After the Exception: HIV/AIDS Beyond Salvation and Scarcity

After the Exception: HIV/AIDSBeyond Salvation and Scarcity

Alan IngramDepartment of Geography, University College London, London, UK;

[email protected]

Abstract: Access to treatment for HIV/AIDS became a flashpoint for global justicestruggles in the late 1990s. An expanding international response, premised to a significantextent on the idea of HIV/AIDS as an exceptional global problem, has since deliveredtreatment, care and prevention to growing numbers of people. HIV/AIDS exceptionalism,however, has increasingly been questioned, many aspects of the response have beencritiqued and donor funding has started to decline. I argue that, having been framed asan exceptional humanitarian emergency, the question of HIV/AIDS as a global problem isincreasingly located within a discourse of scarcity. Tracking the growing entanglement ofglobal HIV/AIDS relief with neoliberal governmentality and the emergence of somethingI term therapeutic neoliberalism, I argue that the shift from a rationality of salvation toone of administration poses new challenges for global health activism. Questioning thediscourse of scarcity remains essential to an alternative global health agenda.

Keywords: HIV/AIDS, exception, neoliberalism, governmentality, global health, security

IntroductionThe global politics of HIV/AIDS have shifted dramatically since the mid 1990s. Whilethe life-extending combination antiretroviral therapy (ART) discovered in 1996 wasrapidly made available in rich countries, it was widely deemed too costly and toocomplex to provide elsewhere. As the life chances of people living with HIV in theglobal North and global South diverged, however, activist and expert mobilizationdrove HIV/AIDS onto the global justice agenda, framing it as an exceptional problemrequiring an emergency relief effort. With a variety of actors also framing HIV/AIDS asa security issue, an expanded international response began to take shape. Whereasbefore 2000 only a tiny proportion of people in need of ART outside the globalNorth could access it, recent estimates (UNAIDS 2011) suggest that some 6.6 millionpeople in low- and middle-income countries are receiving some form of treatment.Access to other HIV-related services has also been increased.

At the same time, the global response to HIV/AIDS remains partial, provisional andprecarious. It is estimated that despite increases in access, less than half of the peoplein need of treatment are receiving it and the pace of scale-up in access lags behindnew infections. While overall prevalence rates have stabilized, the growing numberof people on treatment, growing rates of resistance to first-line medications, growingpopulations and a continuing failure to reduce transmission mean that the responsemust expand just to stand still. However, questions have increasingly been voicedabout the rationality of a continually growing international fiscal commitment toHIV/AIDS. There have also been claims that the response has undermined other

Antipode Vol. 45 No. 2 2013 ISSN 0066-4812, pp 436–454 doi: 10.1111/j.1467-8330.2012.01008.xC© 2012 The Author. Antipode C© 2012 Antipode Foundation Ltd.

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health and developmental efforts, as resources and skills have been drawn intohigh-profile HIV/AIDS programmes that are well funded by comparison with otherareas. The idea of HIV/AIDS as exceptional has come under sustained critique and theglobal financial crisis has intensified a sense of crisis within global health governance.International financing for HIV/AIDS programmes, after flatlining, has started todecline (Kates et al 2011). The response is commonly viewed as being at a crossroadsor facing a moment of truth.

In what follows, I explore what is at stake at this juncture in global health bytracking the growing entanglement between global HIV/AIDS relief and neoliberalgovernmentality, an entanglement that reflects the complex, contested andpolymorphous character (Kay and Williams 2009) of neoliberalism itself. I argue that,having been framed as an exceptional humanitarian emergency with implicationsfor global security, the question of HIV/AIDS as a global problem is increasinglylocated within discourses of scarcity and that HIV/AIDS programming is increasinglyassessed in terms of calculations of cost, impact and efficiency. Here I characterizethis as a shift from a rationality of salvation to one of administration and considerthe challenges this brings for global health activism. In this, I build upon the workof anthropologists such as Biehl (2009), Fassin (2007) and Nguyen (2005, 2010),who, through the era of “scale up”, have maintained a critical skepticism towards theproliferation of governmental practices that seek to foster the lives of HIV-affectedindividuals and populations (see also Li 2007). Their work reveals how projects ofsalvation remain framed and compromised by the persistence of inequality andmaterial deprivation. While such issues often remained submerged during the eraof scale up in HIV/AIDS relief, they are now returning to the surface of global healthpolitics.

I also track the question of exceptionalism as it has appeared in concrete strugglesover the “complex biopolitical assemblage” (Nguyen 2005:125) of HIV/AIDS relief.The idea of HIV/AIDS as exceptional first surfaced in relation to efforts to forge aresponse to epidemics in the United States in the 1980s, which recognized thenovel characteristics and complex politics of HIV and AIDS, such that practices ofcompulsory testing, notification or contact tracing that might have been employedto contain a new communicable disease were rejected. Here the discourse ofexceptionalism meant not invoking public health powers to over-ride individual civilliberties. Furthermore, responding to HIV/AIDS has often spurred the emergence ofwhole new rafts of legislation and fields of juridical practice and led to the creation ofnew, legally constituted bodies (like the Global Fund to Fight HIV/AIDS, Tuberculosisand Malaria). Responding to an issue framed as an exceptional emergency hasthus often entailed the proliferation and dissemination sovereign-juridical power(along the lines suggested by Foucault 2007; see also Elbe 2009), rather than itssuspension (Agamben 2005). At the same time, and as I show, the question ofdeclaring an exceptional situation and suspending the normal rule of law is relevantwhen it comes to the patent regime surrounding ART medication. For severalyears, the US and other global north countries exerted strong pressure on middle-income countries not to exercise their sovereignty by breaking patents on ART toincrease access to treatment. Pushing the envelope of this regime by threatening tobreak patents—to invoke the sovereign exception allowed for in the World Trade

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Organization (WTO) Trade-Related Aspects of Intellectual Property Rights (TRIPS)agreement but suppressed in practice by more powerful states—emerged as a keypractice of HIV/AIDS and intellectual property activists in alliance with concernedmiddle-income states. Such practices indicate that while no one actor or set ofactors can fix the overall shape or function of the dispositif or apparatus (Foucault1980 [1977]) within which they are enacted, things can change when epidemics,activism, expertise and technological shifts converge. However, the transnationalbiological citizenship that might be negotiated at such junctures remains fragileand contingent (Ong 2006).

