Immune Communities, Common Immunities

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Social Text 94 Vol. 26, No. 1 Spring 2008

DOI 10.1215/01642472-2007-021 2008 Duke Universi ty Press

The choice o explanations in medicine is always a choice o values.

Lawrence Kirmayer, Mind and Body as Metaphors: Hidden

Values in Biomedicince

When biomedicine speaks the truth it also speaks morals.

Didier Fassin, When Bodies Remember

For the last seven years, the government o South Arica has been relent-

lessly condemned, reviled, excoriated, chastised, denounced, and ridi-

culed or its ailure to endorse and implement a nationwide distribu-tion o antiretroviral therapy (ART) or people with HIV/AIDS. At the

most recent International AIDS Conerence, held in Toronto in August

2006, the South Arican president, Thabo Mbeki, and health minister,

Manto Tshabalala-Msimang, were regularly personied as recalcitrant

and ignorant, i not pernicious and murderous, or their apparent reluc-

tance to unambiguously arm the doctrine: HIV causes AIDS. Anti-

retrovirals are the only medications currently available that alleviate the

consequences o HIV inection (so read the open letter to Mbeki cal ling

or Tshabalala-Msimangs dismissal, signed by more than eighty o the

worlds leading AIDS experts).1 The outgoing UN special envoy or HIV/

AIDS in Arica, Stephen Lewis, made his moral outrage explicit: The

government has a lot to atone or. Im o the opinion that they can never

achieve redemption. . . . I know that what it is doing is wrong, immoral,

indeensible.2 Though the South Arican government has altered its

position over the past several years and now does oer ART, as well as

Immune Communities,

Common Immunities

Ed Cohen


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postnatal drug protocols to inants born to mothers with HIV/AIDS, its

coverage is ar rom universal. This unevenness o availability (compared

to Brazil, which is oten held up as a model or national ART programs)

leads many critics o Mbeki and Tshabalala-Msimang, both within South

Arica and around the world, to insist that this insuciency betrays their

continuing reusal to acknowledge a basic, universal, incontrovertible,scientically armed act: that HIV is the singular cause o AIDS.

It may seem obvious to those o us in the developed North, and to

many activists and scientists in South Arica as well, that Mbekis and

Tshabalala-Msimangs pronouncements about HIV/AIDS are indeed

lunacy, and conversely that those who speak in the name o science are

objective, reasonable, and sane. However, this opposition belies the com-

plex challenges that arise when we attempt to bring knowledge to bear

upon as dicult and tragic a human situation as the AIDS pandemic. I

the ecacy o antiretroviral treatments seems incontrovertible to those

who espouse the universality o bioscientic paradigms, the contradic-

tory maniestations both o these specic t reatments, and o biomedicine

more generally, in the context and the history o South Arica raise some

uncertainty as to how absolute these claims actually are. In his brilliant

analysis o this troubling nexus o politics, histories, and people, When

Bodies Remember: Experiences and Politics of AIDS in South Africa , Didier

Fassin undertakes to explicate the social logics that underlie the contro-

versial and much reviled positions taken by Mbeki with respect to HIV/

AIDS. Indeed, he argues that Mbekis perspective is not so idiosyncratic

or anomalous as many non South Arican commentators might like to

contend, but rather alls within a range o credible local interpretations that

do not automatically accord truth status to all biomedical claims.

Fassin, a physician, sociologist, and anthropologist, was until 2003

vice president o Mdecins sans Frontires (Doctors without Borders),

so his concerns and experience place him both intellectually and prag-

matically within a dense node o dierent knowledges about HIV/AIDS.

Locating the South Arican experience o HIV/AIDS within the history

o apartheid, and especially with in the history o the role that biomedicine

and social medicine strategical ly played in shoring up the apartheid regime,

Fassin argues that some South Arican skepticism about the biomedical

raming o the epidemic might not be entirely unwarranted. Moreover,

given the countrys dicult i not precarious economic and social condi-tions, where unemployment, inadequate ood and housing, and violence

regularly impinge dramatically on peoples lives, and indeed cause more

deaths each year than AIDS, questions o health and il lness might not be

immediately comprehensible solely in terms o biochemical causality and

treatment. Hence, the assert ion made by the scientists who signed the open

letter to President Mbeki that antiretrovirals are the only medications


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currently available that alleviate the consequences o HIV inection may

precisely miss the point that all the consequences o HIV inection do not

take place solely at the cellular or molecular levels and that these cells and

molecules themselves also necessarily exist with in a larger biosocial world

where causes are not only viral.

Biomedicine limits knowledge about how HIV/AIDS inhabits thisworld and the human organisms who exist within it by arming that

individuals constitute the central, i not exclusive, locus o concern. Since

the middle o the nineteenth century, when experimental physiologist

Claude Bernard rst provided the epistemological justication or using

data gathered in laboratories in order to explain how organisms live (still

the theoretical oundation or all current laboratory-based research pro-

tocols, including those o immunology and virology), biomedical thought

and practice have been increasingly inormed by Bernards overtly politi-

cal corollary:

Medicine must act on individuals. It is not destined to act on collectivities or

people. . . . In reality, one only acts on individuals. Collectives are entrained

in currents upon which we can have no eect. These are general actions

which are beyond us. It is the same with epidemics and epizootics. One can

act on the individual who presents oidium, plague or cholera; but one cannot

act on the general cause o plague, cholera, etc., etc.3

With this opposition o the individual to the general, Bernard biurcates

the living world into an inner and an outer milieu whose causes are dis-

tinct, with only the ormer being subject to medical intervention.4 Subse-

quent to this epistemological justication, over the last century or so bio-

chemical reductionism, especial ly as it has been developed and capitalized

upon in North America, has more and more reduced the locus o medical

and health concerns to the isolated body o the singular individual, as the

eminent medical anthropologist Margaret Lock has succinctly noted:

