CAGH Newsletter

Dear CAGH Members –

On the heels of our meeting in San Jose, we wanted to send several important updates regarding leadership, this year’s initiatives, and Virchow Award winners. Thanks to those who joined us in person at the meetings. If you were not there and wish to remain involved in this year’s initiatives, please see below for further information.

 

Outgoing / Incoming Leadership:

First, we want to give thanks to Sara Lewis and Peter Brown, who served as co-chairs of CAGH over the past three years and led a number of important initiatives. We are so thankful to them for their leadership. We (Amy Dao and Nora Kenworthy) will be taking over the reins as co-chairs this year. Please be in touch with us about any CAGH-related business (Amylm.dao@gmail.com;njk8@uw.edu).

 

Upcoming CAGH Initiatives:

Each year, CAGH solicits information from members about topical initiatives they would like to lead. Oftentimes, these become ‘Take a Stand’ initiatives, and eventually, written pieces or collections. For information on past Take a Stand statements, see: http://cagh.medanthro.net/take-a-stand-policy-statements-by-cagh/. CAGH members who are interested in initiating or leading a Take a Stand initiative for the coming year should email Amylm.dao@gmail.comor njk8@uw.eduwith ideas. We can talk you through the process and connect you with other faculty who may be interested in working on similar topics.

 

There was also some discussion at the meeting this year of putting teaching materials and current bibliographic materials on the CAGH website to share with other scholars. As this work moves forward we will send further updates. Anyone interested in contributing to this effort should reach out to us via email.

 

Virchow Award Winners:

Each year, the Rudolf Virchow Awards are given by CAGH for individuals at three stages of their careers as medical anthropologists: undergraduate students, graduate students, and professionals. In keeping with Virchow’s legacy, the award is given to work that combine a critical anthropology focus with rich ethnographic data, and best reflect, extend or advance critical perspectives on medical anthropology and global public health. This year’s Virchow Award submissions were particularly numerous and outstanding, demonstrating the many remarkable projects anthropologists are carrying out in critical global health. We are thankful to the award committee of Emily Mendenhall, Lauren Carruth, and Nora Kenworthy and to additional reviewer Laura Meeks for their considerable efforts in reviewing the many submissions.

 

While this year’s Virchow Award winners were announced briefly at the SMA meetings, we wanted to also highlight their work here. They are:

 

Undergraduate Award – Sabine Shaughnessy, for her paper “Reproductive Rationalities and Realities of Havana, Cuba during the Post-Fidel Transition.” This paper beautifully wove together ethnographic imagery and theory with topics of vital importance to medical anthropology, and more specifically, reproductive and sexual health.

 

Graduate Award – Raphael Frankfurter, for his paper “Conjuring Biosecurity in the Post-Ebola Kissi Triangle: The Magic of Paperwork in a Frontier Clinic.” This paper demonstrated a deep engagement with individuals, their stories, and their concerns about healthcare and medicine in a place where these aspects of medicine were often lost – and offers important and vital lessons about contemporary global health practices.

 

The Professional award was given to two papers in this year’s highly competitive category:

Elizabeth Roberts, for her paper, “What gets inside: Violent Entanglements and Toxic Boundaries in Mexico City” (Cultural Anthropology). This piece significantly advances the fields of anthropology, global health, and science and technology studies by considering the entanglements of everyday life, health, and toxicity in Mexico City. Her ethnographic prose was particularly striking, encouraging readers to think anew about biology, toxins, the environment, agency, and embodied inequities. This was extraordinary work, in both its intelligence and clarity in considering an understudied domain of global health.

 

Thurka Sangaramoorthy, for her paper “Putting Band-aids on Things that Need Stitches: Immigration and the Landscape of Care in Rural America” (American Anthropologist). This paper was especially striking in its demonstration of what it means to do exemplary global health and social justice scholarship in the US. Her use of ethnography to shed light on the meanings and functions of “band-aids” offers an essential conceptual tool for future medical anthropology, and for understanding the healthcare of underserved populations in the US. This paper was novel as well for its engagement with multiple communities of immigrants and providers who nonetheless intersect within the gaps and inadequacies of the US healthcare system.