I seek to show how, through successive challenges, responses and shifts,the apparatus of global HIV/AIDS relief has become increasingly entwined withneoliberal governmentality and how a rationality of salvation (premised uponexception from the neoliberal norm of scarcity) has given way to one ofadministration (premised upon the subsumption of HIV/AIDS back within a discourseof scarcity). In this way I aim to foreground some of the nuances and dilemmassurrounding the global politics of HIV/AIDS and global health activism today.While during the 1980s and 1990s such activism took the form of open challengeto actually existing neoliberal governance arrangements, the scaling up andmore recent rationalization of the HIV/AIDS response have entailed a deepeningentanglement with corporate actors, market mechanisms and entrepreneurialrationalities, an entanglement that provides resources and opportunities, shapesimaginative horizons in ambiguous ways and gives rise to something that mightbe named “therapeutic neoliberalism”. While innovative proposals to protect andextend the response to HIV/AIDS continue to emerge in and around this assemblage,I suggest that a more overt critique of the discourse of scarcity underlying neoliberalgovernmentality and of its articulations with the material organization of the globalpolitical economy is essential to an alternative global health agenda.

From Abandonment to SalvationHIV/AIDS was first identified as a novel virus/syndrome in 1981, followingthe detection of epidemics in North America and Europe. Though often metwith alarm among people directly affected and among some clinicians andepidemiologists, political responses were slow and reluctant. As prominent expertsand commentators linked the new disease to people that were already stigmatized(gay men, injecting drug users as well as haemophiliacs, and in the USA, Haitians),HIV/AIDS was in many countries initially largely ignored and downplayed bypoliticians. But as epidemics continued to grow and to be discovered, as gay activistsbegan to organize and as expert concern increased, governments in the globalNorth/West and select locations elsewhere (notably Cuba) began to respond. Afterhard struggles and extensive lobbying, medical care and public health programmes(often rather different in different places) were put in place.

Large, growing epidemics of HIV and AIDS were also identified in Southernand Eastern Africa, but domestic activist mobilisation and political responses weregenerally much slower and more limited or absent. In the absence of a concertedinternational response and despite the efforts of pioneering activist-experts like the



late Jonathan Mann, in the most affected parts of the world HIV spread largelyunchecked and deaths from AIDS mounted.

The emergence of HIV and AIDS and the subsequent divergence of life chancesbetween rich and poor and between global North and South was amplified bythe neoliberal structural adjustment of the 1980s and 1990s (Fort, Mercer andGish 2004; Kim and Millen 2000). The lead UN agency for health, the WorldHealth Organization, entered a period of internal crises and lost influence andlegitimacy. The World Bank assumed a dominant position in the formation of globalhealth policy, recommending the provision of selective health services and theintroduction of user fees and cost recovery. Structural adjustment gutted health,pharmaceutical and social support systems, just as HIV was beginning to spread. Insouthern and eastern Africa, HIV capitalized on the downsizing of health and welfareunder neoliberal restructuring as well as historic patterns of labour exploitation andmobility and gendered power differentials. In South Africa, post-apartheid politics,neoliberalization and official AIDS denialism converged to produce conditions highlyconducive to HIV transmission and inimical to effective prevention and treatment. Inpost-communist states, the collapse of welfare and public health systems coincidedwith explosions of commercial sex work and injecting drug use, while in India andChina as well as South and East Asia more generally, neoliberalization and financialcrises provided further impetus to epidemics that were growing as a result of similarepidemiological dynamics.

The sense of divergence between global North and South crystallized sharply in1996 when new, highly active ART began to become available. Utilizing anti-HIVdrugs in combination rather individually, researchers discovered, had a far greatereffect, reversing the onset of AIDS and reducing viral loads in the body. Thesedrugs, however, were produced under patents held by global North pharmaceuticalcompanies. With combination therapies priced over $10 000 per person per year,their cost was many multiples of the average per-capita spend on health in low- andmiddle-income countries and only global North governments could afford large-scale treatment programmes. As people living with HIV in the global North gainedaccess to ART and death rates from AIDS began to fall, those without access (by farthe majority of those in need) were left to a rapid death following the onset of AIDS.

Access to ART quickly became a flashpoint for international mobilization asintellectual property and AIDS activists from the USA linked up with treatmentaccess campaigners in South Africa (Smith and Siplon 2006). In the USA, Brazil,South Africa and beyond, at international AIDS conferences, at court cases andUS presidential campaign events, activists performed a series of highly adeptinterventions that targeted the positions of state and corporate actors in the nameof a global politics of life. Pressured by activists, the Brazilian government made acomprehensive public response to HIV/AIDS a policy priority and challenged thepatent regime surrounding ART. NGOs and middle-income countries started toannounce their intention to import the generic ART medications being produced byIndian pharmaceutical companies, breaking the patents of global North companies.Attempts by global North pharmaceutical companies and governments to forestallthis challenge foundered in 2001, when a lawsuit against South Africa’s newMedicines Act (which would have made it easier for the government to access


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generic ART medications) collapsed. Bolstered by the results of research indicatingthat it would be possible to achieve the necessary high levels of adherence totreatment in so-called resource-poor settings, figures such as UN Secretary GeneralKofi Annan began to call for a dramatically expanded international response, withan additional US$7–10 billion donor funding per year. As on-patent producerswere forced to drop their prices for ART, donors and potential recipients beganto announce their commitment to upgrade their responses. Combating the spreadof HIV/AIDS (and other diseases) was included in the Millennium DevelopmentGoals.

