- Second Chances: Surviving AIDS in Uganda ed. by Susan Reynolds Whyte
The HIV/AIDS epidemic has been exceptional, decimating lives and rupturing families, yet it has also, through both local initiatives and global circulations, produced transformation and new beginnings. This book, innovative in many ways, charts the experience of a generation of Ugandans at a particular historical juncture: the expansion of access to life-saving antiretroviral treatment (ART), during the first decade of the twenty-first century, from its beginnings in private fee-paying clinics or research projects to free programs, financed by the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR). The latter offered new forms of medicine and health care, albeit still within an uneven and unequal landscape of projects, programs, and partnerships between NGOs, research groups, and the Ugandan state. This “projectification” of care meant that the members of one family might be enrolled in different programs, each with different levels of care, a situation that created practical problems and complicated family lives.
Described as a “polygraph,” the book is based on two years of research conducted by a team of four Ugandan and four Danish anthropologists, who “coordinated closely to assemble one common body of material about a unique place and time in African history” (p. vii). Focused on “the first generation” of people living on ART—people who were the first to have “a second chance” at life—the aim is to “illuminate both the diversity and the historical uniqueness of a generation” (p. vii). Rather than situate its analysis in the concerns of global health programs, the book stays close to the concerns of the first generation and their struggles to stay on treatment amid everyday dramas of family life, relationships, and the insecurities of work and livelihoods. The book shows that life on ART is a social achievement and thus also deeply contingent. People’s therapeutic journeys [End Page 576] are intertwined with those of others, dependence and interdependence being fundamental modes of existence in Uganda.
Concerned to “preserve the integrity and situatedness of persons” (p. viii), the authors build up the book around eleven personal accounts, which form its main “cases.” Each story highlights a particular theme—connections, “therapeutic clientship,” mobility, families, partners, children, work, food, bodies, medicines, and “life.” The chapters also draw upon the experiences of a further thirty-seven people living on ART, chosen from different treatment sites in rural and urban Uganda and from different backgrounds and livelihoods. These interlocutors were visited and interviewed in an open format, with the interviewer taking extensive notes but not using a recorder, producing life stories and conversations about everyday lives.
Three innovations underline the originality of the book. First, the authors’ concept of “therapeutic clientship” moves anthropology beyond its love affair with “therapeutic citizenship,” the global shifts in access to ART, and the actors and activists who are able to negotiate these landscapes, to the local moral economies, social relations, and patterns of dependence in which ART is embedded in Uganda. ART programs were innovative, the authors argue, because they introduced a form of health care based on long-term transactions and a contract between provider and patient in which the latter became “clients.” Paperwork and files are crucial materials in this process. Health workers and patients approach access to and treatment at the HIV clinics as a hierarchical relationship of patron and client, which is infused with expectations, obligations, entitlements and duties. The unevenness and “projectification” of ART programs encouraged this pattern of clientship. When a patient is enrolled in a program and demonstrates “compliance,” she becomes “their person.” Rather than analyze this relationship in terms of discipline and biopower, the authors explain why Ugandans were generally appreciative of these forms of sustained care.
A second achievement is the “situatedness” of the accounts about ART that appear in the book. The focus on patients’ lives rather than clinical encounters reveals the larger social and historical context, concerning kinship, family, work, class, and identity...