Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science by Johanna Tayloe Crane (review)

The discovery of highly active antiretroviral therapy (HAART) in 1995 was effectively a response to the high mortality of AIDS in the global North, where the high cost of industrial pharmaceutical development could be afforded, and where large numbers of researchers could be trained and recruited, even though such prosperity did not provide immunity to the problem of HIV. It was in the end only through international aid that the therapy, although nearly one decade late and only available to those striving for inclusion (Nguyen 2010), could be accessed by HIV-infected individuals in the global South. Africa, home to “thousands of never-before treated patients” (4), was subsequently transformed from a field “too poor and chaotic to benefit from the high-tech antiretroviral medications” (6) to a continent that “is in vogue now” (7). Not only have African patients started on life-prolonging treatment thanks to the Global Fund and to the US President’s Emergency Plan for AIDS Relief (PEPFAR), but “a research opportunity. . . lost in the United States” (84) has also been seized to attract US researchers who might generate scientific knowledge by investigating this virgin territory in treatment, and to drive local experts to play their part in the “making of a global health science” (7). However, since those very same people upon whom the North has attempted to impose “salvation” (169) overlap with those who have historically and collectively been on the receiving end of colonialism, it would be overly reductionist to view such lifesaving work as the ostensibly great achievement that proponents of global health might claim it to be. Rather, just as Johanna Tayloe Crane, in her monograph Scrambling for Africa, has invited readers to be critical of “the interplay between HIV science, technology, and global inequality” (12), the field has to be understood both in terms of rejecting the idea that salvation by global powers is a matter of humanitarianism and by considering the question: “Through what mechanisms have the social relations of global inequality become materially embedded within scientific technologies we use to study and treat AIDS?” (12).

By setting out her own travel itinerary and those of US doctors between the US and Uganda since the start of the twenty-first century, Crane begins by briefly depicting how scientific knowledge of HIV/AIDS was conceived from Uganda and how “AIDS related infrastructure and research” (4) began to grow there domestically. Before HAART was increasingly introduced into the South—which ongoing exploitation had left too impoverished to purchase advanced medication and less able to defend itself against HIV, and where inequality had unremittingly catalyzed and deepened the HIV/AIDS epidemic—there existed only simple clinics offering free drugs to local patients for symptomatic relief alone, and certainly no HIV-specialist hospitals, such as appeared in the North, to deliver more efficient therapies or state-of-the-art biomedical services. It was not until a few foreign biomedical visionaries became aware of the potential research value of the swift availability of HAART to patients who would be “receiv[ing] the drugs for the first time” (5) that the “valuable inequalities” (7) associated with AIDS patients in Uganda gave rise, ironically, to “the transformation of the Immune Wellness Clinic into a site of global HIV research” (111).

Such a transformation would never have been possible had there not been scientific evidence to justify financing treatment in order to attract more funding for further research, especially when skeptical Western donors still considered that “problems with patient compliance are likely to be worse in low-income countries due to low education and the many other problems that poor people in developing countries face” (32). The assumption that poor adherence to a HAART regimen might contribute to a higher prevalence of drug resistance in Africa has had to be proved wrong so as to shift donors’ attention to a...