Multisited fieldwork and the South African HIV/AIDS policy process
Following Nomfusi: Studying pathways, locating intersections
Originally from the Eastern Cape, in 2002 Nomfusi moved to Khayelitsha, a township located approximately twenty-five kilometers from the city center of Cape Town. [note 1]Khayelitsha is an isiXhosa word that roughly translates to ‘new home’.
In her mid-thirties when she moved to the township, Nomfusi first resided with members of her extended family. She was introduced to the South African HIV/AIDS movement due to geographic proximity, as her family lived next door to a group of activists affiliated with the Treatment Action Campaign (TAC), an organization focused on improving access to antiretroviral drugs and other treatment for people living with HIV/AIDS. Nomfusi recounted to me how her conversations with the activists developed organically over time, with everyday events leading to deeper conversations about family, children, health, and HIV/AIDS. Contrary to accounts that highlight the role of charismatic male leaders such as Zackie Achmat (Robins 2006; Mbali 2013), Nomfusi was attracted to TAC because of the female leadership within the organization. Through her work with other nongovernmental organizations (NGOs), Nomfusi encountered TAC’s local female leaders in Khayelitsha, whom she described as ‘strong’ and ‘powerful’ women. In 2005, in the process of starting an NGO focused on women’s issues in Khayelitsha, Nomfusi became fully engaged with HIV/AIDS activism. When she attempted to partner with the TAC in developing an event for her fledgling NGO, she was instead convinced to join the organization. Nomfusi was soon training as a treatment literacy practitioner and working with new mothers on the challenges of raising a family while living with HIV/AIDS.
As I was initiating my fieldwork in 2007, Nomfusi moved from TAC’s district office in Khayelitsha to the organization’s provincial office at Community House, located in the Salt River section of Cape Town. [note 2]At the time of fieldwork TAC had three offices in Cape Town: national (Muizenburg), provincial (Salt River), and model district (Khayelitsha). During the course of fieldwork, the TAC national office was moved from Muizenburg to central Cape Town. Due to financial constraints, the TAC provincial office closed in 2009.
Nomfusi now worked throughout the province, and had also been selected to serve on the Western Cape Provincial AIDS Council. My participant observation with Nomfusi involved following her as she navigated her different roles within the Western Cape Provincial AIDS Council, TAC, and her community. Initially, my research with Nomfusi and other members of TAC’s provincial office focused on the organization’s campaign for treatment access within the greater Cape Town metropolitan area. The activities of TAC’s provincial branch were largely focused on the Cape Flats, where the townships are located and the HIV/AIDS epidemic is concentrated. From the historically ‘coloured’ area of Mitchell’s Plain to the largely IsiXhosa-speaking township of Khayelitsha, Nomfusi and other TAC activists engaged with communities in various forums. [note 3]The term ‘coloured’ is a remnant of apartheid-era racial classification that refers to people of mixed European, African, and Asian descent. While the category is a social construction that was used to racially segregate the South African population, it is an important cultural marker that is actively utilized for identity claims in the postapartheid context.
Conducting fieldwork with a provincial-level HIV/AIDS activist allowed me to observe state institutions throughout the Western Cape province. I accompanied Nomfusi to a Western Cape Provincial AIDS Council meeting and was able to observe how the body operated. In addition, I followed Nomfusi to a series of consultative meetings to develop a new HIV/AIDS policy, held in each of the Western Cape’s six health districts, which highlighted the uneven and localized manifestation of the epidemic in the province. Geographic variation in the policy process underscored that the HIV/AIDS policy process did not always correspond to state institutions. Rather, local political formations, which transcended and encompassed organizations and institutions, served to direct where, and how, policy process unfolded.
Following Nomfusi also expanded the scope of my research from the provincial to the national level. As was the case with many of her peers, Nomfusi also participated in gatherings linked to national political institutions that were held outside of the Western Cape province. Of these, a national civil society meeting linked to the South African National AIDS Council (SANAC) was particularly significant. I flew from Cape Town to Johannesburg with members of TAC to a national meeting that brought together HIV/AIDS activists, NGO representatives, and state health officials from across the country. The meeting was held to coordinate the implementation of a new national HIV/AIDS policy and to develop policy recommendations for SANAC’s voting body, the plenary. HIV/AIDS activists had identified the prevention of mother-to-child transmission (PMTCT) of HIV/AIDS as an area for policy development for the meeting, given updated guidelines from the World Health Organization (WHO). In short, rather than simply a national event, the SANAC meeting brought together community-based HIV/AIDS activists, national policy actors, and forms of transnational influence.
Carrying out participant observation research with Nomfusi, therefore, involved moving between different social, political, and geographic contexts that elided easy categorization as ‘global’ or ‘local’. The pathways that I followed were ephemeral, visible only to those who moved alongside HIV/AIDS activists like Nomfusi, whose presence at meetings may or may not be formally recorded, let alone serve to influence policy outcomes. How was I to make sense of the complex dynamics of movement that I experienced following Nomfusi? How could my analysis encompass the multiple contexts encountered during fieldwork, which were marked by social, political, and institutional differences, but also linked by HIV/AIDS politics? How did the events that I was experiencing link to debates about multisited research and the development of HIV/AIDS policy? Indeed, moving alongside Nomfusi and others involved in South African HIV/AIDS politics provoked questions that highlight unresolved tensions in anthropological debates on globalization, policy process, and multisited research that serve as the focus of this article.
