Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa

The human immunodeficiency virus and acquired immune deficiency syndrome continue to be a major public and global health threat, but their distribution is extremely uneven. The African continent remains in the center of debates on global disparities in HIV/AIDS. After all, Africa—specifically, Sub-Saharan Africa—has the most serious HIV and AIDS epidemic in the world: an estimated 23–26 million people infected with HIV live there, and the region carries 70 percent of the global burden of new HIV infections. Many books have presented and explored HIV/AIDS from the public health perspective, focusing on HIV/AIDS epidemiology, public health interventions, and global initiatives. However, sociological perspectives on HIV/AIDS are less prevalent, tend to be narrow in scope, and remain underutilized outside of sociology. ¹ For these reasons, it is refreshing to see a book that gives a broader sociological view and has relevance for areas ranging from global policy to infectious diseases and even pharmacotherapy.

Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa by Claire Laurier Decoteau describes the politics of HIV/AIDS in South Africa between 1994 and 2010. The main goal (per author) is to analyze the political economy of the post-apartheid health system, symbolic meanings of HIV/AIDS, and interaction between the traditional and biomedical approaches to HIV/AIDS. This analysis involves a contextual, descriptive tracing of the social climate, change, and HIV situation in South Africa over the last decades. Notably, the book is based on extensive long-term ethnographic research conducted by Decoteau in several communities affected (predictably) hand-in-hand by deplorable social conditions (slums) and HIV/AIDS. The author explores the underpinnings of the political economy (e.g., colonial history, economic development and modernization, inequality, and neoliberal politics) in relation to the HIV/AIDS epidemic by linking individual stories, understandings, and experiences to the larger structure. The relationships between macro and micro elements, or structure and agency, remain central to the discussion of various substantive issues (e.g., healing approaches, sexuality, and gender relations) and theoretical arguments throughout the book. For example, during the period of AIDS denial in South Africa under President Mbeki’s governance, the state resisted the Western biomedical notion of treating HIV with antiretrovirals. The anti-biomedical sentiments were then and continue to be reflected in many individuals still refusing or delaying antiretroviral therapy (ART) and using traditional and modern alternative healing methods (e.g., herbs or Christian cleansing rituals). Decoteau guides the reader through these examples of where “the self” draws on the structure while shaping it at the same time—reflected, for example, in collective patterns of traditional medicine use and distrust of ART and biomedical providers.

The ethnographic methodology used to explore the topic of political economy and HIV/AIDS may be considered the key contribution and strength of this sociological work. However, theoretical arguments and application of contemporary sociological theory in this book are, in fact, more impressive than the ethnography itself. This could be because most of the book’s content rests on theoretical and interpretive discussion, and it feels at times that the ethnographic data or examples are too few or sparse (despite the wealth of data that the author apparently has at her disposal). This could be somewhat disappointing to readers who connect with personal stories and value such material more than theoretical discussion. Sociologists, however, should appreciate the extensive use of contemporary theorists like Foucault, Bourdieu, Deleuze, and others. For example, in relation to HIV-related risks that people take or avoid (e.g., unprotected sex), the author draws on Foucault’s concept of Homo economicus—a rationally calculating individual. Then, she extends this concept and frames individual practices within a habitus (per Bourdieu): that is, in the communities that she studied (slums), the risks were constant, immeasurable, and hardly avoidable. (This example links to the current debate about the relative value and impact of behavioral and structural HIV interventions.) One weakness in Decoteau’s theoretical explorations is that her approach is somewhat eclectic (multiple theorists/theories popping up here and there throughout the book) and not fully tied back (perhaps in the final part of the book) to the overarching theoretical framework of post-colonial, traditional versus modern, and neoliberal factors shaping the response and experience of HIV/AIDS in post-apartheid South African society.

The topic and content of this book is quite versatile and could be of interest to various audiences. The book has particular relevance to the fields of medical sociology, the sociology of knowledge, public and global health, health policy, and HIV and infectious diseases. Different substantive and methodological aspects of the book (e.g., focus on global HIV struggles and social inequality, ethnographic methodology, and sociological theory applications) make it suitable teaching material for various academic courses. For example, the book could be used as a supplementary text in graduate courses that focus on health and illness, social and global inequalities, comparative-historical sociology, or contemporary sociological theory. It could also be used as an example of ethnographic research for a qualitative/ethnographic methods course. Although conceptual underpinnings may require some knowledge of contemporary sociological theory, and some of the issues in stratification or global disparities are complex, the book may also be suitable for upper-level undergraduate courses, especially honors or capstone courses.

In sum, this book is a useful contribution to the literature. Although it focuses on HIV/AIDS in one specific context, post-apartheid South Africa, its scope is by no means narrow. In the background, and weaving throughout the book, Decoteau paints a dynamic picture of the South African history, colonial legacy, politics, and culture in which the HIV epidemic is embedded and evolving. Several key themes, which connect to global policy, inequalities, health culture, and health systems issues, are introduced early in the book and continue to be explored and illustrated throughout. This book about HIV/AIDS in South Africa could pave the way for similar sociological explorations of HIV/AIDS in other contexts. A body of such comparative work, in turn, could make an important contribution to the understanding of HIV/AIDS throughout the world.