Eorts to reduce suering have habitually ocused on the control and repair

o individual bodies. The social origins o suering and distress, includ-

ing poverty and discrimination, even i feetingly recognized, are set aside,

while eort is expended in controlling disease and averting death through

biomedical manipulations.5

Furthermore, Lock continues:

It is now apparent in most corners o the world, except perhaps in the hear t

o the Leviathan, that science, and in particular biomedicine, has come to be

thought o by many as one orm o neo-imperialism. In an era o struggles to

create and recreate cultural identities and establish grounds o cultural di-

erence, the sel-conscious possession o scientic knowledge, or, alternately,


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its repudiation as inauthentic or culturally inappropriate, is explicitly made

use o to establish local power bases and authority. The production and cir-

culation o technologies are, thereore, not only ar rom autonomous but, on

the contrary, incite and oster culturally inused political activity.6

Biomedical knowledge and biomedical technologies, Lock suggests,

import alongside themselves the underlying political, ethical, and moral

assumptions that they unconsciously incorporate. In this case, the lurk-

ing axiom holds that the individual orms the natural biopolitical atom.

However, this endorsement o one culturally and historically ordained

orm o personhood as the paramount, biologically inscribed instance o

personhood does not in act exhaust the ways that humans think about and

experience either their vitality or their connections. Other ways o imagin-

ing humanness lead to other models o care and treatment, as or example

traditional Chinese medicine, Ayurvedic medicine, or even the history o

humoral medicine il lustrate. Opposition to biomedical explanations and

protocols, then, does not necessarily indicate wrong, immoral, [or] inde-

ensible ideas, as Stephen Lewis opined, but may reveal a undamental

value confict that bioscientic accounts obscure when they declare the uni-

versal validity o their insights. Indeed, the conficts about the importation

o bioscientic treatments may reveal certain unacknowledged cultural and

political limitations secreted within bioscientic truth claims about HIV/

AIDS limitations that inhibit its abil ity to encompass the complexity o

the situation as it exists in South Ar ica and elsewhere.

Pragmatical ly and conceptual ly, Fassin suggests, biochemical reduc-

tionism and individualism may not be u lly adequate either to explain or

to redress the experience o HIV/AIDS in South Arica:

Since the beginning o the pandemic, the ocus o discourse and policies

throughout the world solely on the medical aspects o the illness, and since

the beginning o the South Arican controversy, solely on the availability

o drugs, has made the social issues (both carried and revealed by AIDS)

practically inexpressible. O course a number o opposition critics have

conceded that poverty is certainly a serious problem, that i one were taking

anti-retroviral drugs, one should be able to eat it was hardly possible to do

otherwise than admit it but rare were those will ing to draw the conclusion,

both about what happened yesterday and about what is happening today. 7

From Fassins perspective, the ocus on getting drugs into bodies (as

the amous ACT-UP slogan in the United States put it) may not suce to

ameliorate the health conditions encompassed by the rubric HIV/AIDS.

This is not to say that antiretroviral therapies are not eective or that

they do not provide amazing results or those with enough resources to

acquire them and to take them saely. Undoubtedly, the desire to provide


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eective antiretroviral medications more widely is very laudable, as is the

eort to orce the pharmaceutical industry to provide them at aordable

prices. The discrepancy between access to pharmaceuticals both within

Arica and around the globe clearly bespeaks a massively unjust and

inequitable distribution o resources that contributes to large dierential

distributions o suering and immiseration. Yet by naturalizing thesebiochemical protocols as the most eective i not the only strategies

capable o redressing the consequences o HIV/AIDS, the insistence on

these drug regimes as noncontroversial and universal options eectively

brackets alternate understandings that might locate HIV/AIDS not just

within suering and vulnerable human bodies, but within the biosocial

domain as a whole.

Taking a position complementary to Fassins in her powerul and

moving bookNeoliberalism and AIDS Crisis in Sub-Saharan Africa: Global-

izations Pandemic, Colleen OManique also calls attention to the ontologi-

cal monism o AIDS policies in sub-Saharan Arica at the levels o both

treatment and prevention: The institutional response to AIDS in SSA

remains ocused on the autonomous individual who is to be empowered

to protect hersel or himsel rom inection, or cope with imminent death

in the absence o treatment.8 In OManiques view, this restricted and

restrictive ocus o concern bespeaks the advent o neoliberalism as an

economic imperative that dictates the shape o both national health policies

and international eorts to redress the pandemic within Arica:

Neoliberalism is largely consistent with the biomedical construction o

AIDS, which reduces the AIDS pandemic to its individual clinical and

behavioral dimensions. In eect, what is erased or obscured are the materialconditions which allow the virus to thrive, the broader actors that condition

access to treatment, and the day to day realit ies o aected households where

the tangible impacts are elt. . . . One eect o biomedicines hegemony is

depoliticizing disease; removing the understanding o disease rom its social

context and placing it back into the individual body.9

While enthusiastically concurring with OManiques assessment rom

the point o view o political economy, I cannot however entirely endorse

her sense that the eect o biomedicines hegemony is a depoliticizing

o disease. Nor do I agree with her corollary assertion: The problem

rests not with biomedicine per se. For the issue with biomedicine is notthat it makes politics extrinsic to its theory and practice, but rather that

it incorporates a specic politics, liberal individualism, within itsel as

i it were natural act. Moreover, this incorporation takes place not just

at the levels o corporate development o drugs or treatments and their

distribution through capitalisms market mechanisms. Indeed, it appears

deeply embedded in biomedicines oundational apprehension that the


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singular, epidermally bound, human organism that deends itsel against

a relentlessly pathogenic environment constitutes a universal truth. Thus,

I would claim that the consistency between neoliberalism and the bio-

medical construction o HIV/AIDS is not accidental or conjunctural, as

OManique seems to intimate, but actually reveals the extent to which

biomedicine itsel continually corporealizes the assumptions o classicpolitical and economic liberalism as biological or even natural phenom-

ena. Neoliberalism then might be seen to recapitulate these natural

assumptions both through its economic and political policies and also

through its insistence that the highly capitalized and corporatized orms

o biomedicine provide the most credible treatment options not just or

HIV/AIDS but or maniold challenges to health and well-being around

the world.