Evidence, policy, and anthropology
The development of HIV/AIDS policy has served as a focal point in academic research for some time, growing out of, and reflecting, the political response to the epidemic in North America. The HIV/AIDS epidemic shifted the focus of the gay liberation movement, leading to the transformation of international scientific venues and the process of scientific knowledge production (Epstein 1996). Through extended activism, the International AIDS Conference changed from an institution focused on biomedical science to one where advocacy and research were presented side by side. Clinical trials for HIV/AIDS drugs went through a similar transformation, as American HIV/AIDS activists, led by the AIDS Coalition to Unleash Power (ACT-UP), pressured US federal health agencies to include representatives of people living with HIV/AIDS on oversight panels, among other measures. Consultative mechanisms for HIV/AIDS have influenced global health policy development, such as the country coordinating mechanisms created by the Global Fund to Fight AIDS, Malaria, and Tuberculosis, which grow out of these historical dynamics.
However, over the past two decades, HIV/AIDS policy development has increasingly mirrored a global trend towards evidence-based medicine and evidence-based policymaking. Growing out of the field of epidemiology, research on evidence-based best practices aims to create global universals that apply to any context (Sackett et al. 1996). Heavily supported by donors and global institutions, evidence-based research has also permeated the making of policy based on narrow definitions of both science and evidence (Klein 2000; Dobrow et al. 2004). For example, the incorporation of biomedical research findings into global evidence-based norms has become a central function of the World Health Organization (WHO). However, critical research on evidence-based medicine highlights its tendency to mirror trends in global health while failing to take into account the inherently political nature of policy making (Behague et al. 2009; Hunsmann 2012). In addition to setting norms for global health organizations and donors, evidence-based policy making has served as a basis for policy development within societies, particularly those across the Global South.
However, the ways that global policy guidelines manifest in specific sociocultural contexts are more complex and fraught than the discourse surrounding evidence-based medicine and policy would have one believe. Research on the South African HIV/AIDS policy process highlights the dynamic relation between global norms and local outcomes. For example, global norms for HIV/AIDS treatment and prevention served as important points of leverage for the South African HIV/AIDS movement in its attempts to transform South African PMTCT policy. While WHO recommendations regarding dual-therapy PMTCT served as the foundation for updated South African policy guidelines, it was the work of the South African HIV/AIDS movement that created space for such recommendations to be discussed and considered within national health institutions (Powers 2013a). However, transnational influences operated differently with the HIV/AIDS policy process at the provincial level, where access to a Global Fund grant limited the impact of a national HIV/AIDS policy that included targets for expanded treatment access. Clearly, the South African HIV/AIDS policy process does not adhere to a predetermined set of global universals.
The growth of evidence-based policy making propagates a vision of policy as unfolding in a rational, linear fashion; research within the emerging subfield of the anthropology of policy problematizes this reductionist vision of sociopolitical dynamics, and shows that it deviates from the lived social experiences of those involved in making policy. Rather than start from a set of normative assumptions about the state and policy, anthropologists have approached policy as a domain of contestation, interpersonal connection, institutional conflict, and power (Wedel et al. 2005). From the growing significance of audit cultures to the impact of austerity on social life, anthropologists studying policy offer a necessary critique against the abstract universals associated with evidence-based policy by accounting for the roles of people and sociocultural particularity in policy outcomes (Shore and Wright 1999; Bear 2015).
Anthropological research on policy has facilitated the development of methodologies that place the emphasis on human experience rather than abstract universals. Anthropologists analyzing policy have grappled with how sociopolitical processes unfold across several institutional levels while also taking the role of human actors into account. Building on Marcus’s (1995) theorization of ‘following’, the anthropological study of policy has led to approaches that include ‘following the policy’ and ‘studying through’ the policy process (Shore and Wright 1997). With an emphasis on power relations, ‘studying through’ analyzes interpersonal connections to ‘illuminate how different organizational and everyday worlds are intertwined – and their relationships of power and resources – across time and space’ (Wedel et al. 2005, 40). In a similar vein, ‘following the policy’ takes the chain of interpersonal, organizational, institutional, and political relations that produce the policy process as the jumping-off point for the anthropology of policy (Shore, Wright, and Perot 2011). These approaches closely adhere to Marcus’s original theorization of ‘following the people’ and ‘following the conflict’, but with a thematic focus on policy. In the anthropology of policy, recent research has taken up ‘embedded ethnography’, in which a researcher works within a particular institution or organization as a way of studying sociopolitical dynamics (Greenhalgh 2008; Ho 2009; Mosse 2011). Employing the embedded methodology, Tate (2015) tracks how multiple actors, organizations, and ideas intersect in an analysis of US foreign policy in Colombia, and builds on influential contributions to the anthropology of policy (Greenhalgh 2003; Feldman 2005; Kingfisher 2013).
However, there are inherent points of tension in how one would design a research initiative based on the approaches outlined above. Regarding embedded ethnography, adherence to organizational boundaries may limit the scope for understanding diversely constituted social processes. [note 4]The tendency towards embedded ethnography within a single organization should be understood alongside the ethical clearance process for human subjects research. The complexities of negotiating access to multiple organizations may inadvertently guide researchers to conduct fieldwork with a single organization.
By focusing on a single organization or institution, the ethnographer limits the scope of the study in a way that may not reflect the diversity of actors and organizations actually encountered during fieldwork. After all, a policy process is produced when individuals and organizations with varying backgrounds, goals, and tactics interact. Policy actors move between various social, political, and spatial settings, a fact that underscores how the embedded approach limits the ethnographer’s ability to experience the policy process as it is constituted. Conversely, ‘following the policy’ brings with it the risk of associating policy processes only with state institutions, state policy actors, and formal dynamics of policy development. Focusing on ‘the policy’ carries the possibility of eliminating individuals and organizations operating on the margins of the policy process, including dissenting voices or those promulgating policy principles that differ from those circulating in the formal corridors of power. Finally, if one ‘studies through’ the policy process, the study design must begin with locating policy actors. Given the discipline’s emphasis on participant observation, anthropologists conducting fieldwork would lean towards following research participants in order to locate a policy process. But how can a general analysis of a policy process emerge from such ethnographic foundations? Must anthropologists of policy choose one or the other? Or might it be possible to combine these methodologies in a unified approach?
