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

Vinh-Kim Nguyen’s engaging new study of HIV/AIDS in Côte d’Ivoire and Burkina Faso sheds light on a previously unexplored aspect of contemporary history: the period between 1994 and 2000, once effective antiretroviral treatment for AIDS was discovered but before these treatments became more widely accessible in sub-Saharan Africa. Trained in both medicine and anthropology, Nguyen documents the human suffering of this period with sensitivity, drawing on his experiences as a doctor in Abidjan as well as field interviews. The book’s real focus is, however, the political implications of HIV/AIDS treatment programs in conditions of extreme poverty and political instability. Ironically, HIV/AIDS treatment programs offer what he argues is the only meaningful type of citizenship in these two Francophone West African countries, battered by economic crisis, coups, and, in the case of Côte d’Ivoire, a recent civil war.

Two concepts are central to Nguyen’s study: “therapeutic citizenship” and triage. Therapeutic citizenship refers to the benefits and responsibilities that AIDS treatment programs offer and impose on those enrolled in treatment programs, akin to the functions of a modern state. With their ability to track individual identity and confer access to support systems, ranging from food to credit, AIDS treatment programs provide what the collapsed Ivoirian government could not provide: a social safety net, along with the bureaucratic machinery to run the safety net. Closely allied to the notion of therapeutic citizenship is that of triage, that is, prioritizing some individuals for medical treatment over others. Therapeutic citizenship was available only to the few, especially before 2000, when access to antiretroviral therapy was limited to those who enrolled in clinical research trials, a select few actively involved in NGOs who received donations, or those who had friends, colleagues, or relatives in the West who could send medications.

How were the select few chosen for treatment between 1994 and 2000? Western aid agencies favored those willing to speak publicly about their diagnosis, in hopes that public disclosure would reduce stigma and encourage others to get tested. As Nguyen deftly argues, the idea that public disclosure of HIV status would spontaneously generate solidarity arose from a radically different context: among gay activists experienced in building grassroots support, in Western societies that already enjoyed democratic traditions and a solid economy. Public disclosure was more likely to arouse suspicion and mistrust in West Africa, and for good reason: those publicly claiming to be HIV positive might get medications from charitable organizations, enabling them to survive while others died. Disclosure of status meant individual gain, not group solidarity, in a world of severely limited resources.

Triage also occurred in the context of medical research programs. With their clear clinical criteria for enrolling research subjects, some people were selected for and received antiretroviral therapy, medical care, and even additional support (notably food). For a variety of reasons, such as having anemia, others were excluded and therefore ineligible for the benefits offered, including antiretroviral therapy. Often people learned about their HIV status only by volunteering as subjects for a research trial. Upon learning that they would not be included in clinical trials, these individuals complained of feeling “discarded.” Far from the research abuses of the notorious twentieth-century Tuskegee syphilis research study, where research subjects were denied access to effective penicillin therapy, the West African story of AIDS clinical research presents the other extreme: participation represented one of the best chances at survival. Conditions were desperate in Côte d’Ivoire during the 1990s, after the collapse of world cocoa and coffee prices (the principal exports) and the imposition of structural adjustment programs that curtailed social spending, thereby reducing the numbers of youth attending school and further swelling the ranks of the unemployed. To be HIV positive and enrolled in a clinical trial was, tragically, to be in a position to...