|Authors :||Vanessa Noble, David William Cohen|
|Publication info:||Ann Arbor, Michigan: MPublishing, University of Michigan Library
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no. ns 2, June 2005
Ph.D. student in History and Women's Studies, University of Michigan
Professor of History and Anthropology, University of Michigan
David William Cohen:
In May, 2004, I had the opportunity to spend a few weeks in South Africa. The purposes of the trip were, first, to meet up with several University of Michigan Ph.D. students who were at the time in various stages of doctoral research in South Africa; and, second, to visit with several dear colleagues and former students. It should not surprise anyone familiar with contemporary South Africa that wherever I went in South Africa I was drawn deeply and thickly into the experience, the stories, and the struggles of a country facing, and facing up to, the simply enormous challenge of HIV/AIDS. Even in the relatively brief time I was in Durban, funerals marked the passing, from AIDS, of friends and relatives of students with whom I had worked closely. Colleagues in the University of KwaZulu-Natal faculty were attempting to support students, the progression of whose illness was disrupting and even ending their studies. University staff were equipped and trained to deal with certain contingencies and emergencies as if they were extensions of a public hospital. On the way to the airport to begin traveling back to the United States, the radio carried a report that Durban's cemeteries were shortly to have no further space for burials.
What I also found striking in May 2004 was the degree of engagement of almost everyone I met in some initiative, collective, institutional, and individual project to provide support directly for those infected and to promote important interventions into the raging force of the epidemic, from biomedical research to mother-and-child health to social services to hospice care. While there were certainly histories of tension and competition among organizations and services to be written, one HIV/AIDS project seemed to fold easily into another on a broad front of cooperation among organizations, activists, medical staff, and patients. What seemed especially remarkable was the very intensity of engagement with HIV and AIDS ... but one could equally be moved by the ways that organizational innovation was directed toward the continuing generation, through the grassroots encouragement and training, of new cadres of health activists and service people—many being those infected—to provide support beyond what hospitals and formally trained health practitioners could offer ... and beyond what a national government was then prepared to offer.
These observations that I carried back to the United States led in two directions. First, I was taken back in time to a first South African visit in August-September 1992. At the time I was a faculty member at Northwestern University—Director of the Program of African Studies—working with Professor Caroline Bledsoe, Department of Anthropology, Northwestern, and Ibitola Pearce, then of the Department of Sociology, Obafemi Awolowo University, Ile-Ife, Nigeria, to organize a several month Institute on Health and Demography, the specific topic to be "the politics of reproduction and fertility control". We were interested in bringing "attention to how subjects of population programs respond to injunctions relating to reproduction and reproductive health and how domestic reproductive practices and strategies are organized." I was in South Africa in 1992 to learn about debates, initiatives, and research in southern Africa on questions of population growth, fertility regulation, and especially to explore the assumptions underlying the supposed relationship between development and fertility control. I was also there to encourage researchers, activists, and health practitioners to consider applying to the nine week institute in Evanston. For a report of the 1993 project at Evanston, see the text in the present collection.
In the 1992 visit, HIV/AIDS was raised as a challenge in 7 of 27 engagements that I participated in; HIV/AIDS had a presence but was not a central topic of conversation. In comparison with 2004 there was only one individual with whom I met who acknowledged HIV infection but even this person gave stress to other subjects of concern. Questions of reproductive health, fertility control, and sexuality tended to rotate around concerns for claims for women's rights, and also gay rights, in a society in transition ... and also around opening the way for persons of color to participate fully in the health professions and in decisions regarding the refiguring of national health services in South Africa. In my 2004 visit, these attentions were not off the screen; however, the extraordinary engagement with HIV/AIDS was overwhelming.
