HIV Exceptionalism: Development through Disease in Sierra Leone by Adia Benton (review)

Among the many books written about the HIV epidemic in Africa over the past few decades, book-length anthropological studies remain a rarity. Adia Benton’s new book, HIV Exceptionalism—Development through Disease in Sierra Leone, helps to fill that gap. Through fine-grained accounts describing how individuals navigated new structures, new relationships, and new expectations that came along with being beneficiaries of global HIV funding, Benton reveals the jagged edges and uncomfortable truths about broader global–local health encounters. This book tells a compelling story about an entire society adapting to a sudden infusion of donor money for a disease that, in this particular context, barely existed.

The book is about HIV in Sierra Leone, but the issue of local responses to global health initiatives has relevance beyond HIV or any particular country context. What makes this particular disease in this particular country an interesting case for ethnographic study is the fact that HIV rates here have been historically very low, both before and after the 1991–2002 civil war, and yet the country received a large infusion of foreign aid money specifically for HIV/AIDS prevention and care programs. HIV services were initially introduced on a pilot basis in 2004, and by 2007 the Global Fund had secured enough funding to open a network of treatment centers that offered anti-AIDS treatment free of charge. By 2012, the country had spent more than $12 million USD on HIV/AIDS services, and all the while HIV prevalence rates remained essentially no different than the pre-war figure of 1.5 percent. How did the country and its war-ravaged health systems adapt to absorb those funds? How did people adjust their behavior to become models of “positive living”? How were hierarchies of power established between transnational donors, local health officials, NGOs, AIDS activists, and “expert patients”? What made HIV so exceptional in comparison to all other challenges confronting the country at the time? All these questions are explored in Benton’s anthropological project to hold lived experience in focus while mapping networks, institutions, beliefs, and conceptions that emerged with the flood of post-war HIV/AIDS money.

Sierra Leone’s civil war was winding down just as the international HIV/AIDS industry was revving up. With the 2001 launch of the PEPFAR program (President’s Emergency Program for AIDS Relief) by US President George W. Bush, a multi-billion dollar fund to address the global HIV/AIDS epidemic became available. What some had called “the AIDS industry” roared into action at that time and the search was on for worthy projects and countries to target for assistance. The newly launched PEPFAR program with its billions of dollars was actively searching for worthy projects and countries to target for HIV assistance. Expert consensus then was that war and HIV always conspired against affected populations and constituted a “double emergency.” When it was found that HIV prevalence in conflict-affected Sierra Leone was lower than anticipated, experts argued that normalization in the post-conflict period would lead to increased HIV transmission. While this never happened, it did not stop international funders or Sierra Leonean officials from making a case to secure the attractive emergency HIV/AIDS funds. And why not? With those funds, nearly $80 million allocated over a five-year period, came a wide-range of services—medical care, support groups, income generation projects, education, food supplements, and skills training, among others. All of these were welcomed in the dire social and economic circumstances of postwar Sierra Leone. But HIV was, and remains, exceptional among diseases, and exceptionalism created what Benton refers to as an economy of suffering, whereby those who had AIDS could claim unique hardship in a context where daily suffering was the norm. The exceptional status accorded to HIV, along with the exceptionally large amount of funding appropriated for HIV-specific projects, has produced the largest public health program in history. While some experts have critiqued this notion of exceptionality...