Jessica Hardin on Rijk van Dijk, et al. (eds), Religion and AIDS Treatment in Africa
In 2009, an estimated 2.1 million people with HIV in sub-Saharan Africa had access to antiretroviral therapy (ART). Given that antiretroviral drugs suppress the HIV virus in order to stop the progression of HIV disease, this therapeutic transformation has raised a number of questions about the ethics of prolonging life. For scholars of religion, this biomedical innovation raises questions about the politics of hope. How does biomedically prolonged life productively intersect with religious theories of redemption? The editors propose the concept of “co-productivity” to articulate the dynamic ways that technological innovations have variously shaped religious experience, the religious organization of care, and theological claims. The interdisciplinary volume Religion and AIDS Treatment in Africa brings to light the ways that hope derived from technological innovation threads complex entanglements of religion, civil society, and the state.
Our understanding of how religion and HIV/AIDS treatment therapies intersect suffers from a dearth of research. While public representations of this intersection have tended to focus on the negative impact of notions of divine retribution, this volume explores positive religious responses to HIV/AIDS in the areas of identity formation, healing efficacy, meaning-making, and morality. The framework for this exploration is what Felicitas Becker and P. Wenzel Geissler have termed “‘the prescriptive turn in religious life’; in other words, the notion that one of the prime preserves of religion is to enjoin upon followers and thereafter monitor behavior change,” which productively dovetails with public health endeavors to change behavior.
Another important and productive intersection to which the editors draw attention is the flourishing of global evangelical Christianities across sub-Saharan Africa and the incorporation of HIV/AIDS into moral discourses. Specifically regarding Islam, the authors focus on HIV/AIDS as a “symbol for moral decay” related to a lessening of gender segregation, prostitution, and the influence of tourism. Bridging the two, the volume examines religious ideologies related to syncretic healing practices by examining how people navigate contested orientations towards achieving healing in complex cultural worlds.
Several analytic frameworks tie these chapters together, many speaking to Vinh-Kim Nguyen’s biopolitical concept of “therapeutic citizenship,” which draws attention to the ways biomedicine, humanitarian interventions, and the state shape subjectivity, in turn transforming disease identifications into essentialized identities for sick persons. Authors like Marian Burchardt, Jack Ume Tocco, Bjarke Oxlund, and Caroline Meier zu Biesen variously index their engagement with this concept. However, the volume also expands the theoretical field by incorporating the perspective of religion.
The introduction of ART in sub-Saharan Africa challenged religious practices. The particular histories of ART distribution, the editors argue, “have triggered the formation of new religious spaces,” which are best understood as “‘the redemptive moment’ in the larger history of the HIV epidemic in Africa.” They propose that this temporal concept can bridge diverse scholarship in the social sciences, theology, and religious studies because the concept highlights both the potential for new life while also synchronically anchoring this in a particular moment in time. The redemptive moment arrived in the early 2000s, when ART came to be represented as a magic bullet to ameliorate the HIV/AIDs crisis. In the late 1990s, the HIV epidemic had been represented as a “development and security crisis,” but the introduction of ART introduced new expectations that the losses of earlier periods would be over. This explicit change in the politics of hope is evident in the phrase used by Doctors without Borders in 2001: “From despair to hope,” though scholars know less about how envisioning the possibilities of life in turn shapes religious stances towards authority over life and death.
The volume itself is organized around three primary themes: agency, subjectivity, and authority; contested therapeutic domains and practices; and emergent organizational forms. Rather than rehearsing these well-developed themes, I want to highlight additional cross-cutting analytic threads.
The first is stigma. The volume is in part a response to earlier scholarship focused on how religious responses to HIV/AIDS contributed to growing stigmatization of the illness. With growing stigmatization came religious institutional claims to authority over sexuality and sexual practices. The experience of stigma is apparent in the story written by Oxlund about his interlocutor in South Africa.
Dios was rejected by his family on several occasions because of his HIV status, as well as other factors, which caused his family to “pass moral judgment” on him. In the wake of being kicked off of family land, and because he had been volunteering as a HIV/AIDS activist, he was granted state-administered low-income housing. During this time, Dios also converted to the Zionist Christian Church (ZCC), which discourages ART because ZCC does not “subscribe to a viral aetiology of HIV/AIDS”; he himself reported that he did not use ART. He eventually became a leader in the organization People Living with HIV/AIDS, a ZCC follower, and a HIV/AIDS counselor at the University of Limpopo.
Dios’ narrative is one in which stigma coexists with social acceptance. The coexistence of potentially contradictory meanings and beliefs about HIV/AIDS is also apparent in his position as both counselor and follower of ZCC. To complicate this narrative even further, Oxlund brings to light the possibility of another motivating factor in Dios’ abstention from ART: a CD4 (a type of white blood cell) count below 200 qualified Dios for a disability grant from the South African government. When Oxlund asked Dios if ZCC would permit members to use ART, or perhaps “‘bless’ the pills,” Dios responded that medicines were not strictly forbidden, but the medicines could not be supported by ZCC. As a result, in his role as counselor, Dios said he focused on “abstinence and positive living.” Stigma certainly shaped his earliest experiences of HIV/AIDS, but as he changed churches, this change opened up new networks where he did not experience the same stigma. Similarly, Oxlund writes about another HIV-positive woman who was also an activist, who considered AIDS a “blessing in disguise” because of the opportunities that accompanied her positive status. Dios also felt his positive status created professional opportunities otherwise unavailable to him. His narrative makes clear the ways that Christian moral imperatives for sexual and ART abstinence shape HIV/AIDS activism.
