‘How do we know what we know about HIV?’ is the question driving Joanna Tayloe Crane's penetrating analysis of the rise and routinisation of AIDS research in Africa. Scrambling for Africa provides an original context to our understanding of the epidemic – unearthing the connections that link a man dying of HIV in a hotel in San Francisco to a rural Ugandan doctor's hand-written ledger of patients on antiretroviral (ARV) therapy. This multi-sited cross-hatching of patients, expertise and locales offers a new insight into the circulations of knowledge and value, and the modalities of exclusion, that sustain global health science.
Scrambling for Africa elaborates the making and unmaking of HIV knowledge across five chapters. The first chapter rehearses the debates surrounding the provision of ARVs to afflicted African populations. To contemporary ears the argument that patients are too poor and uneducated to manage a rigorous treatment schedule will sound outrageous. However, in our era of biosecurity anxieties, the spectre of drug-resistant ‘superbugs’ emerging from the continent feels familiar. The ethical register of pharmaceutical development has certainly shifted since the first ARVs were approved by the FDA in the late 1980s, but as Crane argues, the current policy of universal availability only became a reality after studies had proven that resistance levels were far lower in African HIV sufferers than among their American counterparts. While a triumph for some, these findings further entrenched the idea that treatment is a reward for good patient behaviour rather than a basic human right. If anything, low rates of resistance point to the lack of exposure to treatment of any kind—a testament to almost two decades of racist policy masquerading as public health savvy.
It turns out there are also good reasons to be sceptical about the scientific integrity of drug-resistance evidence. In the second chapter, Crane parses the institutional and interpersonal contingencies of HIV immunology and epidemiology. Here, Crane's scientific fluency is particularly impressive. She shows how ‘Africa’ emerges as a statistical entity used to justify health policies that are often antithetical to the well-being of the continent. Chapter 3 thickens that argument by elucidating the diverse scientific and developmental logics that have transformed Africa into the ‘labscape’ for HIV research. The constraints that research infrastructures place on clinical care is brought into relief in Chapter 4, where a series of short biographies of Ugandan clinicians and scientists – reminiscent of Randy Shilts's 1987 gripping account of the unfolding of the HIV epidemic in the USA, And The Band Played On – lays bare the hollowness of policy appeals to partnership. Chapter 5 sets these career trajectories against the background of the financial and administrative structures that delimit their conditions of possibility – including an incisive breakdown of the percentages that US grants allocate to foreign institutional overheads.
It is in these final arguments where the relevance of science studies for global health is most clear. In addition to coming to grips with the post-colonial power dynamics that have transformed Africa into a site of knowledge production, Scrambling for Africa also grants the problematic pairing of ‘humanitarian sentiment and scientific ambition’ considerable affective depth. Crane's reflections about the nostalgia experienced by US scientists when visiting African hospitals are some of the most startling and freshest of any ethnography of transnational medical research that I have read to date. Overall, Scrambling for Africa presents a clear and subtle analysis of an unruly topic, and is relevant reading for a diverse readership ranging from medical anthropologists, science studies scholars and Africanists, to science policy-makers and global health professionals.