In order to tease out some o these claims about the biopolitics o

modern medicine, or the rest o this essay I will ocus on the original

controversy incited by Thabo Mbekis comments at the Thirteenth Inter-

national AIDS Conerence, held in Durban in 2000, which unleashed the

deluge o opprobrium that has inundated the South Arican president since

then. By analyzing the ensuing discursive confict, I want to consider the

ways that it might make visible and intelligible some unarticulated and

unarticulable assumptions about bioscience as a natural and exclusive

ramework or comprehending and addressing HIV/AIDS. In particular,

I want to suggest that the bioscientic paradigm o immunity, which ater

all literally lies at the very center o HIV/AIDS, might not transparently

reveal the material processes o the living organism as it coexists with other

living beings in shared environments. Instead, immunity, which existed

as a powerul jur idical and political concept or over two thousand years

beore it was applied to vital contexts, construes the individual as a natural

unit and thereby renders the social and political mil ieu within which this

individual necessarily lives extrinsic or epiphenomenal with respect to lie

itsel. To the extent that the bioscientic imagination o HIV/AIDS enolds

this individualizing and sel-isolating ramework as an essential t ruth, that

is, as a natural act, it necessari ly represents the phenomena it describes

as an inevitable consequence o the political and legal assumptions that it

unrefectively incorporates.

To a large extent, my project simply extrapolates rom Paul Farmers

observation that a critical epistemology o emerging inectious diseasesis still in the early stages o development. A key task o this endeavor is to

take our existing conceptual rameworks and ask, what is obscured in this

way o conceptualizing disease? What is brought into relie?10 Hence,

though there is certainly much to lament about how treatment and pre-

vention programs or HIV/AIDS have been implemented in South Ar ica

and elsewhere, I am not interested in assessing blame or responsibility,


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or even in discerning the relations between the South Arican presidents

utterances and his governments policies (which Fassin has already done so

well). Nor am I claiming that President Mbekis comments refect a deep

and careul analysis o the epistemological, political, and historical context

o biomedical paradigms. Instead, I merely want to entertain the possibility

that by considering the controversies about HIV/AIDS in South Aricaas conficts ovalues, we might il luminate how the concerns o health

care get construed in bioscientic accounts o HIV/AIDS and reconsider

what the salient biopolitical dimensions o health and lie actual ly are. In

other words, through a reading o the h ighly emotional and oten deeply

polarizing discourse engendered by the tragedy o HIV/AIDS in South

Arica, I hope to oer an opportunity to expand our understanding o how

we l ive and die together as individuals, as collectives, as organisms,

and as species.

Defensive Values, or Whats in a Cause?

South Arican president Thabo Mbekis opening address to the Thirteenth

International AIDS Conerence in July 2000 precipitated an immediate

global uror. Indeed, even beore Mbeki had spoken a single word, the

anticipation that he might call the bioscientically endorsed credo that

HIV causes AIDS into question led more than ve thousand scientists

worldwide to sign the Durban Declaration, categorically rearming

the scientic evidence that HIV is the sole cause o AIDS.11 In his

actual speech, however, Mbeki never denied this correlation between HIV

and AIDS, though he did briefy acknowledge that he and members o

his government had raised questions about the import o the connection.Instead, he spent much o his time ocusing on other causally salient ac-

tors that he believed the bioscientic investment in HIV as the sole cause

o AIDS obscured: that is, poverty, suering, social disadvantage and

inequity.12 While the leading AIDS researchers also acknowledged that

poverty, deprivation, and social and economic injustice played some part

in ostering the devastating spread o AIDS in Arica, they nevertheless

emphatically insisted that when questions o causality arose, only HIV

could be named. Mbeki, on the other hand, seemed to invoke a more

expansive understanding o causal relations: The worlds biggest killer

and the greatest cause o ill health and suering across the globe, includ-

ing South Arica, is extreme poverty. He immediately ollowed this causal

invocation with an expression o its moral and ethical import: Is there

more that all o us should do together, assuming that in a world driven by

a value system based on nancial prot and individual material reward, the

notion o solidarity remains a valid precept governing human behavior.

Mbeki had barely ceased speaking, when the horried chorus o


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bioscience arose en masse, as i to drown out his very utterance. The con-

demnations were ubiquitous, persistent, impassioned, and sel-righteous.

Not only had Mbeki broken aith with the precepts o biomedicine, but he

verged on apostasy by daring to entertain the opinions o scientists (like the

inamous Peter Duesberg) who held that the HIV/AIDS linkage was less

than absolute. As the esteemed international publication Science character-ized the emerging scandal: Not only is Mbeki publicly firt ing with scien-

tically discredited ideas about the cause o AIDS, but a leading skeptic o

HIVs role in the disease has been invited to serve on a panel to discuss how

South Arica should deal with the crisis.13 It is not my intention to consider

the current state o medical dogma on AIDS and its cause or causes. Nor

do I want to refect on the policy implicat ions that Mbekis statement at the

Thirteenth International AIDS Conerence had with respect to the general

distribution o antiretroviral drugs in South Arica or their use by pregnant

women to disrupt HIV transmission to their ospring (oten named as the

most likely deleterious consequences o Mbekis ideas), though I do believe

that all these topics might stil l benet rom urther meditation.14 Instead,

I am interested in refecting on why the scientic and medical reactions to

Mbekis questions and opinions were so ulminating and vocierous that

is to say, so emotional. Ater al l, as Mbeki himsel pointed out, the title or

the conerence was Breaking the Silence, so shouldnt his questions at

least have been allowed, i not even welcomed?

