![Sample our Politics & International Relations journals, sign in here to start your FREE access for 14 days]({"type":"image" , "src" : "/sda/5947/TOC-Subject-Sample-2021-Politics-International-Relations.jpg"})
Abstract
South Africa is known for its high rates of HIV and tuberculosis (TB), where HIV has provided fertile ground for the transmission of TB. Indeed, HIV–TB coinfection is widely understood as one of the, if not the, biggest health problems in the country. In practice, doctors and nurses understand that unusual cases of tuberculosis indicate HIV and they make diagnosis and treatment plans accordingly. International treatment standards and protocols inform this practice as doctors pay little attention to individual people and the political–economic, cultural, social, and environmental contexts in which they live. Political ecology, with its nested, place-based analysis, provides an excellent framework for understanding health in South Africa in the context of poverty; local understandings; and global policies, protocols, and priorities. To develop a political ecology of health, this article builds on the concept of local biologies, which understands health at the community scale as simultaneously biological, cultural, and social. Illustrated with the story of one HIV-negative woman's case of miliary TB, this article incorporates local biologies into a political ecology of health that mobilizes scales from the global to the “internal ecologies” of individual bodies. Centering its analysis on the place of the body, this article offers surprising insights into the HIV/AIDS epidemic. By examining the science of miliary tuberculosis alongside population-scale understandings of HIV–TB coinfection in a specific context, this article challenges the way we understand the health impacts of HIV/AIDS, suggesting that the epidemic has negative health implications even for those who are HIV negative.
南非以高比例的 HIV 和结核病（TB）着称，而 HIV 则提供了TB传染的繁殖基础。HIV–TB 的共同感染，的确被广泛地理解为该国最重要的健康问题之一（若不是唯一的话）。在实际情况中，医生及护士了解到，不寻常的结核病案例，意味着 HIV，并依此作出诊断与提供治疗方案。由于医生鲜少关注病人个人及其所生活的政经、文化、社会及环境脉络，因此国际治疗标准与规章，便为此般实践提供了信息。政治生态学，随着它相互套叠、根据地方的分析，提供了理解南非在贫穷脉络中的健康问题、在地理解，以及全球政策、规章与优先顺位的绝佳框架。为了建立有关健康的政治生态学，本文以地方生物学的概念为基础，该概念将社区尺度的健康问题，理解为同步的生态、文化与社会问题。本文描绘一位患有粟粒状TB、HIV 呈现阴性的女性案例故事，以此将地方生物学整合进动员从全球尺度到个人身体 “内在生物” 尺度的健康政治生态学。本文将分析聚焦于身体的地方，对 HIV/AIDA 的传染病，提出意料之外的洞见。本文透过检视粟粒状结核病科学，随着特定脉络中对 HIV–TB 共同感染的人口—尺度之理解，挑战我们理解 HIV/AIDA 对健康所产生的影响之方式，主张该传染病即便对 HIV 阴性患者而言，亦带有负面的健康意涵。
Sudáfrica es reconocida por sus altas tasas de VIH y tuberculosis (TB), caso en que el VIH ha provisto un campo fértil para la trasmisión de la TB. Ciertamente, la coinfección VIH–TB es ampliamente aceptada como uno de los más grandes problemas de salud del país, si no el mayor de todos. En la práctica, los médicos y enfermeras entienden que los casos poco usuales de tuberculosis sugieren también infección con VIH, y de acuerdo con tal supuesto formulan diagnóstico y planes de tratamiento. Los estándares y protocolos internacionales de tratamiento informan esta práctica en cuanto que los médicos ponen poca atención a la gente como individuos y a los contextos político-económicos, culturales, sociales y ambientales en los que ellos viven. La ecología política, con su análisis anidado y basado en lugar, provee un excelente marco para entender la salud en África del Sur en el contexto de pobreza; entendimientos locales; y políticas globales, protocolos y prioridades. Para desarrollar una ecología política de la salud, este artículo trabaja a partir del concepto de biologías locales, que entiende la salud a escala de comunidad como simultáneamente biológica, cultural y social. Ilustrado con la historia del caso de una mujer con TB miliar pero VIH-negativa, este artículo incorpora las biologías locales dentro de una ecología política de la salud que moviliza escalas desde lo global hasta las “ecologías internas” de cuerpos individuales. Centrando su análisis en el lugar que corresponde al cuerpo, este artículo presenta sorprendentes contribuciones sobre la epidemia del VIH/SIDA. Examinando la ciencia de la tuberculosis miliar en conjunto con el entendimiento de la relación población-escala en la coinfección VIH-TB, en un contexto específico, este artículo reta la manera como entendemos los impactos del VIH/SIDA sobre la salud, sugiriendo que la epidemia tiene implicaciones negativas de salud, incluso para quienes son VIH-negativos.