Movement and context: The anthropology of globalization
Over the past four decades HIV/AIDS has become a global pandemic, mirroring the increased levels of social, political, economic, and cultural integration associated with globalization. Given these overlapping frames, some have characterized the HIV/AIDS pandemic as a disease of the global system (Benatar 2001; Baer et al. 2003). Understanding the origins, expansion, and debates associated with HIV/AIDS, therefore, requires understanding sociocultural dynamics within a transnational framework. Similarly, understanding policy processes often involves accounting for actors, organizations, institutions, and forms of influence with diverse geographic origins. Anthropological research on HIV/AIDS and policy must grapple not only with sociocultural dynamics but also with anthropological theories concerning the contemporary phase of global integration. A point of tension within this literature is whether one should emphasize movement or context when locating sociocultural process in a changing world.
A recurring question in this debate is the significance of time and space in the ethnographic analysis of social life (Lowe 1996; Ferguson and Gupta 1997; Fischer 1999b; Wolf 2001). Scholars have emphasized the role of power, variously theorized as based on political, economic, or sociocultural dynamics, in producing the effects associated with global integration (Harvey 1989; Comaroff and Comaroff 2000; Edelman and Haugerud 2005; Robotham 2005). As a discipline, anthropology has long considered the movement of people, things, and ideas as objects for ethnographic analysis (Malinowski  2014; Gluckman 1941; Barth  1998; Mintz 1985; Appadurai 1986; Kopytoff 1986). More recently, the current phase of transnational integration has spurred an increased focus on the dynamics of circulation, exchange, and movement (Biehl 2007; Thomas et al. 2010; Liu 2011; Dilger et al. 2012). These perspectives highlight the significance of transnational movement in neoliberal globalization.
Appadurai (1990) analyzes the contemporary global era based on types of movement that are conceptualized via different sorts of flows, sketching the distribution and flows of people, images, and technologies via these new patterns of movement. Flows of media, finance, technology, and other domains bypass the presumed container of political, economic, and sociocultural dynamics: the modern state. Appadurai argues that examining the transnational distribution of these traits allows for a more accurate depiction of the global world in which we live. However, an emphasis on movement rather than context produces zones of exclusion in Appadurai’s framework. After all, capital flows do not reach all corners of the contemporary world equally. While Appadurai is aware of the uneven character of contemporary capitalism, it is important to note that emphasizing movement leads to privileging some contexts while others are left unattended.
Tsing (2000) takes a more circumspect position towards grand narratives of globalization and situates transnational dynamics within historically particular sociopolitical processes. In order to ground transnational sociocultural dynamics, Tsing proposes the concept of ‘projects’ to unify sociocultural processes across scales. While offering an ethnographically grounded approach, the concept of projects assumes an unwarranted degree of sociocultural unity across levels, and, in doing so, may reify normative conceptions of power (Powers 2016). As the analysis below highlights, a sociopolitical process operating at one institutional level can operate with a degree of autonomy from related dynamics at other institutional levels. [note 5]Tsing also employs the concept of scale to locate the various nodes that sociopolitical dynamics gravitate towards, which may introduce unnecessary assumptions. As a concept, scale denotes a linear metric by which one can increase or decrease the scope of analysis. Therefore, when one refers to dynamics at a higher scale, the concept presumes that those at a lower scale are subsumed within it. In addition to asserting unity, therefore, the concept of scale may also include an assumption of hierarchy. However, as Guyer (2004) emphasizes, social formations located on the periphery of the global economy have developed multiple systems of valuation upon which culturally particular conceptions of scale have been developed. Indeed, Guyer’s work underscores that standard conceptions of scale betray a Eurocentric bias that may not hold in all sociocultural contexts.
While it may be tempting to assume a causal relation between linked sociocultural dynamics, it remains that differing actors, organizations, and institutional cultures produce differing outcomes at the various levels across which a project operates.
This brief discussion of Appadurai’s and Tsing’s work highlights a choice in emphasis between the tracing of the movement of people and things and the framing of sociocultural dynamics within a historically particular context. This choice in approaches to studying globalization echoes the choice in studying policy: studying the dynamics of movement mirrors ‘following the policy’, while focusing on context echoes ‘studying through the policy’. These similar frameworks in the relevant bodies of literature point to an area for further theorization in the anthropological study of policy: how to study both movement and context, policy and people.
Pathways, intersections, and hotspots
As people, ideas, and objects move with greater frequency and speed, one of the core methodological challenges that contemporary anthropologists have engaged with is multisited research (Fischer 1999a). As Marcus (1995) has noted, anthropological fieldwork has necessitated movement even if it has seldom received conceptual consideration. The increasing spatial mobility of research participants has led some to characterize such mobility as a reflection of changing sociopolitical conditions and an area of anthropological inquiry on its own (Glick-Schiller 2008; Falzon 2009). These perspectives assert that data gathering unfolds as ethnographers move alongside research participants through space, over time, and across institutional levels. In my own research on the HIV/AIDS policy process and the daily work of HIV/AIDS activists, the tension between movement and context generated considerable concern during the initial stages of my fieldwork. How was I to carry out participant observation on a policy process that integrated people working within the HIV/AIDS movement from across South Africa? Conversely, how could I tether the daily work of HIV/AIDS activists in the townships to a broader social process, such as the development of HIV/AIDS policy in national and international arenas?