The second theme I want to highlight is the role of the state. The chapter by Becker highlights the ways the state or institutions more broadly shape subject formation by extending James Ferguson’s concept of “styles.” He describes how focusing on style moves analysis beyond questions of changes in identity, in this case in speaking and acting about AIDS and ART, to an analysis focused on performances. Performances are “not one-offs but add up to persistent patterns, they go beyond exchange, towards the cultivation of forms of comportment that are both personal and interpersonal.”
For example, Becker draws examples from a meeting of twenty-odd Tanzanian Muslim groups, joined together to discuss developing a financial mechanism to allow for the dispersal of funds from the Tanzanian Commission on AIDS. These groups “developed a vocabulary that combined elements of reformist and political Islam with a donor-friendly, Anglophone language of public health education.” Several elements combined in this instance to create the “reliable funding recipient style”: the location of the meeting at a Muslim-owned business in a Muslim-dominated district, the dominance of English as the lingua franca of the event (indexing the “donor friendly” style of younger generations as compared to the older generations’ almost exclusive Swahili-speaking), the attire of the participants in kanzu gowns and kofia caps (retaining an index of the style of this older generation), and the content focus on “AIDS control [as] a political issue” reflecting Muslim alienation from the “Tanzanian polity.”
One of the sheikhs clearly demonstrated adeptness in “style switching” by speaking English, drawing attention to his experiences in the UK, and discussing past experiences working as an adviser to an aid organization focused on gender relations. Outside the context of this meeting, Becker notes that her conversations with the same sheikh were focused instead on Muslims’ problems, drawing from expressions of piety and speaking in Swahili: “The mixture has been effective inasmuch as it has enabled the sheikh to pursue an active career on the interface of religious activism and AIDS-related consulting.” This example highlights how illnesses such as HIV/AIDS inform subject formation at multiple levels simultaneously. It is not only those who are suffering with HIV/AIDS whose subject position is affected, but those who are involved with healthcare provision who are also shaped by the broader context of HIV/AIDS. In this case, those wishing to attract funds occupy positions at the interface of religious politics and epidemic discourses.
A final theme is how the interaction between organizational politics of distribution and religious practices fit productively with neoliberalism. This interaction is particularly evident in chapters that focus on the “therapeutic economy” developed around ART provisioning. In the chapter by Alexander Leusenkamp, the author draws attention to how Christian civil-society organizations dominate the governance and distribution of ART services in Uganda, which have largely replaced the government in this provisioning. In turn, Leusenkamp shows how Christian civil-society organizations have a hand in shaping public health policy and service delivery.
In a similar neoliberal shift, Louise Mubanda Rasmussen argues that the locus of care in a Catholic community-based organization also in Uganda shifted from holistic care — aimed at restoring individual dignity and providing multiple forms of support — to an increasingly biopolitical project of counseling and disciplining clients, ensuring that patients “take responsibility for addressing any social, economic, or emotional barriers they may face in adhering to the medicine and its ‘social rules.’” These two chapters provide very different perspectives on the role of Christian civil society in the distribution of ART. Leusenkamp argues that Christian civil-society institutions could offer deeper resources than state-support public health, while Rasmussen argues that in this shift the social determinants of health are largely ignored in favor of biopolitical disciplining of sick persons. Both chapters, however, illuminate in a detailed fashion the interplay of vital institutions.
Overall, this volume will be of interest to scholars working on HIV/AIDS and those working on the intersection of biomedicine and religion. Particularly valuable is the collaboration across a range of disciplines — including history, anthropology, cultural studies, politics, public health, gender/sexuality, and African studies — to highlight the various scales from which to carefully examine the productive intersection of HIV/AIDS, religion, and healing.
These themes articulate a framework for working at the intersection of medicine, religion, and the state by spanning scales of analysis from individual experiences and dilemmas, to state distribution politics, and finally global institutions and related discourses. The interdisciplinary approaches highlight the scope of possible strategies for carefully examining vertical and horizontal factors that shape the meanings and practices of HIV/AIDS and ART. Methodologically, the volume also shows how field-site choice yields new ways of seeing the intersection of medicine and religion. By opting to study in healthcare organizations or universities, for example, over strictly church-based research, the researchers gain valuable insights into the pathways that connect church with other vital institutions. Overall, the concept of “co-productivity,” articulated in the introduction and then demonstrated in the proceeding chapters, offers an innovative way to think across domains in a relational fashion.
I most appreciate the volume’s explicit focus on temporal ways of analyzing social and religious change through the marking of this historical shift in hope as the “the redemptive moment.” However, the volume does not theorize temporality as such and the lack of engagement with Joel Robbins’ deeply temporal argument is notable. Robbins argued in 2007 that the anthropology of Christianity had previously failed to develop because of the tendency to emphasize cultural continuity, which belies how discontinuity and radical change is emphasized in many forms of Christianity. Authors in this volume highlight the newness of hope derived from the mass-introduction of ART. This raises questions for me: is this redemptive moment one expression of that discontinuity that Robbins describes? Redemption from this perspective would suggest that redemption is historically situated yet ideologically universal. When taking this line of enquiry one step further, as a medical anthropologist I wonder: how are the synergies and conflicts between biomedical renderings of hope and related religious practices of redemption articulated through time-based notions of life?
I generated the questions above because the volume examines a novel way of studying the intersection of medicine and Christianity: how particular illnesses, epidemics, and related technologies, shape religious thought and vice versa. Scholars of Christianity have examined healing processes and the historical entwining of medicine and Christianity, but there are fewer perspectives to draw from when seeking to understand the particular existential dilemmas raised by particular diseases. This volume is a welcome addition to this growing intersection of scholarship because it reveals the complex entangling of institutions, belief, and health inequities in shaping how hope and redemption are culturally articulated, but constrained by historical, social and economic factors.