Acknowledgments
First and foremost, I owe a tremendous debt to Thokozile Nguse, my research assistant and collaborator, for all of her help in the community-based research that underpins this work. I would also like to thank Claire Wendland and Becky Mansfield for thoughtful comments they offered as discussants on different versions of presentations of this article. Matt Turner offered invaluable (thoughtful and tough) comments on the first full draft of the article, strengthening it immeasurably. Susan Craddock and Ramah McKay provided helpful feedback and generous sounding boards that helped me see the forest and the trees as I revised. Three anonymous reviewers as well as Richard Wright and Mei-Po Kwan offered careful, critical feedback from which this article has benefited tremendously. Finally, I must thank Alex Nading, who not only introduced me to the concept of local biologies but has been talking through the ideas behind (and the specifics of) this article for close to a decade now.
Funding
The research in this article was supported by a National Science Foundation (NSF) Doctoral Dissertation Improvement Grant and an NSF Graduate Research Fellowship as well as a Raymond J. Penn Scholarship from the Land Tenure Center at the University of Wisconsin–Madison. Writing and revision was supported by a postdoctoral fellowship in the Agrarian Studies Program at Yale University.
Notes
1. This opening story comes from an extended fieldwork stay in 2008 and 2009. More details follow in the Methods section of the article.
2. In accordance with human subjects protocols, I have changed all names.
3. To conduct this research, I received institutional review board approval and at the clinic and in the communities where I conducted my research, I always asked participants for permission to observe and ask questions. In my write-up here and in other places, I have changed key personal details (in addition to names) to protect the identity of research participants.
4. Scholars from several other disciplines, including public health and anthropology, have sought to articulate health as “biosocial” or “biocultural” (Goodman and Leatherman Citation1998; Singer and Clair Citation2003).
5. The idea of an ecosystem in health has been around for a long time, especially in environmental health circles (cf. Dubos Citation1959, 1965).
6. Even though Gogo Mtembu's miliary TB was in her lungs, it is considered extrapulmonary because it is so uncommon.
7. The title of the South African edition of Steinberg's (2008) Sizwe's Test, a book about HIV/AIDS in rural South Africa, is Three Letter Plague.
8. In sub-Saharan Africa, HIV passes mainly through sexual intercourse. As a result, when the doctor agreed that Gogo Mtembu was “too old” to contract HIV, he was clearly making socially and academically acceptable assumptions about Gogo Mtembu's (and by extension all elderly women's) sex life that might or might not have been true.
9. As part of my research, I conducted a household survey in three communities in Pholela in April and May 2008. My information on household composition and livelihoods comes from that survey.
10. Braun Citation(2007) wrote of the “molecularization of life” to examine how the global extension of sovereign power has been mobilized to shape what biological futures are available to which people. Although Braun was concerned with biosecurity, his focus on the “molecular” in questions around biopolitics and biosecurity provides a valuable framework for thinking about the significance of the presence of HIV (the virus) in the blood of an individual for his or her access to health care and resources.
11. Remember, Gogo Mtembu had had an HIV test six months prior to the day on which this story unfolded and she insisted that she was still HIV negative. Given how pervasive HIV education is, it is reasonable to assume that Gogo Mtembu knew she was still negative. Regardless, if she had contracted HIV in the previous six months, because of the virus's slow-moving nature and the pathology of miliary TB, it would be unwise to blame her (hypothetical) HIV for her miliary TB.
12. For an outstanding account of how different people enact illness in a body, see Mol's (2002) The Body Multiple.
13. A number of medical anthropologists, most notably Farmer Citation(1999, 2005, 2006), offer the concept of structural violence as a way to understand how the health of people in places like rural Haiti is shaped by uneven global political–economic structures. Although incredibly important for this analysis and more generally, this body of work misses the way in which micro- and local processes feed back into and shape global institutions and protocols (even as it acknowledges that they do). In other words, for all of its attention to the ways in which broad structures shape the health and lives of individuals, it remains a model in which the global determines the local. As this story of Gogo Mtembu and her miliary TB reveals, Gogo's internal ecology and that of her neighbors, local concern over the fate of youth, local rates of HIV and TB, and globally produced protocols all shape health and health care in Pholela; the local and the global work together.