As is often the case with anthropological research, the answer to these questions came from my research participants. Tracking the movement and pathways produced by research participants offered a means of understanding and linking social dynamics across field sites, institutional levels, and different aspects of the HIV/AIDS policy process. I followed people involved with HIV/AIDS politics who were affiliated with different organizations and institutions in order to identify where and when their pathways would cross. The pathways produced by research participants were often fleeting and visible only to those also participating in a given meeting, policy consultation, or other sociopolitical activity. [note 6]It may not be the case that all pathways are invisible and ephemeral. As Ingold (2008) notes relative to the drawing of a circle, the movement of the pen and the pathway traced by ink cease to be viewed as such once the shape is complete. The line then becomes a barrier that formally delineates what is inside, and what is not. The transition between movement and fixed form offers insight into whose experiences are formally recognized within policy processes and whose are not. The participation of state administrators is marked by formal notation of their presence, which is often denoted in policy documents. It is seldom the case that the participation of nonstate actors in policy processes receives the same attention. As such, Ingold’s work shows that the selective recognition of policy participants leads to the development of fixed forms, in this case policy, which may not be representative of the social process upon which they are constituted.
The ephemeral character of people’s pathways meant that accompanying research participants provided insight into how meetings of various sorts served as points of convergence within a broader pattern of social mobility. Moving through space and time with different people and groups enabled a complex picture to emerge of the organizational and institutional composition of the South African HIV/AIDS policy process.
My emphasis on movement and pathways meant that the identification of field sites was based on the life experiences of research participants. Following the pathways of policy actors who had diverse institutional, organizational, and political affiliations enabled me to locate points of social, spatial, and political activity where the activities of research participants overlapped and variants of sociality emerged (Holston 1999). Multiple pathways intersected at particular points and some of these emerged as significant for fieldwork; I came to see interpersonal encounters as intersections of overlapping pathways. Tracking these points of intersection entailed observing a wide array of possible interactions and dynamics: some were small congregations of people; others were areas of intense sociopolitical activity. The sociospatial points where multiple pathways intersected, sociopolitical activities concentrated, and localized political formations took shape emerged as key sites for my ethnographic research on the South African HIV/AIDS policy process. Through these, I identified localized political formations where policy outcomes were produced and the influence of transnational donor capital was exerted.
Building on Tsing’s (2005) concept of ‘friction’, I theorize these areas of concentrated sociopolitical interaction and transnational influence for the HIV/AIDS policy process as ‘hot spots’. This concept has been used to describe biodiversity conservation projects, the growth of infectious disease, and social science research (Myers et al. 2000; Jones et al. 2008; Neimark and Schroeder 2009; Paige et al. 2015). Brown and Kelly (2014) utilize the notion of hot spots to describe how infectious disease outbreaks grow out the convergence of a complex array of factors that create the conditions for the transmission of disease. Similarly, I deploy the hot spots concept to describe how sociopolitical conglomerations emerge at particular points of intersection and encompass an array of actors, activities, and forms of influence. These zones of sociopolitical activity generate ‘heat’ via the ‘friction’ created by the influence of transnational donor capital and the concentration of political activity. A research design that focuses on hot spots offers a way for ethnographic research to link together the ‘studying through’ and ‘following’ approaches advocated for by anthropological theorists of the policy process. Focusing on hot spots also bridges the social, political, and institutional boundaries inherent in the embedded ethnography approach.
Focusing on hot spots is also a useful counterpoint to anthropological methodologies developed to understand sociocultural processes operating at different levels. The ‘multilevel approach’ studies sociopolitical dynamics at different institutional scales, weaving together social dynamics from the micro to macro levels based on thematic criteria, such as primary care (van der Geest et al. 1990). The ‘vertical-slice approach’ draws attention to the role of elites by studying how formal and informal hierarchies inform the reproduction of social inequality across class lines (Nader 1972). The ‘three-bodies approach’ explores sociomedical dynamics by linking bodily experience, the symbolic uses of the body in society, and the disciplinary power wielded by modern states on bodies (Scheper-Hughes and Lock 1987). The ‘critical medical anthropology approach’ links illness to social conditions produced by the global economy, highlighting how social inequality leads to the proliferation of disease (Baer et al. 2003). These approaches all link sociocultural activities observed in a local milieu to broader social, political, and economic trends.
They also rely on a series of assumptions that reproduce normative conceptions of hierarchy and power. The multilevel approach relies on abstract notions of the state and hierarchy, which may not reflect the actual experiences of power within a particular social process. Similarly, the existence, and particular form, of social and political hierarchy – attributing power to elites, for example – is taken as a given in the vertical-slice methodology. The three-bodies approach tethers individual experiences to broader social relations based on modes of power associated with the modern state, which may not reflect people’s encounters with political authority in all cultures. While drawing attention to the material conditions that often drive unequal health outcomes, the critical medical anthropology approach presumes a degree of universality relative to the global economy, though the movement and manifestation of capital can vary and have differing local effects. These four approaches tend to assume the form of hierarchy, reify particular versions of authority, and presume particular configurations of state, economy, and society.
