- Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science by Johanna Tayloe Crane
Johanna Tayloe Crane’s multisited ethnographic study of HIV research and treatment makes a conscientious and provocative contribution to a growing body of literature that seeks to locate global health work in diverse historical, social, political, or economic contexts. Here, that context is primarily present-day Mbarara, Uganda. Crane follows American and Ugandan researchers, physicians, and administrators, and occasionally Ugandan patients, as each navigates a world dominated by HIV at Mbarara’s Immune Wellness Clinic. In a crisply written and evocatively told story of research, treatment, and expertise, Crane narrates a history of HIV research and treatment in Africa in the era of PEPFAR, and explores the singular role of HIV/AIDS in the broader development of global health in the past two decades.
Scrambling for Africa examines the arrival of antiretroviral (ARV) drugs and American HIV researchers in rural Uganda between roughly 2004 and 2012, highlighting these changes as generative moments in global health science through which particular tensions become visible. Crane, as an inside woman of sorts, is uniquely positioned to pose a sensitive and probing critique of global health at a moment of profound change. At the core of her study is the problem of “valuable inequalities” in global health, and specifically HIV treatment, that emerged as ARVs were rolled out in Africa in the early 2000s. At the time, American doctors grappled with the intense suffering and misfortune of patients without access to life-prolonging drugs, while also recognizing, and desiring, the extraordinarily rich research potential that such patients embodied. This “uncomfortable mix of preventable suffering and scientific productivity” posed a paradox central to the origins and ethos of global health science, Crane successfully argues, and the persistence of these inequalities presents practitioners with the field’s most serious and durable ethical and logistical challenges (p. 7).
Crane has achieved a difficult balance in grounding her work in local circumstances in rural Uganda while also insisting upon the “in-between space” of international scientific networks as her “field site” (p. 17). The book offers a series of deftly crafted separate pieces that explore these transnational, interstitial spaces of global health, each chapter building upon the last but also lending itself to independent reading. Chapter 1, Crane’s most wide-ranging chapter, details how new ideas about patient adherence to drug therapies and HIV resistance meshed with older thinking about race, poverty, and who deserves treatment to shape early debates on the ethics of introducing ARVs into Africa. Chapter 2 ventures into laboratories worldwide in pursuit of the “molecular politics” of HIV, artfully exploring how the strain of the virus common to North America and Europe became the standard research entity for HIV research. Crane’s work on the problematic biases that this selection has generated is excellent, and captures the dizzying intellectual and practical challenges that arise out of a research decision effectively made by default. Chapter 3 pivots to consider the laboratory and [End Page 366] clinic together, documenting the “turn toward Africa” in American HIV research of the early 2000s and exploring the consequences of the necessary translation of HIV from the “qualitative and clinical” common to Uganda to the “quantitative, molecular terms” of U.S.-based researchers, funding bodies, and journals (p. 82). Chapter 4 focuses on the changing work of the Immune Wellness Clinic, specifically on a register of HIV patients that spawned a research collaboration between Ugandan and American institutions. Crane uses the register, which ultimately became a computerized database, to explore collaborators’ divergent perspectives on donation, compensation, ownership, and collaboration itself. Chapter 5 returns to the United States, leading the reader into well-appointed conference rooms where global health research agendas are awkwardly but persistently being hammered out into the present day. Here and elsewhere, Crane does excellent work in exploring the nature of “partnership” and suggests several key critical, reflective questions that those wishing...