 

Congratulations to all of the award winners!

We are currently seeking volunteers to serve as reviewers for this year’s upcoming Virchow Awards review committee. The commitment is relatively short and involves reading papers such as these and many other fine submissions. Please email Amylm.dao@gmail.comor njk8@uw.eduif you are interested in reviewing for any of these categories of papers. Junior or student scholars are welcome!

 

A call for the 2019 Virchow Awards will go out in the spring. Please keep encouraging undergraduate and graduate students to submit their work.

 

Thanks to all of you, and looking forward to working with you in the year ahead –

 

Amy Dao & Nora Kenworthy

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Job Announcement at Central Washington University

The Department of Anthropology and Museum Studies in the College of the Sciences at Central Washington University invites applications for a tenure track, full-time position in medical anthropology, to begin September 16, 2019. We are seeking a sociocultural anthropologist with expertise in critical medical anthropology and global health. The successful candidate must be grounded in ethnographic methodologies, have prior teaching experience, and have a PhD in hand by April 15, 2019. We prefer candidates who are broadly trained to address issues of health from mixed-method perspectives and at different scales, with expertise in environment and health, social epidemiology, health disparities, social justice, migration and health, and/or medical pluralism. Geographical area is open, but areas of particular interest include Africa, Asia, Southeast Asia, Latin America, or the Middle East.
Find out more here:
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Job Announcement!

The Mel and Enid Zuckerman College of Public Health at the University of Arizona has three open positions in Women’s Health, Global Health and Indigenous Health. Please circulate widely! Details can be found at the following links:

Associate/Full Professor – Women’s Health: https://uacareers.com/postings/27033

Associate/Full Professor – Global Health: https://uacareers.com/postings/27030

Associate/Full Professor – Indigenous Health: http://uacareers.com/postings/26912

 

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The 2018 Rudolf Virchow Awards is now accepting submissions!

Rudolf Virchow, a 19th century German physician and anthropologist, was a key founder of social medicine. His contributions centered on his recognition that multiple intersecting factors – social, political, and economic – produce disease and illness. He argued that the circumstances and deprivations of poverty increase people’s susceptibility to disease and result in reduced life expectancy and quality of life. He eloquently articulated the limits of medicine in the absence of material security, a sentiment which informed his view that nation-states play an important role in ensuring health security for a citizenry. Virchow viewed advocacy as an essential part of health praxis, and, in keeping with this legacy, the Critical Anthropology for Global Health (CAGH) Special Interest Group honors Virchow’s work with three awards.

The annual Rudolf Virchow Awards are given by the Critical Anthropology for Global Health Caucus, a special interest group of the Society for Medical Anthropology. Each year there are three awards for individuals at different stages in their careers as medical anthropologists: (1) the Professional Award honors a recent published article in a professional journal; (2) the Graduate Student Award honors a paper that was written between 2017 and 2018 and has not yet been submitted to a journal; (3) the Undergraduate Student Award honors a paper written during a student’s undergraduate career and has not been published. There are prizes of $100 for each student winner.

Winning submissions combine a critical anthropology focus with rich ethnographic data, and best reflect, extend, and/or advance critical perspectives in medical anthropological questions in the general area of global public health. All winners will be honored at the SMA business meeting at the American Anthropological Association meetings.

Submissions
The submission deadline for the 2018 Rudolf Virchow Awards is July 1st, 2018.
We encourage you to submit your own work and/or to nominate papers of your students or articles of colleagues. If you wish to submit a paper for consideration, please e-mail the paper and a cover letter of introduction to the Virchow Awards Co-Chairs, Emily Mendenhall, Lauren Carruth, and Nora Kenworthy at em1061@georgetown.edu by July 1, 2018. Hard copies are no longer accepted. Confirmation of receipt will be sent. To ensure a prompt and fair review, papers will not be accepted after the July 1, 2018 12 pm PST deadline. Winners will be contacted by October 1, 2018.

