Ancestors and Antiretrovirals

The Biopolitics of HIV/AIDS in Post-Apartheid South Africa

Claire Laurier Decoteau

• Publisher: University of Chicago Press
• Year: 2013
• ISBN:
  9780226064628
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

In the years since the end of apartheid, South Africans have enjoyed a progressive constitution, considerable access to social services for the poor and sick, and a booming economy that has made their nation into one of the wealthiest on the continent. At the same time, South Africa experiences extremely unequal income distribution, and its citizens suffer the highest prevalence of HIV in the world. As Archbishop Desmond Tutu has noted, "AIDS is South Africa's new apartheid."In Ancestors and Antiretrovirals, Claire Laurier Decoteau backs up Tutu's assertion with powerful arguments about how this came to pass. Decoteau traces the historical shifts in health policy after apartheid and describes their effects, detailing, in particular, the changing relationship between biomedical and indigenous health care, both at the national and the local level. Decoteau tells this story from the perspective of those living with and dying from AIDS in Johannesburg's squatter camps. At the same time, she exposes the complex and often contradictory ways that the South African government has failed to balance the demands of neoliberal capital with the considerable health needs of its population.

ONE

The Struggle for Life in South Africa’s Slums

Pheello Limapo believes he has been HIV-infected since 1994, when he suffered from a serious bout of tuberculosis. “At the time, one of the doctors mentioned HIV, but no one was really familiar with the disease at this point, so this meant nothing to me and I quickly forgot about it.”¹ Pheello moved from the Free State to Johannesburg in 2001, where he initially worked in construction, but his constant illnesses made this work difficult at first and eventually impossible. He first lived in central Johannesburg and then moved to a squatter camp about an hour southwest of Soweto, named Lawley, where he still lives today. “My wife and I had a child before we knew we were HIV positive, and the child died. We went to many doctors trying to figure out what was wrong. Another child died before we realized that we were both HIV infected, and that breast-feeding was part of the problem. We had a third child and did not breast-feed the child. This child is still fine, healthy and HIV negative.”² Pheello and Elizabeth had another HIV-negative child (thanks to nevirapine³ and formula milk) in 2008.

In 1999, Pheello became so ill he was hospitalized, and he was given an HIV antibody test. When he returned for the results, “the doctor called me into a special room where he actually disclosed my status to tell me that I’m positive. . . . Well, I chose not to believe it. . . . When I went home, I decided to keep quiet, not to tell everybody, because I actually saw the kind of circumstances that will come with it, especially if I disclose, because I will be discriminated against at home and by everybody.”⁴ At another point, he explained: “No one was talking about AIDS. I went to two funerals of comrades I worked closely with in my community . . . and no one mentioned the disease.” He paused and took a deep breath, “it was when my brother died that I realized that if I didn’t take a chance and talk to people and ask for help, I was going to die just like everyone else . . . with no one knowing.”⁵

FIGURE 2. The Limapos in front of their home in Lawley. Photo taken by the author in June 2009.

And so Pheello started talking. He became a strong advocate for himself and the other people in Lawley who were living with or affected by HIV/AIDS. In addition to battling the silences and stigmas that cloak the disease in his community, Pheello has learned there are other more insidious forms of political silence that need to be broken. He became involved in my research, he never ceased to remind me, because he strongly believed that the stories of people living with HIV/AIDS in squatter camps needed to be told as it was all too easy for the government to forget they existed.

It’s not that the government has got no capacity or no money to assist people living with HIV. There is a lot of money that is there for AIDS. A lot of this money is donated from different countries all over the world. . . . And the government is only the custodian of that money. But instead of the government using that money where it is supposed to be used—like in the squatter camps, it uses this money to make millions of condoms and millions of fancy pamphlets. Spending a lot of money on things that are secondary and not primary. . . . But it’s the people in the squatter camps who are vulnerable. The government does not even try to go to the squatter camps to find out what is needed. It is the people with the nice lives who are deciding on the money. People are struggling as we speak—in different squatter camps. But the government does not want to help us.⁶

. . .

As Mike Davis (2006) points out, the rapid urbanization that has accompanied the global implementation of neoliberal economics has resulted in a “late capitalist triage of humanity” (199) in which millions of people throughout the world have been converted into surplus populations, abandoned on the peripheries of hypercities, and marginalized by their inability to participate in the accumulation or consumption of capital. The plight of informal settlement residents has recently become a focus of international attention. Indeed, one of the United Nations Millennium Development Goals is to significantly improve the lives of slum dwellers globally by 2020 (UN 2010). Despite this increasing global awareness, there is still much to be learned about the intricate causal relationships between neoliberalism, urbanization, and disease epidemiology, as postcolonial countries the world over fight to stem the tide of increasing informality. In this chapter I provide historical, ethnographic, qualitative, and quantitative data on two squatter camps outside of Johannesburg where I have been conducting research since 2004: Sol Plaatjie and Lawley. I begin by providing detailed evidence of the endogenous relationship between poverty and HIV/AIDS, and then explain the material and ontological vulnerabilities associated with living in slum conditions.

Informal Settlements

As in other developing countries, the historic “mushrooming” of informal settlements in South Africa began in the 1980s due to rapid deindustrialization and rising unemployment; however, in the South African context, the relaxation and eventual eradication of influx controls⁷ at the end of the decade accelerated an already escalating rate of urbanization (Hunter 2007; Harrison 1992; Crankshaw 1993). There are different kinds of housing informality in South Africa: “informal settlements” are squatter settlements of the urban poor that develop through the unauthorized occupation of land (Huchzermeyer and Karam 2006, 3). Other informal dwellings include shacks built on serviced sites or in the backyards of formal township houses (Huchzermeyer 1999). From 1996 to 2003 the number of informal dwellings rose by 688,000 in South Africa, despite the existence of house-building projects funded by the state (Hunter 2006, 160–61; Mail and Guardian 2006a). By 2009, 14.4 percent of households (1.9 million) in South Africa were informal dwellings or shacks (South African Cities Network 2011, 49).

