Both HIV/AIDS and global health in African countries have been the subject of much recent academic scholarship. Analyses have ranged from epidemiological and biomedical studies of health outcomes to on-the-ground studies of patients’ lives and populations in need of care. In HIV Exceptionalism, anthropologist Adia Benton makes an incisive contribution by investigating the paradoxes of AIDS interventions in Sierra Leone in the early to mid-2000s. How, she asks, was a large-scale transnational and institutional response to AIDS mobilized in a context that belied fundamental assumptions of HIV/AIDS programming?
Drawing on ethnographic fieldwork and critical readings of development discourses, Benton investigates the political, economic and institutional frameworks that constitute the ‘topography’ of AIDS responses while also providing granular accounts of the patients, health workers, development actors and others who populate this landscape. She unpacks the notion that HIV is an exceptional disease requiring an exceptional response, and investigates the consequences of this approach for HIV-positive and -negative Sierra Leoneans, and for social and political life in Sierra Leone.
A central implication of the book is that the global AIDS response has been as much ideological as it has been epidemiological. Highlighting the disjuncture between numbers of those infected and the money and attention given to HIV, Benton demonstrates the extent to which AIDS programmes are driven by imaginations of an ‘epidemiological Africa’ and of the subjects who populate it – subjects in need of intervention and remaking. While her story is specific to Sierra Leone, where less than 2 per cent of the population is HIV-positive, these contradictions are characteristic of much of the continent, where HIV programmes generate 40 per cent of total spending on health despite a disease burden of less than 20 per cent (p. 46).
Through a critical reading of the narrative and numerical accounts through which AIDS responses are produced, Benton shows how the ideologies and contradictions that underpin HIV programming have both corrosive and poignant effects. In a key argument, Benton notes that, on the one hand, ‘[i]n places like Sierra Leone that suffer from radical inequalities and broken health systems, HIV exceptionalism actually serves to amplify existing disparities. On the other hand, it also provides a means by which poorer HIV-positive people can benefit from a healthcare system that normally privileges the priorities of its wealthy donors’ (p. 43). The tension between a system that generates and amplifies inequality and the life-sustaining resources that this system makes available shapes what Benton calls the ‘double-bind of HIV exceptionalism’: HIV is not a ‘run-of-the-mill public health problem’, yet by characterizing it as exceptional, it becomes impossible to sublimate HIV programmes to a more equitable and efficacious primary healthcare or public health agenda (p. 47). The result is HIV programmes that weaken healthcare as a whole even as they sustain life for a few.
The attention given to ideologies, and to those who tell and respond to epidemiological stories, allows Benton to intervene in debates regarding the role of the state in the context of development. In contrast to frequent accounts of state decline, Benton demonstrates that national imaginaries and institutions remain highly salient, even as they coexist alongside transnational agencies. Government health programmes and spaces (such as clinics), for instance, play a central role in mediating relationships between patients and providers and in distributing medical goods. Thus, Benton demonstrates that ‘the state remains a potent entity imbued with meaning and “meta-capital”’, and suggests that transnational HIV programmes also enable and transform relations ‘between so-called “failed states” and individual citizens’ (p. 126). These relations include deeply gendered and moralizing modes of sexual citizenship (p. 119) through which women's bodies and behaviours are scrutinized and policed. This attention to gendered modes of citizenship suggests that scholars might usefully attend to which state capacities are eroded, endure, or even expand, in which contexts, with what effects, and for whom.
Benton's attention to the complexities of relations between transnational actors, state presences, situated politics and lived experiences appears particularly prescient in light of the 2014 Ebola outbreak and the resultant social scientific, biomedical and epidemiological debates regarding the role of fragile primary healthcare and public health institutions in the spread of epidemic disease. As pandemics beyond or after HIV reanimate calls for transnational health investment, attention to the irreducibly political nature of public health is much needed, as are accounts of how exceptionalizing disease responses produce health fragilities.
Well-written and engaging, the book won the 2017 Rachel Carson Prize from the Society for Social Studies of Science. I have used HIV Exceptionalism in courses on medicine in African countries, and the book would be easily incorporated into graduate and undergraduate courses on global health, HIV/AIDS, African politics, critical development studies and related fields.
