde, Ina. 2008. “HSRC Receives Gates Foundation Grant to Support SANAC Research Sector.” Media Briefs 2008. Van der Schaaf, Gahsiena. 2008. “The NSP Remains a Document for a Few.” AIDS Legal Quarterly (September/October 2008): 44–54. Van der Vliet, Virginia. 1994. “Apartheid and the Politics of AIDS.” In Global AIDS Policy, edited by Doug Feldman, 107–28. Westport: Bergin and Garvey. Van Onselen, Charles. 1972. “Reactions to Rinderpest in Southern Africa 1896–97.” Journal of African History 13 (3): 473–88.

226

References

Van Velson, Jaap. 1979. “The Extended Case Method and Situational Analysis.” In The Craft of Anthropology, edited by A. L. Epstein, 129–49. London: Tavistock. Verdery, Katherine. 2002. “Seeing Like a Mayor: Or, how Local Officials Obstructed Romanian Land Restitution.” Ethnography 3 (1): 5–33. Vietra, Marcelo. 2010. “The Social Innovations of Autogestión in Argentina’s Worker-Recuperated Enterprises: Cooperatively Reorganizing Productive Life in Hard Times.” Labor Studies 35 (3): 295–321. Vincent, Joan. 1982. Teso in Transformation: The Political Economy of Peasant and Class in Eastern Africa. Berkeley: University of California Press. Von Holdt, Karl, Malose Langa, Sepetla Molapo, Nomfundo Mogapi, Kindiza Ngubeni, Jacob Dlamini, and Adele Kirsten. 2011. The Smoke That Calls: Insurgent Citizenship, Collective Violence and the Struggle for a Place in the New South Africa. Johannesburg: Centre for the Study of Violence and Reconciliation; Society, Work and Development Institute, University of the Witwatersrand. Von Schnitzler, Antina. 2008. “Citizenship Prepaid: Water, Calculability, and Techno-Politics in South Africa.” Journal of Southern African Studies 34 (4): 899–917. Watts, Susan. 2008. “UK to Give £15m to Fund S Africa Aids Fight.” BBC News, November 28, 2008. http://www.bbc.co.uk/blogs/newsnight/susanwatts/2008/11/uk_to_give_15m_to_fund _s_afric.html. WC-Nacosa (Western Cape Networking HIV/AIDS Community of South Africa). 2007. Connecting People Turning the Tide: 2006 Annual Report. Cape Town: WC-Nacosa. Weber, Max. 1946 [1919]. “Politics as Vocation.” In From Max Weber: Essays in Sociology, edited by H. H. Gerth and C. Wright Mills, 77‐128. New York: Oxford University Press. Wedel, Janine, Cris Shore, Gregory Feldman, and Stacy Lathrop. 2005. “Toward an Anthropology of Public Policy.” Annals of the American Academy of Political and Social Science 600: 30–51. Werbner, Richard. 1984. “The Manchester School in South-Central Africa.” Annual Review of Anthropology 13: 157–85. Western Cape Department of Health. 2007. 2006 HIV Antenatal Survey Prevalence by District: Western Cape. Cape Town: Department of Health. WHO (World Health Organization). 1983. Apartheid and Health. Geneva: WHO Publications. Whyte, Susan Reynolds, Michael A. Whyte, Lotte Meinert, and Jenipher Twebaze. 2013. “Therapeutic Clientship: Belonging in Uganda’s Projectified Landscape of AIDS Care.” In When People Come First, edited by João Biehal and Adriana Petryna, 140–65. Princeton: Princeton University Press. Willoughby-Herard, Tiffany. 2015. Waste of a White Skin: The Carnegie Corporation and the Racial Logic of White Vulnerability. Berkeley: University of California Press. Wolf, Eric. 2001. Pathways of Power: Building an Anthropology of the Modern World. Berkeley: University of California Press. Wolpe, Harold. 1972. “Capitalism and Cheap Labor in South Africa: From Segregation to Apartheid.” Economy and Society 1 (4): 426–56. Wouters, Edwin, H. C. J. van Rensberg, and Herman Meulemans. 2010. “The National Strategic Plan of South Africa: What are the Prospects of Success After the Repeated Failure of Previous AIDS policy?” Health Policy and Planning 25: 171–85. Yates, Luke. 2015. “Rethinking Prefiguration: Alternatives, Micropolitics and Goals in Social Movements.” Social Movement Studies 14 (1): 1–21.

References

227

Zuern, Elke. 2002. “Fighting for Democracy: Popular Organizations and Post-Apartheid Government in South Africa.” African Studies Review 45 (1): 77–102. Zuern, Elke. 2006. “Elusive Boundaries: SANCO, the ANC and the Post-Apartheid South African State.” In Voices of Protest: Social Movements in Post-Apartheid South Africa, edited by Richard Ballard, Adam Habib, and Imraan Valodia, 179–203. Scottsville: University of KwaZulu-Natal Press.