This phase of activism is easily characterized in terms of resistance and challengeto the neoliberal globalization agenda of the 1990s, and one of its centrepieces,the WTO intellectual property regime, in particular. The global politics of HIV/AIDSmight thus be characterized in terms of a political economy of social rights andredistribution against neoliberal governance. But while useful, such an approachoverlooks important dimensions of global HIV/AIDS relief. In what follows I trackshifts and struggles in and around this assemblage in relation to some of thecharacteristic rationalities, technologies and practices of neoliberal governmentality.This helps to deepen and extend our understanding, I suggest, of the dilemmasof exceptionalism and security surrounding HIV/AIDS and of the rationalizationcurrently sweeping through the response.

Crucial to the emergence of scaled up HIV/AIDS relief was the framing of thepandemic as more than a health, development or human rights issue: it becamea humanitarian emergency with global security implications (see also Fassin andPandolfi 2010, Nguyen 2010). Important to this framing was UNAIDS, a hybridagency established in 1996 to inform, coordinate and mobilize the response acrossthe UN system. UNAIDS was thus expected both to provide information on HIV/AIDSand to act as an advocate for HIV/AIDS as a global policy priority, and acted as acrucial site for challenging widespread official indifference to HIV/AIDS epidemicsoutside the global North. It did so by framing HIV/AIDS in increasingly dramaticterms, as a global pandemic out of control (Pisani 2008). UNAIDS, along with otheractors, also sought increasingly to highlight what were described as the pandemic’ssecurity implications.

In a declassified report, the US National Intelligence Council (NIC 2000) identifiedHIV/AIDS among other emerging infectious diseases as a threat to US and globalsecurity. Shortly thereafter, the UN Security Council held sessions linking HIV/AIDSwith the maintenance of international peace and stability. This led to Resolution1308, which stressed “that the HIV/AIDS pandemic, if unchecked, may pose arisk to stability and security” (UNSC 2000:2). In more dramatic terms, a seriesof think-tank reports extrapolated a looming geopolitical as well as humanitariancatastrophe and envisaged deepening conflict, state failure and new terrorist threats(eg International Crisis Group 2001). This fuelled the emergence of a discursive andaffective environment within which the idea of HIV/AIDS as an exceptional diseaserequiring an exceptional global response resonated increasingly loudly. Accordingto the crucial UN Declaration of Commitment entitled “Global Crisis, Global Action”,HIV/AIDS constituted “a global emergency” (General Assembly 2001:6); Africa inparticular faced a “state of emergency” and it was stated that “the dramatic situation



on the continent needs urgent and exceptional national, regional and internationalaction” (General Assembly 2001:8). Other regions meanwhile faced “similar threats”and it was observed that “that the potential exists for a rapid escalation of theepidemic and its impact throughout the world if no specific measures are taken”(General Assembly 2001:9). As Elbe (2009) suggests, HIV/AIDS threatened the kindof crisis of circulation identified by Foucault (2007) in his discussion of modernmechanisms of security.

This framing of HIV/AIDS as an exceptional humanitarian emergency withsecurity implications is highly significant in the context of struggles over neoliberalglobalization because it enabled the argument that HIV/AIDS should be ex-ceptedfrom the actually existing neoliberal regime for dealing with infectious disease. AsSparke (2009) describes, this had been underpinned by a narrative that “wealthbrings health”, in which health was understood as a private good best secured viathe operation of markets, supported by legal regimes that protected and rewardedinnovation (in other words, monopoly patents), except in emergency situationsand crises. HIV/AIDS thus became a prime candidate for what Sparke describesas “market foster care”, where specific diseases or health problems are seen asbarriers to populations and states entering the global economy on competitiveterms. In market foster care, limited, targeted (or exceptional) aid is justified tosave populations and enable countries to join in the neoliberal growth paradigm.The apparent security implications of HIV/AIDS only increased the urgency of thesituation.

Scaling up the ResponseIn a wave of innovation and commitment, state, corporate and philanthropic actorsbegan to increase funding and to create sui generis institutions for global HIV/AIDSprogramming. In 1999 the World Bank launched a dedicated Multicountry AIDSProgram for Africa. In 2002, the Global Fund to Fight AIDS, Tuberculosis and Malariawas established to channel donor financing to country-level health programmes andin 2003, the Bush administration launched the US President’s Emergency Plan forAIDS Relief (PEPFAR), the largest single funding stream for HIV/AIDS programming.Annual donor support grew from US$1.6 billion in 2002 to US$8.7 billion in 2008and HIV/AIDS programmes in many highly affected countries were able to expand.

