Adia Benton

HIV Exceptionalism: Development through Disease in Sierra Leone

Contents Preface Introduction: HIV Exceptionalism in Sierra Leone: Christianas Story Part I. The Exceptional Life of HIV in Sierra Leone 1. The HIV Industry in Postwar Sierra Leone 2. Exceptional Life, Exceptional Suffering: Enumerating HIVs Truths Part II. Becoming HIV-Positive 3. The Imperative to Talk: Disclosure and Its Preoccupations 4. Positive Living: Hierarchies of Visibility, Vulnerability, and Self-Reliance Part III. HIV and Governance 5. For Love of Country: Model Citizens, Good Governance, and the Nationalization of HIV Conclusion: The Future of HIV Exceptionalism Acknowledgments Notes Bibliography Index

Enumeration, identity, and health.

Although the production of national spaces, citizens, and populations through enumerative practices has been well explored in a variety of disciplines, anthropological methods and analysis can help to illuminate the everyday practices of enumeration, their unexpected consequences, and the co-construction of identities through these processes by both the “counted” and the “counters.” The authors in this special issue illustrate how enumeration inflects lived experiences, produces subjectivities, and reconfigures governance. Focusing on the spatial, temporal, ideological, and affective dimensions of the techniques of enumeration, the authors also provide insights into the multiple forms of biopolitical expertise and knowledge that accumulate legitimacy through numerical discourse. They also highlight the ways in which governing structures, institutional and cultural norms, market logics, and rational–technical interventions influence the relationship among numerical categories, subjectivity, and everyday experience.

Exceptional Suffering? Enumeration and Vernacular Accounting in the HIV-Positive Experience

Drawing on 17 months of ethnographic fieldwork in Freetown, Sierra Leone, I highlight the recursive relationship between Sierra Leone as an exemplary setting and HIV as an exceptional disease. Through this relationship, I examine how HIV-positive individuals rely on both enumerative knowledge (seroprevalence rates) and vernacular accounting (NGO narratives of vulnerability) to communicate the uniqueness of their experience as HIV sufferers and to demarcate the boundaries of their status. Various observers’ enumerative and vernacular accounts of Sierra Leones decade-long civil conflict, coupled with global health accounts of HIV as exceptional, reveal the calculus of power through which global health projects operate. The contradictions between the exemplary and the exceptional—and the accompanying tension between quantitative and qualitative facts—are mutually constituted in performances and claims made by HIV-positive individuals themselves.

Temporality and Positive Living in the Age of HIV/AIDS: A Multisited Ethnography

Drawing on comparative ethnographic fieldwork conducted in urban Mozambique, the United States, and Sierra Leone, the article is broadly concerned with the globalization of temporal logics and how specific ideologies of time and temporality accompany health interventions, such as those for human immunodeficiency virus (HIV) infection and AIDS (HIV/AIDS). More specifically, we explore how HIV-positive individuals have been increasingly encouraged to pursue healthier and more fulfilling lives through a set of moral, physical, and social practices called “positive living” since the advent of antiretroviral therapies. We describe how positive living, a feature of HIV/AIDS programs throughout the world, has taken root across varied political, social, and economic contexts and how temporal rationalities, which have largely been underexamined in the HIV/AIDS literature, shape communities’ responses and interpretations of positive living. Our approach is ethnographic and comparative, with implications for how anthropologists might think about collaboration and its analytical possibilities.

African expatriates and race in the anthropology of humanitarianism

Anthropological critiques of humanitarianism in Africa emphasize the workings of power, usually along lines of cultural, class, economic, and political difference. While these critiques often mention race, they engage less explicitly with structural racism and white supremacy as intimately woven into humanitarian professional practice. Such an engagement requires looking at how structures of inequality, white supremacy among them, shape the everyday practices of humanitarianism: from recruitment and hiring practices to reception and expectations by local staff. Drawing on work experience (7 months, 2003–2004) and ethnographic data from post-conflict Sierra Leone (20 months, 2005–2007) and recent in-depth interviews with former colleagues (2012), I focus on African expatriates working in African countries in which they are not ‘native’ to re-format critical analyses that have emphasized translational or intermediary roles for African elites. I argue that African expatriates navigate multiple levels and scales in their work and operate under conditions in which assessments of their expertise, mobility and professional ‘success’ are racialized. Ultimately, I suggest that expatriate Africans operate as figures that call into question the metaphors of direction and scale implied in a discussion of studying up in Africa, while they also compel anthropologists to examine how institutions embody and reproduce inequalities.

Risky Business: Race, Nonequivalence and the Humanitarian Politics of Life

Analyses of humanitarian imagery generally highlight how images are used to mobilize empathy and collective action. Recent critical ethnographic accounts of humanitarianism have either disregarded or underplayed the role of race in the practice of humanitarianism, focusing on risk as crucial to a “humanitarian politics of life.” In this article I suggest that combining textual and visual analysis deepens the evidentiary base for claims linking race, risk and humanitarianism. I argue that heroism and humanitarianism are often conflated, and that this conflation relies on racialized perceptions of risk, in which blackness is a central mediator.

Surgical referral coordination from a first-level hospital: A prospective case study from rural Nepal

BackgroundPatients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems.MethodsWe undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization’s Health Systems Framework.ResultsWe followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US

International Political Economy and the 2014 West African Ebola Outbreak

840, which was over 1.5 times the local district’s per capita income. We identified and mapped challenges according to the World Health Organization’s Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity.ConclusionThe results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.