Professional Award Category
The professional award will be awarded for an article or chapter published during 2017 or 2018 in a peer- reviewedjournal(printoronline)orpeer-reviewededitedvolume. Articlesmaybesingly-orco-authored. Technical reports and other contracted works are not considered for this award. Professional articles must be submitted electronically in Adobe PDF format as they appeared in print.

Graduate Award Category
The graduate student award will be awarded for a paper that was written between 2017 and 2018 and that has not yet been subjected to editorial review. Papers that have been submitted to a journal or edited volume, but that have not yet benefited from review may be included in this category. Theses and dissertations will not be accepted. However, a summary no longer than 30 pages double-spaced (inclusive of references) of a thesis or a dissertation that can stand on its own, or a chapter that has been revised to stand on its own will be considered for this award. Papers from students who have graduated are still accepted in this category as long as the paper was written in 2017 or 2018. Graduate student papers must be submitted in Adobe PDF or Word format with a title-only first page. File sizes must be less than 2MB. The document must exclude the author’s name, author’s advisor, and university affiliation throughout. The cover letter should include this information. Only papers, not interactive media, will be considered for this award.

Undergraduate Award Category
The undergraduate student award will be awarded for a paper written in 2017 or 2018 while the student was still an undergraduate. Honors theses are not accepted. However, a shortened version no longer than 30 pages double-spaced (inclusive of references) of the thesis or a chapter from the thesis that has been revised to stand on its own will be considered for this award. Undergraduate student papers must be submitted in Adobe PDF or Word format with a title-only first page. File sizes must be less than 2MB. The document must exclude the author’s name, author’s advisor, and university affiliation throughout. The cover letter should include this information. Only papers, not interactive media, will be considered for this award.

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Announcing a new reader/textbook for people teaching Global Health by Peter Brown and Svea Closser

Announcing a new reader/textbook for people teaching Global Health. Foundations of Global Health: An Interdisciplinary Reader by Peter Brown and Svea Closser (March, 2018) now available from Oxford University Press.

It is easy to order an examination copy with the orange button at https://global.oup.com/ushe/product/foundations-of-global-health-9780190647940?cc=us&lang=en& . This hybrid book contain 49 articles with introductions and discussion questions, as well as extensive pedagogical materials called “conceptual tools,” web resources, and case studies https://arc2.oup-arc.com/access/brown-closser . The readings were selected for undergraduate students for their accessibility. There is an emphasis in the readings of background issues from History and Medical Anthropology rather than premature professional training in Public Health. The OUP editor suggested that anyone planning to teach such a course in the future request an examination copy.

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Emerging Voices for Global Health

CAGH member Priscilla Magrath shares a training opportunity that may be of interest:

We would like to bring to your attention the recently issued call for EV4GH2018 venture, linked to the 5th Global Symposium on Health Systems Research scheduled to be held in Liverpool in 2018.

The Emerging Voices for Global Health (EV4GH) is an innovative multi-partner blended training program that includes face-to- face training and virtual training components, for young, promising, and emerging health policy & systems researchers, decision-makers and other health system professionals with an interest in becoming influential global health voices and/or local change makers, particularly in LMIC. Five successful EV ventures have been conducted so far linked to major global health symposia and conferences in 2010, 2012, 2013, 2014, 2016 with over 232 alumni from 54 countries.

This year, there will be two tracks for which participants can apply to.
The first, for researchers involved in health policy and systems research,
The other aimed at other health professionals, activists, journalists with an interest in health systems & policies, decision makers or policymakers, and/or other health systems actors.

Further details about the program and application process can be found on the website – call for EV4GH2018 .

The deadline for applications is 5th March 2018. For those who are interested and fit the eligibility criteria, for the EV4GH 2018 call, we encourage you to apply soon. For those who are ineligible to apply, we hope you can spread this call in your networks, if you know someone who could be a potential EV4GH2018.
Thanks for your collaboration!

