Since its independence from Great Britain in 1966, Botswana has largely been considered an Africa success story. It had a stable transition to democracy, has held free and fair elections, and for decades had the fastest-growing economy in sub-Saharan Africa. It also provides citizens with free primary education and healthcare. Yet by 2001, the estimated adult prevalence rate of HIV was 37 percent – the highest prevalence rate in the world.

In response, the government of Botswana, supported by private foundations in the United States, launched sub-Saharan Africa’s first free public antiretroviral (ARV) treatment program. The epidemic also prompted other US-based private foundations and private medical schools to offer assistance, drawn by their growing interest in global health. Visiting Fellow Betsey Behr Brada, an assistant professor of anthropology at Reed College, is examining the implications of this response to the epidemic, including the tensions that arose between healthcare professionals working in Botswana’s national health system and American biomedical practitioners. 

While at the Kellogg Institute for International Studies, she is completing her book, Learning to Save the World: Global Health Pedagogies and Moral Transformation in Botswana. In it, she draws on ethnographic data to trace how biomedical professionals, trainees, patients, and their families frame themselves and one another in terms of global health in the daily pedagogic practices that make up HIV treatment in Botswana.

Why study global health practices related to HIV treatment in Botswana?

Paradoxically, Botswana both fulfills and defies stereotypes of global health. On one hand, as a site it seems to epitomize global health: a devastating epidemic, an overtaxed public health system, and an African population in desperate need of medical care. The country’s public health infrastructure, oriented towards preventative public health, was unprepared for the burden of hospital-based care and chronic debility the epidemic engendered. Until a few years ago, the country even lacked a medical school; the government relied on foreign physicians to fill positions in public hospitals while also sponsoring its citizensto train overseas and relying on them to return to Botswana. On the other hand, even as the treatment program has relied on American funds and institutions for the program’s infrastructural requirements as well as specialized medical expertise, Botswana’s government has been administratively and financially invested from the very beginning. And while popular American representations of Africa tend to assume the incapacity of both African states and African healthcare providers, citizens of Botswana themselves readily recognize the state as the foremost provider of health services, even when they receive those services from expatriates working in the public health system. In short, demarcating institutions, forms of healthcare, or individual practitioners as belonging to “global health” (or not) could actually be quite a precarious exercise.

You found that American medical care providers sometimes expected children in Botswana to be able to say “HIV” in English to prove they understood their diagnosis, even though English wasn’t their first language. What conclusions did you draw from this?

One of my field sites was a pediatric HIV clinic staffed by nurses who are citizens of Botswana and by American pediatricians who spoke almost no Setswana (Botswana’s national language spoken by the vast majority of the population). The more English children spoke, the more pediatricians understood them. But practical concerns aside, pediatricians sought to manage children’s emotions regarding their infections through the use of particular words. Pediatricians feared that children whose relatives lied to them about having HIV would stop taking ARVs – either because they saw no reason to, or because, having realized the truth, they felt betrayed. But like many people in Botswana, pediatricians regarded telling children they had HIV or AIDS as deeply traumatizing. Instead, clinic staff engaged children in stories about masole a mmele, soldiers of the body, who protected children from a sleeping ‘bad guy’ and who children strengthened each time they took their medications. If children didn’t take their medications, the ‘bad guy’ might awaken and the children’s weakened soldiers might not be able to protect them. The big reveal, of course, was that ‘bad guy’ was HIV. But while pediatricians framed this storytelling as shielding children from both too-harsh truths and their families’ harmful lies, it also shielded pediatricians from truths they themselves couldn’t face, like the possibility that the treatment program might fail.

You argue that language plays a surprising important role in the biomedical management of an infectious disease. Why is that?

Language has long been part of the epidemic’s politics. Consider former US President Ronald Reagan’s refusal to say “AIDS” in public, or the insistence by ACT UP (the AIDS Coalition to Unleash Power) that “silence = death.” Other anthropologists have shown that ARV treatment programs entail new forms of speech as well as new bodily habits and sites of socialization, but anthropological research on HIV/AIDS has not taken up linguistic anthropology’s analytical tool kit. For one thing, biomedical practitioners tend to view language as something used to refer to things, but assume it has no real effect on those things even if words shape individuals’ perceptions or behavior. Medical anthropologists likewise tend to consider bodies more real and more important than words. You might expect an emphasis on therapeutic talk in accounts of mental health, but a linguistic analysis of HIV treatment threatens to seem epiphenomenal, like I’m not taking my informants’ suffering seriously. But I was stunned by the sheer amount of time American pediatricians spent coaching HIV-positive children in Botswana into talking about HIV in highly specific terms with the goal of making their adherence to their medications measurable and, more importantly, making them into children who took their pills, thus forestalling a nightmare scenario wherein children developed and even transmitted untreatable strains of HIV. 