INDE X

Abdullah, Fareed, 110 Abstinence, Be Faithful, and Condomize (ABC), 122 Achmat, Zackie, 59, 69–71, 79–80, 106–8, 159 Africa: economic transformation in, 182–83; expansion of poverty in, 5–6; liberation movements in, 182–83; nationalism in, 165; postcolonial societies in, 181–83, 188–190; structural adjustments and, 5–6. See also South Africa African National Congress (ANC): early activism, 28–29; African nationalism and, 165; AIDS dissidence in, 2–3, 7, 9, 66–73, 75, 77, 105–6, 153–55, 158–59; austerity policies and, 60–61, 63; cabinet revolt in, 71; economic policy and, 100; exile and, 45–46; Freedom Charter and, 44; global pharmaceutical corporations and, 201n11; HIV/AIDS movement and, 7, 17, 58, 65, 69–72; HIV/AIDS policy and, 58, 72–73; ineffectual leadership and, 43–44; internal governance of, 49; missionary education and, 36; National Health Plan, 55; patterns of accumulation in, 186–87; political centrism and, 165; privatization and, 63–64, 149; race-based programs by, 165–66, 205n6; resistance to apartheid by, 44; resistance to unified white rule by, 36; SANCO and, 149–52; sexual equality rights and, 56–57, 59; social programs and, 185, 191; socioeconomic challenges and, 61–63, 65, 67; transnational influences and, 206n8. See also National Department of Health Africa’s Solution, 73 Afrikaans Medium Decree (1974), 48 Afrikaner republics, 31–33. See also Dutch colonists; Orange Free State; Vaal Republic

Afrikaners, 37–39, 199n41 Agamben, Giorgio, 173 AIDS. See HIV/AIDS epidemic AIDS Consortium, 59, 66 AIDS dissidence: activist challenges to, 69–73, 83, 102, 156; ANC and, 2–3, 7, 9, 66–73, 75, 77, 105–6, 153–55, 158–59; ANC Women’s League and, 153, 177; ARVs and, 138–39; black liberation agenda in, 164–65; community politics and, 146–47, 150–51, 153–55; HIV/AIDS politics and, 66–68, 143, 165; local health institution impact, 138–39; MSATS and, 153, 156; national health institutions and, 9, 68–70, 74–75, 82, 87; PMTCT and, 67–68, 70; policy process and, 98; provincial HIV/AIDS politics and, 111; RathSANCO alliance, 74–75, 150, 155–56; SANAC and, 68, 75, 82, 87, 91; social effects of, 3; transnational influences and, 168; UN critique of, 77. See also National Department of Health AIDS Law Project (ALP), 55, 59, 70–71, 79, 106 AIDS Legal Network (ALN), 108, 113–14 Alexandra, 24 ALN. See AIDS Legal Network (ALN) ALP. See AIDS Law Project (ALP) ANC. See African National Congress (ANC) ANC Women’s League, 153, 177 Angola, 46 anti-apartheid movement: emergence of HIV/AIDS and, 54–55; Freedom Charter and, 44; gay rights movement and, 57, 59; impact on HIV/AIDS movement, 4, 14–16, 18, 24, 55, 69–70, 78–79, 154, 161–62, 189; international partners in, 46; MK attacks and, 45; nonracial alliance

230

Index

anti-apartheid movement (continued) building in, 44, 46, 50; nonviolent civil disobedience and, 44, 52; organizational composition of, 45; periurban township mobilization, 48, 50; political organization and, 43; social justice activism and, 55; South African networks in, 14–15; student movement and, 46–48; symbolic imagery in, 14; trade union movement and, 48; urban roots of, 24; violent repression of, 44–46, 48–49 Anti-Privatization Forum, 149 antiretroviral drugs (ARVs): azidothymidine (AZT), 67–68, 95–96, 98; critique of, 2–3, 67, 69, 73; distrust of, 67–68, 138–39; dual therapy and, 82; legal action in support of, 73; Nevirapine, 70–72, 96 antiretroviral therapy (ART), 74, 142 apartheid: black resistance to, 43–46; closure of missions in, 41; expropriation and, 39; health care limitations and, 7, 41–42; industrial sector and, 43; international partners in, 46; militarization of, 45, 49; policy changes in, 40; racial segregation and, 24, 35, 39–40, 43; reordering of urban space in, 39–41; separate development in, 42–43; social reproduction and, 41–43; socioeconomic inequality and, 6–7, 39; UN condemnation of, 48 Appadurai, Arjun, 8–9 Aron, Janine, 62 ARVs. See antiretroviral drugs (ARVs) azidothymidine (AZT), 67–68, 95–96, 98 Bantu Authorities Act (1951), 43 Bantu Education Act (1953), 41 Bantu Homelands Citizenship Act (1970), 43 Basotho Kingdom, 31 Bechuanaland. See Botswana Biehl, João, 13 Biko, Steve, 29, 47–48, 55–56, 206n4 Bill and Melinda Gates Foundation, 90–91 Black Consciousness Movement (BCM), 29, 46–48, 52, 55, 206n4 Black Economic Empowerment (BEE), 165–66 black liberation, 15, 46, 162, 164–65 Black Lives Matter, 18 Black Local Authorities Act of 1982, 148