The openly hostile and aective quality o the opposition to Mbekis

speech seems, to me, to indicate that something else might have been

at stake in the critical responses besides alerting the public to Mbekis

wrongheadedness along with whatever signicance it may have or South

Arican health policy. The horried challengers to Mbekis really quite

tentative broaching o the possibility that considerations o AIDS causality

might need to encompass more than a retrovirus did not just lament his

benighted ideas about HIV/AIDS; they sought to revile him as either an

idiot or a political monster. The voices o science spoke as one to proclaim

all positions other than their own illegitimate: that is, they proessed that

not only are no other possible explanations credible, they are not even

worthy o being considered. Whatever understanding the South Arican

presidents position relies upon, the ocial voices o science intoned, they

necessarily lie outside the pale o what bioscience denes as the truth

o the situation. Thereore, they must be violently repulsed insoar as theyreveal threatening monsters on the prowl, as Michel Foucault named

such epistemological outliers, lurking beyond the borders o veriable

knowledge.15 Mbekis comments were not just seen as errors o knowledge,

then, or such errors would at least be subject to protocols o verication

and alsication. Rather they were an aront to the very ground o truth

that science represents as act and in whose name it claims its authority.


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Thereore, or the spokespeople o science, they were not just risible, they

were actively malignant.

Nothing illustrates this rhetorical strategy more clearly than the

remark made by the Oxord-trained president o South Aricas Medi-

cal Research Council and ormer Mbeki ally, William Makgoba, who

said: The sad part is, hes trying to politicize scientic acts and thatswhat the Nazis did.16 The infammatory invocation o the Nazis here to

characterize the South Arican presidents position might alert us to the

possibil ity that more than science was at stake in this controversy. Clearly,

by playing the Nazi card, Makgoba intends to trump Mbeki, with no ur-

ther discussion needed. Yet still we might wonder, i the scientic acts

possess so much certainty, and i these acts are indeed so apolitical, why

has the scientic community responded so deensively? Obviously no one

disputes that the AIDS epidemic engages political concerns. Even the

most cursory refections on the global distribution o HIV/AIDS and the

measures taken (or not taken) to ameliorate the pandemic must recognize

the complex political and economic challenges that shape how care and

prevention operate. Furthermore, the inamous history o the highly con-

tested bioscientic discovery and naming o HIV itsel, as well as the

ensuing pharmacological investments and prots that derive rom ocusing

exclusively on this retroviral agent, also plainly indicate that both politics

and economics percolate through the HIV/AIDS art iculation. However,

while acceding to the notion that AIDS might be a political issue, what

seems to have incensed the bioscientic community is the suggestion that

their own scientic explanations or the aggregate phenomenon denomi-

nated as HIV/AIDS might themselves be directly political.

Consider or a moment how the signers o the Durban Declaration

arm their understanding o the scientic acts. In their statement,

the Durban Declaration signatories repeatedly invoke their credibi lity as

authorities to speak truthully about HIV/AIDS. They cite a whole archive

o documentation produced by what some now reer to as the AIDS

industry in order to arm their assertion that HIV is the sole cause o

the AIDS epidemic. Nonetheless, they also eel obliged to acknowledge

that limited resources and the crushing burden o poverty in many parts

o the world constitute ormidable challenges to control o HIV inection.

Then, ollowing this glancing gesture toward the biopolitical world in

which HIV/AIDS lives, they nevertheless conclude: To tackle the diseaseeveryone must rst understand that HIV is the enemy. While they might

have imagined that this statement simply arms an indisputable, scientic

assessment o the situation, it actually does not. Instead, their rhetorical

characterization o HIV as the enemy explicitly reveals the politics

deeply embedded in their putatively nonpolitical position. The language

o riend/enemy in no way derives rom the matter o the world; it does


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not describe the unolding o natural, biochemical processes according to

immutable natural laws; it does not constitute an unmediated representa-

tion o an essential physical truth; rather the trope o riend/enemy grounds

the development o politics as it has unolded in Western culture since

the time o Aristotle.17 In act, it has provided one o the most canonical

rameworks or dening the political as such ever since there rst wasa polis. More important or my purposes, though, it has underwritten the

bioscientic investment in immunity as a biological orm o sel-deense

or the last one hundred years.

By identiying HIV as the enemy, bioscientic representatives who

signed the Durban Declaration construe AIDS in terms o a thoroughly

biopolitical investment in immunity the Iin both HIV and AIDS that

rst emerged at the end o the nineteenth century. Since then medicine

has implicitly divided up the lie world into riend or enemy camps, eec-

tively dening the human organism as what immunitys rst theorist,

the Russian zoologist Elie Metchniko, called lechamps de bataille the

eld o battle.18 Today the bellicose spirit o vital warare infects and

inects the prevailing ethos o modern medicine in many respects. As

Donna Haraway and Emily Mart in have noted, within the contemporary

biomedical ramework, the human organism appears as a deended rontier,

bound within an epidermal envelope that establishes the limits o a sel,

which is both exposed to and opposed to microbial others who threaten to

negate its very existence.19 One critical consequence o this raming has

been that scientic medicine came to ocus its concern almost exclusively

on the individual as a putatively natural unit o analysis, concomitantly

bracketing all social, political, economic, and environmental actors as

at best secondary or epiphenomenal. Insoar as the war on AIDS has

paradoxically marshaled, and indeed radically expanded, the resources

o immune discourse against an inectious agent that lays waste to the

very deensive capabilities usually ascribed to the immune system itsel, it

redoubles the biopolitical commitment to this individualizing perspective

by excluding the human organisms vital contexts rom its purview.

