Probably more than any other disease in the contemporary world, AIDS has both revealed and precipitated major social, cultural, political changes in society in general as well as in science and medicine more specifically. As such it has been a challenge for anthropologists, who have had a difficult time situating their work in relation to the epidemic. During the first decade in particular, their attitude oscillated between mere lack of interest and uncritical involvement as activists, whereas their engagement on the African continent has often been renewed with a caricatured culturalism sometimes tinged with racial prejudices. From the second decade on, conversely, new approaches have developed, exploring the political economy of the disease, mobilizing historical parallels with other plagues, incorporating perspectives from the social studies of science and proposing innovative ethnographies.
To understand the impact of the epidemic on societies as well as on social sciences, some factual data are necessary. The Acquired Immune Deficiency Syndrome, better known under the acronym AIDS, is severe immunodeficiency due to infection by the Human Immunodeficiency Virus, HIV. The first cases of the disease, at that time not identified as such, were reported in the USA in 1981, but retrospective studies have shown that similar clinical conditions had been described as far back as the early 1950s. The epidemic spread dramatically in the following two decades, reaching particularly high incidence rates on the African continent. Out of the 33 million people living with the disease in 2007, two thirds were in Africa. That same year, 2.7 million persons were newly infected and 2 million died, mostly young adults, with the consequence that 12 million under 18 have become orphans. In Southern Africa, which is the region by far most severely hit with almost 40 per cent of the world mortality, prevalence rates have reached 30 per cent in certain areas and a decrease in life expectancy to 20 years has been estimated for certain groups.
In this context, AIDS can be analysed as an epidemiological crisis, not only from the perspective of the tragic figures just evoked and of their critical consequences for public policies, but also etymologically as a crisis in the discourse (logos) on the epidemic. Although the reasons for the differential spread of the infection — mostly limited to exposed groups like gay communities or intravenous drug users in the Western world, broadly disseminated through the whole of society in the Third World — are not well understood by specialists, it has been the subject of numerous interpretations based on moral views, religious condemnations, cultural prejudices, racial ideas and commonsense which are encountered not only in lay opinion but also among physicians, biologists, epidemiologists, and even anthropologists. AIDS has been saturated with meaning from its beginning. In Paula Treichler’s words (1999: 11), it is ‘an epidemic of signification’. It is associated with sex and death, with deviance and danger, with exoticism and stigma. It arouses fear and exclusion, imagin-aries and metaphors, mixed with scientific data and established knowledge. The limit between facts and rumours, between evidence and beliefs, between truths and errors, is sometimes indiscernible and often porous. The social construction of the African epidemic illustrates this semantic saturation and cognitive hesitation.
In 1982 the first African cases presenting a clinical condition similar to that of US homosexuals and drug users were diagnosed among Zairians in Belgium and Congolese in France. It soon appeared that the epidemic had been spreading at a rapid pace in Central and Eastern Africa. Two conclusions were immediately drawn: that the origin of the disease was on the African continent and that Africans had singular practices accounting for their anteriority in the epidemic. Ritual practices, such as scarification,excision and circumcision, were investigated in the Human Relations Area Files, and sexual oddities, such as injections of simian blood supposedly used as aphrodisiacs, were searched for in classical ethnographies. Traditions were explored as if they could offer clues to the origin of the epidemic. African imagined proximity with nature gave rise to explanations in terms of zoophilia (with monkeys) and bestiality (virgin rapes). This literature was sometimes described as ‘ethnopornography’. But the most common interpretation concerned the ‘sexual promiscuity’ of men and women, which revived a long history of ‘scientific’ discourses on African ‘hypersexuality’, recently reinvented by socio-biologists who have compared complex indices of ‘sexual restraint’ among so-called ‘Cauca-soids’, ‘Mongoloids’, and ‘Negroids’. Remarkably, even when epidemiological studies started to demonstrate that there were not higher rates of HIV infection in the places where people declared more sexual partners, the idea remained deeply entrenched in the minds of many, including scientists. As Randall Packard and Paul Epstein (1992: 346) have argued, this approach of the epidemic, resembling what had occurred earlier with tuberculosis and syphilis, was imposed on anthropologists in such a way that they were initially incapable of thinking outside of the paradigm of ‘risk behaviours’, which they were expected to apprehend from the perspective of the ‘sexual life of the natives’. In spite of the efforts of a few pioneers, it thus took medical and social anthropologists almost a decade to develop an autonomous thought on the epidemic, liberated from its culturalistic simplifications.