Black People’s Convention, 47 Black Review, 47 black South Africans: citizenship rights and, 36; colonial state and, 32–35; disease blaming and, 35, 197n22; education and, 41–42, 48, 57; exclusion from parliament, 50; forced removal of, 35, 39–40, 43, 199n52, 199n53; health care and, 29, 41, 55, 69, 141–42; HIV prevalence among, 141–42; infectious disease and, 51, 198n32; limits on access to education for, 41; mining industry and, 33–34, 38; missionary movement and, 28–29, 41, 197n22, 197n23; periurban townships and, 35, 43, 49; political organization and, 43; post-apartheid, 180–81; professional class of, 36; racial segregation and, 24, 34–35, 39, 199n43; resistance to apartheid by, 43–46; resistance to colonization by, 25–28, 31–32; rinderpest outbreak and, 33, 198n30; social formations, 36, 38, 42, 197n25, 198n29; socioeconomic inequality and, 6–7, 180–81, 184–88, 191–92; socioeconomic stratification, 34, 42; state control over, 42; state violence towards, 39–40; subsistence farming by, 36; urban employment and, 35, 37–38; urban segregation and, 34–35; wage labor and, 33–34, 39. See also indigenous peoples black townships: anti-apartheid movement and, 44, 48, 140; community clinics and, 55, 69; development of, 35; forced removal to, 35, 40, 43; HIV prevalence in, 141; infectious disease and, 140; mobilization in, 48, 50, 70, 80; overcrowding in, 40; self-governance in, 46, 49; statesponsored violence in, 48, 140 black urbanization: household composition and, 199n45; political resistance and, 200n54; racial segregation and, 34, 40, 199n46; rape scares and, 38; right to property ownership, 199n44; selfgovernance and, 19, 24, 38, 50; social formations, 37; traditional authority and, 38; workforce and, 37. See also urban communities Boehringer Ingelheim, 70 Botha, P. W., 113 Botswana, 32, 45–46

Index British colonists: annexation of Botswana, 32; Cape Colony expansion of, 27–29, 31; conflict with Afrikaners, 33; conflict with indigenous peoples, 27–28, 32; economic power and, 29; landownership of, 27; mining industry and, 33–34; pass system and, 26; resistance to, 27; state administrators and, 23; support for slave labor by, 27; Vaal Republic and, 32–33; wage labor and, 33–34; white settler alliances, 24–27, 32, 35–36; Zulu Kingdom and, 26, 32 Broad-Based Black Economic Empowerment (BBBEE), 205n6 Brown, Hannah, 12 bubonic plague, 35 Cameron, Edwin, 56, 58–59, 66, 79 Cape Colony: abolition of slavery in, 27; Afrikaner conflict with, 31; British-Dutch alliance in, 26–27; British expansion in, 27–29, 31; conflict with Xhosa people in, 28; diamond reserves in, 32; Dutch migration from, 27, 30; expropriation of land in, 29; racial segregation in, 35, 139 Cape Flats, 55, 139, 152, 154–55 Cape Frontier Wars, 27 Cape Town, 29, 40, 50, 141 Cape-Xhosa wars, 197n17 capitalism, 205n7 Carnegie Corporation, 37 Castro Hlongwane document, 73 Centers for Disease Control and Prevention, 160 Centre for Applied Legal Studies (CALS), 55–56, 58–59, 79 Charter for Rights on AIDS and HIV, 58–59 colonialization: agricultural sector and, 27–29; black elite and, 35, 39, 42, 198n39; black resistance to, 25–28, 31–32; Christianity and, 23, 28–29; conflict with African social formations, 30–32; economy in, 182– 83; expropriation of land, 23–24, 27, 29–32, 34, 36, 197n17; indigenous peoples and, 23, 25–31; pass system and, 26, 32; public health and, 29; racial segregation and, 32, 34–39; resistance to, 25–28; rural reserves and, 33–34; socioeconomic stratification and, 35; violence and, 25, 28, 32, 39; white settler alliance in, 24–26, 32, 35–36 Coloured People’s Congress, 44

231

Comprehensive Treatment Plan, 72–73, 162 Congress of South African Trade Unions (COSATU), 17, 71–72, 75, 80, 106 context, 7–9, 11 Crossroads, 55, 140 De Beers Consolidated Mines, 34 Defiance Campaign (1952), 44, 200n55 Department of Social Development, 122 Development Bank of Southern Africa, 160 diamond reserves, 32 Dlamini-Zuma, Nkosazana, 58, 95 Dr. Rath Health Foundation Africa. See Rath Foundation Dube, John, 36 DuBow, Saul, 15 Dubula, Vuyiseka, 80, 206n8 Dugard, John, 56 Durban, 29, 40, 47 Durban Declaration, 69 Durkheim, Émile, 167 Dutch colonists: conflict with British, 26; conflict with Xhosa people, 27; displacement of indigenous people by, 30–31; enslavement of Khoisan people, 25, 196n4, 196n13; migration of, 27, 30–31, 197n15, 197n28; mining industry and, 34; resistance to, 25; slave economy of, 23, 27; social organization of, 27; white settler alliances, 24–26, 35–36; Zulu Kingdom and, 26. See also Afrikaners Elbadawi, Ibrahim, 62 Electricity Supply Commission (Eskom), 37 Elizabeth Glaser Pediatric AIDS Foundation, 97 End AIDS! Break the Chains of Pharmaceutical Colonialism, 150 End Conscription Campaign, 55 European Union, 65 Fanon, Frantz, 46–47, 181–83, 185, 188–90, 193, 206n2, 206n4 Fassin, Didier, 51, 141 Ferguson, James, 166 First, Ruth, 49 flows, 8–9 Foucault, Michel, 17, 170–71 Freedom Charter, 44, 46, 50–52, 60, 162, 164, 200n56