The Germs of History

Refecting briefy on immunity-as-sel-deense as the conceptual arma-

ture around which the discourse o HIV/AIDS builds itsel reveals some

o the political implications that bioscience unwittingly imposes even as

it claims to provide universal and invariant explanations. Thus, despite

whatever eccentric, or misguided, or perhaps even noble intentions moti-

vated it, Thabo Mbekis address to the Thirteenth International AIDS

Conerence could also alert us to the ways that biosciences unconscious

and unacknowledged political assumptions might actually circumscribe


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its ability to achieve the ameliorative eects it and we desire. Immunity-

as-sel-deense dramatically entered scientic thinking in the 1880s as a

way o making sense o Pasteurs triumphant vaccination experiments.

First articulated by Metchniko, the new concept sought to explain how

multicellular organisms coexist in shared environments with microorgan-

isms that are sometimes deleterious to their well-being.20

Adapting hisinsights about the evolutionary conservation o unction to amoeboid cells

that he named phagocytes (macrophages), Metchniko theorized that

what had been a digestive unction in single-celled organisms came to

serve as a deense mechanism in the course o evolutionary development.

He named this mechanism immunity.21 Yet long beore either immunity

or sel-deense had any biological valence whatsoever, they had deep and

complex legal and political signicance.

Immunity was rst conceived during the Roman Empire and has

served rom then until now as one o the most important means by which

conficting political and legal demands can be reconciled while maintaining

the universal applicability o the law.22 Sel-deense emerged as the rst

Right o Nature during the seventeenth century when Thomas Hobbes

dened it in Leviathan (1650) as an obligation incumbent on individual

subjects insoar as they are politically constituted as essentially vulner-

able to being killed by other individuals.23 These two concepts have pro-

oundly shaped the unolding o Western politics: immunity has circum-

scribed the ways dierent political domains negotiate their relative elds o

power (local /imperial, church/state, sovereign/subjects, nation/state/local /

individual, nation/nation, etc.) and sel-deense has grounded the rights

o individuals per se. It is hard to get more political than that. Moreover,

immunity never meant sel-deense until Metchniko used the two

concepts in order to comprehend what he imagined as a naturally antago-

nistic relation between microbes and the organisms that they inect.

Metchnikos resignication o immunity and/as sel-deense pro-

vided Pasteur with a plausible explanation or why his vaccines worked

which is why he immediately hired Metchniko and set him up in a lab at

the new Pasteur Institute, where he stayed or the rest o his li e. Together

their two innovations, vaccination and immunity, secured the credibility

o germ theory and simultaneously undermined the more diuse causal

explanations oered by the until then prevailing public health move-

ment, as Bruno Latour has demonstrated.24

Indeed, I might argue thatwhen Metchniko used legal and political concepts to explain Pasteurs

triumphs, it transormed germ theory into a virtual law o nature.

Beore the Pasteur-Metchniko revolution, however, monocausal theories

o disease had not yet been legitimated. Instead, a variety o environmen-

tally and humorally centered notions prolierated.25 In these earlier medi-

cal rameworks, organisms were comprised o, and thereore inextricably


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linked to, the elements that constituted the world in which they lived. Illness

resulted rom imbalances among these constitutive or ambient elements,

while health emerged rom the restoration o inner and outer harmony. 26

Immunity replaced the goal o harmonizing the organism both in itsel and

with its environment the historical basis or the notion onatural healing,

the Vis Medicatrix Naturae with the premise that lie necessitates a violentengagement against the world as a condition o its continuity.27

Not coincidentally, this deensive translation o immunity rst

appeared in a historical context where epidemics o inectious diseases

(typhoid, typhus, measles, tuberculosis, cholera, infuenza, smallpox)

caused extensive mortality and morbidity, oten threatening the economic

and political stability o European nations. Indeed, European governments

implemented complex policies and devoted extensive resources to circum-

venting or dampening the impact o these bouts o contagion. Beginning

in the 1850s, international congresses were regularly convened to debate

the relative merits o measures such as sanitary reorm, umigation, and

quarantine or interrupting the circulation o inections with in and across

geopolitical boundaries.28 In order to address these epidemics, states were

orced to acknowledge that their concurrence not only could be a matter

o political, economic, or military concern, but must also literally be a

matter o liv ing and dying together. Epidemic il lnesses remapped the

conceptual space o Europe. As states struggled to regulate and control the

fows o resources and peoples that served as the vectors or contagion, they

conceptually regured their boundaries, i not the very notion o bounded-

ness itsel. No longer would borders appear only as contiguous rontiers

demarking the l imits within which territory and nation get mapped onto

each other. Instead, boundaries now needed to be rethought in order to

circumscribe those internal conditions through which contagions (rom

the Latin con- + tangere, meaning touching together) brought the touch

o the other home.

In this contiguous biopolitical context, the idea o immunity-as-

sel-deense assumed its signicance as a modern biomedical concept.

