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AIDS and HIV Infection in the Third World:
A First World Chronicle

Paula A. Treichler

Understanding the AIDS epidemic as a medical phenomenon involves understanding it as a cultural phenomenon. Yet excessively positivist or commonsensical notions of "culture" may limit our ability to recognize that AIDS is also a complex and contradictory construction of culture. This is particularly true of AIDS in developing countries. AIDS in the developed world (the "First World" and, to a lesser extent, the "Second World") is now routinely characterized as a social as well as a medical epidemic, as a challenge to conflicting values, and as an unprecedentedly complex cultural phenomenon; in contrast, AIDS in the developing world—the "Third World"—is believed to lead a much simpler life.^[1]

For an excellent discussion of the vexing terms First World, Third World, and Second World, see Carl E. Pletsch, "The Three Worlds, or the Division of Social Scientific Labor, circa 1950 to 1975," Comparative Studies in Society and History 23, no. 4 (1981): 565-90. Pletsch argues that the notion of the Third World is bogus; indeed, he writes that, except for the political categories of left and right, "the scheme of three worlds is perhaps the most primitive system of classification in our social scientific discourse" (p. 566). I agree with Pletsch that as a framework for investigation this classification system yields studies in which non-Western civilizations—that is, the Second and Third Worlds—are "almost pure fantasies" (p. 566). Because it is these "fantasies" I am attempting to chronicle, I deliberately use the First World/Third World terminology in this essay, along with such alternative signifiers as colonial, postcolonial, industrialized, developing, and poor. See also my "AIDS, Homophobia, and Biomedical Discourse: An Epidemic of Signification," in AIDS: Cultural Analysis/Cultural Activism, ed. Douglas Crimp (Cambridge, Mass.: MIT Press, 1988), pp. 31-70.

Even when these cultures themselves are seen as mysterious, AIDS is seen as a scientifically understood infectious disease that, without our help, will devastate whole countries, whose passive citizens struggle against it in vain.

This vision is well intentioned and perhaps even necessary to marshal external resources. But it obscures the fact that diverse interests are articulated around AIDS in the developing world in ways that are socially and culturally localized and specific. Deeply entrenched institutional agendas and cultural precedents in the First World prevent us from hearing the story of AIDS in the Third World as a complex narrative. One consequence of this inadvertent cultural imperialism is that very simple generalizations about the epidemic may be accepted as "the truth about AIDS," with few efforts made to unravel their diverse and often contradictory claims.

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This essay does not seek to determine "the truth about AIDS." Rather, I look closely at how selected First and Third World publications attempt to chronicle and conceptualize the epidemic. I begin with a discussion of AIDS in Haiti, to show a typical discursive construction of "Third World AIDS." I then contrast the familiar statistical chronicle of the global epidemic with other accounts, suggesting how differing conceptualizations, different "truths," work to promote differing material consequences. Contradictory accounts of the epidemic in Kenya, for example, suggest the value of listening carefully to contradictions; selecting too readily a given account as the definitive truth short-circuits efforts to better understand how truth is situated—and how it is produced, legitimated, sustained, and interpreted. I conclude that understanding the discursive production of the AIDS crisis—the production, that is, of these differing narratives—is a necessary if not sufficient part of addressing its conceptual and material complexity. In turn, such understanding provides crucial grounding for genuine cooperation between the developed and the developing worlds.

A U.S. Doctor Unmasks Truth In Haiti: Third World Aids In First World Media

We had come near the end of a long line of anthropologists working in these remote villages. … Coming at the end gave us certain advantages. … But as time passed we became aware that we had also inherited serious problems. The !Kung had been observing anthropologists for almost six years and had learned quite a bit about them. Precedents had been set that the !Kung expected us to follow.
Shostak, Nisa^[2]

Marjorie Shostak, Nisa: The Life and Words of a !Kung Woman (New York: Vintage, 1983), p. 26.

The very activity of ethnographic writing —seen as inscription or textualization—enacts a redemptive Western allegory.
Clifford, "Allegory"^[3]

James Clifford, "On Ethnographic Allegory," in Writing Culture, ed. James Clifford and George E. Marcus (Berkeley: University of California Press, 1986), p. 99.

