I sit down to write this book review on December 1, 2023—World AIDS Day—having attended an event at the University of Pretoria in South Africa that looked back on local and global attempts to address HIV/AIDS in southern Africa over the last 30 years. Much of the discussion was about the failures of social science to get to grips not only with HIV’s remarkable ability to thrive in diverse local contexts, but the frustrations of social scientists who have struggled to bring qualitative data into meaningful engagement with biomedical advances in understanding the virus and how to treat it.
As a practicing psychiatrist, Kalofonos joins a long line of medically trained anthropologists who set out to wrestle with the dynamics of HIV in a specific setting, in this case Chimoio in rural Mozambique. The book is, essentially, a critique of global neoliberal approaches to HIV/AIDS interventions. The central argument is that health must be understood in terms of collective social responsibility and not as an individual process in purely biomedical terms.
Kalofonos makes this argument by presenting an ethnographic account of an HIV/AIDS organization through the stories of several individuals with whom he has clearly developed a deep connection through long-term fieldwork. This connection permeates the text, giving the reader a rare sense of empathy for the interlocutors’ lives. The opening chapters set the scene by providing a historical account of the region—precariously located in an area known for high population mobility and thus a potential highway for HIV transmission. Chapter Two introduces the reader to what Kalofonos calls the “AIDS economy”—an umbrella term for the myriad ways that the virus has played out locally and globally. The core ethnographic chapters take us through detailed accounts of religiously orientated associations of people living with HIV/AIDS, community home-based care groups and a “day hospital,” through which treatment is prescribed and monitored.
Specific attention is given to the ways in which patients “earn” access to treatment (166). They do this through biomedical assessment of their CD4 count via doctors and through social workers who assess knowledge of antiretroviral medication and the patient’s chances of maintaining adherence to it. The argument presented here is that to access treatment, patients must embody the core tenets of neoliberalism—individualization and self-reliance—although it is not entirely clear how this squares with the ethnography of community support groups.
The original contribution of this book comes towards the end, in Chapter Six, where the arguments around hunger, adherence, and health start to take shape. Kalofonos describes the difficult relationship between food, hunger, and HIV treatment. The medication makes people hungry, and for it to work people need to eat. It becomes clear, however, that access to food is not a simple process. There is no shortage, but the politics of food insecurity in the region are complicated by international organizations who brought with them the inequalities wrought through structural adjustment programs and who would appear to perpetuate rather than nullify suffering and injustice. With the mass roll-out of HIV treatment in the region, this argument has profound implications. It leads to the conclusion—as mentioned above—that for HIV treatment and public health in general to be efficacious in the long term they must be framed as a collective, social process involving the provision of housing, employment, education, food security, and infrastructures of statehood, instead of being treated as a stand-alone “vertical” issue through biomedical treatment of bodies.
For readers who are even partially familiar with the vast literature on HIV/AIDS in medical anthropology and cognate disciplines, all this will come as no surprise. It is clearly essential for international organizations and “philanthrocapitalists” (199) who underwrite them to be aware of the necessity for HIV treatment to be part of a “horizontal,” holistic approach to healthcare. But this line of argument has been around for a long time. At international AIDS conferences since the mid-2000s, anthropologists have been arguing that we cannot treat our way out of the pandemic, and that the insights of social science—whilst complex and often specific to particular local contexts—must be taken seriously in HIV interventions. In this vein, attempts have been made over many years to engage major players such as PEPFAR in discussions with anthropologists, only to fall on deaf ears.
In this sense, then, All I Eat Is Medicine runs the risk of frustrating readers who have a sense of arguments in medical anthropology over the last few decades. The opportunity—indeed the suggestion in the title—to delve deeply into the politics of food security, treatment adherence, and a wider theoretical engagement and contribution to an anthropology of hunger is, unfortunately, not fully realized. Much of what appears in the nuanced and well-written ethnographic accounts has already been analyzed in great detail by previous scholars. Topics such as the problematics of a “traditional/modern” dichotomy, medical pluralism, rumor and witchcraft, community-based support groups, the emergence of AIDS entrepreneurs who convert HIV positive status into social capital whilst courting significant risk for doing so, immoral accumulation from foreign donors, conspiracy theories, and therapeutic citizenship have been subjected to anthropological interrogation for decades but are at times here given rather nonchalant footnotes in passing.
As a result, the book sits rather uneasily in the established literature and feels slightly out of time. It may well be best placed as an introductory ethnographic text for undergraduate students in a course aimed at more detailed and theoretically ambitious contributions to the specific topics mentioned above. It will also be essential reading for medical practitioners with little to no background in the humanities. With HIV treatment now well established in southern Africa, there is a need for continued ethnographic and theoretical analysis of the complex dynamics developing around it. Things move very fast in the “AIDS economy,” and for more health interventions based on social justice to be realized, social science must keep the pace, even set the pace, of analysis.
