Even though it is hardly fashionable today to regard plagues as God-sent, the African AIDS pandemic is a catastrophe of such massive proportions that we have to struggle not to think about it in a religious way. More than 2 million people are perishing each year; millions more will die if they do not receive treatment. Out of this colossal theft of human beings, we have a great need to tell a story about this epidemic that ends with redemption.
In our secular age, though, the agent of the redemption we conjure is not a god but Science with a capital S. In this case, Science’s lodestar is antiretroviral treatment, or ART, which, if made accessible across the continent, has the potential to save millions of lives.
Great redemptive hope has been invested in ART. The distinguished African historian John Iliffe, for instance, has suggested that the drugs will inspire Africans to challenge the dire leadership that has afflicted the continent since independence in the 1960s, thus heralding an era of renewal in African public life. We watch with keen interest as social movements rally around treatment, in the hope that they will elevate African countries to new heights.
The healing powers that have been invested in these drugs are medical, to be sure, but they are also so much more. It is as if they promise to pay back to Africa what it has lost, with interest.
Buried in these new hopes is an old wish, one that people in the West have held for their relationship with Africa for many generations. It is a familiar story about saving Africa by bringing Science and Progress to its shores, in this instance, in the form of medicine. Put the fruits of Science on the clinic shelves in deepest Africa, and the poor and the sick will line up for them. Bring treatment, and the wretched will heal.
It will never be that simple.
In my home country of South Africa, for instance, a robust and creative social movement is slowly winning a decade-long battle against a recalcitrant government to make ART available at public healthcare facilities. And yet as victory comes closer, the story gets more difficult. Some of South Africa’s new treatment sites are full, while others are woefully empty. Some people embrace treatment; others shun it.
Particularly interesting is that the sick are dividing along gender lines. Men make up just under half of the HIV-positive population in South Africa, yet 70% of people on treatment are women. Men are clearly staying at home and dying in large numbers.
So where are the missing men? Part of the answer has to do with the fact that HIV is carried not only in blood but in semen. “How can I ever be ready to hear that I’m HIV-positive?” one man told me. “If I test today, and the result is positive, I will have to call off my marriage. No woman would be my wife and risk having a child with the virus.” His fear was as simple as it was powerful: The virus constituted an attack on his capacity to have children who would bear his name and thus on his permanence beyond the grave.
If AIDS is indeed experienced as an attack on a man’s generative capacity, who is the attacker? At times, this man, along with scores of other young men I interviewed in South Africa, was certain that there was a white conspiracy. “Why is it a disease of blacks,” he asked, “and not a disease of whites? And why did it come only after [the advent of democracy in] 1994? We have a saying in Xhosa: ‘When you see smoke in the sky, it means that some people have been lighting a fire.’ ”
Raising these issues is uncomfortable for two reasons. First, they suggest that helping a continent in need is complicated and difficult. Second, asking why sick Africans do not always rush to get treatment requires thinking and speaking about them anthropologically, which brings its own special fear: the fear of patronizing them, of blaming them and their indigenous ways for their illness.
But that in fact applies a double standard -- one for Africans, another for Westerners. In the United States, nobody has seriously argued that medicine single-handedly contained the gay AIDS epidemic. Long before triple-dose antiretroviral therapy became available, gay men entered into a collective dialogue that slowly and painfully reexamined the fundamentals of their identities and sexual practices. Gay men were forced to think about themselves anthropologically and to recalibrate their relation to themselves and the world.
And so it will have to be with Africans. Many are staying home and dying despite the availability of treatment because of shame and stigma. A sexually transmitted disease borne in blood and semen is so intimate an attack because it is so opaquely bound up with conceptions of self and of worth; it is precisely on this terrain that human behavior becomes mysterious. Drugs alone cannot wish this complexity away.
Of course, the struggle to make ART universally available on the African continent is as urgent as it has ever been. But my hunch is that the odds are stacked against these drugs becoming the harbinger of a wider African redemption. Many of those stigmatized by AIDS are never going to wear their HIV status on their sleeves. They run from any social movements.
Paradoxically, ART will work best in Africa only after it has been stripped of the magical powers that have been ascribed to it. We need fortification against the comforting Western fantasy that Africa will be saved by Science alone. Drug programs ought to heed the frailty and complexity of the human beings they aim to reach. In particular, for men who have been disabled by shame, treatment needs a new face, one that presents AIDS not as the core of a new political identity but as a chronic illness like any other. The environments in which they test and begin treatment ought to be quiet, professional and workaday. Frailty and complexity also need to be more generally acknowledged.
A great epidemic by its nature assembles people into difficult relations with themselves and one another. There is no substitute for working through this terrain. Africans, after all, are as complicated as gay white men.