The paradigm of risk has had the well-known consequence of ‘putting the blame on the victim’. AIDS patients were held responsible for their disease: by their dangerous behaviour, they had provoked the infection. Soon a moral division was drawn among patients according to their mode of contamination. Homosexuals, intravenous drug users, and heterosexuals as far as they were suspected of sexual promiscuity were twice stigmatized: for their illness and for their reprehensible behaviour. Haemophiliacs, children, and heterosexuals when represented as infected by an unscrupulous partner were seen as victims. This ‘geography of blame’, as Paul
Farmer (1992) coined it, was extended from groups to countries, as Haiti was accused of being the source of the US epidemic and returned the suspicion onto the North Americans. These conflictive interpretations had equivalents in Eastern Europe, Latin America, Southeast Asia and above all on the African continent where the idea that Western tourists, doctors or militaries had imported the epidemic became a widespread belief. In fact these paranoiac interpretations followed lines of power and domination much more than traditional schemes. The imaginaries therefore reflected, as had been the case previously with plague or cholera, the political economy of inequality.
Beyond behavioural or cultural patterns, in effect, AIDS should be understood from the perspective of the disparities of its distribution. Preventive and educational programmes in public health have focused on knowledge and attitudes, as if the exposure to risk or the access to treatment were mere cognitive issues implicitly related to a theory of the rational actor. This approach ignored the historical background of the inequalities observed. In South Africa, for instance, where almost one fifth of all cases in the world is concentrated, ser-oprevalence rates in certain industries are ten times higher among Black unqualified workers than in the White management, and reach 28 per cent among men and 37 per cent among women in certain mining areas. Considering these figures to merely reflect risk behaviours would be missing the fact that industries and mines have been for more than one hundred years sites of male concentration where work and leisure, alcohol and prostitution have been part of the organizational schemes developed by companies to facilitate the exploitation of millions of African workers. This ‘embodiment of history’ (Fassin 2007: 173) thus corresponds to the inscription of the past in individual bodies through a structural violence that explains, much more accurately than behavioural or cultural abstractions do, the conditions of living and, in the end, the risk of dying in townships and former bantustans. But it also refers to the permanence of narratives and emotions that inscribe collective experiences of the epidemic within moral economies of resentment and suspicion leading to imaginaries of extermination.
Considering this objective and subjective reality of the disease, one may see the controversy at the top of the South African state – about poverty rather the virus being the cause of AIDS — as less surrealistic than it could seem at first sight.
This controversy, and several others, more or less structured and stabilized, are signs that the epidemic has also been a challenge for biomedi-cine. Certainly, the advances in the understanding of the virus and its action, of the disease and its treatment, have been remarkably fast. However doubts (about modes of transmission) and failures (about the vaccine) have shown the limits of science. Moreover, contestations of the official knowledge have been numerous, both within the biomedical realm (with the heretic thesis of the non-viral aetiology) and in the public sphere (with the mobilization of activists in the USA and of heads of state in Africa against the scientific orthodoxy). These alliances of mistrust, studied in North America by Steven Epstein (1996), have concerned almost all societies. Much more than the simplistic qualification of ‘denial’ and ‘denialism’, they help understand problems encountered with individuals as well as governments who reject what they see as opaque and hostile processes. AIDS has thus been a major example for exploring the reconfiguration of the relations between power and knowledge in the contemporary period, and as such has nourished the anthropology of science.
The role of new actors, the development of networks, the deployment of coalitions, and the use of technologies of social intervention in the field of biomedicine, have been emphasized by many studies. NGOs like Aides, Act Up, Doctors Without Borders (MSF), and Treatment Action Campaign have initiated innovative social movements which have transformed the place of civil society in the negotiation of scientific activities (clinical trials for the French group TRT5) and the contestation of the authority of governements (court cases against the South African health minister). They have tried to impose the idea of an ‘expert patient’ and of a ‘sanitary democracy’, even at the global level, obtaining the status of an "’exception’ for AIDS drugs in the intellectual property agreement of the World Trade Organization’s Doha round. In certain cases, states themselves have become ‘activists’, Brazil being generally considered as a model. However, Joao Biehl (2007) shows that the other side of the Brazilian picture is more complex as questions of access to treatment, stigmatization of patients, and everyday consequences of deprivation remain critical among the poor. More generally, the HIV epidemic has crudely revealed and aggravated social inequalities not only in terms of infectious risk and health care, but also, in a broader way, in the face of life and death.
During three decades, AIDS has thus been a crucial factor of social change in many sectors of contemporary societies. Its significance goes far beyond the field of medical anthropology. Using the Maussian formulation, it may be seen as a ‘social total fact’ that enlightens and mobilizes many dimensions of social anthropology. One of them — and not the least — is the world’s image of the anthropologists themselves. It has been put to the test by the urgent need to act in a way that has rarely been observed before in the field of anthropology. Many texts, from the early period until now, express this sense of urgency, which in some cases has led to inaccurate normative assumptions. AIDS thus reminds us of the tensions between ‘involvement and detachment’ that, according to Norbert Elias, run through the social sciences.