In one sense, I did not need to travel to South Africa to recognize the intensification of attention to HIV/AIDS. From the late 1990s, I have found that virtually every University of Michigan undergraduate who participated in my courses (and many coming to be for independent studies) wanted to do a research paper or special project on HIV/AIDS in South Africa. Some traveled to South Africa, particularly KwaZulu-Natal to work on HIV/AIDS. I suspect that historians in the future will reckon that President Mbeki's astonishing ruminations and declarations on HIV and AIDS paradoxically stirred people all over the world to learn more, engage more, in this critical story unfolding in South Africa. But then these historians will have to work through the implications and meanings of the vast losses to our world, which seem so magnified in the light of the Mbeki government's resistance and hesitations to confronting the crisis in its midst. Catherine Burns article in this collection points to the tragic end-life of one university student, "T.S.", 1977-2003; Liz McGregor's obituary of Phaswane Mpe, 1970-2004, reminds one of the remarkable literary work that was defining an affecting and inflicted world somehow in the shadows of a celebrated political transition (see Mpe's novel Welcome to Our Hillbrow 2001 — http://www.unpress.co.za/book.php?action=displaybook&conf%5Bbookid%5D=162 and http://www2.univ-reunion.fr/~ageof/text/74c21e88-610.html —). Mpe's Hillbrow is a world in which HIV/AIDS is engaging all. In her Guardian obituary, McGregor cannot name the cause of Phaswane Mpe's death yet she cannot separate his life, his works, his promise, and his death from the epidemic. [See also http://www.litnet.co.za/inmemoriam/to_phaswane.asp ]. Phaswane Mpe's death on December 12, 2004, also reminds us of the moment in which we began our work on this compilation.
The 2004 observations led in a second direction and this has been to consider the values of disseminating a broad range of recent writings engaging the HIV/AIDS challenge for South Africa, writings that themselves reflect in depth and diversity the extraordinary commitment of South Africans, individually and collectively, to address the widest range of challenges of HIV/AIDS in all its registers of effect. The recently revitalized web-based journal passages offered an especially accessible venue for the compilation, publication, and dissemination of these writings. Vanessa Noble, completing a Ph.D. in History and Women's Studies at the University of Michigan, has generously agreed to serve as a guest editor of passages | http://quod.lib.umich.edu/p/passages/ns 2 for this collection. 
I was one of the doctoral students David visited in South Africa in 2004. I had been away from the University of Michigan for two years conducting the research for my dissertation in South Africa and was affiliated to the University of KwaZulu-Natal. However, this wasn't my first experience there. I was an undergraduate and graduate student at the University of Natal (known as the University of KwaZulu-Natal since 2004) during the mid- to late-1990s - in the university, and in the province that was quickly becoming the epicenter of the HIV/AIDS pandemic. When I started at the University of Natal in 1994, I was amongst the first generation of university students who started their tertiary education in the year of South Africa's first democratic elections. I remember feeling very privileged to be at university and to experience, really for the first time, being in a multi-racial student environment. And I remember the many debates that were taking place at the university level and national level about the enormous political, economic and social restructuring changes and resistances that were taking place in wider South African society, the demographic staff and student changes at various educational levels, and the early national debates taking place in the new government about how to deal with the growing HIV/Aids threat.
When I left the University of Natal in 1999 to start my graduate studies at the University of Michigan, I remember that while the Treatment Action Campaign (TAC) had just begun its work (see Mandisa Mbali's paper) and that national level debate was heating up on the issue, it was something "out there", away from the University and my student colleagues there. I don't remember my "home" history department, or its faculty, being heavily involved in assisting - financially or emotionally - students and/or staff at the University affected or infected by HIV/AIDS. When I left South Africa, I followed the news stories online as the devastating pandemic ravished the lives of thousands of men, women and children, at every level of South African society, every day, every week, every month. And I remember discussions with a few students in America, when some asked me why I wanted to go back to South Africa when so many people were dying of AIDS. To many, living in HIV/AIDS ravished South Africa seemed like a situation to awful to consider. To me, South Africa is my home.
The scenario was very different when I returned to conduct my Ph.D. research in South Africa between 2002 and 2004. I distinctly recall noticing the increased level of involvement and activism of faculty and students in my old history department as well as at the University of KZN more generally. There were distinct attempts to distribute free condoms to students, the University clinic was promoting and advertising its medical and counseling services to students and staff affected or infected by HIV/AIDS, the University started a ART plan for students and staff infected with the virus, and there were many public lectures given by people such as Judge Edwin Cameron and TAC leader Zachie Achmat of their personal experiences of being HIV+, as well as their activist experiences of trying to get the government to roll out ART drugs to the masses of people suffering from HIV/AIDS. Many of the faculty members in my old history department were actively engaged in raising awareness of the disease, and assisting their students and other University staff - both emotionally and financially - with coping with the disease. The student and faculty level of awareness of the etiology, prevention and treatment of the disease was far more advanced then when I left in 1999. We all knew at least one person that was HIV infected or had already died from AIDS related diseases. The spiraling nature of the growing impact of the HIV virus was enormous.