With this, the HIV/AIDS response became a key site for the proliferation ofnew institutional and organizational forms and rationalities in global health anddevelopment, under the banners of “global public private partnerships”, “globalhealth partnerships” and “global health initiatives” (Rushton and Williams 2011).While it is true that the HIV/AIDS response has been a site for the dissemination ofliberal governmental rationalities (Elbe 2009)—in that the health, rights, welfare andfreedom of populations with regard to HIV and AIDS have been made a criterion ofa particular kind of security—these have become entwined in a neoliberal matrix inthat the HIV/AIDS response has also been premised upon the growing engagementof philanthropies, for profit and not-for-profit corporations and non-governmentalorganizations. As the key United Nations (General Assembly 2001:15) declarationstates (in phrasing echoed in the legislation enabling PEPFAR), while the leadership


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of governments is “essential”, “their efforts should be complemented by the fulland active participation of civil society, the business community and the privatesector”. This is accompanied by a turn towards managerialism, entrepreneurialism,market mechanisms and commodification in global health governance (see alsoBarnes and Brown 2011). Global HIV/AIDS relief is thus better characterized as aneoliberal rather than liberal dispositif of security.

This is illustrated in a whole range of initiatives for increasing access to ART andother commodities. For example, the Clinton Foundation Health Access Initiative(which also works on malaria) focuses on “improving market dynamics for medicinesand diagnostics” (CHAI, nd). UNITAID (nd), which describes itself as a “laboratoryfor innovative financing for development”, seeks to contribute to increased accessto treatment for HIV/AIDS (and malaria and tuberculosis) “by leveraging pricereductions for quality diagnostics and medicines and accelerating the pace at whichthese are made available”. Corporations have been enrolled in HIV/AIDS relief viainitiatives like the Global Business Council on HIV/AIDS (which subsequently added“Tuberculosis” and “Malaria” to its mandate before becoming GBCHealth in 2011).Something we might call therapeutic neoliberalism (a counterpart to the therapeuticsovereignty identified in Nguyen 2010) is also at work in high-profile initiatives like(PRODUCT) RED, which link purchases of consumer goods from corporations such asApple, Gap and Levi’s with donations to the Global Fund (O’Manique and Labonte2008, Youde 2009).

What is most notable and significant, however, is the manner in which neoliberalrationalities and technologies have been mobilised by HIV/AIDS activists themselves.This is evident first in efforts to engineer price competition between on-patent andgeneric ART medications and between generic producers, a move that has enabledscaling up access to ART (Smith and Siplon 2006). It is also evident in efforts to bringlegibility and calculability to the market for ART drugs by publishing detailed annualguides to pharmaceutical pricing (see Medecins sans Frontieres 2011 ). In this sense,exploiting new opportunities created by the emergence of generic ART production,activists have leveraged quintessentially neoliberal rationalities (that freely operatingmarkets can be used to increase welfare), technologies (making prices increasinglyvisible and comparable) and tactics (bringing different producers into competitionwith each other in the name of consumers) against actually existing neoliberalism(in the form of patent monopolies and willfully obscured trading conditions). In thisway, elements of neoliberal governmentality have been deployed against some ofthe actors frequently held to benefit most from neoliberal governance and haveserved to enroll them in the international response to HIV/AIDS.

In many ways this represents one of the most remarkable activist success stories ofrecent decades and indicates the possibilities that may exist for working creativelywith neoliberalism (or at least certain of its rationalities, techniques and tactics) toexpand welfare, and it is perhaps emblematic of the legitimacy-generating powerof neoliberal governmentality—as well as the evident benefits of extending ART andother HIV-related services—that this turn in global health governance has proven soresistant to critique.

Indeed, a blanket critique would be misplaced. Before global HIV/AIDS activism,many state actors were at best indifferent or, worse, in outright denial about the



causes, nature and implications of HIV/AIDS; corporate actors were focused ontheir own bottom lines to the exclusion of global health concerns; and globalhealth and development institutions had failed to prioritize the disease and werein many respects dysfunctional. Furthermore, if HIV/AIDS is to be construed asa multidimensional phenomenon requiring a comprehensive response, then theinvolvement of multiple actors from multiple sectors (including corporations andthe military) is arguably necessary (though their precise roles might be debated).Still further, an effect of the attempt to mount a rapid scale up in access to treatmenthas been to reveal numerous weaknesses, absences, bottlenecks, opacities andinequities in global drug markets and logistical systems, problems that have in turnbeen addressed by entrepreneurial, cooperative action in order to reduce costs andexpand access further. The HIV/AIDS response is thus both a product of resistanceto the neoliberal abandonment of the 1980s and 1990s and a leading edge of theneoliberal developmentalism of the 2000s, with its concern with saving lives viapartnerships, advocacy, leverage and empowerment.

At the same time, these successes are fraught and ambiguous and the possibilitiesfor working with and within neoliberalism (Ong 2006) require careful evaluation.In political economic terms, concessions have been hard won and exceptions toneoliberal governance regimes have been partial. In the final year of his presidency,Bill Clinton switched his administration’s position on the WTO TRIPS regime, inso far as HIV/AIDS was concerned. While Vice President Gore had been in thelead in defending patents and promoting US pharmaceutical company interestsin TRIPS, the administration was instructed to do nothing that would interferewith access to ART in Africa (Behrman 2004). HIV/AIDS medication was thus tobe an exception to the globalizing intellectual property regime promoted by theUS corporate and state actors via the WTO and bilateral and regional treaties. Thisexception has been a sine qua non of the HIV/AIDS response in that concessionson ART patents have been essential to the scale up in access to treatment achievedso far. But it remains a narrow exception that has been continually contested andwhich has remained limited. After the Bush administration announced PEPFAR, hardstruggles were necessary before the US Food and Drug Administration (a regulatoryauthority that is crucial to the global pharmaceutical political economy) agreed toadopt an expedited approval process that would allow US tax dollars to be used topurchase generic medications. After the Bush administration expressed interest inusing a compulsory license for the on-patent antibiotic drug Cipro (following theanthrax attacks of autumn 2001), however, it was forced to concede that othercountries could also exercise the flexibilities allowed for within the TRIPS agreementin support of public health, a concession reflected in the WTO Doha Declaration(WTO 2001). In practice, however, outside of the global North it is generally onlymiddle-income countries that have been able to exercise these flexibilities and thenonly in relation to first-generation ART, not other on-patent medicines. Second-and third-line ART, which are needed to treat patients who become resistant tofirst-line treatment (a growing problem), as well as new generation formulationsthat are simpler to take, more heat resistant, more effective and less toxic, remainlargely on-patent and are much more expensive. While much broader exceptionsare ostensibly allowed under TRIPS (with the Doha Declaration recognizing that


