INTRODUCTION
People, Pathogens, and Power
Situating the South African HIV/AIDS Epidemic
Matamela shook his head as he spoke to me, a wistful expression coming over his face.1 He turned and looked out of the window, pensively stroking his beard for a moment, deep in thought. Matamela was a leading activist for the Treatment Action Campaign (TAC) at the organization’s district office in Khayelitsha, a black urban township approximately twenty miles from Cape Town’s city center. TAC’s district office was housed in an off-white building in a shopping complex adjacent to the Nonkqubela railway station, and it was the base of operations for community-oriented activities designed to limit the spread and impact of HIV/AIDS in the township. As night fell we leaned toward the cracked windows, hoping to catch the last moments of light. Matamela adopted an urgent tone as he spoke of the daily obstacles faced by those accessing HIV/AIDS services in the South African public health sector.
If you go out and you say to people, “We are coming to your community to talk about VCT [voluntary counseling and testing for HIV/AIDS]. Come out and go and have voluntary counseling and testing.” And people go to the clinic, and wait hours to go do VCT, and at the end of the day, they do not want to go to the VCT anymore, then there’s a problem there. That quality of service is compromised. Because no one wants to wait for two hours, three hours just for testing for HIV. No one wants to wait. Because you will wait, and at some point [you will be] be told that, “Come tomorrow, because we are about to close down now.” In some instances, you are being told that there is no medication for this particular illness that you are suffering from. It creates a problem.
Emphasizing how often people waited in line for hours but were unable to see a doctor, Matamela painted a picture of underresourced and understaffed public health services in a community where nearly one in three pregnant women are HIV positive. In this and other conversations, Matamela attributed the continuing challenges of HIV to the socioeconomic conditions created by colonization, segregation, and apartheid. His was a sobering analysis of the world’s largest HIV/AIDS epidemic.
I met Matamela during one of my first visits to TAC’s office in Khayelitsha. A tall Xhosa-speaking black South African in his mid-thirties, his expression alternated between a broad smile and a searing gaze. As one of the senior activists at the district office, Matamela was often too busy to sit and discuss the broader politics of the South African HIV/AIDS epidemic. That night, another activist had left with the only set of keys, and we had been locked in the office due to a power failure in the township. As was the case for many homes and offices in South Africa, the TAC office had a steel gate and a locking door that had been installed to deter would-be intruders, imagined or real. As I had realized the first time I had locked a gate of this kind, the barrier not only prevents someone from entering but also restricts the movement of those inside. Now, fortunately for me, being locked in the office enabled me to learn more about Matamela’s background and his experiences confronting the HIV/AIDS epidemic.
Matamela was born and raised in the Cape Flats, a series of townships that stretch out from the Cape Town city center across a broad floodplain. Brought up in a working-class household, he was radicalized by the Soweto student uprising in 1976 and the subsequent intensification