Incorporating the same economic and political imperatives that made

responding to epidemics a national necessity, immunity came to be dened

as an organismic orm o sel-deense that metaphorically andmaterially

injected politics into nature. By ascribing hybrid juridical and political

unctions to the living organism, the coincident translation o immunityand sel-deense rom law and political philosophy respectively into bio-

logical terms simultaneously acknowledged and yet also masked the deeply

social stakes entailed in the putatively natural phenomena o inectious

disease. For, with the biologization o immunity-as-sel-deense, the appro-

priate political response to inect ion would now seem to emanate rom the


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organism itsel. In the context o requent epidemics and their maniold

costs, the ear o illness organized medical thinking about disease not

only as a phenomenon o living organisms, but also as a political, economic,

and national threat. Metchniko literalizes this ear by internalizing it:

immunity gures the organism in a relentlessly hostile world against which

it deends itsel by deploying an evolutionarily adapted unction that con-stitutes its interior as a champs de bataille. Biological immunity, imagined as

the organisms deensive resource, thus unwittingly construes, or perhaps

misconstrues, the human lie world as a refection o the very biopolitical

context in which biomedicine seeks to intervene.

Living with the Enemy

When Thabo Mbeki questions the premise that the Durban Declaration

categorically armed, namely that HIV is the sole cause o AIDS, he

opens a space rom which to reconsider the implicit yet unacknowledged

biopolitics that immune discourse secrets within the juridico-political

metaphors that orm its core. Moreover, Mbeki calls attention to the limits

that biomedical notions o causality import when they claim to encompass

the historical events we now know as AIDS: One o the questions I have

asked is are sae sex, condoms and anti-retroviral drugs a sucient

response to the health catastrophe we ace? The question o suciency

seems critical here: Mbeki does not say that HIV has no agency; rather he

intimates that ocusing on HIV as a cause o AIDS may be (scienti-

cally) necessary but not (politically) sucient.29 Yet in response to this

suggestion, biomedical experts vocierously, i not aggressively, insist not

only that HIV is a sucient condition, but that claiming otherwise wouldbe both scientical ly invalid and politically naive. However, Mbeki is not

so naive as all that either politically or scientically. Listen to how he

characterizes the health crisis o enormous proportions that conronts

Arica, a crisis that includes but is not totalized by HIV/AIDS, a crisis

that encompasses many other inectious diseases and environmental con-

ditions that oten coexist with and/or exacerbate the suering o those

people living with HIV/AIDS:

One o the consequences o this [health] crisis is the deeply disturbing phe-

nomenon o the collapse o immune systems among millions o our peo-

ple, such that their bodies have no natural deense against attacks by many

viruses and bacteria. . . . It seems to me that every living Arican, whether

in good or ill health, is prey to many enemies o health that would interact

one upon the other in many ways, within one human body. And thus I came

to conclude that we have a desperate and pressing need to wage a war on all

ronts and realize the human right o all our people to good health.


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I we view the controversy over Mbekis perspectives on HIV/AIDS in

light o Fassins analysis, we begin to discern the social and historical

logics that make his position not only comprehensible but critical. Mbeki

not only challenges the political, economic, and epistemological assump-

tions that have been brought to bear in order to make truth claims about

the AIDS epidemic in his nation, he demonstrates that the epistemologi-cal claims are also political and economic ones. Surely this insight could

have very signicant consequences or how HIV/AIDS is addressed in

South Arica and around the world. Insoar as it troubles the ontological

and epistemological grounds upon which biomedicine ounds its exclusive

claims to alleviate the consequences o HIV inection (as the scien-

tists open letter to Mbeki put it), it may open up other as yet unutilized

or underutilized ideas and resources, which might then both alter what

such consequences appear to be and oer dierent ways o addressing

them. At the very least, it might help rerame the ways the subjects and

objects o concern whether viruses and drugs, individuals and collec-

tives, housing and ood, money and resources, laboratories and clinics,

policies and politics, bir th and death, immunity and community get

conceived when we speak about HIV/AIDS.

Since I am not in any position to speculate about what dierent

possibilities might emerge rom the local, national, transnational, or even

global contexts where these concerns actual ly live, I would not presume

to suggest what the appropriate orms o such reconceptualizing might be

either or South Arica or anywhere else. Instead, I will close by merely

noting (with respect to a situation I do know something more about) that

Mbekis implicit critique also points to a more general confation that

biomedical understanding incorporates and imports when it assumes that

its paradigms speak or nature itsel. When bioscience takes immunity-

as-sel-deense to describe the natural condition o possibility or how

organisms o dierent sizes and scale coexist, it orgets that these

concepts emerge out o a long history o political and legal thinking that

unolds primarily across the history o Europe and North America, rom

the Roman Empire to the International Criminal Court.31 Recalling the

contingency o this ramework, Mbekis critique o HIV/AIDS discourse

inverts the immunological understanding that we are condemned to live

in a permanent state o internal war by the very resources through which

we imagine ourselves to heal rom illness. Furthermore, it prompts us toremember that as organisms we are constrained to live together, and insoar

as we must modulate our openness both to other humans and to the other

others with whom we coexist, we can never not also remain open to them

without kill ing ourselves. As Donna Haraway so eloquently put it: Lie

is a window o vulnerability. It seems a mistake to close it. 32


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How might this venerable and vulnerable insight make the world

we live in a little dierent? When in the early 1880s Elie Metchniko

sought to characterize a orm o organismic activity that he described

as deense, he gave the term immunity its modern biomedical valence.