In contrast, the hot spots approach relies on the lived experience and movement of people to unify discrete events and experiences into a single ethnographic dataset. Rather than analyze power dynamics or policy processes based on predetermined criteria, the hot spots approach uses human experience to select field sites and link social dynamics at different institutional levels. This differs from the approaches outlined above, which incorporate normative conceptions of hierarchy and the state into their research design, and, in doing so, reproduce spatial hierarchies in how the levels of the state are imagined, which may deviate from actual experiences of policy processes and power (Ferguson and Gupta 2002). Beginning by identifying hot spots enables power relations to emerge from participant observation with research participants as they navigate social processes where power, hierarchy, and state authority manifest.
Given the critique and claims put forward above, I find it necessary to provide some explanation of how I selected participation for my research. I initiated fieldwork on the South African HIV/AIDS epidemic based upon epidemiological, historical, organizational, and spatial criteria. South Africa has the world’s largest HIV/AIDS epidemic in absolute terms. The epidemic’s exponential growth in the 1990s led to a decade of divisive political contestation over the biomedical link between HIV and AIDS and access to HIV/AIDS treatment. In addition, there is a well-established history of the South African HIV/AIDS movement’s input into the HIV/AIDS policy process. While far from being the only organization involved in the South African HIV/AIDS movement, I selected the TAC for participant observation due to its leading role in the campaign for HIV/AIDS treatment access. Many of its founding activists participated in the antiapartheid struggle, and TAC has built upon the tactics, symbols, and interpersonal networks that emerged during the late apartheid era (Robins 2006; Grebe 2011).
Historical continuities with social activism during the late apartheid era were also evident in the choice to site TAC’s provincial office in the Western Cape. TAC’s provincial office was located in a building called Community House, which has served as the epicenter of social justice-oriented political activities for the Western Cape province since the mid-1980s. Founded to serve as a ‘springboard’ for the struggle to end apartheid in South Africa, Community House included the offices of several social justice-oriented NGOs (The Archival Platform 2010). At the time of my research, the organizations based at Community House included: The Labour Research Service, Worker’s World Media Productions, International Labour Research and Information Group, and the Western Cape office of the Congress of South African Trade Unions (Cosatu). I selected TAC’s provincial office as the starting point for my research given Community House’s historical role as a social justice hot spot in the Western Cape. From this sociospatial starting point, I followed the movement of HIV/AIDS activists, which led me to various points of intersection that included community meetings, local subdistrict coordinating institutions, and an array of other sociopolitical gatherings. As I followed HIV/AIDS activists to the points where their pathways intersected with those of different policy actors, the contours of the South African HIV/AIDS process came into focus.
After providing a brief history of the HIV/AIDS epidemic in South Africa, as a means to illustrate how research on the policy process must be multisited and participant-led, I focus the remainder of this article on two points of intersection that served as hot spots for the HIV/AIDS policy process: the Western Cape Provincial AIDS Council and SANAC. I describe my anthropological research with different research participants, organizations, and institutions that were linked to the extended campaign for HIV/AIDS treatment access in South Africa through two additional ethnographic vignettes, which illustrate the conceptual claims put forward above. In addition to TAC, I carried out participant observation with the Western Cape Networking AIDS Coalition of South Africa (WC-Nacosa). [note 7]At the time of fieldwork, WC-Nacosa’s organizational purview was limited to the Western Cape province. Subsequently, the NGO expanded to operate nationally and now goes by the acronym NACOSA.
The overlapping pathways, intersections, and hot spots I encountered highlighted how the South African HIV/AIDS policy process rests uneasily with normative conceptions of the state and universalistic claims to policy development.
A brief history of the HIV/AIDS movement and HIV/AIDS policy in South Africa
Since its emergence in the mines in 1982, the HIV/AIDS epidemic has expanded into all corners of the country and become a central aspect of everyday life in South Africa (Iliffe 2006). The HIV/AIDS epidemic grew amidst the militarization of the apartheid state and the coalescence of various strands of political opposition into a mass democratic movement. Despite the threat of an epidemic, the apartheid state did little to stem the tide of HIV/AIDS during the 1980s (Van der Vliet 1994). As the antiapartheid movement grew, along with the expansion of the trade union movement and the formation of urban civic associations, antiapartheid activists from the gay rights movement, the primary health care movement, and the human rights movement combined into an HIV/AIDS movement (Powers 2017). From the outset, the activists of the South African HIV/AIDS movement developed organizations that focused on establishing a rights-based approach to the epidemic and on cultivating relationships with leading members of the African National Congress (ANC) to transform national policy norms (Heywood and Cornell 1998).
The tactical approach taken by the South African HIV/AIDS movement – to work through state institutions to influence formal policy decisions – proved successful during the movement’s first wave. Led by ANC activist Simon Nkoli and future Constitutional Court justice Edwin Cameron, the HIV/AIDS movement secured a rights-based approach to the epidemic with the National Aids Plan (1994) and influenced the ANC to include protection against sexual discrimination in the postapartheid constitution. The relationship between the ANC and the HIV/AIDS movement looked set to continue when they joined together to challenge international pricing for pharmaceutical drugs with the Medicines Act (1997). However, the emergence of a faction that questioned the link between HIV and AIDS within the ruling ANC strained the alliance and led to the rise of a radical edge within the diversely constituted HIV/AIDS movement.
The extended political struggle that resulted from the rise of this dissident faction within the ANC centered on the availability of antiretroviral therapy (ART) in South Africa’s public health sector. The dissidents critiqued the efficacy of biomedical HIV/AIDS treatment, the profiteering of transnational pharmaceutical corporations, and neocolonial portrayals of Africans as oversexualized and unable to govern themselves (Gevisser 2007; Nattrass 2007). The dissident clique exerted power via political control of the presidency and national health institutions. While the Global Fund and the US Presidential Emergency Plan for AIDS Relief (PEPFAR) both supported the HIV/AIDS response, their impact on South African society was limited by the country’s middle-income status and the ANC’s efforts to limit transnational donor influence on their development agenda (Powers 2012).
