Religion and AIDS Treatment in Africa

Saving Souls, Prolonging Lives

Hansjörg Dilger, Thera Rasing, Rijk van Dijk, Rijk van Dijk

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317068198
• Edition: 1
• Topic: Theology & Religion
• Subtopic: Theology

This book critically interrogates emerging interconnections between religion and biomedicine in Africa in the era of antiretroviral treatment for AIDS. Highlighting the complex relationships between religious ideologies, practices and organizations on the one hand, and biomedical treatment programmes and the scientific languages and public health institutions that sustain them on the other, this anthology charts largely uncovered terrain in the social science study of the Aids epidemic. Spanning different regions of Africa, the authors offer unique access to issues at the interface of religion and medical humanitarianism and the manifold therapeutic traditions, religious practices and moralities as they co-evolve in situations of AIDS treatment. This book also sheds new light on how religious spaces are formed in response to the dilemmas people face with the introduction of life-prolonging treatment programmes.

PART I
Agency, Subjectivity and Authority

Chapter 1
Fashioning Selves and Fashioning Styles: Negotiating the Personal and the Rhetorical in the Experiences of African Recipients of ARV Treatment

Felicitas Becker

Introduction

The increasing availability of ART in Africa has greatly reduced the terror attendant on an HIV-positive diagnosis. It has also given rise to debates about the effects such treatment, and the specific ways it is administered, has on the patients beyond safeguarding them from full-blown AIDS. Some of this literature suggests that the discourses surrounding ART provision encourage new forms of self-reflection and control, described sometimes as ethical self-fashioning or subject formation. This chapter problematizes these interpretations from several angles. The underlying concepts can be derived variously from Weber or Foucault, but in both cases imply a distinction between ‘modern’ and ‘pre-modern’ selves and therefore tend to relegate Africans to a ‘pre/not-yet-quite-modern’ sphere that is difficult to conceptualize. Moreover, observers need to connect self-fashioning in the context of ART to the wider social projects pursued by ART providers, such as the upwardly mobile social identities that born-again Christianity helps create. Most importantly perhaps, researchers also need to pursue the political and rhetorical dimensions of pronunciations on ART recipients’ self-care, whether by recipients or providers. The chapter argues that such strategic speech or ‘context-appropriate’ rhetoric is not ‘mere’ rhetoric but an instantiation of a very entrenched and effective kind of practice. It is related to what James Ferguson has described as the context-specific ‘styles’ of comportment and interaction that Africans have developed in managing their extremely changeable and hybrid social environments. These findings do not negate the possibility of subject formation in the context of ART provision, but situate it as one of several related processes that need to be studied together.

One day in the mid 2000s, Tatu Mohamed, the sister of my long-standing research assistant in the provincial Tanzanian town of Lindi, showed me a kind of scrapbook she had made in preparation for her marriage. Although she knew little English and did not normally speak it, many of the captions were in English. They included the sentence ‘I will respect my body’ as well as references to cleanliness, purity and self-care. The illustrations were predominantly of modestly yet fashionably dressed women and items of comfortable domesticity, including soaps and skincare products. The English captions were cut from a printed text and read like extracts from an ‘abstinence education’ manual.

This document reflected currents in the social life of Tatu’s home town, Lindi, as well as her particular circumstances. Anxiety about AIDS was then running very high and the disease was commonly attributed to a crisis in sexual morals. At the same time, vocal criticism from young reformists had prompted mainstream Muslims, such as Tatu’s family, to emphasize their Islamic credentials, including the maintenance of the proprieties of women’s behaviour (Becker 2007, 2009; Beckmann 2009). But at the same time, an ongoing road-building project in the district had brought in English-speaking strangers, encouraged trade in the sort of consumption goods represented in Tatu’s scrapbook and created opportunities for transactional sexual encounters.

