The Republic of Therapy: Triage and Sovereignty in West Africa's Time of AIDS (review)

In the summer of 1999, Vinh-Kim Nguyen faced an identity problem. In the AIDS clinic in Burkina Faso where he worked, the physician/anthropologist realized that many of his patients had been registered under multiple entries, leading to confusion in interpreting clinical and epidemiological data regarding their treatment outcomes. Usually in this sort of situation, one "cleans" the data by registering each person once by name and date of birth, but this solution was not workable: some individuals had no birth certificates, others had multiple birth certificates with differing names and birthdays. With no effective national ID program existing in the state of Burkina Faso, Nguyen's clinic instead issued each patient an ID card with a unique identifying number based on the order in which he or she began antiretroviral therapy. A crucial but neglected role of the state—the sorting out of the identity of its subjects—had been redefined in terms of access to pharmaceutical agents provided by a nongovernmental organization (NGO).

This brief auto-ethnographic moment encapsulates the central problem of "therapeutic citizenship" elaborated in Nguyen's excellent book, The Republic of Therapy: Triage and Sovereignty in West Africa's Time of AIDS. Drawing on more than two decades of experience as a physician and ethnographer of individuals seeking treatment for HIV/AIDS in Montreal, Burkina Faso, and the Cote d'Ivoire, Nguyen extends the theory of "biological citizenship" advanced by anthropologists and sociologists such as Adriana Petryna and Nikolas Rose to ask pointedly: what new political formations have inadvertently been generated in the global response to HIV/AIDS and the expanded "rollout" of antiretroviral medications? As with the case of the ID cards, Nguyen describes a set of complex local worlds in which vital access to basic resources, livelihood, and security are mediated not through the state but through access to international aid delivered laterally by an assemblage of donor nations, NGOs, and academic centers in Europe and North America. As Nguyen elaborates with observation and narrative, this "therapeutic citizenship"—while increasingly vital for survival—is a tenuous form citizenship indeed.

Once I opened this book I could not put it down. The narrative begins in the early years of the AIDS epidemic in Francophone West Africa, and charts the emergence of a community of activist groups formed before the first open declaration of HIV-positivity by afflicted individuals. Nguyen is interested here in exploring how various "technologies of confession," or strategic ways of talking of one's identity in relation to illness—travel between places such as Montreal, Brussels, and Ougadougou. Nguyen sketches out the weaknesses of the communities formed around the spread of HIV counseling and prevention technologies, many of which fractured over internal assymetries between members who could parlay their position within NGOs into access to antiviral treatment and those unable to do so.

As Nguyen narrates the formation of early treatment networks among resourceful West Africans with connections to physicians and activists in European and North American cities, his story begins to mirror Steven Epstein's account, in Impure Science (Berkeley, University of California Press, 1998), of the early years of North American AIDS activism. But unlike Epstein's activists, who quickly establish broad pill-sharing networks, Nguyen's actors must establish brutal triage structures to restrict the limited amounts of antiretrovirals available through leveraged social networks to Europe and North America. Initial triage of these vital resources privileged those most adept at operating in a system of AIDS-confession and support groups, and Nguyen deftly illustrates how this structure of informal medication triage became codified into formal protocols of triage adopted by local clinics, national programs, and the global structure of bilateral and multilateral aid. Even as funding and international interest in antiretroviral rollout grew over the past decade, Nguyen charts the persistence of triage structures in determining who is allowed into, and who...