During David's visit to South Africa in May 2004, I was frantically trying to get the last of my research and interviews done before returning to America in August 2004. I was researching the historical experiences of black (African, Indian and Coloured) medical doctors who were trained in South Africa - particularly at the University of Natal Medical School - during the apartheid period. While conducting my interviews with a number of different ex-students of the school, many of whom are now faculty members at their Alma Mater, the issue of the effect of HIV/AIDS on their lives and work kept being raised. The widespread effects of HIV/AIDS on the patients at the King Edward Hospital (one of the teaching hospitals attached to the Durban medical school) was a central concern for Prof. Jerry Coovadia. He is now the Professor of HIV/AIDS research in the newly opened Doris Duke Medical Research Institute (opened in July 2003), which was built on the premises of the Durban medical school to provide quality research laboratories and expanded opportunities to train HIV/AIDS clinical researchers. Prof. Coovadia, speaking about the devastating effects of apartheid and later HIV/AIDS on doctors and medical students working at the King Edward Hospital, asserted in a 2003 interview with me:
"If you work in outpatients ... and you s[ee] 80 patients, I mean what is left of you? You are totally brutalized. ... at the end of the day ... [there is] no generosity or humanity left in you. ... So it weighs you down. ... And if that isn't bad enough the AIDS epidemic comes in and ... eliminates any trace of humanity that existed. Because now you see ... all the problems magnify and then you can't do much for them. At least previously you could do something. Now you know for heaven's sake if we had a programme which prevented this infection ... and even if they are infected ... there's treatment available and you can't give them this treatment, which is just terrible!"
For many of the present faculty at the Durban medical school, the effects of the huge numbers of patients they see daily in their teaching hospitals is overwhelming and to most disheartening, as despite their best efforts they feel that they cannot make the needed impact to improve the lives of thousands of their patients dying of AIDS. This is because there isn't a cure and because government sponsored ART plans have been slow to develop.
I was also interested to speak to present day medical students at this medical school, to see whether the HIV/AIDS pandemic had altered their thoughts about their medical training and future career choices. During the middle of July 2004 I was able to interview a few medical students who are presently in the last stages of their medical degrees. This is what three of them told me:
BH: "... if you ask half of the first years ... one of the things they want to do ... is find a cure for AIDS. It's actually attracting them into the fraternity you know. And of course, for the first years, reality kicks in - and there's no fighting AIDS, it's just wanting to get your degree you know".
AM: "Even the nurses [are] leaving the country because of the extra workload, not only because they are not getting enough money but [because] the impact of HIV is such that their workload has doubled. So you find yourself in the health system where the budget is not enough but the human resources also [are not enough], because you are training but the more you train the more people leave the country. ... about 20% of our graduates, even if they don't leave to go overseas, will not practice medicine because of exactly what you see in the ward. You came to medical school thinking you know here I am going to train as a doctor and I'm going to help people. But when you see people d[ying], day in [and] day out and there isn't anything you can do about it ... At the emotional level ... it's devastating ... because you see young people basically withering away ... It's all good and nice for people to talk about HIV ... [talk about] the numbers, [but when you see] the[ir] faces, that's when it really hits you most. I think it's a very ... sad story."
NM: "HIV has shifted the focus in medicine because whether you are in Gynaecology, ... Medicine, Paediatrics, Psychiatry, Emergency Medicine, you always think of HIV/Aids and you find that every second patient you get to see in the labour ward is HIV positive. ... And that affects your career decision for some of us. For instance ... I can't see myself working all my life as a clinician ... because it's hard to go there ... everyday you see people dying in front of you ... the reason HIV ... [and] we are trying everything, doing your best, using a lot of resources but the person at the end of the day is going to die."