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“each member state has the right to determine what constitutes a nationalemergency or other circumstances of extreme urgency” and that public healthcrises may qualify; WTO 2001:1) these are in practice much harder to exercise. WhileHIV/AIDS is now supposedly a “security issue”, the ability of actors to invoke thesecurity argument and exercise sovereignty in the global pharmaceutical politicaleconomy remains constrained. While concessions to generic production enabledthe scale up of access to first-line ART, the global HIV/AIDS response continues tobe framed by a contested constellation of political-economic interests concerningproperty rights, production and trade.

A Crisis of GovernmentalityAs the response to HIV/AIDS has been scaled up and rolled out, criticism of its effectsand implications has become increasingly forceful. By 2008, the response and thediscourse of HIV/AIDS exceptionalism sustaining it were already facing twin crises ofrationality and legitimacy.

First, the idea of HIV/AIDS as a security issue has been modified over time. Therewere always nuances and variations among how different actors framed HIV/AIDS asa matter of security. But from 2003 onwards, a series of evaluations (Barnett and Prins2005; de Waal, Klot and Mahajan 2009; Elbe 2003, 2009; Whiteside, de Waal andGebre-Tensae 2006) began to question and erode the idea that HIV/AIDS wouldor could in and of itself trigger or exacerbate state failure, violent conflict or thespread of terrorist networks. Though these ideas were often a matter of speculationor extrapolation in the key official documents, think-tank reports and speechesdefining HIV/AIDS as a matter of security, they helped to establish a resonance withother geopolitical anxieties that undoubtedly contributed to the sense of urgencyand necessity surrounding HIV/AIDS in 2000–2002. Over time, a more sophisticatedunderstanding of relationships between HIV/AIDS, military and police forces andother state institutions has emerged, but at the expense of rendering HIV/AIDS lessthreatening, while security anxieties about avian influenza, climate change, energysecurity and the global economy have come to the fore.

Second, a related—and highly significant—factor in the erosion of a sense ofemergency and exceptionality surrounding HIV/AIDS as a global problem was thefact that much-improved data began to indicate an overall stabilization in theepidemic in terms of prevalence, just as the expanded international response wascoming online (UNAIDS 2007). The most affected states in southern and easternAfrica have not collapsed and the “break out” of HIV in so-called “second wave”countries (notably China, India and Russia as well as elsewhere in Eastern Europe,Central Asia, South and South-East Asia) from concentrated to generalized epidemicshas largely failed to transpire. Thus the picture of an out of control pandemic thatwas cultivated through to 2002 has been increasingly difficult to sustain.

Third, a series of commentators and former insiders began to articulate misgivingsand criticisms of the response in a much more prominent manner than had been inevidence during the securitization and early scale-up phases.

There has been questioning of the epidemiological understanding of HIV/AIDSdisseminated by AIDS activists and international institutions tasked with organizing



the response. While situating generalized epidemics in eastern and southern Africain terms of the impacts of post-colonial development and economic globalization,Epstein (2007) observed that the main prevention strategies being promoted bydonors were poorly aligned to the reality of normative sexuality in the region.Conversely, in another highly influential commentary, Chin (2006:vi–vii) argued:

The vast majority of the world’s populations do not have sufficient HIV risk behaviors tosustain significant epidemic HIV transmission. This epidemiologically sound conclusion issufficient to explain past, current and future HIV patterns and prevalence, but has beenminimized and ignored by UNAIDS and AIDS program activists. UNAIDS’ more politicallyand socially acceptable public health message is to say that HIV risk behaviors are presentin all populations and therefore all populations are at risk of HIV epidemics.

In a further key intervention, Pisani (2008), an epidemiologist who had workedat UNAIDS writing annual reports, acknowledged that the organization’s staffmembers had sought to dramatize information about HIV/AIDS epidemics, forexample emphasizing rapid increases rather than absolute levels of HIV prevalence inearly-stage, concentrated epidemics. As Chin notes, media organizations frequentlyreproduced UNAIDS figures and narratives (which contributed to the securitizationof HIV/AIDS) without question or scrutiny. However, while Chin decried globalhealth inequity and the lack of adequate HIV/AIDS programmes for prevention,treatment and care, in critiquing the discursive and affective basis on which theexpanded response had been secured, his argument aligned with those seeking to“de-fund” HIV/AIDS and/or redistribute resources to other programmes. In this vein,HIV/AIDS exceptionalism was targeted much more directly by England (2007:344),who argued that:

The exceptional status according HIV, and its excessive relative funding, has producedthe biggest vertical programme in history, with its own staff, systems and structure. Thisis having deleterious effects apart from underfunding of other diseases. These includeseparating HIV from sexual and reproductive health and creating parallel structuresthat constrain the development of health services. National AIDS commissions, countrycoordinating mechanisms, UN agencies etc are tripping over each other for funds andinfluence.

