“But, that’s blackmail!”

Ahmed Veriava and Prishani Naidoo

In response to Ahmed Veriava, Prishani Naidoo and Ulrike Kistner’s provocative presentation on the ‘Politics of Life and Survival,’ I would like to take up the matter Ahmed and Prishani admitted is a source of contention in their own work – the politics of survival. As someone whose research is focused on the bio-politics of HIV/AIDS in post-apartheid South Africa, I greatly appreciated the way in which Ulrike make a connection between Ahmed and Prishani’s discussion of the governance of the poor (and the notion of responsible citizenship) in the context of antiretroviral (ARV) provision. For example, she mentioned that in the treatment contracts to which people must agree in order to be provided ARV medication for HIV, Ulrike mentioned 4 factors that can disqualify a candidate: too low CD4 counts, too many opportunistic infections, alcohol or drug use, or insufficient social support. In the minds of policy makers, one of the primary concerns is drug resistancy (especially given the scarcity of drug combinations available within the public sector). Therefore, those who are not able to adhere to a strict drug regimen might pose a risk to the sanctity of the ARV roll-out by introducing drug-resistant strands of the virus within already vulnerable communities. However, the implications of this ‘contract’ are wide-reaching because it does indeed draw a line between the deserving and undeserving of citizenship rights (which was a theme both Prishani and Ulrike mentioned).

However, another complicating factor in this matter is the way in which these policies are also disciplinary in nature, and quite specifically a biomedical form of disciplinary power. As João Biehl (2006) discusses, in the context of ARV provision in Brazil, a kind of ‘biomedical citizenship’ has developed, in which survival is premised on the ability (or desire) to adhere to a strict biomedical drug regimen, which includes not only a calculus of the number of pills and their timetables, but also food intake, social support, and an agreement not to engage in other forms of healing (most specifically, traditional forms of healing). But other forms of social support, including grants, are also being premised on this biomedical discipline. So, for example, there have been recent discussions about replacing the Disability Grant with a Chronic Illness Grant. One of the issues is that the disability grant, in its current administration, is only available to patients whose CD4 count is under 200 (which is not official policy, but rather, the way in which doctors draw the line). This means that ARV provision actually undermines the provision of social support (since ARVs cause one’s CD4 count to rise), forcing the poor to make ridiculous choices between income and life-saving medications. To counter such a trend, there have been recent conversations, introduced and facilitated by SANAC and the AIDS Law Project about introducing a chronic illness grant, which would not punish people (by refusing them state support) for being on ARVs, but rather require people to be on ARVs in order to receive state support. In other words, only people who are enrolled in the state’s ARV programme would be eligible for a chronic illness grant. This switches the terms of providing for the poor and makes biomedical discipline a requirement of citizenship rights.

When I explained the debates around introducing this policy to my informants (who are all HIV-positive residents of urban informal settlements), one response I received was: “but, that’s blackmail!” So, why would people think of this as blackmail, or put another way, why wouldn’t people want to willingly enroll in the state ARV program? There are several different reasons, and I’ll just name a few. First, some people subscribe so completely to a traditional healing paradigm that they don’t utilize biomedical treatment at all. My research shows that at least in urban areas, such a strict divide between using biomedical and traditional healing is quite rare – a large portion of my respondents mix the two. But the fact that doctors are telling people not to combine the two forms of treatment might keep some from enrolling in the programme. Second, people are skeptical of the public availability of ARV treatment. As one informant recently asked me, “if rich people take different drugs, then are the drugs provided for free as effective?” Others are simply scared of the side-effects. Finally, and this is very important, many are simply concerned that their everyday living conditions, which are extremely precarious in nature, make the discipline required to be on the ARV regimen extremely difficult. There are concerns about being able to take the drugs at the same time every day for the rest of one’s life, but also about accessibility to constant and nutritious food sources and clean water.

This brings the question of the politics of survival, the notion of the ban, and the viability of ‘responsible’ citizenship into new light. There are conclusions that can be drawn about these policies, which I hope may spark further conversation on these matters. First, minimal state provision to the poor (in the form of grants, ARV treatment, water provision, debt eradication) is predicated on disciplinary biopolitics (which in the case of HIV are biomedical in nature) which further insist on subjects’ willingness and capacity to assume ‘responsible’ citizenship. So, this constitutes a form of exclusionary inclusion (to borrow one of Agamben’s formulations). And, it draws a clear line between those who are minimally included and those who are deemed unworthy of salvation and biopolitical inclusion. But, then, what role do the poor (and the HIV-infected) play in the constitution of the body politic? Achille mentioned, in his talk on Monday morning, that the poor are given minimal provisions in exchange for their consent. The government, then, provides for the poor in order to quell the violent protests against the lack of proper service delivery and to thus gain symbolic legitimacy by offering bare survival in exchange for political inclusion. However, Ahmed has also pointed out to me (in a personal conversaion) that the poor are also an important political mechanism for promulgating the mythology of the ANC, which is perhaps most apparent in the poors’ overwhelming support of Jacob Zuma.

But, then, the questions of survival and resistance still remain. In the informal settlements where I work, people are so intent on simply surviving from day to day, that the communities are rife with competition over scarce resources, intense social antagonisms, and brutal violence; as a result, there is a real lack of any sense of shared identity and social cohesion. In a conversation with Helena Chávez, she questioned whether this kind of basic service provision really, then, constitutes survival? Does the provision of the most basic of social services actually serve to give the appearance of inclusion while sustaining the conditions of bare life in South Africa’s zones of indistinction (Agamben)?

And further, does the provision of ARVs (and the policies which police that provision) circumscribe resistance because some form of bare survival is at stake? Therefore, poor, HIV-infected South Africans are given the choice between struggling to attain (and sustain) responsible citizenship (through biomedical discipline) and resistance through death?

Claire Decoteau