Personally, Tatu had had to gain acceptance from a distant father and meddling stepmother for a suitor from out of town who was also a convert from Christianity, and had only just reached the stage of setting up her own household. In a sense, Tatu (considered the most diplomatic among their number by her siblings) had won a certain amount of independence after her wedding by first demonstrating the self-restraint required to have the marriage permitted. ‘Self-restrained’ here denotes a quality her parents and neighbours would have understood partly in terms of an established Islamic discourse on women’s modesty. But the scrapbook suggests that it has also taken on overtones of a more recent derivation, related to the sort of self-care advice long given to HIV-positive people and reworked for ART recipients, and perhaps also to a wider ‘post-permissive’ drift in Western discourses on sexuality, evident for instance in the American ‘true love can wait’ campaigns. Certainly, her actions in putting together this scrapbook were not purely strategic. If so, she would have had no reason to share this object with a visiting outsider like myself, however friendly.

The existence of this scrapbook and its contents can be seen as indications of the occurrence of a process which, in the context of AIDS, has been described as the construction of new forms of selfhood around the management of HIV, of ethical self-regulation fostered by treatment regimes that are often accompanied by a new or intensified religious orientation. Burchardt (2009: 346–7) uses the terms ‘ethical selfhood’ and ‘ethical subject formation’ (see also Nguyen 2009; Van Dijk 2009; Dilger 2012). In this view, ART, delivered in the form of programmes with in-built control mechanisms, not only provides for survival but also inserts Africans into a process whereby medical providers seek to reshape their subjectivities in ways inspired by deracinated religious or technocratic discourses, and shaped by the conditions neoliberal governance imposes on aid provision.

Tatu’s scrapbook suggests that such changes can reach beyond those who themselves are subject to ART regimes. ART was available at the time in Lindi but only through a private practice. PEPFAR-funded provision was being prepared but was slowed down by problems of coordination between the different agencies involved. The empirical material in this chapter mainly deals with people party to communal and, as Tatu’s example shows, also very personal debates about sexuality and public morality in times of AIDS and ART, rather than with recipients of ART and the attendant counselling. Nevertheless, I argue that the insights obtainable from this material are relevant to the discussion of ‘subjects of counselling’ more specifically. Put differently, the aim is to place the examination of subject formation in a wider context than that of ART provision and counselling and to trace some of the processes at play here to a longer history of Africans making sense of AIDS.

The above-mentioned observations on subject formation have immediate plausibility. Even with ART, an HIV-positive diagnosis remains a personal crisis and learning to live with it is likely to require a profound reorientation. Patients have to reconsider their relationships, their use of their body and their place in the world. Moreover, the presence of an ethical element in much of the advice given to HIV-positive patients, even before ART, is undeniable: it is indeed about taking care of one’s body as well as one’s relations, and many patients draw upon their religious allegiances in this process. It is also evident that the language in which advice on the management of AIDS as a survivable condition is couched has specific institutional origins and is bound up with particular visions of personhood (Prince 2012). As Dilger (2012) puts it, it is a language about empowered or to-be-empowered individuals heavily conditioned by international donor organizations that are providing funding for AIDS/ART education and care projects.

The concepts at play are not, however, without problems. The demands for personal reform in the context of ART counselling can be far-reaching, as can be the claims by recipients of counselling. It is difficult even to ask how true these claims are because the question smacks of what Glassman (2011: 50) has called the ‘implication of insincerity’: the observer appears to either ascribe hypocrisy or a form of ‘false consciousness’ to the observed. But at the same time, the intellectual authorities who, implicitly or explicitly, validate the concept of the self, from Freud to Foucault, would agree that purely verbal evidence is a poor guide to the processes under discussion. Moreover, a focus on the self is a poor guide to the interactive, interpersonal, sometimes collective nature of processes of subject formation in the context of AIDS/ART counselling.