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Please fill out membership form for CAGH by Dec. 15

Dear CAGH members,

 We would like to alert you to recent changes in our membership policy and procedures for Special Interest Groups (SIGs). The Society for Medical Anthropology (SMA) supports SIGs as an important part of strengthening communication and collaboration among scholars based on topical interests. As a Special Interest Group (SIG) of the Society for Medical Anthropology (SMA), we are required to report our membership demographics to the SMA board, which helps them determine SIG status and resource allocation. In an effort to promote and streamline SIG membership, a single membership form was created.

 The form is available on October 15th through December 15th. The form is very brief and will be used to establish memberships in all the SIGs. We ask that all CAGH members who would like to be part of a SIG(s) fill out this form whether you are currently a member of a SIG(s) or not. If you do not fill out the form by December 15th, you may be removed from (or not added to) your SIG(s)’ roster.

 Please note : You do NOT need to be a member of SMA to continue your membership in CAGH. Simply indicate on the form whether you are a member of SMA or not and select the appropriate SIG(s) in which you would like to maintain membership. We are committed to keeping our membership open to those who are not members of SMA and AAA.

 You will only need to fill out this form once per year. Please direct any questions/comments to Elizabeth Wirtz <wirtz@purdue.edu>.

 You can find the form here. Or copy and paste the following into your browser: https://goo.gl/forms/QKzFrV5gpxMVkteg1

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TAS initiative “End of AIDS” published. Access it now!

The Take a Stand (TAS) initiative on the ‘End of AIDS’ is happy to announce that its TAS statement has now been published in the journal Global Public Health. This was one of several TAS initiatives coordinated by the Critical Anthropology of Global Health Special Interest Group (SIG) this past year. Nora Kenworthy, Matthew Thomann and Richard Parker co-chaired this committee and published the statement with input and feedback from many other scholars in the CAGH. It will run in a special section of the journal on the topic of the End of AIDS, but is available for online early view – and free to access through the end of November.

http://dx.doi.org/10.1080/17441692.2017.1365373

More details below.

Nora Kenworthy, Matthew Thomann & Richard Parker.  (2017). “From a global crisis to the ‘end of AIDS’: New epidemics of signification”Global Public Health, DOI: 10.1080/17441692.2017.1365373

ABSTRACT

In the past decade, discourses about AIDS have taken a remarkable, and largely unquestioned, turn. Whereas mobilisations for treatment scale-up during the 2000s were premised on perceptions of an ‘epidemic out of control’, we have repeatedly been informed in more recent years that an end to AIDS is immanent. This new discourse and its resulting policies are motivated by post-recession financial pressures, a changing field of global institutions, and shifting health and development priorities. These shifts also reflect a biomedical triumphalism in HIV prevention and treatment, whereby shorter term, privatised, technological, and ‘cost-effective’ interventions are promoted over long-term support for antiretroviral treatment. To explore these changes, we utilise Treichler’s view of AIDS as an ‘epidemic of signification’ to develop a review of ‘End of AIDS’ discourses in recent years. We use this review to investigate the political and philanthropic interests served by efforts to rebrand and re-signify the epidemic. We also hold up these discourses against the realities of treatment access in resource-poor countries, where ‘Ending AIDS’ has not heralded the end of an epidemic per se, but rather the end of external support for treatment programmes, highlighting new difficulties for sustaining treatment in this new era of the epidemic.

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The CAGH Virchow Awards are now open for submission!

The Virchow Awards are now open! Submit to the professional, graduate, and undergraduate categories. To learn more, visit: http://cagh.medanthro.net/virchow-award/.

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Open for Comments: TAS Statement on the End of AIDS

Dear CAGH Members,

The TAS Statement on the End of AIDS is looking for comments/feedback on their statement. Please send feedback by April 15, 2017 to Matthew Thomann (Matthew.Thomann@kzoo.edu), Richard Parker (rgp11@cumc.columbia.edu) or Nora Kenworthy (njk8@uw.edu). Please find the full draft below or download the Word doc here: https://drive.google.com/open?id=0B2GzTtH-fmWed09XMjZWYmJBRG8

——-
From a Global Crisis to the “End of Aids”: New Epidemics of Signification

Nora J. Kenworthy (University of Washington, Bothell), Matthew Thomann
(Kalamazoo College) and Richard G Parker (Columbia University)