Imagine what might have happened i he had not been so ocused either

on the individual organism as an epidermally enclosed system, or on thedynamics o aggression and response that underwrote his political ontol-

ogy, his evolutionary worldview, and his laboratory experiment. He might

then have chosen instead to describe the dynamics through which complex

organisms systematically mediate their relations with those others with

whom they necessarily concur by using immunitys etymological opposite:

community, since community oregrounds the co-constitutive dynamics o

living.33 Imagine what might have happened i community had achieved

the same status o biological concept in the way that immunity did. How

dierently might we live in the world imagining that our commune sys-

tems mediated our living relations with and in the world? How might we

experience ourselves as organisms, i we imagined that coexistence rather

than sel-deense provides the basis or our well-being? How might we have

organized our care or the ill and our systems o healing, or indeed our

entire political and economic relations, i we imagined that our ability to

respond to corporeal chal lenge represents an aspect o our ability to com-

mune with others? Might biological community have enabled us to perceive

healing not just as a biomolecular phenomenon but also as a political, ethi-

cal, and material value? Might it encourage us to ask along with Thabo

Mbeki: Is there more that all o us should do together, assuming that in

a world driven by a value system based on nancial prot and individual

material reward, the notion o solidarity remains a valid precept governing

human behavior? A silly thought experiment, perhaps. Nevertheless, it

does suggest that there may be more to what we call biological immunity

than we currently know, or are indeed even capable o knowing, so long

as we remain inected by those biopolitical perspectives that it deensively

denes as our nature.

Coda

While my hypothetical contrast o immunity to community at best seeks

to ollow up Paul Farmers suggestion that we ask, What is obscured

in this way o conceptualizing disease? What is brought into relie?

other more engaged writers are also posing similar questions. By way o

conclusion, let me oer one compelling example. In his book Fassin cites

an underground document making the rounds o the Arican National

Congress (ANC) in March 2002:


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This monograph accepts that our people, and others elsewhere in Arica

and the rest o the world, ace a serious problem o AIDS. It accepts the

determination that AIDS stands or acquired immunodeciency syndrome.

It accepts that a syndrome is a collection o diseases. It proceeds rom the

assumption that the collection o diseases generally described as belonging

to the AIDS syndrome has known causes. It rejects as illogical the proposi-

tion that AIDS is a single disease caused by a single virus, HIV. It accepts

that an essential part o AIDS is immune deciency, that this immune de-

ciency may be acquired, that there are many conditions that cause acquired

immune deciency, including malnutrition and disease. It thereore argues

that, in our current situation, many and varied interventions have to be

made to protect and strengthen the immune system o our people. It accepts

that these include attention to our nutrition and the eradication o the dis-

eases o poverty that afict millions o our people.34

In elucidating its premises, the ANC document begins by articulating its

relation to the bioscientic accounts o HIV/AIDS. It accepts the basic

description o AIDS as proered by medical explanations, but it breaks

with these explanations over the construal o causality. Distinguish-

ing between a syndrome as a collection o diseases and a disease, it

rejects on logical grounds the notion that a syndrome can have a single

cause. It then expands the causal nexus rom which it imagines immune

deciencies might arise to include biological variables (malnutrition and

disease) that have social, political, and economic determinants. Obvi-

ously, rom what I have written here, I share many o these critiques o

monocausal explanations. Yet the more compelling ormulation, rom

my perspective, is the collective articulation: the immune system o our

people. With this turn o phrase, the document radically subverts theprevailing, highly individual notion o the immune system, resigniying

it so that it appears no longer as something that lives only in the singular

organism, but rather a lso as something that exists in the world maybe

even constituting an immune community with common immunities. Per-

haps this is one thing that the tragedy o the AIDS pandemic can teach

us: that wherever we take it to be localized, the biological unction we cur-

rently call immunity necessarily lives in the world. We might even say that

however we conceptualize it, it necessarily reers to the matter o living

in the world, or indeed literally to the matter that allows us to live and to

continue to live in the world as organisms, as individuals, as peoples, andas species. Or lets hope so, anyway.


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Notes

Id like to thank Julie Livingston, David L. Eng, and the anonymous readers or

Social Textor greatly enriching this essay.

1. Letter to South Aricas President Thabo Mbeki, www.aidstruth.org/

letter-to-mbeki.php (accessed 1 August 2007).

2. Stephen Lewis, Remarks to the Closing Session o the XVI InternationalAIDS Conerence, www.whrnet.org/docs/perspective-lewis-0608.html (accessed

1 August 2007).

3. Claude Bernard, Penses: Notes dtaches (Paris: Bailliere & Fils, 1937),

76 77.

4. Bernards amous epistemological intervention was to posit the quasi-

oxymoronic ormulation milieu intrieuras the locus where the organism really lives.

With this paradoxical turn he eectively denes milieu intrieuras the actual living

environment and thereby eschews the material social context as a relevant biologi-

cal variable. For an extended discussion o Bernards signicance, see Ed Cohen, A

Body Worth Defending: Immunity, Bio-politics, and the Apotheosis of the Modern Body

(Durham, NC: Duke University Press, orthcoming).

5. Margaret Lock, Displacing Suering: The Reconstruction o Death inNorth America and Japan, Daedalus 125, no. 1 (1996): 210.

6. Ibid., 211.

7. Didier Fassin, When Bodies Remember: Experiences and Politics of AIDS in

South Africa, trans. Amy Jacobs and Gabrielle Varro (Berkeley: University o Cali-

ornia Press, 2007), 189.

8. Colleen OManique, Neoliberalism and AIDS Crisis in Sub-Saharan Africa:

Globalizations Pandemic(New York: Palgrave Macmillan, 2004), 4.

9. Ibid., 5 6.

10. Paul Farmer, Infections and Inequalities: The Modern Plagues (Berkeley:

University o Caliornia Press, 2001), 40.

11. The text o the Durban Declarat ion was published in Nature, 6 July 2000,

15 16.

12. The text o Mbekis speech can be ound at www.virusmyth.net/aids/

news/durbspmbeki.htm (accessed 1 August 2007). All urther reerences will be to

this site.

13. Jon Cohen, AIDS Researchers Decry Mbeki Views on HIV, Science, 28

April 2000, 590.

