2009 Society for Medical Anthropology Conference: Global Public Health through the Eyes of Medical Anthropologist Didier Fassin

At the 2009 Society for Medical Anthropology Conference at Yale University, anthropologist Didier Fassin discussed social inequality and the politicization of health in the context of global public health.U.S. Rep. Joe Wilson shouted, “You lie!” during President Obama’s denial that the proposed health care reform bill would cover illegal immigrants, and anthropologist Didier Fassin used that antagonistic stance toward what the 1978 Declaration of Alma-Ata [1] had called a fundamental human right to best illustrate the issues of social inequality and the politicization of health.Global public health was one focus of the 2009 Society for Medical Anthropology Conference at Yale University in September. Since its inception in 1948, the World Health Organization (WHO) has striven to provide health assistance to the world population, especially those in developing countries. But Fassin, professor of social science at the Institute for Advanced Study at Princeton, professor of sociology at the Université de Paris, Nord, and director of studies in political and moral anthropology at the Ecole des Hautes Études en Sciences Sociales, argued that the concept of global health, albeit well-meaning, is problematic. Its utopian nature is clearly apparent in the rhetoric of politicians, he said, adding that health as a gift of nature, a common good, and the core of the WHO, quickly becomes an object of politics and the coverage in times of sickness of a select few is akin to entitlement and privilege.The present age of globalization certainly makes health threats such as epidemics a threat to all, and nations are in it together to take preventive measures or put up a concerted fight. However, threats like bioterrorism or predicted consequences of global warming such as population migration may be viewed, particularly by Western countries, as security issues that menace national interests and state sovereignties. The consequence being that new policies are implemented that may directly or indirectly affect the rest of the world population.And then there is the issue of humanitarian intervention, which Fassin refers to as “politics of life” [2]. How can we view humanitarianism with the eye of a cynic when it is, in essence, the effort to demonstrate the very best of our nature? Yet the transformation of some humanitarian interventions into military operations and the decision to intervene (Iraq, Kosovo, Bosnia) or not (Rwanda, Ethiopia, Cambodia), politicize this notion. Additionally, Fassin believes that the key nation-states integrate their own cultural and political biases during interventions in troubled regions.Nowhere is this subjectivity more apparent than in the image of suffering as depicted by psychologists and psychiatrists working for non-government organizations (NGOs). NGOs compile testimonies of traumatized people in war and conflict zones, but their subjective narratives enmeshed in the diagnosis reports are increasingly supplanting faithful witness accounts. Fassin sees this trauma as “political expression of the world” [3]. The experts, in trying to raise awareness on issues that need immediate attention, may dramatize certain situations or get emotionally involved during their missions and take sides. They become the new voice of the conflict and their efforts may throw the victims into a state of confusion.It’s no surprise then that some nations view with distrust Western practices and their portrayal of aggressors and victims [4]. In 2000, Thabo Mbeki, then president of South Africa, convened an advisory panel that aimed to collect scientific data to prove that HIV does not cause AIDS. In return, he received the Durban Declaration with the signatures of more than 5,000 scientists and doctors who unilaterally declared the opposite to be scientifically true.Fassin brings up the abovementioned issues in order to shift attention to the difficulties that face our common efforts for better health services. It is truly challenging for Western leaders to mend the rift between their political agendas and accessible health for all, and as long as that continues to be the case, health care will elude millions.     

The Politics of Ecology in South Africa on the Radical Left

The South African ecologist and political activist Edward Roux (1903–1966) used evolutionary biology to argue against racism. During the cold-war, he transformed his communist beliefs into advocacy for scientific rationalism, management, and protection of nature against advancing capitalism. These pleas for saving the environment served as a vehicle for questioning the more risky issue of evolution and racial order in society. The link between ecological and political order had long been an important theme among the country's ecologists and politicians alike. The statesman Jan Christian Smuts' holistic theory of evolution and racial order inspired the nation's ecologists to sanctify an ecologically informed racial policy. This idealist informed methodology stood in direct opposition to the materialist approach to ecology of Roux. These methodological debates reflected differing political support from within the Union Party and people on the radical left, respectively. Ecology was of concern to politicians because understandings of the order of nature had direct implications for the racial order of the South African society. This revised version was published online in July 2006 with corrections to the Cover Date.     

Patient Experiences following Acute HIV Infection Diagnosis and Counseling in South Africa

Individuals in the acute stage of HIV infection (AHI) have an elevated potential to transmit HIV and play a critical role in the growth of the epidemic. Routine identification and counseling of individuals during AHI could decrease transmission behavior during this key period. However, diagnosis of AHI may present challenges distinct from those experienced through diagnosis of established HIV infection. A study was conducted in a public youth clinic outside of Cape Town, South Africa, to identify and counsel individuals with acute stage HIV infection. In-depth interviews were conducted with patients following diagnosis. After counseling, patients were accepting of the testing regimen used to diagnose AHI. They used the knowledge of having been recently infected to identify the source of their infection, but did not retain or place importance on information regarding the increased ability to transmit HIV during the acute stage. Future interventions directed at the reduction of HIV transmission following diagnosis with AHI will need to find ways of making this information more salient, possibly through more culturally meaningful educational approaches.     