As he subsequently wrote:

The foundations of exceptionalism were laid when the “rights” arguments of gaymen succeeded in making HIV a special case that demanded confidentiality andinformed consent and discouraged routine testing and tracing of contacts, contraryto proved experience in public health. But exceptionalism grew—to encompass HIVas a disease of poverty, a developmental catastrophe, and an emergency demandingspecial measures, requiring multisectoral interventions beyond the leadership of theWorld Health Organization (England 2008:1072).

England framed HIV/AIDS in the countries most affected as an issue of themiddle classes rather than the poor and asked why there were no special fundsfor pneumonia or diabetes, on the basis that they kill more people. Arguing thatHIV had been treated more like an economic sector than a disease and proclaimingAIDS exceptionalism to be dead, England argued instead for abolishing UNAIDS,pooling all health aid and allocating it on the basis of relative contribution to


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the burden of disease. Pisani (2008:269, 276), meanwhile, levelled criticism atthe “ants in the sugar bowl” and “beltway bandits” that had been drawn intothe AIDS response by the influx of funding, to the extent that the main priorityfor some organizations was simply to spend their budget rather than achieve realresults.

These critiques began to articulate views that were in some respects widely sharedby many working in global health beyond HIV/AIDS. They also began to identifysome anti-political (Ferguson 1994; Li 2007) effects of the response. But for someworking within HIV/AIDS organizations, England’s critique in particular threatenedto return global health politics to the 1980s, when health budgets were seen asfixed, to be allocated as scarce resources in a landscape of unmet need. Suchcriticism would open the way for conservative retrenchment and the de-funding ofglobal health rather than moves towards greater equity.

Some of these debates were beginning to be played out during the reauthorizationof the Bush PEPFAR programme, which was up for legislative renewal in 2008. One ofthese debates was between those who were calling for a narrowing of the responseto focus on expanding access to treatment as a proven, deliverable and verifiablemeans of “saving lives” and those who argued that the response had revealed theneed for a much more expansive developmental effort that would take in thingslike access to clean water, food and education (Loewenberg 2008). In the end,PEPFAR II reflected an incoherent compromise between these positions.

The significance of such debates, I suggest, is that they reflect a crucial faultline underlying the response more generally, namely, whether it represents anexceptional humanitarian and security intervention premised upon a kind ofbiopolitical minimalism (“saving lives”) or a stepping stone towards a more radical,expansive and equitable global health agenda (“justice”). During the phase ofexceptionalism, securitization and scale up, these propositions coexisted in anuneasy and largely unexamined symbiosis. With budgets flatlining and falling, thetensions between them have resurfaced.

From Salvation to ScarcityOverall donor allocations for HIV/AIDS programming have flatlined since 2008and started to decline (Kates et al 2011). In 2009, US$15.9 billion was madeavailable for addressing HIV/AIDS in low- and middle-income countries (againstan estimated need of US$25 billion for achieving “universal access”). In 2010 theGlobal Fund replenishment process resulted in pledges below the level necessary tomaintain existing activity and in late 2011 the Fund cancelled its next round of grantmaking (Avert 2011; Boseley 2011). With advisors recommending that US aid dollarswould be more effectively spent on other health problems (Denny and Emanuel2008), PEPFAR’s budget for the purchase of ART medication has been reducedand there have been reports of donor-funded HIV/AIDS clinics being instructed tocease enrolling new patients, as well as increased rationing and sharing of ART(Medecins sans Frontieres 2009). The end of “scale up “ marks a break point inthe international response to HIV/AIDS, with significant implications for how theresponse is to be conceptualized and managed. In short, HIV/AIDS is decreasingly



regarded as exceptional and is being reintegrated into a health and developmentparadigm premised upon scarcity.

In this context, proposals that take scarcity as an axiomatic starting point forrationalization become especially significant. What such proposals envisage is a morethoroughly neoliberalized response, in which market rationalities, techniques andsubjectivities become the epistemological grid and mode of veridiction (Foucault2008) for HIV/AIDS interventions. Consider the reframing of access to ART as an“entitlement” rather than a right or humanitarian/security necessity. According toOver (2008:6), writing about US support:

PEPFAR is creating entitlements which cannot be assumed by most of the recipientcountries and is hard to justify on investment grounds. These features of PEPFAR suggestthat it is really an international transfer program, comparable perhaps to US foodassistance. Programs to redistribute consumption from rich-country taxpayers to thepoor in developing countries constitute state supported international welfare programs.

As he further argues, “Because support for AIDS treatment converts foreignassistance from discretionary to entitlement spending, past treatment expenditurehas already locked the US and the rest of the donor countries into a new aidparadigm” (Over 2008:18). The redefinition of access to ART as an entitlementmarks a further shift in the discursive framing of the HIV/AIDS response, one thatis closely related to its biopolitical economy. With new infections continuing tooutpace the number of people being placed on treatment, with growing demandfor more costly second- and third-line treatments as well as more effective ones,and with growing numbers of people on donor-funded treatment as morbidity andmortality for people living with HIV is postponed, there are multiple pressures forincreasing costs. While HIV/AIDS may no longer be understood as being out ofcontrol as a pandemic, it threatens to become a “ballooning entitlement burden”(Over 2008).

