JOURNAL OF WORLD-SYSTEMS RESEARCH Review of Claire Laurier Decoteau’s Ancestors and Antiretrovirals New articles in this journal are licensed under a Creative Commons Attribution 4.0 United States License. This journal is published by the University Library System, University of Pittsburgh as part of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. Claire Laurier Decoteau. 2013. Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa. Chicago, IL: University of Chicago Press. 324 pages, ISBN 978-0226064598 Paper ($32.50). Before South Africa became famous for implementing the largest public sector antiretroviral (ARV) treatment program in the world, it was infamous for the Mbeki government’s refusal to recognize the efficacy, safety and sustainability of ARVs and his administration’s endorsement of “vitamins and vegetables” as efficacious HIV/AIDS treatments (Cullinan & Thom 2009). The activism required to bring about this policy transformation has been extensively documented by treatment activists themselves (Geffen 2010), and by academics who have sought to explain how these struggles have reconfigured the contours of postapartheid citizenship (Robins 2010), social rights and intellectual property rights law (Pieterse 2014, Kapstein & Busby 2013), transnational activism for access to essential medicines (Mbali 2013), and the political and economic feasibility of providing free ARVs to all who need them (Nattrass 2004). Unlike much of this literature, Claire Laurier Decoteau’s Ancestors and Antiretrovirals is not primarily concerned with explaining why treatment activists were successful in popularizing the principle of universal access to ARV treatment, nor with exploring the effects of this victory on political and legal institutions. Instead, she analyzes debates about HIV/AIDS treatment in order to (1) identify and critically evaluate the conflicting strategies politicians, treatment activists and HIV-positive informal settlement dwellers propose for managing the “postcolonial ISSN: 1076-156X | Vol. # 21 No. 2 | http://dx.doi.org/10.5195/jwsr.2015.21 | jwsr.org Vol. 1 | DOI 10.5195/JWSR.1 http://www.library.pitt.edu/ http://www.pitt.edu/ http://www.pitt.edu/ http://www.library.pitt.edu/articles/digpubtype/index.html http://upress.pitt.edu/ https://creativecommons.org/licenses/by/4.0/ http://dx.doi.org/10.5195/jwsr.2015.21 Journal of World-Systems Research | Vol. # 21 No. 2 | Paremoer jwsr.org | http://dx.doi.org/10.5195/jwsr.2015.21 569 paradox”; and (2) identify and critically evaluate the impact of proposed solutions to this paradox on the subjectivities of HIV-positive people living in South Africa’s informal settlements. According to Decoteau, all postcolonial states face the paradox of simultaneously having to “respect the demands of neoliberal capital in order to compete successfully on the world market and a responsibility to redress entrenched inequality, secure legitimacy from the poor, and forge a national imaginary” (7). She examines how South African politicians and treatment activists have sought to resolve this paradox by creating an HIV/AIDS treatment regime that has “restructured welfare rights in the post-apartheid era by biomedicalising citizenship…As a consequence of these efforts, citizenship rights have become dependent upon the successful adoption of certain health behaviours sanctioned by biomedical practitioners” (135-6). This treatment regime seeks to create a “responsibilised citizenry” (146) which distributes social citizenship rights on the basis of individuals’ embrace of “a biomedical paradigm of “truth’” (137). Decoteau argues that individuals who cannot (or do not want to) subscribe to this truth regime, and instead embrace indigenous healing practices, are framed by the “biomedical industry made up of public health institutions, pharmaceutical corporations, NGOs and various Western governments” (137) as rendering themselves ineligible for the social citizenship rights extended to more “responsible” HIV-positive individuals. Such “irresponsible” patients are often framed as not only failing themselves, but also as endangering public health in at least two senses. Firstly, patients who refuse to take ARV treatment endanger public health by failing to suppress their viral loads, thereby making it more likely that they will transmit the virus through unprotected sex. Secondly, patients who use ARVs but combine them with indigenous healing practices risk reducing the efficacy of ARVs, thereby increasing the risk that more treatment- resistant strains of the virus might emerge. There is no space for these delinquent citizens in a treatment program that operates according to a “simultaneous process of incorporation and abandonment” (100): incorporating and distributing privilege only to patients who conform to its prescriptions, and abandoning the rest. Why do HIV-positive individuals reject the biomedical conception of HIV/AIDS and/or fail to comply with the treatment regimens consistent with this conception of the illness— particularly in situations where compliance would render them eligible for life-saving medication? Decoteau makes a valuable contribution in pointing out that most South Africans living with HIV/AIDS are forced to consume ARVs within the context of a biomedical treatment system that perpetuates injustice by (1) misrecognizing them and (2) by routinely ignoring structural impediments to adhering to ARV regimens. Through the judicious use of quotes from interviews and focus group discussions, Decoteau shows that HIV-positive people living in informal settlements struggle to obtain access to ARVs http://dx.doi.org/10.5195/jwsr.2015.21 Journal of World-Systems Research | Vol. # 21 No. 2 | Book Review jwsr.org | http://dx.doi.org/10.5195/jwsr.2015.21 570 due to stigma, a lack of safe and affordable public transport, and difficulties in accessing respectful and effective medical care in a timely manner. Once they have obtained these drugs, they struggle to consume them as prescribed due to their lack of access to affordable and nutritious food, potable water, safe and affordable housing, a clean environment, and a basic minimum income. Decoteau argues that the biomedical approach to treatment fails to address these obstacles because it is premised on and promotes neoliberal rationalities of rule. These governance strategies task individuals rather than governments with overcoming the postcolonial paradox by becoming “entrepreneurs of their own development and deliverance” (85)—i.e. by functioning more effectively within the prevailing neoliberal orthodoxy with progressively fewer