From "Rights" to "Ritual": AIDS Activism in South Africa

In this article, I investigate how the moral politics of HIV/AIDS activism in South Africa is contributing toward new forms of citizenship that are concerned with both rights-based struggles and with creating collectively shared meanings of the extreme experiences of illness and stigmatization of individual HIV/AIDS sufferers. I argue that it is precisely the extremity of the "near death" experiences of full-blown AIDS, and the profound stigma and "social death" associated with the later stages of the disease, that produce the conditions for HIV/AIDS survivors' commitment to "new life" and social activism. It is the activist mediation and retelling of these traumatic experiences that facilitates HIV/AIDS activist commitment and grassroots mobilization. It is also the profound negativity of stigma and social death that animates the activist's construction of a new positive HIV-positive identity and understanding of what it means to be a citizen–activist and member of a social movement.     

AIDS in Africa: distinguishing fact and fiction

The data widely purporting to show the existence and heterosexual transmission in Africa of a new syndrome caused by a retrovirus which induces immune deficiency are critically evaluated. It is concluded that both acquired immune deficiency (AID) and the symptoms and diseases which constitute the clinical syndrome (S) are of long standing in Africa, affect both sexes equally and are caused directly and indirectly by factors other than human immunodeficiency virus (HIV). Seropositivity to HIV in Africans usually represents no more than cross-reactivity caused by an abundance of antibodies induced by the numerous infectious and parasitic diseases which are endemic in Africa. The apparently high prevalence of AIDS and HIV seropositives is therefore not surprising and is not proof of heterosexual transmission of either HIV or AIDS.E. Papadopulos-Eleopulos is with the Department of Medical Physics, The Royal Perth Hospital, Perth 6000, Western Australia, Australia; V.F. Turner is with the Department of Emergency Medicine, The Royal Perth Hospital, Perth 6000, Western Australia, Australia, J.M. Papadimitriou is with the Department of Pathology, University of Western Australia, Perth, Western Australia. H. Bialy is with Bio/Technology, 65 Becker St, New York, NY 10012, USA.     

Getting the Message Across: Art and Craft in the Service of HIV/AIDS Awareness in South Africa

The struggle against the HIV/AIDS pandemic is one of the most serious challenges South Africa faces today. Great efforts have been and are being made to create awareness of the disease, utilizing a variety of strategies that range from straightforward educational messages in magazines, billboards, and radio/TV broadcasts, to more creative or artistic approaches in media such as film, drama, music, art, and crafts. Many of these projects (notably the Sarafina II drama production) have drawn criticism of some sort, usually focused on the perceived efficacy of the project, especially in relation to its cost or usage of resources. There sometimes appears to be an implicit expectation that HIV/AIDS awareness projects must state the “message” in simple, blunt, or easily comprehensible terms to “reach” people. This can be argued not only to be patronizing, but to disregard the complex ways in which visual stimuli are received and processed by diverse audiences.

In this article, I will investigate three different creative visual art/craft initiatives that have been employed in South Africa in the past few years to create HIV/AIDS awareness. They comprise: first, HIV/AIDS community murals, sponsored by the Department of Health and painted primarily in townships and on university campuses throughout the country; secondly, a print portfolio/billboard project, involving local and international artists whose “fine art” prints are enlarged to billboard size and placed in high traffic areas in cities and townships; and thirdly, a craft project employing rural women in KwaZulu-Natal who produce beaded dolls, badges and wire baskets (imbenge) with an HIV/AIDS awareness message.

The theoretical framework for this study is informed by semiotics and post-structuralism. It presumes that meaning is always constructed—both by the author/artist and by the recipient/viewer. Artists may want to convey clear educational messages, using seemingly unambiguous symbols and metaphors. However, as every signifier has multiple meanings, which constantly shift and slide, an artist cannot control how individual viewers will decode the message. In view of this, I will argue that it may be short-sighted to dismiss certain types of creative art projects around HIV/AIDS as incomprehensible or inaccessible and therefore ineffective in raising awareness of the disease and associated issues such as stigmatization.     

Progression to AIDS in South Africa is associated with both reverting and compensatory viral mutations

We lack the understanding of why HIV-infected individuals in South Africa progress to AIDS. We hypothesised that in end-stage disease there is a shifting dynamic between T cell imposed immunity and viral immune escape, which, through both compensatory and reverting viral mutations, results in increased viral fitness, elevated plasma viral loads and disease progression. We explored how T cell responses, viral adaptation and viral fitness inter-relate in South African cohorts recruited from Bloemfontein, the Free State (n = 278) and Durban, KwaZulu-Natal (n = 775). Immune responses were measured by γ-interferon ELISPOT assays. HLA-associated viral polymorphisms were determined using phylogenetically corrected techniques, and viral replication capacity (VRC) was measured by comparing the growth rate of gag-protease recombinant viruses against recombinant NL4-3 viruses. We report that in advanced disease (CD4 counts <100 cells/µl), T cell responses narrow, with a relative decline in Gag-directed responses (p<0.0001). This is associated with preserved selection pressure at specific viral amino acids (e.g., the T242N polymorphism within the HLA-B*57/5801 restricted TW10 epitope), but with reversion at other sites (e.g., the T186S polymorphism within the HLA-B*8101 restricted TL9 epitope), most notably in Gag and suggestive of “immune relaxation”. The median VRC from patients with CD4 counts <100 cells/µl was higher than from patients with CD4 counts ≥500 cells/µl (91.15% versus 85.19%, p = 0.0004), potentially explaining the rise in viral load associated with disease progression. Mutations at HIV Gag T186S and T242N reduced VRC, however, in advanced disease only the T242N mutants demonstrated increasing VRC, and were associated with compensatory mutations (p = 0.013). These data provide novel insights into the mechanisms of HIV disease progression in South Africa. Restoration of fitness correlates with loss of viral control in late disease, with evidence for both preserved and relaxed selection pressure across the HIV genome. Interventions that maintain viral fitness costs could potentially slow progression.