Introduction

If the decade following the first Durban AIDS Conference in 2000 was marked by
discourses about an “epidemic out of control,” and a politics of emergency
that justified exceptional activism and action, the decade of AIDS responses
beginning in 2010 has been distinctly framed by declarations that an AIDS-free
generation is within our grasp, that the end of AIDS is not only possible, but
immanent, and that renewed optimism regarding an AIDS cure is justified. Crafted
in the wake of the 2008 financial crisis and honed by years of funding plateaus
and program retrenchments, the prominence of an “End of AIDS” discourse was
enshrined this past summer, first at the 2016 UNAIDS High-Level Meeting on
Ending AIDS in June, and subsequently at the International AIDS conference in
July. By the time the throngs of conference-goers were descending on Durban,
however, a forceful challenge to this discourse could be heard from academics,
activists, and commentators. Questioning the feasibility of an end to AIDS
without renewed long-term financial commitments, and highlighting the persistent
and frustrating challenges of sustaining effective treatment and prevention
programs, detractors moved to quickly unmask the appeal of this new campaign.
“Although the…strategy is carefully delineated and politically endorsed, it
is financially unsecured; and hard choices await,” writes Nana Poku (2016,
743), highlighting the urgency of a “strategic reckoning of expanding needs
and diminishing means.”
Yet triumphalist discourses about the End of AIDS show considerable durability,
particularly among the larger donors and organizations dominating the
policymaking field. In one video promotion created by Nike and (PRODUCT)RED, an
imagined end of AIDS is brought about by the purchase of goods related to
Nike’s “lace up and save lives” campaign, and a resulting storm of tweets
by celebrities and sports stars (ONE 2011). These then transform into ARVs and
fits of solidarity spreading across the globe, culminating in an imagined future
in which African schoolchildren are being taught the history of a disease that
once was, but is no longer, in existence. Though heavily commercial in its
messaging, Nike’s ad helps to expose a broader set of strikingly similar
discursive frames through which the futures of AIDS are imagined and its ends
are envisioned. These discursive frames include a focus on technological,
short-term interventions, an embrace of social media messaging and slogans as
measures of implementation, and a general avoidance of discussions about
long-term financial commitments by donors to comprehensive treatment, health
systems building, and patient-centered prevention modalities.
In this Take a Stand statement, we highlight the contested social terrain
surrounding the End of AIDS discourse by utilizing Treichler’s (1987) view of
AIDS as an “epidemic of signification.” What, we ask, does the End of AIDS
signify, and for whom? Who stands to benefit from a triumphalism that few
believe but many endorse? And most importantly, what kinds of AIDS response does
this discourse promote, and what forms of knowledge is it rooted in? As we will
argue below, the irony of this discourse is that, though intended to elicit
further commitments to the HIV/AIDS fight, it may instead elicit a complacency
among donors, who, as El-Sadr and colleagues (2014, 166) write, may perceive it
as “minimizing the challenges that remain.” It may thus provide a timely
exit strategy for donors fatigued by the long-term, hard work necessary to
feasibly make inroads against AIDS. As a result, the “End of AIDS” may
likely herald – and justify – two notable shifts in HIV policy: first, the
tapering of donor support for long-term treatment; and second, a pronounced
embrace of technical, short-term interventions–a “biomedical turn” that has
significant impacts on civil society, health systems, and the real futures of
the epidemic.