Each of these challenges is now being addressed with heightened urgency.This includes a push for new technical solutions to the continuing challengeof preventing HIV transmission, such as anti-HIV microbicide gels for women,an effective vaccine, male circumcision (which can reduce female to maletransmission only) and “treatment as prevention” (TrASP). There is also increasedcontestation over patents on new ART formulations, and efforts to drive downcosts by rationalizing procurement, logistics and supply chain management areintensifying. As a group of authors closely associated with US HIV/AIDS policyargue:

In the second phase of PEPFAR, characterized by an increased emphasis on sustainability,programs must demonstrate value and impact to be prioritized within complex andresource-constrained environments. In this context, there is a greater demand to causallyattribute outcomes to programs. Better attribution can be used to inform midcoursecorrections in the scale-up of new interventions (eg, male circumcision) or to re- evaluateinvestments in programs for which impact is less clear (Padian et al 2011).

As this suggests, the need for greater visibility, calculability and attributability of allaspects of the response is intensified by a discourse of scarcity (often rendered as“sustainability”).


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This is driving global health policy more generally towards technical interventionswhere problem, cause and effect can be quantified, costed and compared withothers. This is evident in the growing influence of the Institute for Health Metricsand Evaluation (IHME), a new initiative based at the University of Washington andlargely funded by the Bill and Melinda Gates Foundation (also based in Seattle; seeSparke 2010). The IHME vision is of health improvement through the application ofscientific rationalism, a vision which connects with a growing donor preference (seealso Williams and Rushton 2011) for provable, quantifiable and replicable successes,but also the need for rationalization on grounds of efficiency. In sum, the metrics-oriented global health technology articulates easily with a broader discourse ofscarcity and retrenchment. It also articulates a shift in intellectual and politicalleadership in global health, which passed from Geneva following World War IIto Washington DC in the period of post-Cold War high neoliberalism, and now toSeattle in the period of what Peck (2010) calls zombie neoliberalism. These shiftsin turn have implications for the kinds of HIV/AIDS interventions and programmesthat might begin to gain donor support.

Proposals for performance-based incentives (PBIs) for the prevention of HIVtransmission are indicative of what an intensified therapeutic neoliberalism—wherea rational economic calculus is brought to bear on all aspects of life pertainingto HIV/AIDS—might look like at the level of managerial techniques and modes ofsubjectification. As Over (2010:13) describes:

The main purpose of PBIs—also known as pay for performance—is to adjust individualagents’ incentives to better align with the interests of the community and the country.On the demand side, they should heighten the interest of individual clients. On thesupply side, they should motivate service providers to try harder.

PBIs are amenable to the kinds of experimental, randomized control trials borrowedfrom biomedicine that are gaining ground in mainstream development thinking.Tests of demand-side interventions (Thornton 2005, described in Over 2010) haveincluded randomly distributing vouchers equivalent to a day’s income, redeemableupon submission to an HIV test and receipt of results at a voluntary counsellingand treatment (VCT) clinic. In one test it was reported that even small sums couldgenerate substantial increases in testing uptake and condom purchases. Anothertest involved cash payments for school attendance by girls, on the hypothesisthat this could reduce HIV risk behaviours. A further proposal is to offer cashpayments on condition of avoiding new sexually transmitted infections. In general,grafting PBI structures for providers and recipients onto all promising approaches isrecommended as part of a “prevention revolution”, a term adopted by UNAIDS.

While many questions may be raised about such approaches, the point I wishto highlight is that though their goals may be unobjectionable in their own terms,they are premised upon and fail to question a neoliberal rationality within whichscarcity and uneven development are assumed as prior existing conditions andpremises for the rationalization of welfare, reciprocity and citizenship. There is littlesuggestion that such techniques are appropriate or effective for people who arenot poor, and no discussion of why it is that small cash amounts can induce suchsignificant changes in behaviour. Rather than questioning underlying disparities



and inequities in wealth and access to healthcare, they articulate these disparitiesto a constellation of techniques for the surveillance and regulation of individualbehaviour and relationships in the name of the health of the population. Exposureof oneself and others to HIV is rendered as a problem of economic irrationality. Thisis not to suggest that greater equality is a panacea for dealing with HIV/AIDS; theproblem is that inequality is screened out altogether.

A different approach to rethinking the response is premised on the changingdynamics of the epidemic itself. This starts to look at both HIV/AIDS and theresponse as long-wave, but finite, phenomena that will play out over decades.Modelling HIV/AIDS over a period of 50 years, one study (AIDS 2031 Consortium2011) composed by a group of high-level figures from the worlds of HIV/AIDSand global health governance distinguishes two trajectories, one based on flatfunding, which implies increased costs over the longer term, and another onfurther increases in resources now, which it is suggested can forestall future costsby accelerating the decline of HIV/AIDS epidemics. With this temporal reframing,HIV/AIDS is repackaged as a development intervention that is cost effective ratherthan unaffordable over the longer term.

Whiteside and Smith (2009) meanwhile seek to qualify exceptionalism by makinga distinction between low-, mid- and high-prevalence countries. HIV/AIDS shouldbe normalized, they argue, in low-prevalence countries and mid-level prevalencecountries capable of funding treatment without outside assistance. HIV/AIDS shouldstill be regarded as exceptional in countries with prevalence rates over 10% and inmid-level countries where treatment is funded from outside sources. In contrast withthe idea of HIV/AIDS as a global pandemic, Whiteside and Smith (2009:2) argue that“AIDS is exceptional, but not everywhere”. Their argument that, while not a globalpandemic, HIV/AIDS still deserves a global response thus represents a spatializationof HIV/AIDS as a problem and matter of responsibility that is both more nuancedand less dramatic, while still making the case for North–South support. However, insegmenting HIV/AIDS epidemics and responses from global health more generally—delimiting it as a field for a costed policy intervention—these proposals do notengage with the systemic features of the global political economy that shape healthand health care worldwide.