14. See, or example, a recent essay which itsel has led to yet more con-

troversy and recriminations assessing both the scientic evidence or the HIV

causes AIDS mantra and the faws in the Uganda study that underwrites the asser-

tions that ART administered to pregnant women cuts the transmission o HIV to

newborns: Celia Farber, Out o Control: AIDS and the Corruption o Medical

Science, Harpers, March 2006, 37 53.

15. Michel Foucault, The Discourse on Language, in The Archaeology of

Knowledge, trans. A. M. Sheridan Smith (New York: Pantheon, 1972): Within its

own limits, every discipline recognizes true and alse propositions, but it repulses

a whole teratology o learning. The exterior o a science is both more, and less,

populated than one might think: certainly, there is immediate experience, imaginary

themes bearing on and continually accompanying immemorial belies; but perhaps

there are no errors in the strict sense o the term, or error can only emerge and be

identied within a well-dened process; there are monsters on the prowl, however,


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whose orms alter with the history o knowledge. In short, a proposition must ulll

some onerous and complex conditions beore it can be admitted within a discipline,

beore it can be pronounced true or alse it must be, as Monsieur Cangui lhem might

say, within the true (223 24).

16. See, or example, Jon Cohen, A Research Renaissance, South Arican

Style, Science, 23 June 2000, 2169, and Richard Chaisson, World AIDS Coner-

ence in South Arica: Science, Politics and Health, The Hopkins HIV Report, Sep-tember 2000, www.hopkins-aids.edu/publications/report/sept00_1.html (accessed

1 August 2007).

17. Jacques Derrida, The Politics of Friendship, trans. George Collins (New

York: Verso, 1997).

18. Elie Metchniko, Sur la lutte des cellules de lorganisme contre linvasion

des microbes,Annals de LInstitut Pasteur, July 1887, 328.

19. Donna Haraway, The BioPolitics o Postmodern Bodies: Constitutions o

Sel in Immune System Discourse, in Simians, Cyborgs, and Women: The Reinven-

tion of Nature (New York: Routledge, 1991), 203 30; Emily Martin, Flexible Bodies:

Tracking Immunity in American Culture from the Days of Polio to the Age of AIDS

(Boston: Beacon, 1994).

20. Alred Tauber and Leon Chernyak,Metchnikoff and the Origins of Immu-

nology: From Metaphor to Theory (New York: Oxord University Press, 1991); Alred

Tauber, The Immune Self: Theory or Metaphor? (New York: Cambridge University

Press, 1994).

21. Elie Metchniko, Immunity in Infective Diseases, trans. Francis Binnie

(Cambridge: Cambridge University Press, 1905).

22. Ed Cohen, Metaphorical Immunity: A Case o Bio-Medical Fiction,

Literature and Medicine 22 (2003): 140 63.

23. Thomas Hobbes, Leviathan, ed. C. B. Macpherson (New York: Penguin,

1968), 189. See also Ed Cohen, A Body Worth Having, or A System o Natural

Governance, Theory, Culture, and Society 25 (2008).

24. Bruno Latour, The Pasteurization of France, trans. Alan Sheridan and John

Law (Cambridge, MA: Harvard University Press, 1988).

25. Michael Worboys, Spreading Germs: Disease Theories and Medical Practice

in Britain, 1865 1900 (London: Cambridge University Press, 2000); Nancy Tomes

and John Harley Warner, Introduction to the Special Issue on Rethinking the

Reception o the Germ Theory o Disease: Comparative Perspectives, Journal of

the History of Medicine and Allied Sciences 52 (1997): 7 16.

26. On the history o humoral medicine in the West, see Noga Arikha, Passions

and Tempers: A History of the Humours (New York: HarperCollins, 2007).

27. On the idea o the natural power o healing, see Max Neuburger, The

Doctrine of the Healing Power of Nature throughout the Course of Time (1926), trans.

L. J. Boyd (New York, 1932). Tauber and Chernyak succinctly explain the distinc-

tion between healing and immunity: It is apparent that the idea o healing

power is quite dierent rom . . . immunity. The ormer does not imply, as does

the latter, that the healing power is exercised by a special subsystem in order torestore the integrity o the organism. On the contrary, it implies that the integrity,

as an essence underlying particular physiological processes, acts on behal o the

processes. Ater Metchniko, the immune idea argues or a special activity (a sub-

system) o the whole that perorms the unctions o a personal physician in respect to

the whole. The normal activity o this special part takes place when the normal (the

integrity) is violated. Quite opposite to that, the healing power o Nature is nothing

else but the expression o the whole on behal o its parts (in order to prevent their


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extreme deviation under the infuence o cosmic tendency) (Metchnikoff and the

Origins of Immunology, 119).

28. The literature on public health measures is vast. For a wonderully compre-

hensive treatment, see Peter Baldwin, Contagion and the State in Europe, 1830 1930

(New York: Cambridge University Press, 1999).

29. On the conusion between causes and agents in bioscience, see Rich-

ard Lewontin, Causes and Their Eects, in Biology as Ideology (New York: Harper-Perennial, 1991), 39 58.

30. Fassin, When Bodies Remember, 253.

31. On orgetting as the basis or truth, see Freidrich Nietzsche, On Truth

and Lie in an Extramoral Sense, in Philosophy and Truth: Selections from Nietzsches

Notebooks of the Early 1870s, trans. Daniel Breazeale (Amherst, NY: Humanities

Books, 1979), 92.

32. Haraway, BioPolitics o Postmodern Bodies, 224.

33. Indeed, there existed within late-nineteenth-century bioscience an alterna-

tive though to be sure nondominant strain o explanation that sought to account

or evolution not through competition and the struggle or survival, but through

cooperation and mutuality. On the history o these accounts, see Jan Sapp, Evolution

by Association: A History of Symbiosis (New York: Oxord, 1997).

34. Fassin, When Bodies Remember, 101.

Immune Communities, Common Immunities

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