After initially working with the ANC on the Medicines Act, TAC responded to the dissident faction by developing a campaign to secure access to HIV/AIDS treatment. The TAC-led second wave of HIV/AIDS activism built on the antiapartheid tactics of direct action, alliance building, and civil disobedience to pressure the government into providing ART. The eventual success of the HIV/AIDS movement in securing access to treatment in the public sector depended on mobilizing a broad alliance of organizations and entities and the restructuring of national health institutions and HIV/AIDS policy (Powers 2013b). However, public sector access to HIV/AIDS treatment was also predicated on the support of transnational networks of solidarity, constituted by HIV/AIDS activists, donors, and international health institutions.
Research on the politics of the South African HIV/AIDS epidemic has largely focused on the divisive sociopolitical dynamics that ensued following the emergence of the ANC’s AIDS dissident faction. A second, growing body of literature has analyzed the role of traditional beliefs in HIV/AIDS testing and treatment uptake (Steinberg 2010; McNeill 2011; Niehaus 2012; Decoteau 2013), the negotiation of intimate relationships in urban townships (Hunter 2010), the role of sexual networks in HIV transmission (Thornton 2008), the inscription of moral sentiment in transnational donor programs (Susser 2009), the incorporation of biomedical practices into identity formation (Robins 2006), the growing influence of religious organizations in counseling and care for people living with HIV/AIDS (Burchardt 2015), and the HIV/AIDS epidemic as an embodiment of South Africa’s history of inequality (Fassin 2007). These accounts have underscored the complex social, cultural, and material dynamics that drive HIV transmission and highlight why interventions predicated on individual behavior change, such as abstinence programs, have had negligible effects on the South African HIV/AIDS epidemic.
With respect to research that has analyzed the South African HIV/AIDS movement particularly, scholars have focused on the appropriation of practices from the antiapartheid movement (Grebe 2011), defined South African HIV/AIDS activism as a transnational social movement (Mbali 2013), analyzed the emergence of HIV/AIDS activists in urban townships (Robins 2004), and traced the appropriation of biomedical norms as a source of power for HIV/AIDS activists (Comaroff 2007). The research on HIV/AIDS activism has focused on TAC as representative of the HIV/AIDS movement. As the radical edge of the second wave of HIV/AIDS activism, TAC has certainly played a central role, if not the central role, in the eventual success of the campaign for treatment access. However, a solitary focus on TAC underestimates the importance of alliance building in the development of a broad-based HIV/AIDS movement.
Reframing the South African HIV/AIDS movement as a broad, issue-based alliance of individuals and organizations that manifested spatially, politically, organizationally, and institutionally offers a more precise representation of how the politics of the epidemic unfolded. Conceptualizing the HIV/AIDS movement as a geographically dispersed aggregation of actors and organizations with varying interests and constituencies also raises the methodological questions alluded to above. [note 8]As de Waal (2006) notes, TAC is itself not a single-issue organization, with broader questions of social justice and equality at the core of its organizing work along with the campaign for HIV/AIDS treatment access. The South African HIV/AIDS movement is a diverse entity with competing interests and constituencies, which converged during the extended campaign for HIV/AIDS treatment access.
How is one to carry out research with HIV/AIDS activists who move between various field sites and interact with individuals associated with the state at different institutional levels? How does one conceptualize connections across institutional levels and within the localized political formations where HIV/AIDS policy and treatment access were negotiated? To what extent do existing anthropological approaches reflect the lived experiences of South African HIV/AIDS activists? Moving with individuals associated with different organizations and institutions through space and time underscored that the South African HIV/AIDS policy process did not neatly cohere to abstract notions of the state or policy. Rather, the intersection of individual and organizational pathways highlighted how the composition of localized political formations, rather than state actors alone, played a decisive role in producing policy outcomes.
Following Padmini: Tracking intersections and the HIV/AIDS policy process
Following Nomfusi and other HIV/AIDS activists working with TAC led me to encounter another person, Padmini, whose movement in turn led to new areas of research. At a SANAC meeting in 2007 I met Padmini in a working group on new national policy guidelines for PMTCT. Within the working group Padmini and others actively refuted a state health official’s critical assessment of the NGO response to the HIV/AIDS epidemic. Stories of local challenges and governmental inaction created space for the discussion of updated guidelines on PMTCT that had been released by the WHO. During a break in the meeting, I had the chance to share a cup of coffee with Padmini and learn more about her work on HIV/AIDS in South Africa, which focused on the provision of mentorship services to NGOs and community-based organizations (CBOs) addressing the HIV/AIDS epidemic in the Western Cape through WC-Nacosa. After the national meeting, I maintained contact with Padmini to follow her trajectory as a provincial-level coordinator of various HIV/AIDS-focused NGOs. As I came to learn, Padmini was intimately involved in the HIV/AIDS policy process at both the national and provincial levels.
Having observed her involvement in the development of national PMTCT guidelines, the next step in following Padmini was to understand her role within the local political formation that drove the HIV/AIDS policy process in the Western Cape province. In the months following the SANAC national civil society meeting, the HIV/AIDS process took shape in the Western Cape around a new national HIV/AIDS policy. The National Strategic Plan (NSP) had been developed in large part by SANAC’s civil society sectors, which were predominately occupied by members of the HIV/AIDS movement; it set the ambitious goals of halving HIV infections and providing HIV/AIDS treatment to 80 percent of those in need. In the Western Cape, an interdepartmental committee of government policy specialists had developed a draft Provincial Strategic Plan (PSP, a provincial version of the national policy). I had learned of the draft through Padmini, who had heard of its development through her work within WC-Nacosa. While the NGO ostensibly operated to support CBOs addressing the epidemic in the Western Cape, the PSP policy process underscored WC-Nacosa’s central role in the provincial HIV/AIDS policy process.
