Background
Therapeutic citizenship is defined as, “the benefits and responsibilities that AIDS treatment programs offer and impose on those enrolled in treatment programs, akin to the functions of a modern state” (McGough 2012: 697). Coined by Vinh-Kim Nguyen, an anthropologist who studied antiretroviral treatment (ART) in Sub-Saharan Africa between 1994 and 2000, therapeutic citizenship is about how governmental and non-governmental organizations control and manage bodies through access to healthcare. Nguyen’s argument is that in order for people in Sub-Saharan Africa to receive treatment, they have to be willing to advocate for the treatment. Her study about AIDS treatment about the beginning of ART in Sub-Saharan Africa discussed therapeutic citizenship. In a society, such as Africa, where HIV is associated with stigma, a lot of people were not comfortable with advocating for ART. (McGough 2012: 697). This was a period before the treatment was made easily accessible and many Africans were suffering from AIDS.
Triage is another concept that is closely associated with therapeutic citizenship because it is the first step in therapeutic citizenship, as it decides who receives medical care. Nguyen defined triage as “prioritizing some individuals for medical treatment over others” (McGough 2012: 698). Therapeutic citizenship is the benefits of treatment that programs offer and triage is the mechanism behind how these programs choose who receives treatment. Therapeutic citizenship was not available to many members of Sub-Saharan Africa due to the fact that ART was extremely limited. Nguyen states that those selected during this time for treatment were people “willing to speak publicly about their diagnosis, in hopes that public disclosure would reduce stigma and encourage others to get tested” (McGough 2012: 298). Triage was closely linked to this because some people were selected based off of their willingness to participate in trials, while others were excluded from treatment for reasons such as having anemia (McGough 2012: 298).
Topical Context
A qualitative study took place at a health care clinic in KwaZulu-Natal, South Africa in order to determine how to get more men to come to the clinic to receive access to care (Zissette 2016: 265). 21 HIV-infected men were interviewed in order to collect data on how masculinity has promoted or inhibited their willingness to receive HIV care (Zissette 2016: 265). The data conveyed that masculinity involved three steps in the journey to receiving care: “a) delayed HIV testing and linkage to care; b) motivators and challenges for continuous care engagement; and c) advocacy and long-term perspectives beyond care engagement” (Zissette 2016: 267). Something that was also studied was the participants’ commitment to advocating for treatment. The study found that “the notion of therapeutic citizenship empowers men in their health and alternate forms of masculinity, yet demands alterations on other sources of identity” (Zissette 2016: 270). So these men embraced therapeutic citizenship by becoming advocates for their clinic, but also resisted it by refusing to take their advocacy public due to the stigma associated with HIV (Zissette 2016: 270). These men “assumed the roles of therapeutic citizens as part of their involvement in an HIV support group” (Zissette 2016: 270). Advocating for clinics came after HIV support groups were implemented. These support groups encouraged men to promote their own HIV status in order to challenge the stigma and create a new identity for hegemonic masculinity.
Perspectives
Michael Foucault relates therapeutic citizenship to biopower and epidemiology. Foucault defines biopower as “forms of power that aim to control, regulate, and monitor a population’s biologic life” (Fuhrer 2015). This means that the topic of individual health becomes a political concern. Non-governmental organizations are the most important governing bodies in many African countries and these NGOs have the power to “discipline society” through public health (Fuhrer 2015). These NGOs are the groups providing most of the free or charitable healthcare to developing nations and this gives them the power to choose who receives this care.
Epidemiology plays a role in identification and is defined as “naming, mapping, grouping” (Fuhrer 2015). Foucault states that epidemiology is not purely descriptive, “in contrast, often the groups identified in statistical analyses are not ‘naturally existing groups” (Fuhrer 2015). This can create social identities and realities. In relation to therapeutic citizenship, “membership in an epidemiologically defined group allowed people to access crucial infrastructure” (Fuhrer 2015). Anyone who did not fit into a category was rejected access to care and then a “paradox arises that ‘sometimes the only way to survive is by having a fatal illness” (Fuhrer 2015). Biopower has a huge impact on epidemiological research and those who are not willing to participate will not have access to certain services. There is also the problem of when someone’s needs are not fully covered because failure to access the therapeutic citizenship could result in death.
How This Relates to Politics of Health
As previously talked about, therapeutic citizenship relates to politics of health because it exemplifies topics covered in class such as biopower, or how the government regulates health and our bodies. During the late 1900s, access to antiretroviral treatment was extremely exclusive and NGOs decided most of it based off of who was most likely to advocate for their treatment. Because HIV had a stigma associated with it, this excluded a lot of people from receiving treatment. Political ideologies in the United States also disagree on who has a right to healthcare. Does everyone have a right to have access to healthcare? This correlates to ART because in an impoverished area like Sub-Saharan Africa, access to healthcare is extremely regulated, just like it is in the United States. Our own NGOs donate millions of dollars to healthcare in developing country but we do not even give everyone in our country healthcare.
This topic also relates to biological citizenship, because as previously stated, receiving therapeutic citizenship was extremely political. There was a certain criteria you had to meet in order to obtain care. Those who allowed NGOs to disclose their information had a better chance of receiving treatment. This is an example of those with power aiming to control and regulate bodies, which also ties back into biopower.
References
Fuhrer, Amand, Eichner, Friederike. “Statistics and Sovereignty: the workings of biopower in epidemiology.” Global Health Action 8 (2015), accessed February 26, 2017. https://search-proquest- com.proxy.library.vanderbilt.edu/docview/1693336715/9AA2846A6E194F FBPQ/6?accountid=14816.
McGough, Laura. “The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS.” Bulletin of the History of Medicine 86 (2012): 697-698, accessed February 26, 2017. https://search-proquest-com.proxy.library.vanderbilt.edu/docview/1288084366/23503BB352264B7PQ/1?accountid=14816.
Zissette, Seth, Watt, Melissa. “’If you don’t take a stand for your life, who will help you?’: Men’s engagement in HIV care in Kwazulu-Natal, South Africa.” Psychology of Men and Masculinity 17.3 (July 2016): 265-273, accessed February 26, 2017. https://search-proquest- com.proxy.library.vanderbilt.edu/docview/1756520830/D05DDB504DE04E 64PQ/7?accountid=14816#REF_c29.
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