The Republic of Therapy: Triage and Sovereignty in West Africa's Time of AIDS by Vinh-Kim Nguyen (review)

The Republique of Therapy is a great book. The AIDS literature on Africa is huge, but Vinh-Kim Nguyen has managed to write a compelling and interesting book about the extremely important period of the AIDS epidemic in Africa, starting in 1994, when antiretroviral treatments for HIV were discovered, to 2000, when the international policy consensus that HIV drugs should not be used in Africa due to the high costs and logistical challenges involved was overturned. One of the main strengths of the book, I think, is that Nguyen's writing is saturated by his engagement and drive—and not least by his contempt for the fact that so many preventable and treatable diseases still cause millions of deaths in Africa. In his own words, "I was driven to write this book to explore and expose the obscene inequalities and insidious logic that values lives differently" (4). Nguyen is a medical doctor, an activist, and a sensitive scholar, who since the start of the epidemic has been involved in the treatment and care of AIDS patients, in campaign activities in Africa, and in academic discussions about the disease and its implications. One can sense this engagement throughout the book.

The first part of the book (chapters 1-4) explores how the promise of treatment was implemented in West Africa. When various types of organizations tried to respond to the epidemic, perhaps without realizing the consequences, they became caught in the problem of having to select who should live and who could go without treatment, thus implying that not all lives were of the same value. Triage—the medical process of determining the priority of patients' treatments based on the severity of their conditions—became institutionalized in absurd ways. For example, the process of selecting who should be given medicine became influenced by the need to show results. This led to a triage based on patients' willingness or ability to disclose their HIV-positive status and provide testimonials. The AIDS NGOs started to apply "confessional technologies"—that is, they began to train patients in how to testify. While it might be helpful to be open about a positive HIV status—thereby being able to talk and exchange experiences with other patients and eventually also to disclose that status to family members and friends—the skill of providing a personal testimony also became part of the triage process in the sense that those who learned how to confess also acquired easier access to treatment. Knowing how to navigate and master the specific forms of testimonies conferred on selected individuals what Nguyen calls "therapeutic citizenship," a "thin citizenship" (109) that arises in the absence of stable institutions providing lifesaving therapy. Thus, a few such HIV-positive patients got access to scarce life-saving medicines.

While the first half of the book draws on work and fieldwork in both Burkina Faso and Côte d'Ivoire, the second half (chapters 4-7) mainly examines the history of such differential access to treatment in Côte d'Ivoire, with the aim of providing an understanding of how the various forms of triage may have developed. Chapter 5 explores the colonial and postcolonial struggles over sovereignty; chapter 6 deals with the period of economic growth in the 1960s and the crisis of the late 1970s, which sharpened social inequalities; and chapter 7 provides an analysis of the "war of the sexes" in the city of Abidjan and the civil war in 1999 (the fall of the first republic) and the political unrest around 2000 during the establishment of the second republic. In these chapters Nguyen discusses how the widening of social and economic inequalities during these different historical periods formed the background to the introduction of triage when the AIDS epidemic hit—that is, triage based on tactical forms of citizenship favoring specific types of...