Discursive histories and the “End of AIDS” narrative

Nearly 30 years have now passed since Paula Treichler (1987) originally argued
that AIDS could be understood as “an epidemic of signification.”  She
emphasized that in AIDS, “meanings are overwhelming in their sheer volume and
often explicitly linked to extreme political agendas” (39). Precisely because
of this, she argued, “[w]e need an epidemiology of signification – a
comprehensive mapping and analysis of these multiple meanings – to form the
basis for official definition that will in turn constitute the policies,
regulations, rules, and practices that will govern our behavior for some time to
come.”  Writing from an explicitly activist perspective, she stressed that
“what AIDS signifies must be democratically determined:  we cannot afford to
let scientists or any other group of experts dismiss our meanings as
‘misconceptions’ and our alternative views as noise that interferes with the
pure processes of scientific inquiry” (39).  Now more than ever, Treichler’s
arguments ring true as we reflect critically on the discursive construction of
the “End of AIDS” narrative in recent years – and on the ways in which
this narrative has shaped policies and practices that constitute the response to
HIV mid-way through the fourth decade of the epidemic.
In examining the discursive history of the epidemic (and its relation to
material practices) over roughly the past decade, we can highlight a number of
key trends and events leading to the End of AIDS moment.  For example, just
shortly before 2007-8 financial crisis, we began to see important shifts towards
new modalities of prevention and treatment that in retrospect led to a massive
re-biomedicalization of the epidemic.  As a result of the financial crisis, a
series of important donor withdrawals marked the beginning of a shift from
“scale-up” to “scale-down” that is increasingly visible today.  In the
wake of this shift, donors’ fear of long-term treatment commitments, and of
the resource-intensive work to ensure treatment/prevention success, took form in
new discourses of sustainability, accountability, and country ownership, which
served as both prelude and justification for scale-down.  PEPFAR, and similar
agencies, redirected aid from earlier priorities (the “general” population
and treatment scale-up) towards a new set of targets (“key” populations and
biomedical prevention technologies and techniques). Simultaneously, the
financial crisis initiated a reassessment of donor commitments that would later
become visible in the failure to fully fund the Global Fund and other aid
shortages (Kates 2016).
The politics of shifting priorities and slogans in the definition of HIV
response strategies is hardly new.  It is important to remember that just prior
to the emergence of End of AIDS discourses, the so-called “AIDS Backlash”
was in full swing. Many in the global AIDS industry had become champions of
“health system strengthening” as a way of defending their funding streams
and averting attacks on scale-up as a vertical undertaking.  But it is
nonetheless striking to see how health system strengthening began to give way to
talk of Ending AIDS as we moved from the third decade of the epidemic into the
fourth.  Perhaps most vividly evident in UNAIDS’ battle to stay relevant, talk
of “crisis” shifted towards “winning the battle.”  Something resembling
what would later become the End of AIDS began to be constructed, for example, in
a 2010 UNAIDS document that first announced its 2011-2016 “getting to zero”
strategy (zero new infections, zero AIDS-related deaths and zero
discrimination).  That strategy, formally adopted by the UN General Assembly in
its 2011 UNGASS declaration, set a goal of getting to 50% (on the road to zero)
by 2015. The UNAIDS Fast Track Strategy, with the goal of 90-90-90 (90% of
people with HIV diagnosed, 90% of diagnosed people on treatment and 90% of
treated people with fully suppressed viral load) by 2020, was then issued in a
2014 UNAIDS document.  To our knowledge, this is the first explicit articulation
of the goal to end AIDS by 2030.  Finally, the 2016 UN General Assembly High
Level Meeting on Ending AIDS, held in June of this year, officially adopted the
“Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the
Fight against HIV and to End the AIDS Epidemic by 2030.”  So while the concept
of ending the epidemic began to be floated by global AIDS administrators as
early as 2010, it then took roughly five years of sloganeering and issuing lower
level UN documents to gradually get to the point where it would become an
official policy declaration adopted by the General Assembly.
Not wanting to be left out of the game, over roughly the same time period, the
US State Department also developed its own version of this goal, most clearly
articulated in Hillary Clinton’s 2011 speech (as US Secretary of State) at the
NIH, which initiated the US/PEPFAR push for “an AIDS-free generation.” This
goal quickly became the official discourse for President Obama and other US
officials, and an organizing call for the 2012 International AIDS Conference in
Washington, D.C.
The majority of other major donor agencies then began to endorse the UNAIDS Fast
Track Strategy starting in 2014.  As soon as the Fast Track Strategy was issued
(basking in the “success story” that had been told by the global scientific
community at the Melbourne AIDS conference in July of 2014), we find other major
players (the Global Fund, USAID, etc.) issuing statements that articulate “the
end of AIDS in 2030” goal, and at some level begin to turn it into a fait
accompli (at least in theory).  Private donors seemed slower, but by 2015 and
2016, we begin to have private donor buy-in (for example, people like David
Furnish made statements about it for the Elton John AIDS Foundation), and civil
society organizations rallying around the slogan (for example, UNAIDS sponsored
a large CSO meeting in Bangkok in 2015 where the clear goal was to get everyone
to sign on to the “90-90-90 by 2020” and “the end of AIDS by 2030”
goals).  Perhaps somewhat ironically, all this was happening at precisely the
same time as the elaboration of the post-2015 development goals, in which HIV
largely fell from the list of primary development concerns.