232

Index

Gay and Lesbian Organization of the Witwatersrand (GLOW), 57 Gay Association of South Africa (GASA), 56–57 gay rights movement, 54–57, 59, 80 GEAR. See Growth, Employment and Redistribution (GEAR) macroeconomic strategy Geissler, Paul Wenzler, 13 Glen Grey Act (1894), 36 Global Fund, 68, 76, 104, 110, 119, 122, 131, 152 global health interventions, 13 globalization, 5–9 Global North, 5, 9 Global South, 5, 9, 63, 67, 174 Gluckman Commission, 199n51 Gluckman Report, 42 gold deposits, 32–33 Gramsci, Antonio, 172, 173 Great Trek, 27, 197n15 Group Areas Act (1950), 40, 43 Growth, Employment and Redistribution (GEAR) macroeconomic strategy, 63, 95, 149, 165, 184 Gugulethu, 40 Hani, Chris, 58 health care: accreditation of facilities, 74, 87–88; apartheid limitations on, 41–42; barriers to, 200n59; black South Africans and, 29, 41, 55, 69, 141–42; black townships and, 141–42; community clinics and, 47, 55, 69; fiscal austerity impact on, 64; HIV/TB clinics, 142; racial segregation and, 196n10, 197n26; rural communities and, 41–42; universal access movement, 55, 58; urban areas and, 29. See also public health hegemony, 172 Heywood, Mark, 59, 69–70, 72, 79–80, 90, 92, 94, 101 HIV/AIDS activists: black townships and, 80; challenges to injustice by, 83–85; civil disobedience and, 72, 77, 163; community organizing and, 10, 81, 107, 110, 161–62, 164, 169; everyday activities of, 10–11; first-wave, 53, 55–59, 65–66, 70, 79–80, 163; occupation of the state by, 16–18, 99, 169, 189; pathways of, 11, 175–77;

provincial, 105; second-wave, 54, 57–60, 66, 69–72, 77, 79–80, 163, 189; transnational HIV/AIDS movement and, 3–4 HIV/AIDS councils, 101 HIV/AIDS epidemic: anti-apartheid movement and, 54–55; community politics and, 156; control of, 192; discrimination and, 59; disease transmission and, 141; globalization and, 5–7; informal settlements and, 64; mortality rates and, 70; MSATS and, 152–53; neoliberalism and, 7; public response to, 60; rights-based approach to, 55, 58–59, 79, 81, 86–87; socioeconomic inequality and, 5–6, 137–38, 191–92; sociopolitical dynamics of, 4, 9; spread of, 6–7, 54, 60, 64, 141–42, 179, 190–92; state response to, 54, 64; structural adjustments and, 5–6; women and, 191 HIV/AIDS movement: alliance building by, 14, 17, 77–80, 161–63, 174, 176; ANC and, 7, 17, 58, 65, 70–73; anti-apartheid movement’ political principles and, 4, 14–16, 18, 24, 55, 69–70, 78–79, 154, 161–62, 189; COSATU and, 80; decisionmaking structures within, 168–69; donor capital and, 102; gay rights movement and, 54–57, 80; human rights movement and, 54–56, 59, 79; legal action and, 71, 73, 75, 79–80; mobilization of, 16–17; nongovernmental organizations (NGOs) and, 12–13; nonracialism in, 163–64, 166; policy development and, 18, 82–83, 174–75; policy implementation oversight by, 73–74; primary health care movement and, 55–56; public health and, 4, 110; social change and, 189–90; state elites and, 162–63, 169, 174; transnational influences and, 168; women and, 80, 202n20, 206n8 HIV/AIDS policy: activists and, 82–83, 101–2, 152; ANC and, 73, 75–76; expiration of strategic plan for, 74; government undermining of, 82–83, 98; implementation oversight, 73–74; institutional levels of, 104; institutional mandates and, 99–100; international attention and, 77–78; interpersonal networks and, 101; localized political formations and, 175– 76, 178; national health institutions and, 87, 99; post-apartheid fiscal constraints

Index and, 65; resource-allocation strategies and, 66; SANAC and, 68, 77–78, 88, 97–100, 102; sociopolitical influence and, 132–33; support for, 66, 72; transition period alliances on, 58, 61; transnational donors and, 12. See also AIDS dissidence; National Strategic Plan (NSP); provincial HIV/AIDS politics HIV/AIDS politics: AIDS dissidence in, 67–68, 143, 146–47, 167; hot spots for, 14, 175, 177–78; nongovernmental organizations (NGOs) and, 12–13, 189; political compromise and, 191; post-apartheid, 65, 188–89, 191; protests and, 105–7; racism and, 166; social groups and, 167–68; sovereignty and, 173; state officials and, 87, 173; transnational influence on, 102, 168, 178, 205n2; unorthodox HIV/AIDS treatments and, 66–67. See also provincial HIV/AIDS politics HIV/AIDS/STD Strategic Plan (2000– 2005), 74 HIV/AIDS treatment access: accredited facilities and, 74, 87–88; activism and, 4, 9–11, 14, 16, 18, 161, 167; anti-apartheid movement and, 78; antiretroviral therapy (ART) and, 74; campaign for, 69, 71–73, 100–102, 134, 178, 192–93; disclosure and, 120; fiscal austerity impact on, 64; international price-setting and, 8; limitations on, 7, 9; national health institutions and, 4, 9, 11; obstacles to, 1–2, 74, 87–88, 95–96; post-Mbeki expansion of, 160–61; race and, 15–16, 162; understanding state and society through, 167; transnational donors and, 8, 190; Western Cape, 105, 108–12. See also AIDS dissidence; National Department of Health HIV/AIDS and debates on treatment: Africa’s Solution, 73; AIDS drug pricing, 201n11; antiretroviral drugs (ARVs), 2–3, 67–73, 77, 82, 138–39; azidothymidine (AZT), 67–68, 95–96, 98; dual therapy in, 82, 96–98; homeopathic remedies and, 2; Nevirapine, 70–72, 96; unorthodox, 66–67, 73, 77; Virodene scandal, 65–66, 201n13; vitamin regimens, 74–75, 139, 150, 155 HIV and AIDS Care, Management and Treatment Plan. See Comprehensive Treatment Plan