This chapter explores the possibility of adapting Ferguson’s concept of ‘style’ and the development of context-specific styles by groups of African actors to the description of the changes wrought by AIDS and ART programmes. The attraction of this concept is threefold. Firstly, it recognizes that actors may speak and comport themselves in different registers in different contexts without being insincere in any of them. Following Judith Butler, Ferguson (1999: 99) calls the styles he examined ‘strategies of survival under compulsory systems’: they are ways of working with the practical necessities and cultural possibilities that actors face and that vary between contexts.

Secondly, Ferguson (1999: 99) calls these styles ‘motivated, intentional and performative, but not simply chosen or lightly slipped into’. They are both intuitive and pragmatic, capturing the tentative way in which intellectual, ethical and social positions are developed and adopted in the ‘rough and tumble of everyday struggle’ (Glassman 1995). This is useful because it cautions against expecting too much cohesion of the resulting stances, and against literal acceptance of verbal claims. Moreover and thirdly, ‘style’ thus conceived acknowledges the interpersonal nature of this quest for tenable positions in shifting social contexts. It therefore helps to think about the ongoing processes of personal reorientation in the context of ART programmes without opening up a chasm between the individual nature of changes to the self and the interpersonal nature of treatment programmes.

The Theoretical Antecedents of the Concept of ‘Self’

Different terms are used to describe the process under discussion, with ethical self-fashioning, ethical subject formation and new forms of care of the self all jostling with each other. This multiplicity reflects the difficulty of defining not only the ongoing process of change but also the thing that is changing. What is a self? The term oscillates between meanings established in developmental psychology, psychoanalysis, the study of ethical religions as inspired by Max Weber, the study of intimate, ‘capillary’ forms of power as inspired by Foucault, and meanings in literary studies and philosophy that draw on all of the above (Bosma and Gerlsma 2003; Weber 1988; Foucault 2008; Irigaray 1985; Bhabha 1995). In the context of AIDS-related changes, it refers to a phenomenon as impossible to ignore or dismiss as it is to pin down.

The following attempts to identify and disentangle at least some of the overtones of the notion of ‘self’ that are important in the present context. Three strands of discussion can be identified. Firstly, there is the long-standing proposition of the existence of specifically African forms of the self, typically glossed as less monadic than Western ones. Secondly, there is the proposition, associated with modernization theory, that selves have been changing, or ought to have been changing in Africa due to the social change induced by colonial and post-colonial upheavals. Thirdly, there is the Foucauldian suggestion that the self owes its existence not to advances in personal autonomy but rather to advances in social control; that selves are increasingly being coaxed into being by intimate, to some extent embodied forms of power that are often described as ‘biopower’. Evidently, the term ‘self’ can be called upon to do different kinds of work in a discussion of medically induced social change.

The proposition of a more relational, less individualist form of personhood prevailing on the continent is old and widespread (e.g. Gulliver 1971; Mbiti 1969). It has recently been restated in a sophisticated way by Geissler and Prince (2010: 164), who observe that among the people they observed in western Kenya, ‘personhood … is not centred on an autonomous and bounded self, which then engages with others … the boundaries between persons, others and things are fluid and permeable’ (see also Kresse 2007). The enormous reach and density of personal networks in Africa is indisputable, and Geissler and Prince’s assertion that the atomized individual is not taken as a given in their Kenyan research site is convincing.

Nonetheless, the kind of ‘networked’ personhood they describe is not incompatible with active individualism, as they would also acknowledge (see also Prince 2012). Perceptive studies of social relations in Africa at times emphasize the subtly conflict-focused character of the networks sustaining selves in Africa: they are animated by the self-centred and conflicting designs and desires of their members (e.g. Mitchell 1956; Falk Moore 1996). Such a tense and political personal network possibly makes the contours of the individual self sharp in circumstances where deeply personal interests are at stake. Tatu’s quiet and determined campaign to leave her paternal household and enter the marriage she desired comes to mind. Ultimately, therefore, the proposition of the relational self in Africa cannot support a specific account of the way selves are changing because the pre-existing selves are already very open to interpretation. Nevertheless, the prevalence of such networked personhood is quite compatible with the absorption and elaboration of new, including more individualist, ethical stances and social practices. This is part of what the developing literature on AIDS and self-fashioning is about.