At the SANAC meeting, Padmini had informed me that WC-Nacosa and the provincial government would lead a series of consultative meetings for the PSP in the Western Cape. After I followed both Nomfusi and Padmini back to Cape Town, I met the latter at WC-Nacosa’s offices to acquire a copy of the draft PSP. At the time I was also introduced to a member of WC-Nacosa who would oversee the policy consultations, Lynnette. Lynnette had previously held managerial positions in government, including the departments of health and social development. After joining in 2005, Lynnette led efforts to grow WC-Nacosa from a small, activist-oriented group into an organization that provided mentoring services to over three hundred organizations in the province. Government was a key funder of the organization’s activities, with over 75 percent of WC-Nacosa’s budget coming from the South African state (WC-Nacosa 2007). With the support of donors and the state, WC-Nacosa advised NGOs and CBOs in their efforts to access donor capital to support their HIV/AIDS-related activities.
WC-Nacosa, therefore, was positioned as an intermediary organization among the state, transnational donor capital, and community-based initiatives related to HIV/AIDS in the Western Cape. In addition, WC-Nacosa had expanded the purview of its activities into the policy domain by agreeing to lead the PSP policy consultations. In order to gain insight into the dynamics of the provincial HIV/AIDS policy process, I volunteered to serve as note taker for the meetings. And so I attended and observed the consultative meetings for the PSP in each of the Western Cape’s six health districts. Attending the policy consultations would entail following Lynnette, HIV/AIDS activists, and state health officials. However, an event that would influence the outcome of the consultative meetings occurred just before they were to begin and at the intersection of Lynnette and Nomfusi’s pathways: a meeting of the Western Cape Provincial AIDS Council.
Overlapping pathways and hotspots: The Western Cape Provincial AIDS Council
As the summer sun beat down in Cape Town in February 2008, I arrived at the TAC provincial office to meet Nomfusi prior to a meeting of the Western Cape Provincial AIDS Council. As we parked and walked over to the offices of the Western Cape Department of Health in the center of the city, I could sense that Nomfusi was a bit tense, if not nervous. As she had indicated to me in a conversation earlier that week, she was taking up an important new role with little advance notice. Walking into the foyer of the building, I saw Lynnette from WC-Nacosa sitting next to a high-ranking official from the provincial health department named Linda. Nomfusi and I walked over to greet the women, but rather than the usual pleasantries, our brief introductions were greeted with silence and pensive expressions. Clearly, we had interrupted a conversation that was not for our ears.
Soon after, a smartly dressed group of around ten individuals filed into a large meeting room. Those of us sitting in the foyer quickly followed suit and took our seats around a large oval table some fifteen feet in length. To my left sat Nomfusi and to my right sat a high-ranking member of the provincial health department. Lynnette sat directly to his right, with Linda next to her. In the room were high-ranking officials that included a member of Parliament; private sector representatives; members of the departments of social development, health, and education; and a representative from the religious sector. The meeting was called to order in a brisk and perfunctory manner. After cursory remarks and the adoption of the minutes from the previous meeting, the Western Cape Minister of Health asked for items not appearing on the agenda to be raised. Several around the room asked for an update on the progress of civil society response for the NSP. Linda addressed these concerns, stating that the Department of Health had been discussing the policy consultation process with WC-Nacosa. Linda stated that the organization had received the support of the health department to manage the consultation process on behalf of the province. Following this prompt, Lynnette described the general parameters for the consultative meetings. The purpose of the meetings, according to Lynnette, was to discuss the NSP and to align the national plan with the provincial plan. However, the discussion of the consultative meetings was soon overtaken by the announcement that donor funding was unstable.
After Lynnette’s presentation, Linda broke news of a possible end to donor support from the Global Fund in the province. The Global Fund had played a central role in both the extension of HIV/AIDS treatment access and support for CBOs in the Western Cape. Linda’s announcement was greeted with bewildered expressions, particularly on the face of the member of Parliament in attendance. Linda opened conversation on the future of the Global Fund by stating that the Western Cape Department of Health did not plan to reapply for an additional extension of the ongoing Global Fund grant cycle, and that the department planned, in principle, to continue to support the community-based response to the epidemic. The expressions of concern around the room spilled out into open debate after it became clear that there were no firm plans to replace donor funding to CBOs across the Western Cape province. Some were incredulous, asking how a program that funded over five hundred organizations could be allowed to lapse. Others inquired into how exactly the provincial health department planned to continue to support the community-based response. When Linda clarified that the Global Fund contribution stood at R15.5 million (approximately US$2 million at the time), the provincial minister of health formally stated his concern and the need for a clear exit strategy and timeline.
As the issue seemed ready to drop, Lynnette reinserted herself into the conversation. She put WC-Nacosa forward as a possible mechanism for the continuation of donor support from the Global Fund. Lynnette relayed to the group that there had been a brief discussion of the issue at the previous Global Fund coordinating meeting, and that WC-Nacosa could step forward to apply for continued funding alongside municipalities in the Western Cape province. Lynnette told the group that doing so could allow for continued donor support for the community-based response to the epidemic. Lynnette’s intervention changed the atmosphere of the room: rather than dwelling on the possibility of losing funding, those in attendance began inquiring as to whether the proposed strategy could succeed. Lynnette indicated that the proposed change in grant management would have to be approved by both the Western Cape Provincial AIDS Council and SANAC, the country coordinating mechanism for the Global Fund. The proposal received immediate support from the council delegates and was passed unanimously. The conversation then shifted to ensuring that support could be garnered for the initiative at SANAC. Linda indicated that she would take the lead in analyzing the community-based response as part of the exit strategy for the provincial health department’s involvement in the Global Fund grant.