233

HIV transmission, 122 Hogan, Barbara, 159–60 hot spots, 12, 14, 175, 177–78, 195n8 human rights movement, 54–56, 59, 79 Human Sciences Research Council, 90 Hunter, Mark, 191 indigenous peoples: colonialization and, 23–35; enslavement of, 25; mfecane and, 30–31; political role of women and, 33; resistance to colonization by, 25–28, 31–32; settler expropriation of land from, 23–24, 27, 29–31, 36; social formations, 25–26, 30–33; white settler alliance and, 25; Zulu warfare and, 30. See also black South Africans influx control, 42 Ingold, Tim, 177 Inkatha Freedom Party, 58 Integrated Development Planning (IDP), 205n3 Inter-Ministerial Committee on AIDS, 68 International AIDS Conference (2000), 68 International AIDS Conference (2006), 2, 77, 111, 206n8 International AIDS Conference (2016), 186 International AIDS Vaccine Initiative, 105 International Monetary Fund (IMF), 5, 54 Iron and Steel Corporation (Iscor), 37 Jackson, John L., 15 Janice, 89–91 Johannesburg, 32, 34, 38–40 Joint Civil Society Monitoring Forum, 74, 78 Joint United Nations Program on HIV/ AIDS (UNAIDS), 192 Kark, Sidney, 41 Kelly, Ann, 12 Khayelitsha: activism in, 1–3, 9, 116, 134–38, 150–51; AIDS dissidence in, 143, 146–47, 150–51, 153–55; community education in, 4, 142, 150–51; HIV/ AIDS politics in, 134, 145–46, 156; lack of health services in, 141–43; PMTCT and, 109, 111; SANCO influence in, 147–52, 154–55, 177–78; settlement of, 140; socioeconomic dynamics in, 137–38, 140, 143; treatment models in, 142; unemployment in, 136–37

234 Khayelitsha Development Forum, 141 Khayelitsha Health Forum, 154–55 Khoisan people, 25–26, 30, 196n3, 196n4, 196n13 Khumalo, Nonkosi, 206n8 Kimberley, 44 KwaMashu, 40 KwaZulu-Natal Province, 30, 58, 155 labor migration, 34 Leeukop Political Prisoners Support Committee, 70 Legal Resources Centre (LRC), 71, 79 Lesbians and Gays against Oppression, 56 Lesotho, 34 Lewis, David, 13 Lewis, Stephen, 77 Loram, Charles, 41 Lovedale Missionary Station, 28–29, 41, 197n24 Maas, Tine van der, 73 Madikizela-Mandela, Winnie, 149 Madlala-Routledge, Nozizwe, 77, 104–7, 110, 203n2 Maharaj, Mac, 49 Makgoba, William, 70 Malema, Julius, 186 Mandela, Nelson, 41, 44–45, 61–62, 72, 163 Mankahlana, Parks, 73 Manuel, Trevor, 62 Marcus, George, 11, 195n5 Marx, Karl, 205n7 Marxist Workers Tendency, 59, 69–70 Mass Democratic Movement, 14, 24, 46, 50–52, 79, 110, 162, 164 Matabele Kingdom, 30–31 Matthews, Z. K., 28, 44 Mauss, Marcel, 167 Mbali, Mandisa, 164 Mbeki, Govan, 28, 45 Mbeki, Thabo: African Renaissance and, 164; AIDS dissidence and, 67–71, 73, 77, 105, 143, 165; Castro Hlongwane document and, 73; dismissal of MadlalaRoutledge and, 105–6; HIV/AIDS politics and, 87, 106; missionary education and, 28–29; National Department of Health scandals and, 66; Operation Vula and, 49; resignation of, 159

Index Mbembe, Achille, 173 Mbewu, Anthony, 70, 74 McKinley, Dale, 36 Médecins sans Frontières (MSF), 109–11, 142 Medical Research Council, 70, 155 Medicines Act, 164 Medicines and Related Substances Control Amendment Act (1997), 201n11 Medicines Control Council, 66, 68, 75 mfecane, 30–31, 197n27 Mfengu, 30 migrant labor, 34, 38, 50, 198n33, 200n61 mining industry, 33–34, 38, 198n33, 198n35, 199n42 missionary movement, 28–29, 196n1, 197n22, 197n23 Mitchell, Timothy, 171 MK. See Umkhonto we Size (Spear of the Nation) Mlambo-Ngcuka, Phumzile, 77, 101 Motlanthe, Kgalema, 159 Motsoaledi, Aaron, 160 movement, 7–9, 11 Mozambique, 34, 46 Mpanza, James, 38 MSATS. See Multi-Sectoral Action Teams (MSATs) Mseleku, Thami, 73, 87 MSF. See Médecins sans Frontières (MSF) Multi-Sectoral Action Teams (MSATs), 116–17, 119, 152–56 Nacosa Informer, 131 Naidoo, Jay, 61 Namibia, 46 NAPWA. See National Association of People Living with AIDS (NAPWA) Natal, 31 National AIDS Congress of South Africa, 56 National AIDS Coordinating Committee of South Africa, 58 National AIDS Plan, 58–59, 65, 79 National AIDS Task Force, 58 National Association of People Living with AIDS (NAPWA), 69, 74 National Civil Society Conference on Implementing the National Strategic Plan on HIV & AIDS, 91–99 National Coalition for Gay and Lesbian Equality, 59