What were some of the problems or misunderstandings that arose between health professionals in Botswana and American care providers?

Visiting Americans and “local” practitioners had very different understandings of what they were doing and of each other. “Local” was a category Americans used that erased the fact that public-sector physicians come from other African countries and from South Asia, China, and Cuba, as well as from Botswana. It also erased differences among physicians from Botswana, who trained in places as diverse as Ireland, Australia, and South Africa. But American medical students, particularly, arrived assuming their knowledge was superior to anything “local,” and found the way to define themselves as budding “global” practitioners was to ascribe to anything “local” a sense of inferiority, backwardness, and parochialism. That “local” practitioners did not share American students’ perception of Botswana as an ongoing emergency was seen by students as further evidence of “local” practitioners’ inferior training and disregard for patients, thereby requiring students to intervene with more vigor and less restraint, and further justifying their presence in Botswana. But what students saw as necessary acts of “taking charge” of patients’ care confirmed “local” practitioners’ suspicions that students held little regard for “local” authority and, lacking the moral sensibilities entailed in a long-term engagement with Botswana’s epidemic, were insensible of their capacity for violence toward patients.

Did you find anything in your research that surprised you?

I found the level of tension, bitterness, and even antagonism that suffused the partnerships I observed surprising and very difficult. And global health carries such a positive moral weight that even some of my colleagues seem unconvinced that such hostility persisted. It’s not a question of whether people meantwell: Many individuals within these institutions are skilled practitioners with good intentions who want to care for patients. But the missteps, misunderstandings, and missed opportunities for mutual recognition and collaboration were simply staggering. For example, everyday greetings are a practice that many people in Botswana value highly and linger over; notgreeting someone, even someone you see every day, is deeply antisocial, even suggestive of witchcraft. But this kind of cultural knowledge was totally ignored, utterly unvalued by American institutions. More than four months after one group of American pediatricians arrived, one of the doctors that Americans called “local”– who was actually from a neighboring country – told one of the American pediatricians that he’d realized that the reason the pediatricians regularly failed to greet their “local” colleagues was this: “You just don’t like black people.” The pediatrician was dumbfounded. This type of thing, and worse, happened all the time, and each iteration reinforced the dynamic. Good intentions simply weren’t enough.

Your research asks tough questions about the nature of global health: Is it part of a new movement for social justice, and a reparative gesture in the face of colonial legacies and worldwide inequities? Or is it inherently neocolonial, creating new dependencies under the flag of humanitarianism?

My book proceeds from the argument that global health itselfis an argument, a stance or claim that creates possibilities for individuals to position themselves relative to other individuals and collectivities, to their own and others’ institutions, materials, and ideas, and even in terms of time and space. To say that the book is about global health, then, is a somewhat deceptive statement because I focus on global health’s contingencies. My concern is with how individuals strive to recognize themselves and others in terms of global health or, at other times, to resist this category altogether. But insisting that global health is an argument is only part of the point. Instead, the book’s central question is: How do people useglobal health and related categories to morally transform themselves and those around them? In other words, I track how individuals and the institutions to which they belong wrestle with the inchoate nature of global health, and the sheer labor they must invest in framing what they are doing and to whom they are doing it as belonging to that category and making it legible to others in those terms. This is what I mean by learning to save the world.

After conducting research for your book, what’s your verdict?

For that, you’ll have to read the book. I’d hate to spoil the big twist!

In all seriousness, my research raises questions about the role scholars like myself play not just in determining what counts as global health, but in enacting and validating moral stances that limit the scope of criticism of global health and the forms of accountability to which institutions and practitioners can be held. The book interrogates how anthropologists themselves have participated in constituting the category of global health and its moral stances. It’s not just children in Botswana who learn scripted ways of talking; American medical students and anthropologists of global health describe emotional encounters with suffering others in strikingly similar ways that emphasize redemptive emotional transformations. For all three groups, narratives are imagined to reflect and enact a new moral way of being in the world. Rather than question their sincerity, I’m struck by the conventionalization of self-reflexivity. Global health, in the end, emerges as a kind of moral barometer, a way of imagining the world that shields some of us from accusations of wrongdoing or exploitation as long as we can produce the “right” account of how we feel, and that encourages us to evaluate others in those terms.