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The Republic of Therapy tells the story of the global response to
the HIV epidemic from the perspective of community organizers,
activists, and people living with HIV in West Africa. Drawing on
his experiences as a physician and anthropologist in Burkina Faso
and Cote d'Ivoire, Vinh-Kim Nguyen focuses on the period between
1994, when effective antiretroviral treatments for HIV were
discovered, and 2000, when the global health community acknowledged
a right to treatment, making the drugs more available. During the
intervening years, when antiretrovirals were scarce in Africa,
triage decisions were made determining who would receive lifesaving
treatment. Nguyen explains how those decisions altered social
relations in West Africa. In 1994, anxious to "break the silence"
and "put a face to the epidemic," international agencies
unwittingly created a market in which stories about being HIV
positive could be bartered for access to limited medical resources.
Being able to talk about oneself became a matter of life or death.
Tracing the cultural and political logic of triage back to colonial
classification systems, Nguyen shows how it persists in
contemporary attempts to design, fund, and implement mass treatment
programs in the developing world. He argues that as an enactment of
decisions about who may live, triage constitutes a partial, mobile
form of sovereignty: what might be called therapeutic sovereignty.
Drawing on various disciplinary perspectives, this book re-focuses
the debate on what makes a good health system, with a view to
clarifying the uses of social science research in thinking about
health care issues in Africa. The explosion of the HIV/AIDS
pandemic, the persistence of malaria as a major killer, and the
resurgence of diseases like tuberculosis which were previously
under control, have brought about changes in the health system,
with implications for its governance, especially in view of the
diminished capacity of the public health facilities to cope with a
complex range of expanded needs. Government responsibilities and
objectives in the health sector have been redefined, with private
sector entities (both for profit and not-for profit) playing an
increasingly visible role in health care provisions. The reasons
for collaborative patterns vary, but chronic under-funding of
publicly financed health services is often an important factor.
Processes of decentralisation and health sector reforms have had
mixed effects on health care system performance; while private
health insurance markets and private clinics are pointers to a
growing stratification of the health market, in line with the
intensified income and social differentiation that has occurred
over the last two decades.These developments call for health sector
reforms.
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