Index National Department of Health: AIDS dissidence and, 67–68, 71–73, 75–76, 87, 96, 160, 165, 176; civil disobedience and, 77; civil society and, 76–77, 93; dismissal of Madlala-Routledge and, 105–6, 203n2; funding for, 100; HIV/AIDS policy and, 99; intransigence of, 74–75, 82, 87–88, 101; limitations on treatment by, 74, 87–88; post-Mbeki era, 160; public sector response to HIV/AIDS and, 60, 64; Sarafina II scandal, 65–66; undermining of policy by, 82–83, 98; Virodene scandal, 65–66 National Economic Development and Labour Council (NEDLAC), 162, 205n4 National Health Council, 155 national health institutions: AIDS dissidence and, 9, 68–70, 74–75, 82, 87; HIV/AIDS activism and, 73, 87; policy process and, 10, 12, 16; treatment access and, 4. See also National Department of Health National Health Plan, 55 National Party: apartheid and, 39–48; international condemnation of, 45, 48; reformist policies of, 200n60; separate development and, 43; traditional authorities and, 42; tricameral legislative structure in, 50; violent repression by, 44–46, 48–49 National Progressive Primary Healthcare Network (NPPHCN), 55–56, 58, 200n1 National Security Management System, 49 National Strategic Plan (NSP): activism and, 77, 106, 108, 132; activist workload and, 88–89; goals of, 78; priority areas of, 92; provincial HIV/AIDS politics and, 108; provincial implementation of, 108, 115; SANAC implementation of, 78, 88, 90–99, 108; treatment access and, 160 National Union of Mineworkers, 50, 159 National Union of South African Students, 47 Native Affairs Act, 198n36, 199n40 Native Resettlement Board, 40 Natives Land Act (1913), 36, 43, 198n38 Nattrass, Nicoli, 166 Ndlovu, Hastings, 48 neoliberalism, 6–8, 12, 15, 67, 100 Nevirapine, 70–72, 96 New National Party, 109 Ngonyeni, Neliswa “Peggy,” 155

235

Nguni migration, 25–26 Nkoli, Simon, 56–57, 59–60, 69–70, 80, 105 nongovernmental organizations (NGOs): analysis of, 12–13; global health and, 13; Global South and, 173–74; HIV/AIDS movement and, 53, 74, 79, 91, 162, 189; MSATS and, 152, 154; PSP policy consultations and, 113, 132; SANAC and, 88–89; social movements and, 14–15; transnational donor capital and, 21, 128 Nongqawuse prophecy, 28, 197n20 nonracialism, 163–64, 166 nonviolent civil disobedience, 44, 52, 163 Novalis Institute, 115 NPPHCN. See National Progressive Primary Healthcare Network (NPPHCN) Nyanga, 40 Occupy Wall Street, 18, 168 Office of the Reconstruction and Development Programme, 61 Operation Vula, 49 Orange Free State, 30–31 Organization of Lesbian and Gay Activists (OLGA), 56 Pan-Africanist Congress, 45, 165 Partners in Health, 142 pass system, 26, 32, 43, 45, 163, 180 pediatric HIV infections, 95–98 People Living with HIV/AIDS Sector, 89 PEPFAR. See President’s Emergency Plan for AIDS Relief (PEPFAR) periurban townships. See black townships pharmaceutical corporations, 8, 67, 164, 201n11 Philemon Mauku Defense Campaign, 70 Pholela Health Centre, 41 Pieterson, Hector, 48 Pityana, Barney, 47 Plaatje, Sol, 36 PMTCT. See Prevention of Mother-to-Child Transmission (of HIV) (PMTCT) Polanyi, Karl, 205n7 policy process: broad-based consultation in, 162, 205n3; HIV/AIDS activism and, 82–83, 103, 174–75; hot spots and, 12; nonstate actors in, 175–77; poor/working class and, 17, 21, 163; state health institutions and, 10, 12, 16; studying through,

236

Index

policy process (continued) 11; transnational influences and, 172–73. See also HIV/AIDS policy Posel, Deborah, 40 postcolonial societies, 181–83, 188–190 power: Foucault on, 170–71; nonstate actors and, 177; sovereignty and, 173; state and, 17, 170–74, 177; traditional authorities and, 32, 34, 39, 42–43, 171 Presidential Advisory Committee on HIV/ AIDS, 68, 165 President’s Emergency Plan for AIDS Relief (PEPFAR), 102, 122, 136 Prevention of Illegal Squatting Act (1951), 40, 50 Prevention of Mother-to-Child Transmission (of HIV) (PMTCT): AIDS dissidence and, 67–68, 70; AZT-based, 95–96; dual therapy, 82, 96–98; HIV/ AIDS activism and, 80; HIV/TB clinics and, 142; international best practices for, 95; Médecins sans Frontières (MSF) and, 109–10; Nevirapine and, 70–71, 96; policy guidelines for, 82, 92–99, 103; provincial program for, 109 primary health care movement, 55–56 Promotion of Bantu Self-Government Act (1959), 43 provincial HIV/AIDS politics: activist input in, 129; AIDS dissidence and, 111; barriers to participation in, 129–30; MSATS and, 116–17; mutual distrust in, 111–12; national intervention in, 110–11, 117–18; National Strategic Plan (NSP) and, 108; policy consultations and, 104, 113–31; sociopolitical influence and, 132–33; state power and, 126–27; transnational donors and, 109–10, 119–120, 122, 130–31; treatment access and, 105, 108–12; urban/rural divide in, 128–29; working relationships in, 128. See also Western Cape Networking AIDS Coalition of South Africa (WC-Nacosa) PSP. See Western Cape Provincial Strategic Plan (PSP) public health: alliance building in, 58; ARTbased treatment and, 71, 87, 110, 142; black/white disparities in, 34; day hospitals, 141, 204n6; donor capital and, 102; “end AIDS” rhetoric and, 192; colonial

