Orly Farber received her B.A. from the University of Chicago and now does allergy research.
In The Republic of Therapy, medical anthropologist and physician Dr. Vinh-Kim Nguyen traces the local and international responses to the HIV epidemic in French-speaking West Africa. Nguyen’s work spans the years between 1994 and 2000, a pivotal period in the global AIDS epidemic. This period begins with the discovery of effective treatments for HIV and ends with the reversal of the international consensus that those treatments should not be used in Africa. Until 2000, international organizations deemed antiretroviral drugs too expensive and too difficult to formally administer in Africa, but not in North America. Consequently, millions of individuals selectively lived and died with HIV/AIDS. As Nguyen writes, his work aims to “explore and expose the obscene inequality and insidious logic that values lives differently” (4). He asks: who lived, who died, and why?
Nguyen points to a paradox, which he terms “triage.” With the advent of life-saving drugs, international and local organizations tasked with responding to the epidemic in West Africa unwittingly triaged, sorting those who should receive treatment and live from those who would go without treatment and, likely, die. In its original conception, triage was a military tactic employed to preserve manpower. It was a calculation used to allocate scarce resources and medical care to those who were combat-ready rather than to those who needed care most. In civilian use, triage serves an alternate purpose, providing care first to those who need it urgently in order to maximize the number of lives saved. Therefore, in medicine, there exists a precedent for deploying triage to different ends--whether that end be to return the healthiest soldiers to the battlefield or to save high-risk civilians. Those ends, Nguyen argues, are based on criteria that value life differently under different circumstances.
The Republic of Therapy elucidates how triage evolved during the HIV epidemic in the West African countries Burkina Faso and Côte d'Ivoire, where Nguyen worked as an HIV physician, community organizer, and activist. Using ethnographic and historical accounts, Nguyen walks his readers through his argument: the HIV epidemic and its struggle over access to treatment ushered in a new form of political power, a power he terms “therapeutic sovereignty.” The informal and formal processes deployed to negotiate who should receive treatment during the AIDS epidemic constitute an exercise of sovereignty; they reveal how and by whom power over life was exercised.
The Republic of Therapy chronicles the efforts to organize communities with HIV and focuses on the emergence of testimonials as a tool for triage. Although political and economic circumstances barred a much-needed influx of HIV treatment, drugs did trickle into West Africa and, the more visible one made his or her illness, the more likely he or she was to acquire drugs. Having a good story about living with HIV could grant access to treatment. Furthermore, as Nguyen writes, “[P]roducing ‘real’ people with HIV came to be seen as evidence that ‘something is being done’” (23). As such, across the continent, Africans were urged to give testimonials, to produce narratives of their illnesses--often, for financial compensation. The bulk of The Republic of Therapy explores how privileging those testimonials for triage--even, Nguyen suggests, rendering them valuable capital--disrupted local HIV communities and altered the course of treatment in West Africa.
Nguyen’s argument culminates with the assertion that, “[T]riage is not just political, it is politics. More fundamentally, triage is about sovereignty” (176). Triage embodies a battle over resources and power that, ultimately, dictates life or death. Through his ethnographic narratives and the history of the African AIDS epidemic, Nguyen constructs a framework that transcends its own historical moment. He reminds his readers to examine all global efforts to “heal” and interventions to “rescue” with a critical, political eye. He reminds us to contend with the powers at work when decisions of life and death are being made. In global health politics, we must pause and ask: who lives, who dies, and why?