While these students very powerfully relayed the negative consequences on their emotions, and for a few on their career choices, they also told me that there is much constructive and productive energy being pumped into HIV/AIDS research and teaching at the medical school:
NM: "[HIV/AIDS] has shifted ... the focus of medicine, the research. Everyone is doing HIV [research] ... And even with ... this faculty, they want to form a speciality that will deal with HIV medicine ... [and train] specialists on HIV. ... we [also] have a big research centre that side. Everyone there, whether it's biomedical scientists, they are also researching on HIV, whether it's Paediatricians - HIV. Everyone - HIV. ... It has shifted medicine's focus".
For this new generation of student doctors-in-the-making (who actually remain in the medical profession), much of their work will be focused on researching, treating and preventing HIV/AIDS in South Africa. With such enormous odds stacked against them - as at present there is no cure and without the necessary level of government ART support in many instances - they together with their nursing and other health worker colleagues are the beleaguered frontline biomedical health care providers for South Africa's HIV infected post-apartheid citizens. While the post-apartheid "struggles" of the students and faculty at the Durban medical school are different from the legendary anti-apartheid "struggles" of their apartheid generation predecessors, the medical school's present attempts to train, research and provide ART treatment for all their patients is no less worthy. Their "struggles" are against a new enemy - HIV/AIDS - and against a new government with an inadequate ART roll-out plan.
With this history in mind, when David asked me if I would be interested in being a guest editor for this No. 2 edition of the online version of passages, which would focus on HIV/AIDS in KwaZulu-Natal South Africa, I was excited about the opportunity. Since one of the primary objectives of the publication of passages | http://quod.lib.umich.edu/p/passages/is to provide the circulation of ideas, knowledge, and research in various stages of production and by different people on different continents, in both academic and non-academic spaces, I thought it would be appropriate to try to retrace the HIV/AIDS network of transatlantic contacts and connections - i.e. some of the students, academic colleagues, doctors, nurses, and researchers - that David made during his 2004 trip to South Africa. Since I knew many of these contacts already through my own undergraduate and research work at the University of KwaZulu-Natal, I was able to converse with many of these people via email to see whether they'd be interested in submitting pieces of their work on HIV/AIDS in South Africa to our journal. Further contacts were made with researchers working on this subject in the USA too. Many people generously submitted astute and exciting pieces of their research work, while others submitted deeply personal reflection pieces. The genuine interest that has been shown to our project over the past few months is greatly appreciated.
Without denying the enormously negative effects of HIV/AIDS in South Africa, which comes through very clearly in many of the submissions in this journal, in other ways this issue of passages | http://quod.lib.umich.edu/p/passages/also serves to highlight and even celebrate the multi-layered struggles and debates that have continued to take place in South Africa and abroad despite often overwhelming obstacles. Various individuals and institutions in South Africa - at the local, provincial and national levels - have continued to challenge, question and critique those powerful players - such as the Department of Health, the pharmaceutical companies and others - that have hindered early development of preventive programs and continue to obstruct access to treatment of all suffers of HIV/AIDS (see articles by Ahmed Bawa and Mandisa Mbali). It is important to recognize that there are many committed activists, health practitioners, academics, politicians, teachers, social workers etc working daily to improve the present situation for millions of HIV/AIDS sufferers and their support networks. People in South Africa haven't simply given up in the face of this monstrous epidemic. The assemblage of different works on the subject included here aim to highlight some of the great work being done by individuals, in their different spheres of work, to rethink and approach in new ways, the complicated social and biomedical dimensions of this pandemic. This is especially evident in the submissions by: Janet Giddy on Sinikithemba HIV/AIDS clinic work at McCord Hospital in Durban, Mbongiseni Buthelezi and Christopher Hurst on the innovative HIV/AIDS educational prison theatre work being done by University of KZN drama students, Emma Durden and Dominique Nduhura on HIV/AIDS educational work amongst workers in a factory in Durban, Zanele Mchunu and Eleanor Preston-Whyte on AIDS orphans and their income-generating schemes in rural KZN, Philippe Denis on AIDS orphan "memory box" work, and by Nesha Haniff on student empowerment workshops in different South African townships. The deeply personal and very moving autobiographical accounts by HIV+ people such as Judge Edwin Cameron and TAC activist Sindi Mbandlwa also highlight the incredible determination of South African HIV+ survivors, who continue to lead productive and meaningful lives, and fight for the right to life and access to treatment for all HIV+ people.