medicine and, 29; HIV/AIDS impact on, 64–65, 96; HIV/AIDS movement and, 4; primary health care movement and, 55; racial segregation and, 7, 35; rights-based approach to, 161; structural adjustment impact on, 54, 60; understaffing in, 2, 111, 142, 190. See also health care; HIV/AIDS treatment access race, 15–16, 24, 37, 184 racial segregation: campaigns against, 36; colonialization and, 32, 34–39; cultural explanation for, 42–43; education and, 41; normalization of, 34–35; political divide and, 39; public health and, 35; traditional elites and, 42; urban communities and, 34–35, 39–40; U.S. role in, 41. See also apartheid Ramphele, Mamphela, 47 Randlords, 34 Rath, Matthias, 74, 111 Rath Foundation, 74–75, 111, 150, 152, 155–56 Rath-SANCO alliance, 74–75, 150, 155–56, 177 Reconstruction and Development Programme (RDP), 61, 184, 201n6 Rhodes, Cecil, 34 rinderpest outbreak, 33, 198n30 Rivonia Trials, 45 rural health care, 41–42 rural reserves, 33–35, 41–43, 199n52, 199n53 SANAC. See South African National AIDS Council (SANAC) SANAC Program Implementation Committee, 87 SANAC Resource Management Committee, 87 SANCO. See South African National Civics Organisation (SANCO) Sarafina II scandal, 65–66 “Save Our Babies” campaign, 96 scale, 195n4 Schuller, Mark, 13 Seekings, Jeremy, 166 sexual equality rights, 56–57, 59 Shaka, King of the Zulu, 26, 30 Sharpeville Massacre, 44–46, 52 Sidibé, Michel, 192

Index Silver Ring Thing, 136–37 Sisulu, Walter, 44–45, 163 Slavery Abolition Act of 1833, 27 Smuts, Jan, 38 Sobukwe, Robert, 41, 165 social change, 167 social justice activism, 17, 46, 55 social movements, 168–69, 189–90. See also anti-apartheid movement; gay rights movement; HIV/AIDS movement; sexual equality rights socioeconomic inequality: apartheid and, 6–7, 39; black South Africans and, 6–7, 180–81, 184–88, 191–92; HIV/AIDS epidemic and, 5–6; poor whites and, 36–37, 199n41; post-apartheid, 180–81, 184–88, 191–92; race and, 184; stratification and, 34–35 Sophiatown, 38, 40 South Africa: apartheid and, 6–7, 39–51; colonial period in, 23–39; educated black class in, 28–29; expropriation of land in, 23–24, 27, 29–31, 36, 43; foreign investment in, 61–63; indirect rule in, 38; infectious disease in, 51, 140–41; interwar period, 37; mineral wealth in, 31–34; missionary movement and, 28–29, 196n1, 197n23; negotiated political transition in, 40, 43, 56–61, 64, 139, 149, 162, 180, 184; neoliberalism and, 6–7; poor whites question in, 36–37, 199n41; post-apartheid, 181, 184–88, 191–92; pre-European contact, 25–26, 196n2; racialized inequality in, 15, 24; racial segregation in, 24, 34–39, 86; social justice activism in, 46; socioeconomic inequality in, 6–7, 61, 180–81, 184–88, 191–92; state officials in, 86–87; state violence in, 44–46, 48–49; unemployment in, 185–86; unified white rule and, 35–36; white elite in, 34, 37; white welfare state in, 37; xenophobia in, 187–88 South African Bill of Rights, 56 South African Communist Party (SACP), 17, 44–45, 71, 77, 106 South African Congress of Democrats, 44 South African Constitution, 56 South African Indian Congress, 44 South African Medical Association, 75, 106, 111, 156

237

South African National AIDS Council (SANAC): HIV/AIDS activists and, 16, 77–78, 90, 99, 103, 160–61; AIDS dissidence and, 68, 75, 82–83, 87, 91, 150–51; ANC alliance and, 149–52; civil society representation on, 73, 75–76, 78, 89–99, 101, 103, 108, 149, 162, 175, 201n15; community politics and, 147–52, 154–55; COSATU and, 80; formation of, 68; funding for, 160; HIV/ AIDS policy and, 10, 14, 68, 77–78, 88, 97–100, 102; implementation of NSP and, 88–99, 108; institutional mandates and, 99–100; institutional obstruction in, 75–76, 90–91; resource shortages in, 90; restructuring of, 80, 82, 85, 87, 89, 94, 103; TAC and, 88–89, 92; ward development forums and, 151; Women’s Sector, 89–90 South African National Civics Organisation (SANCO), 74–75, 111 South African Native National Congress, 36 South African Republic, 31 South African Reserve Bank, 62–63 South African Student Organization, 47 South African Students Movement, 48 South African War, 33 Southern Africa, 6, 25–27, 33–34 South-West Africa, 46 sovereignty, 173 Soweto, 24, 38, 40 Soweto Electricity Crisis Committee, 149 Soweto Students Representative Council, 48 Soweto Uprising, 46, 48–49, 55–56 state: activist occupation of, 16–18, 99, 169, 189; anthropological theories of, 16–17; civil society and, 162, 167, 171–72; context and, 9; hegemony and, 172; power and, 17, 170–74, 177; security apparatus in, 49; social effects of, 17–18; social justice and, 17; social processes and, 177; sovereignty and, 173; work of people within, 177 state-owned enterprises, 37 State Security Council, 49 Statistics South Africa, 70 structural adjustment programs, 5–6, 54, 63–64, 195n2 student movement, 46–48 Swaziland, 34