In the end, the consultative process for the PSP came to naught, an example of the unpredictable effects of transnational influence on local politics (Ferguson 1990). The draft policy was put into place without input of any kind from nonstate policy actors. The unraveling of the PSP consultations caused considerable tension between TAC and WC-Nacosa. HIV/AIDS activists from TAC actively pushed for a more in-depth policy process that took into account the local realities of the epidemic across the Western Cape. A national policy process that had been driven by the South African HIV/AIDS movement and achieved within SANAC ran aground the shoals of provincial politics. In the end, the policy process was far kinder to WC-Nacosa, with a successful application to the Global Fund and national expansion of the organization. Such an outcome leads one to question the unity of any policy process across state institutions at various levels.
Conclusion: Pathways, hot spots, and power
These ethnographic vignettes illustrate how following the movement of multiple research participants illuminates the interpersonal relationships, organizational ties, and institutional dynamics that infuse power dynamics in the South African HIV/AIDS policy process. The linked concepts of pathways, intersections, and hot spots enable insights to be generated on the basis of people’s lived experiences rather than normative concepts such as the state or policy. The pathways forged by Nomfusi tied together a wide array of actors and organizations at points of intersection that ranged from community-based gatherings to national meetings. Her movement across the political terrain of HIV/AIDS highlighted the influence of actors and organizations within different local political formations. From the township of Khayelitsha to the SANAC national civil society meeting in Johannesburg, Nomfusi’s pathways unveiled how HIV/AIDS activists operated socially, spatially, and politically. Nomfusi’s movement, and the political formations illuminated by it, necessitated a multisited research methodology in order to ethnographically encapsulate her experiences. In short, Nomfusi’s movement served as a scaffold for expanding participant observation research from an embedded ethnography of TAC to the hot spots where political formations emerged and policy development occurred.
Following Nomfusi also highlighted the points of intersection in the pathways of different actors involved with the South African HIV/AIDS policy process. From HIV/AIDS activists associated with TAC to those linked to WC-Nacosa and provincial health institutions in the Western Cape, I utilized points of intersection to locate new points of intersection for data gathering. The SANAC National Civil Society meeting served as both a hot spot for the HIV/AIDS policy process and a point of intersection for the political pathways of Nomfusi and Padmini. Following the latter back to the Western Cape allowed for the pathways of actors associated with TAC, WC-Nacosa, and the Western Cape Department of Health to be followed simultaneously. Following individuals from these organizations to the PSP consultative meetings expanded the geographic range of the research throughout the Western Cape province. The spatial and institutional diversification of the provincial policy process further underscored the significance of movement in understanding how different actors, organizations, and institutions are implicated in the policy process.
The movement of individuals linked to TAC, WC-Nacosa, and the state converged in the Western Cape Provincial AIDS Council, unveiling another hot spot in the South African HIV/AIDS policy process. Participant observation there revealed the influence of transnational donor capital. Due to a transfer of managerial authority for a Global Fund grant, the national policy process that produced the NSP did not lead to substantive change in the joint state-civil society response to the HIV/AIDS epidemic in the Western Cape province. The efforts of the South African HIV/AIDS movement at the national level were undone by WC-Nacosa’s efforts to redirect the PSP policy consultations and to continue transnational donor support for CBOs in the Western Cape. The unraveling of the provincial HIV/AIDS policy process demonstrates how political formations at different levels can produce varying outcomes.
The concepts of pathways, intersections, and hotspots offer a conceptual framework that can be used to link the life experiences of research participants to broader sociopolitical processes. Growing out of participant observation research, the hot spots approach follows research participants and reflects on how their movement leads to the identification of multiple coherent field sites. The approach discussed here attends to the historical particularity of South African society and allows for the theorization of power to emerge from experiences, rather than from abstract forces or universal norms. As such, the hot spots approach may offer promise as a means of linking together movement and context, on the basis of people’s lived experiences.
This case study underscores the importance of following the movement of actors affiliated with different organizations and institutions in order to understand how policy processes unfold and particular outcomes are reached, and how policy can be understood as a sociopolitical process. From the local to the national level, the movement and activities of individuals involved in the South African HIV/AIDS policy process served to guide the research towards the places where policy was actively being produced, negotiated, and nullified.
Special thanks go to Keith Hart, who actively supported this line of analysis from its initial stages. I would also like to thank Ida Susser, Meena Khandelwal, Ellen Lewin, and Michael Chibnik for their insightful feedback on earlier drafts of this article. Three anonymous peer reviewers also provided comments that led to substantive changes in the manuscript, and I wish to express my thanks for their constructive engagement. All errors or shortcomings in the article are mine alone.
About the author
Theodore Powers, PhD, is a sociocultural anthropologist who holds the positions of Assistant Professor of Anthropology at the University of Iowa and Research Associate with the Human Economy Program at the University of Pretoria. Focusing on the politics of HIV/AIDS, austerity, and public health in postapartheid South Africa, his work analyzes how transnational forces, state institutions, material conditions, and health social movements influence health outcomes and life trajectories in postapartheid South African society. Email: firstname.lastname@example.org
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