resources and less assistance from the state. This dynamic has been entrenched under the Zuma government’s embrace of the biomedical treatment paradigm and its failure to address the structural inequalities that define contemporary South Africa. Why does the existing treatment policy misrecognize many South Africans living with HIV/AIDS? Decoteau argues that the debate about HIV/AIDS in South Africa has been a key site for contesting how notions of “tradition” and “modernity” should be deployed in order to ameliorate the tensions inherent in the postcolonial paradox. She argues that presidents Mbeki and Zuma have deployed these concepts as “ideological tools” (21) and see them as distinct and opposing terms. They have both celebrated “tradition” – “traditional” medicine, in the case of Mbeki, and “traditional” Zulu masculinity, in the case of Zuma – in order to shore up their legitimacy and to divert attention from their governments’ failure to fulfil the social citizenship rights of the poor. In these instances, Decoteau argues, political elites celebrate “tradition” purely for strategic gain. She contrasts this opportunistic instrumentalization of “tradition” with the important role that this idea plays in shaping the subjectivities, survival strategies and solidarities of HIV- positive shack-dwellers. These actors, Decoteau argues, don’t see “tradition” and “modernity” as mutually exclusive and binary opposite terms. Instead, they combine and repurpose practices and subjectivities associated with both “tradition” and “modernity” in order to seek out health care interventions that address the biological causes of their illness, as well as the social and symbolic transgressions that explain its manifestations. This pluralistic approach to healing allows patients to improve their health in a holistic fashion: through these interventions their physical wellbeing is promoted and the moral and social order is restored. However, it also fulfils an important function in shaping patients’ subjectivities: patients’ refusal to reject indigenous healing practices affirms their belonging to and embeddedness in communities that have historically been constituted by and reproduced through respect for the authority of indigenous healers and diviners. Decoteau argues that these patients reject treatment interventions that rely exclusively on “modern” ARVs because they http://dx.doi.org/10.5195/jwsr.2015.21 Journal of World-Systems Research | Vol. # 21 No. 2 | Paremoer jwsr.org | http://dx.doi.org/10.5195/jwsr.2015.21 571 perceive them as being premised on the misrecognition (and the eventual erasure) of the hybrid self. This “self”, which emerged under apartheid and rejected its construction of traditional and modern as distinct spheres, enabled black South Africans to “traverse the divides” between tradition and modernity and “to strategically deploy the languages and symbolic practices associated with each to survive and resist” this violent regime (235). Decoteau argues that embracing modern ARVs exclusively – as is demanded by the national treatment program – is politically significant because it reinscribes and repoliticizes this construction of tradition and modernity as mutually exclusive spheres. It demands a rejection of hybridity, thereby constraining the range of oppositional subjectivities available to poor citizens who wish to resist and reject neoliberal modes of self-governance that are designed to obscure and elide the structural roots of the forms of material and symbolic disenfranchisement that define their experience of postapartheid “liberation.” Ancestors and Antiretrovirals demonstrates how neoliberal governmentalities are deployed by the South African government and treatment activists to make individuals responsible for forging subjectivities that allow them to better “cope” (Marais 2011) with the precarity associated with the concurrent crises of the HIV/AIDS epidemic, mass unemployment, generational poverty and contested gender norms, while encouraging them to reject subjectivities that are hostile to “coping” and more amenable to a politics that prioritizes social citizenship ahead of the demands of neoliberal capital. I find Decoteau’s argument convincing. For the most part, it is well substantiated by her careful analysis of the data she collected over a decade-long period (from 2002-2012) by means of an ethnography, interviews with key informants, and focus group discussions. However, more could be said about the possibilities – but especially the limits – of forging an anti-neoliberal, pro-poor politics on the basis of hybrid subjectivities that combine the modern and traditional. Though Decoteau claims that “in the late neoliberal era, the survival of the poorest of the poor becomes an increasingly political project” (23) much of the book is preoccupied with explaining the survival strategies of the poor. It remains silent on political projects forged by and for the poor. A future contribution might more fully explore the possibilities for engaging in forms of collective action that are animated by the hybrid subjectivities she discusses, their potential for forging new solidarities, and the philosophical roots of their scepticism of neoliberal modes of self-management. References Cullinan, K. & Thom, A. 2009. The Virus, the Vitamins and the Vegetables: The South African HIV/AIDS Mystery. Johannesburg: Jacana. http://dx.doi.org/10.5195/jwsr.2015.21 Journal of World-Systems Research | Vol. # 21 No. 2 | Book Review jwsr.org | http://dx.doi.org/10.5195/jwsr.2015.21 572 Geffen, G. 2010. Debunking Delusions: The Inside Story of the Treatment Action Campaign. Johannesburg: Jacana. Kapstein, E. & Busby, J.W. 2013. AIDS Drugs for All: Social Movements and Market Transformations. Cambridge: Cambridge University Press. Marais, H. 2011. South Africa Pushed to the Limit: The Political Economy of Change. Cape Town: University of Cape Town Press. Mbali, M. 2013. South African AIDS Activism and Global Health Politics. Basingstoke: Palgrave Macmillan. Nattrass, N. 2004. The Moral Economy of AIDS in South Africa. Cambridge: Cambridge University Press. Pieterse, M. 2014. Can Rights Cure? The Impact of Human Rights Litigation on the South African Health System. Pretoria: Pretoria University Law Press. Robins, R. 2008. From Revolution to Rights in South Africa: Social Movements, NGOs and Popular Politics After Apartheid. Scottsville, KZN: University of Kwazulu-Natal Press. Lauren Paremoer Department of Political Studies University of Cape Town lauren.paremoer@uct.ac.za http://dx.doi.org/10.5195/jwsr.2015.21 mailto:lauren.paremoer@uct.ac.za