Secondly, there is the Weberian proposition of individualization as a part of the ongoing modernization in Africa. In its strong form, this narrative is now largely discredited. In the mid twentieth century, it was widely used to class Africans, with other inhabitants of the ‘Third World’, as not-yet-modern, in counter-distinction to the modern West.¹ The association of HIV/ART with the operations of a technocratic medical bureaucracy, the manifest need for self-control and self-reflection to minimize risks in one’s sexual and personal life, is easily associated with the concept of rationalization, which was central to dividing the world into modern countries and those in need of modernizing, which in this mode of reasoning include all of Africa.

Observers of ART and ‘ethical subject formation’, to use Burchardt’s term, need not therefore be understood to be bringing back modernization theory through the back door. Even where they do not address their relationship with modernization theory explicitly, it is clear that they differ from its classical version in a crucial respect: these theories regularly posited secularization as another core element of modernization, in addition to individualization. This ‘secularization hypothesis’ has of late become highly controversial, some would say obsolete. Whatever may be salvaged from it, it is clearly orthogonal to the recent work on subject formation among subjects of counselling, where religious elements often mix with medical ones.

The differences between the modern African individuals predicted in the 1960s (Ferguson 1999) and processes of individuation and self-reflection under study today reflect the end of optimism and of the naïve universalism once inherent in notions of progress or modernization among researchers. The ‘subjects of counselling’ (Burchardt 2009) are kindred to the modern Africans once prophesied by modernization theorists in that their lives are inserted into bureaucratic or bureaucratizing institutional structures. But these structures are no longer seen as emancipatory or rational in a positive sense. They are essential lifelines for people stalked by a slow death, and their behaviour is conditioned by ever-scarce funding as well as religious/ideological orientations that their clients have to take in their stride. Overall, recent accounts of subject formation serve more to counteract modernization-theoretical ideas of individualization as an increase in personal sovereignty than to underpin them.

Concomitantly, the echoes of Michel Foucault are the strongest overtones in the literature on ART and subject formation. His insistence that the development of a self-reflexive sexual self in Europe is at heart an extension of power, of diffuse forms of social control, into the most intimate regions of life, gives a good deal of drama to the processes under discussion. But Foucault gives little thought to the possibility that the configurations of institutions he examined – of psychiatry, schools, prisons and the different partly institutionalized forms of speech he called ‘discourse’ – could weaken as well as grow. In Africa, by contrast, the transience of institutions dedicated to ‘programmes’, always started with the fiction that organizations would eventually make themselves superfluous as programmes become self-sustaining, is a hallmark of the institutional contexts of subject formation (Prince 2012). Of course, this transience does not mean that such institutions can have no effect on personhood. But how these effects survive the institutions is a question in itself.

As Stoler (2010), one of the strongest proponents of the usefulness of Foucault in non-European contexts, has remarked, he is better used for developing questions than answers. Two in particular come to mind. Firstly, should the echoes of Foucault in what African subjects of counselling experience be taken to imply that Africans are being made ‘subject’, in the sense of ‘lacking sovereignty’, in a new way? Do ART programmes imply their subjection to treatment regimes shaped by neoliberal agendas and ideologies of care determined elsewhere? Secondly, at the risk of sounding repetitive, where within persons do we find the Foucauldian kind of self? It is clear that we are looking at a phenomenon that can be ‘called into being’ by counselling encounters. How foundational is it?

The answer to the first question surely has to be ‘yes’. Of course dependency on ART provision is about as stark as dependency can get, and enables the provider to impose conditions on the recipient. At the same time, providers want their drugs to be used; withholding them is self...