The biomedical turn and its impacts

All of these events of course develop in tandem with what might be described as
a “biomedical turn”:  an increasingly powerful biomedical triumphalism
regarding HIV treatment and prevention, whereby shorter-term, privatized,
technological, and, at least in some instances, (allegedly) more cost-effective
interventions are promoted, to the deficit of long-term support for lifetime
antiretroviral treatment.  This trend obviously moves in multiple directions at
the same time, ranging from large-scale biomedical prevention research trials
(such as the $45M iPREX studies) to the IAS Towards an HIV Cure Initiative
(championed by Françoise Barré-Sinoussi as well as many others).  But in all
of these directions, biomedical advances, in turn, become the “scientific”
justification for an End of AIDS discourse that has been articulated by public
health experts and policymakers. They play a key role in ensuring that the
biomedical community will endorse the End of AIDS story line, just as they
substantiate, with scientific validity, the feasibility of the policymakers’
claim that we really can end the epidemic by 2030.  These narratives thus become
key sources of mutual reinforcement that sustain a vision of the End of AIDS
that brings together policy-making, diplomacy, program implementation and
science in the transformation (or assemblage) of the End of AIDS narrative.
Defining what “Ending AIDS” will entail in practice has elicited a powerful
chorus of voices defending not one, but many, heavily biomedical programmatic
initiatives: from treatment as prevention (TasP) and test and treat initiatives,
to pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), to
microbicides, and to renewed enthusiasm about vaccine and HIV cure research.
These biomedical strategies are based in declarations of faith in the powers of
bench science, big data, population targeting, implementation science, and
“smart investments” (Fauci and Marston 2013; PEPFAR 2012). Such initiatives
encrypt and occlude a neoliberal policy agenda that favors cutting costs
(particularly long-term financial commitments) by limiting broad-based scale-up
efforts and instead promoting targeted prevention and solely biomedical
treatment expansion as a means of halting the epidemic. Even as treatment
expansion has fallen far short of its goals, and patients are routinely lost to
follow-up because of the socioeconomic challenges that remain unacknowledged by
such an approach, donors and experts are doubling-down on a biomedical turn.
“Rather than seizing [the opportunity for reduced transmission and better
illness management created by treatment expansion] by demedicalizing the
provision of ART,” argues MSF’s Tom Ellman (2015, 304), “programs are
medicalizing HIV infection in the healthy.”
What is then ironic is that the End of AIDS discourse has managed to discredit
and open the door to de-funding the very interventions and investments that have
the potential to make treatment and prevention more successful. This includes
interventions rooted in health systems strengthening, community-based provision,
and an embrace of the right to health, as well as those which attend to the
broader social inequities and socioeconomic constraints that threaten the
success of solely biomedical interventions. The recent decade of increasingly
technocratic scale-ups of HIV treatment has left a legacy across many health
systems of defunded community-based care and prevention projects (Kalofonos
2014; Maes & Kalofonos 2013), overworked and overburdened health systems
(Pfeiffer & Chapman 2015; Pfeiffer et al. 2014), and increasingly fragmented and
disjointed landscapes of care (Geissler 2014; Moyer 2015; Whyte 2014).
In addition to these general and much-remarked upon trends, we wish to note
three crucial but under-examined impacts. The first is the especially perverse
impact of the biomedical turn on activism, whereby the far-reaching rights-based
dialogues of previous decades become distilled into a narrow focus on the right
to (biomedical) treatment, as access to rights-based prevention modalities,
structural interventions, and broad-based socio-economic support fall by the
wayside. The second impact, much related to the first, is the
institutionalization of a two-tiered system of treatment access. While access to
first-line treatments was ensured by earlier activist movements, many patients
in poorer countries today only retain access to the cheapest and most toxic drug
cocktails, a second-class first-line of treatments that fosters far more
side-effects. In turn, these are harder to address within depleted health
systems and more likely to result in treatment disruptions. Meanwhile, access to
second-line treatments and consistent viral-load monitoring is extremely
fragile. These trends point to the dual effects of an increasingly neutralized
and side-lined AIDS activism combined with the power of the pharmaceutical
industry, which has continued to wage battles around intellectual property,
trade, and pricing schemes while fueling End of AIDS discourses.
Finally, an acute environment of fiscal austerity following the 2008 financial
crisis, combined with the additional demands placed on health systems by uneven
and overly biomedical methods of HIV program scale-up, has produced a depleted,
overworked, and increasingly disillusioned health workforce in many countries.
Within underfunded health systems, mid-level policymakers and clinicians are
essential to keeping the basic machinery running and ensuring more broad-based
health system improvements. Combined with these other constraints and pressures,
the production of ever-more unrealistic public health policies related to Ending
AIDS (such as Lesotho’s claim to be implementing universal access to treatment
while less than 50% of its existing population in need of treatment has access
to it), produces dystopian health systems in which patients’ disruption or
“failure” on treatment is nearly ensured, while bureaucratic fantasies are
peddled at international meetings and summits.