People move to informal settlements for a number of reasons, which can be attributed to either push or pull factors. Push factors include overcrowding, unaffordable housing, stigma, and eviction, and pull factors are usually associated with job opportunities (or, for HIV-infected South Africans, health care accessibility) (Smit 2006, 108). Often the push factors are more likely with intraurban movement and pull factors with rural-urban migration (ibid.). Intraurban migration is becoming increasingly common. Greenberg notes that the rural-urban migration that marked the apartheid era has simply turned into perpetual migration in the post-apartheid period—as people move from one informal location to another in search of economic security (2004, 31). A community participatory research survey I conducted in Sol Plaatjie and Lawley in 2009 revealed that 75 percent of residents from Lawley and 85 percent of those from Sol Plaatjie most recently lived somewhere else in the Gauteng province⁸ before moving to these locations.⁹

Housing is a basic right enshrined in the 1996 South African Constitution (Republic of South Africa 1996b). This right includes not only housing but also secure land tenure, domestic access to basic services (like water, electricity, and sewage), and “socially and economically integrated communities” with “health, educational and social amenities” (Department of Housing 1994). Post-apartheid housing policy is marked by the same antinomy I argue is a result of South Africa’s attempt to resolve the postcolonial paradox: the state is committed to and proud of its constitutional goal of providing “adequate housing” to every citizen,¹⁰ and yet it selected a market-based delivery procedure that made this goal practically impossible to achieve.¹¹ In the early years of democracy, the national government attempted to provide housing through a “one-off product-linked capital subsidy scheme.”¹² In other words, people signed on to a queue at the Department of Housing (filling out what is commonly referred to as a C-form), and were slowly allotted small one-room homes, usually on the outskirts of urban centers (where the land is cheaper). But it soon became evident that not only was this an untenable solution but it also exacerbated spatial racial segregation (Huchzermeyer 2001; Greenberg 2004). This venture also sidelined the unemployed or those employed in the informal sector as it assumed access to mortgage finance (Huchzermeyer 2001, 313); it also left completely untouched the tricky political question of informal settlements and squatting (ibid., 323–24). “The challenge,” according to Paulos Ntsooa, deputy director of Human Settlements, “is that the residents in these [informal] settlements live in a permanent state of legal and social insecurity. This makes them reluctant to invest in their dwellings to make better living environments” (Social Housing Foundation 2010, 3).

Building low-cost housing has been a key priority of the ANC government in the post-apartheid era. The homes built by the state are referred to as “RDP houses,” named for the Reconstruction and Development Programme (the plan adopted in 1994 to deliver services through government subsidies). From 1994 through 2003, the state funded the building of one million RDP houses, which was accelerated in the late 2000s, so that two million had been built by 2007 (Hunter 2010, 110–11; Statistics South Africa 2007a). But during this same period, the number of informal settlements was steadily on the rise. By 2007, two million households still lived in informal dwellings (Statistics South Africa 2007a). Mark Hunter suggests that this is, in part, because unlike the “matchbox” houses built by the apartheid government, which were four rooms and 51.2 square meters, the RDP houses are two-room residences and provide a living space of less than 30 square meters (Hunter 2010, 110).¹³ As a result, households have had to break apart, and average household size has decreased dramatically in the post-apartheid era. “Put simply, as the state built RDP houses, thousands of new, overwhelmingly poor, households mushroomed—a reality speaking to the dynamic nature of movements, space and the household. Shacks are not simply a ‘legacy’ to be overcome through technocratic ‘development’” (ibid., 111).

Because of the continued proliferation of squatter camps in the urban areas of South Africa, the national government developed an Informal Settlement Upgrading Programme in 2004 (Huchzermeyer 2006, 41)—intended to move South Africa “towards a shack-free society” (Sisulu 2004; quoted in Huchzermeyer 2006, 44). A further impetus came when South Africa won the bid to host the 2010 World Cup, thus clinching the policy that “visible” informal settlements should be replaced with formal housing,¹⁴ whereas nonvisible informal settlements were to receive in situ upgrading (Huchzermeyer 2006, 45).

The city of Johannesburg established a new approach to “Informal Settlements, Formalisation and Upgrade” in 2008 (Masondo 2008), with the goal of formalizing all informal settlements in the city by 2014. At the time, there were 180 informal settlements in the city, containing 200,000 households (ibid.).¹⁵ “In summary, the policy states that, where possible, informal settlements will be upgraded in situ, i.e. where settlements are safely located and their location does not compromise the development objectives of the City,” explains Philip Harrison, executive director of development planning and urban management (Davie 2008).

In the late 1990s and early 2000s, many informal settlements were declared un-upgradable, and residents were told this was because of unsafe environmental conditions like undermining and the existence of dolomite.¹⁶ Residents suspected that the government simply used these environmental justifications to warrant eviction in the face of unauthorized land seizure (propelled by a desire to eradicate rather than manage squatter settlements). These suspicions were confirmed when a few years later the formalization of informal settlements was declared the most economical means of providing housing to the urban poor, and many informal settlements previously declared “un-upgradable” were upgraded. Sol Plaatjie is undermined and already suffers from sinkholes, and Lawley residents were told the land was dolomitic. Both were nonetheless upgraded from 2006 to 2008.

Basic service provision was also very politically linked to the issue of housing provision and land tenure. Prepaid water and electricity meters were introduced in the early 2000...