A reoccurring theme in many of the submissions is the link between stigma or silences, HIV/AIDS infection, prevention and patient acceptance of ART treatment programs. As during the 1980s and 1990s when issues of stigma and thus silences around a person's HIV/AIDS status was a central issue (see Mandisa Mbali's and Edwin Cameron's pieces), silences continue to shape the present post-apartheid HIV/AIDS situation. The reflection piece by Catherine Burns highlights in a very poignant way the enormous silences and stigma that is still associated with HIV/AIDS sufferers, even amongst the most highly educated university students. Her piece together with Adam Ashforth and Mxolisi Mchunu's articles seek to reassess, rethink and grapple in different ways with deeply rooted social and cultural ideas that have influenced how people speak about the disease (or not), silencing around disclosure of a person's HIV+ status, the influence on the success or failure of preventive or educational programs, and more importantly, the (un)willingness to even accept ART treatment programs. According to these authors, failure to take account of these social and cultural issues will ensure the failure of HIV/AIDS preventive and treatment approaches. Other scholars - such as Mark Hunter, Suzanne Leclerc-Madlala and Mxolisi Mchunu - also make very strong cases for the need to take account of the gendered nature of this epidemic and gendered inequalities in South Africa if more successful outcomes are to be achieved. Importantly, these pieces call for a new analysis of gendered power inequalities, to focus on the masculine gendered identities of different men in South Africa. It is this new focus - away from the predominant attempts thus far to educate women (who are often socially and economically the subordinate partners in sexual relationships with men) about HIV/AIDS in preventive work. These new studies on masculinity will hopefully have a positive impact on new HIV/AIDS preventive and treatment programs.
We have also included some resources for people interested in, and for those teaching about, HIV/AIDS. We have included a list of the most recent books published during the last three years on HIV/AIDS in South Africa. There is also a very useful film list, compiled by Lucia Saks in the Department of Film and Video studies at the University of Michigan, which includes films made around the topic of South Africa and HIV/AIDS. We have tried to include a diverse range of material in this HIV/AIDS edition of passages. Like the meaning of the word "a passage", we hope your journey or migration through this edition will inspire and challenge you and lead to the creation of new ideas and writings, awareness, conversations and practical approaches to addressing and dealing with HIV/AIDS issues in South Africa.
Vanessa Noble is currently completing her Ph.D. in the Joint Program of History and Women's Studies at the University of Michigan in Ann Arbor. She obtained her master's degree in history at the University of Natal in Durban, South Africa in 1999. Her present research focuses on the social and political history of black medical students in South Africa (particularly those trained at the University of Natal Medical School) during the apartheid period.
David William Cohen is Lemuel A. Johnson Collegiate Professor of African Anthropology and History and Director of the Doctoral Program in Anthropology and History. He was a member of the faculty of The Johns Hopkins University from 1968 to 1989. From 1989-1993 he was Director of the Program of African Studies at Northwestern University, where he founded the Institute for Advanced Study and Research in the African Humanities and the journal Passages. He joined the Michigan faculty in 1993 as founding Director of the International Institute. Among his publications are a trilogy authored with E. S. Atieno Odhiambo: Siaya: A Historical Anthropology of an African Landscape (1989), Burying S.M.: The Politics of Knowledge and the Sociology of Power in Africa (1992), and The Risks of Knowledge: Investigations into the Death of the Hon. Minister John Robert Ouko in Kenya, 1990 (2004).
1. I am most grateful for Ben Cohen's facilitation of some of the contacts and some of the invitations to prospective contributors to this collection. Now based in Cleveland, Ohio, where he an attorney working on death penalty appeals, Ben worked at the AIDS Law Project at the Wits Law School in 1996 and 1997.
passages | http://quod.lib.umich.edu/p/passages/