Alternative futures?

It seems clear (at least to anyone with a minimally critical view), that the end
of AIDS is not around the corner, and that a future with AIDS will be with us
for some time to come. But we can help contribute to a better understanding of
these policies’ impacts as well as their alternatives.  We can also help to
call failed policies into question by documenting them, unmasking the
mystifications that are contained in the fictions being created about them, and
witnessing their real impact in the lives of people on the ground.  This is a
contribution that the anthropology of AIDS has been making since the very
beginning of the epidemic, and it is as relevant today as it ever was (Moyer
2015).  In closing, it is worth emphasizing some of the ways in which
anthropological research and analysis can build on this legacy and contribute to
the broader field of HIV research in the fourth decade of the epidemic.
Examples abound, but we offer a few for consideration:  anthropologists can link
analysis of policy/discourse with realities in geopolitically specific places,
revealing disjunctures and opportunities; we can continue documenting (through
careful, long-term ethnographic research) the experience of human suffering that
takes place at the grassroots, far from the meeting rooms of Geneva, New York
and Washington; we can reveal how populations – patients, clinicians, service
providers, policymakers, activists – are coping with AIDS, not as it ends, but
as it continues to unfold and evolve; and we can use ethnographic approaches to
call attention to the forms of community-based expertise that exist (albeit in
different ways and to different degrees) in affected communities everywhere
(remember who invented safe sex and harm reduction!) and ask how
re-biomedicalization of the epidemic undermines the promise of these local forms
of knowledge.  Real-world expertise still resides in the hands of affected
communities, and careful, long-term anthropological fieldwork can document this
like perhaps no other approach can.  We can also do a much better job than we
have thus far of studying up, and investigating the global health and AIDS
industries, the ways in which they operate, and the interests that they tend to
serve.  We can also do a better job of linking studying up to studying down,
drawing attention to the kinds of political mobilization and resistance that are
still possible to observe in some places in response to these industries.
This list could of course extend much further, but let us end by emphasizing the
importance of anthropology’s long-term focus on the dialectical relationship
between both continuity and change:  while there are striking similarities here
over time in the histories of signification that we have briefly analyzed here
(just think about the persistence of AIDS-related stigma and discrimination),
there is also remarkable evidence of affected communities’ ability to reinvent
themselves, even in the face of immense structural constraints.  Anthropological
research may be better able to document this than almost any other discipline
– but only if it remains critical, reflexive, and politically engaged.  This
is a project that is worth taking on.

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