A further set of proposals attempt to redefine the situation in a way thatwould enable the response to be integrated with a broader global healthagenda. Recognizing the criticism that the “verticalizing” nature of the response,while enabling rapid scale-up, has compromised other health programmes andstrengthening of health systems, one group of influential figures (Ooms et al2008) involved in HIV/AIDS politics and programming has suggested a moveto a “diagonal” approach that would link dedicated HIV/AIDS programmes withsystemic efforts. This acknowledges other high-profile global health initiatives aimedat building human resources for health and systems strengthening, but, whileproposing turning the Global Fund into a Global Fund for Health, still leaves openthe question of where financing will come from.

A third proposal has been to “generalize the exception” (Ooms et al 2010).This is premised on the argument that the scaled-up response to HIV/AIDSeffectively entailed an open-ended commitment to growing redistribution on


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the grounds of solidarity and that, now that the response has revealed theextent of need in highly affected countries, the only coherent political positionis to extend the exceptionality principle from HIV/AIDS to global health as awhole. This argument is potentially productive in that it begins to challenge thelogic of scarcity, but does not yet engage sufficiently with the question of therelationship of global health to the global political economy within which questionsof scarcity and exception are posed. This, I suggest, is the key move for criticallyre-envisioning the response to HIV/AIDS as part of a revitalized global healthagenda.

Conclusions: Beyond Scarcity?Discursively, exceptionalism is productive in that it creates a field within whichhumanitarianism can function as a field of action concerned with the amelioration ofsuffering and in which security mechanisms may be deployed to stabilize crises. Butas a variety of interventions have clarified (Fassin and Pandolfi 2010), the dilemmaof humanitarian/security exceptionalism is that it risks a depoliticized understandingof human suffering and renders people the objects of sovereign discretion. It alsorelies upon a boundary making practice in which the humanitarian situation issegmented from the norm (where scarcity and inequality are acceptable), whenwhat is required is a questioning of this ordering practice itself and its relationshipto the global political economy. Similarly, as deployed within neoliberalism, scarcityis a discursive practice that pathologizes the poor while diverting attention awayfrom questions of inequality and distribution. In a climate of austerity, the neoliberaldiscourse of scarcity risks complicity with a politics of abandonment.

My goal has been to relocate debates about global HIV/AIDS relief in termsof neoliberal governmentality as a means of conceptualizing, exploring andcrystallizing what is currently at stake in the entanglement between global healthand the discourses of exception, salvation and scarcity. What flows from this analysisis, first, a need to think about HIV/AIDS and global health within these terms,by unpacking the manner in which neoliberal governmentality and the globalpolitical economy of health are assembled at the intersections between activismand expertise. Second, there is a need to think beyond the discourses of salvation,exception and scarcity that frame our understandings of security.

It is perhaps encouraging that the conceptual critique of neoliberalism,humanitarian exceptionalism and scarcity is finding its counterpart in critical workon the exceptional practices and zones of the global political economy. A seriesof accounts (eg Palan 2009, Shaxson 2011) is increasingly rendering visible themanner in which a variety of actors fabricate and use secret jurisdictions to evadethe redistributive and regulatory capabilities of sovereign-territorial jurisdictions,and to concentrate wealth upwards by moving it offshore. Also notable is a phase ofcritique and innovation around the question of intellectual property, with a rangeof proposals (see eg Faunce and Nasu 2008) seeking to develop alternatives tothe monopoly rights regime that involve more democratic, collective deliberation.Critical theorization of the response to HIV/AIDS needs both to engage with the



latest refinements in therapeutic neoliberalism and to be connected to debates andstruggles over the global political economy (see also Sparke 2009).

This task is complicated by economic crisis and the shifting geopolitics of theglobal political economy itself. Since the end of the Cold War, the most powerfulnodes in the global health field have been centred in the USA. But global healthpolitics is increasingly shaped by the interests and strategies of emerging states,notably Brazil, China, India, Thailand, South Africa, which are coordinating policypositions via a variety of international groupings and sui generis initiatives. Theconcurrent emergence of discourses, knowledges and practices surrounding “globalhealth diplomacy” signals recognition of a desire to reach new accommodations inglobal health in the context of emerging multi-polarity, particularly when it comesto questions of intellectual property, access to medicines and trade. In such a contextthe influence of neoliberal policy prescriptions may be qualified. While there is noguarantee that any new settlement in global health will be more equity orientedthan the current situation, such emerging developments hold out the possibility atleast of a revitalized global health politics that is concerned to develop a critique ofthe discourse of scarcity in tandem with an account of the material organization ofthe global political economy.

This is urgent at a time of economic crisis and retrenchment in which complexlife support systems constructed over the course of the last decade are underthreat. While immense efforts are being expended in the search for new scientificand technical fixes, there is a need to reflect upon and challenge the terms inwhich the widely proclaimed crisis of global health is being posed. My concernis not necessarily for the implications of new medical technologies or ideas likesustainability, efficiency, attributability or accountability in and of themselves; it israther the way they are articulated within a form of governmentality that is all toofrequently complicit in the reproduction of the conditions it is ostensibly concernedto rectify.

AcknowledgementsEarlier versions of this article were presented at conferences in 2011 in Durham (InternationalMedical Geography Symposium), Lausanne (New Spaces of Scientific Knowledge) and Sussex(at the British International Studies Association Global Health Working Group), and I amgrateful to participants at these events for their comments. I would also like to thank thethree anonymous reviewers for their careful and constructive readings, which enabled me todevelop my argument further. The article draws on research on PEPFAR funded by a BritishAcademy Small Research Grant. Sole responsibility for its content lies with the author.

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After the Exception: HIV/AIDS Beyond Salvation and Scarcity

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