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TAC. See Treatment Action Campaign (TAC) Tambo, Oliver, 44, 49, 163 Tanzania, 46 Toms, Ivan, 55–57, 200n1, 200n2 toyi toyi, 14, 105, 145 trade union movement, 46, 48, 50 traditional authorities: black urbanization and, 38; complicity with colonial state, 42, 182, 198n31; influx control and, 42; intermediary role of, 33; migrant-labor system and, 34, 42; political role of women and, 33, 42; power of, 32, 34, 39, 42–43, 171; rural reserves and, 42; social order and, 199n48 transnational donor capital: decline in, 190; HIV/AIDS policy and, 12, 104; HIV/ AIDS politics and, 102; provincial HIV/ AIDS politics and, 119–20, 122, 130–31 Treason Trials, 44 Treatment Action Campaign (TAC): activism and, 1–3, 79, 83, 85, 91, 134–37, 144, 169, 190; alliance building by, 71–72; antiretroviral drugs and, 138; civil disobedience and, 72; community clinics and, 69; community organizing and, 70; counseling and, 142; decisionmaking structures in, 169; founding of, 105; gender dynamics in, 202n20, 206n8; implementation of NSP and, 88–89; International AIDS Conference protests, 2, 77; legal action and, 71, 75, 156; nonracialism and, 164; policy change and, 103, 108; SANAC and, 88–89, 92; in Western Cape, 107–8, 110–12, 115–16 Tshabalala-Msimang, Manto: accreditation of facilities by, 87; AIDS dissidence and, 67–68, 71, 75, 87, 111, 143, 151, 165; homeopathic remedies and, 2, 77; recall of, 159; sick leave of, 77–78, 82 Tsing, Anna, 9 Tutu, Desmond, 104 Ubhejane, 155 Ukuvula, 143–48, 150–52, 180 Umkhonto we Size (MK and/or Spear of the Nation), 45, 159 Umlazi, 40 UNAIDS, 102

Union of South Africa, 36, 45 United Democratic Front (UDF), 50, 59, 140, 162 United Nations Security Council, 45, 48 United Party, 39 United States Agency for International Development (USAID), 65 University College of Fort Hare, 41 University of the Witwatersrand, 56 Urban Areas Act (1923), 199n44, 199n46 urban communities, 34–35, 37–41. See also black urbanization Uys, Pierre, 110–11, 203n7 Vaal Republic, 31–33 Virodene scandal, 65–66, 201n13 volkekunde school, 42 voortrekkers, 30–31 ward development forums, 151 Washington Consensus, 60, 67 WC-Nacosa. See Western Cape Networking AIDS Coalition of South Africa (WC-Nacosa) Western Cape: ART-based public sector response in, 109–10; HIV/AIDS activism in, 104–8; HIV/AIDS politics in, 104–12, 176; implementation of NSP and, 108; National Party control of, 109; TAC and, 107–8, 110–12, 115–16, 156 Western Cape Department of Health, 109–10, 112–13, 121, 124, 130–31 Western Cape Networking AIDS Coalition of South Africa (WC-Nacosa): donor capital and, 130–32; electronic submissions to, 129–30, 204n28; government support for, 130–31; provincial policy consultations and, 108, 113, 116–32, 176 Western Cape Province, 152 Western Cape Provincial Department of Health, 108 Western Cape Provincial Strategic Plan (PSP), 108, 112–15, 117, 122–29, 131–32 white South Africans, 29, 34, 36–39, 45. See also British colonists; colonialization; Dutch colonists white supremacy discourse, 46–47 women: HIV/AIDS activism and, 80, 202n20, 206n8; HIV exposure and, 191;

Index limitations on political power, 33, 42; as migrant laborers, 50, 200n61; violence against, 145 Women’s Sector, 89–90 World AIDS Day, 59, 65 World Bank, 5, 54, 63 World Health Organization (WHO), 82, 92, 96–98 World Trade Organization (WTO), 8 xenophobic violence, 187–88 Xhosa Frontier Wars, 27 Xhosa people: Cape-Xhosa wars, 197n17; cattle herding and, 25, 28; cattle killing

239

crisis and, 28, 197n19; chiefdoms of, 196n8; displacement of Khoisan by, 26; missions and, 28, 36; resistance to colonists by, 26–28; southern migration of, 25; trade by, 197n18 Xhosa War, 197n21 Xundu, Nomonde, 93–95 Zambia, 46 Zanempilo Community Health Centre, 47 Zuern, Elke, 149 Zulu Kingdom, 26, 29–32, 196n9 Zuma, Jacob, 49, 72, 159 Zwelithini, Goodwill, King of the Zulus, 187