All accounts of the AIDS epidemic in the Third World, whether they are medical reports, patient testimony, media observations, investigative journalism, World Health Organization news bulletins, or government reports, are at some level linguistic constructions. These diverse

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representations of AIDS in the Third World draw their authority from many sources, including the credentials and persuasive powers of individual authors, consistency with accepted beliefs and knowledge about AIDS and about the Third World, compatibility with our own social and political perspectives, and resonance with familiar traditions of discourse. Though often covert, the influence of discourse is powerful and pervasive in establishing and legitimating a given representation.

Discourse about AIDS, for example, draws on widely accepted narratives of past epidemics. Though these histories may be employed to supply a variety of arguments and moral conclusions about today's epidemic, they share the premise that any infectious disease is a knowable biological phenomenon whose strange and seemingly contradictory aspects are ultimately illusory: decoded by experts, its mysteries will one by one become controllable material realities. Discourse about AIDS in the Third World shares but exaggerates this premise, first equating the Third World (especially Africa, "the dark continent") with the savage, the alien, or the incomprehensible, then asserting the importance and achievability of reason and control. Though these two features may initially seem to be in conflict, they exist in fact in a relationship of discursive symbiosis: the metaphors of mystery and otherness produce the desire for control, which is in turn fulfilled and justified by the metaphors of otherness and mystery.^[4]

See Homi Bhabha, "The Other Question—the Stereotype and Colonial Discourse," Screen 24, no. 6 (November-December 1983): 18-36; and Chandra Talpade Mohanty, "Under Western Eyes: Feminist Scholarship and Colonial Discourses," Boundary 2 12, no. 3 and 13, no. 1 (Spring and Fall 1984): 333-58.

A highly visible story, for example, was written for Life magazine by the physician-author Richard Selzer, who visited Haiti in the mid-1980s in an effort to learn the truth about AIDS behind the government's apparent attempts to downplay its prevalence.^[5]

Richard Selzer, "A Mask on the Face of Death: As AIDS Ravages Haiti, a U.S. Doctor Finds a Taboo against Truth," Life 10 (August 1987): 58-64. Hereafter documented internally by page number.

The metaphor of the article's title, "A Mask on the Face of Death," invokes the government's denials in the language of exotic tropical rituals such as carnival and voodoo. The subtitle is "As AIDS Ravages Haiti, a U.S. Doctor Finds a Taboo against Truth"; although these probably are not Selzer's words, they suggest to the reader not only that official denials mask the brutality of the epidemic but also that Selzer, the expert medical observer, can perceive the reality beneath the mask. Selzer's article is in the tradition of the privileged First World informant of conventional anthropological, ethnographic, and travel literature—the stranger in a strange land, whose representation of AIDS in the Third World is legitimated by its claim to be an objective, scientific account of phenomena observed or experienced firsthand. As Mary Louise Pratt has observed, travel writing has provided ethnographic description with a discursive legacy, despite the ethnographer's desire to repudiate it; both, in turn,

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permeate representations in other genres.^[6]

Mary Louise Pratt, "Fieldwork in Common Places," in Writing Culture, ed. Clifford and Marcuse, pp. 27-50; see pp. 35-45 for discussion of arrival scenes. The Clifford and Marcus collection offers an extended reflection on relationships between anthropology, ethnography, and travel writing.

Thus, Selzer's article opens with the conventional arrival scene of this dual legacy: "It is 10 o'clock at night as we drive up to the Copacabana, a dilapidated brothel on the rue Dessalines in the red-light district of Port-au-Prince" (p. 59). Outside the bar Selzer is importuned by men and women offering a variety of sexual pleasures; inside, he interviews three female prostitutes from the Dominican Republic who describe AIDS as an economic problem for them, not a health problem. The direct interrogation of the native informant is another staple of privileged observer accounts; in AIDS narratives it is often prostitutes who are interviewed, and they always seem to be wearing red.^[7]

Photograph of "Mercedes" by J. B. Diederich for Life 10 (August 1987): 60; story on Mombasa by Tom Masland, "AIDS Threat Turns Shore Leave into Naval Exercise in Caution," Chicago Tribune, March 17, 1988, sec. 1, p. 13; Newsweek photo of prostitute, p. 46 in Rod Nordland, with Ray Wilkinson and Ruth Marshall, "Africa in the Plague Years," Newsweek, November 24, 1986, pp. 44-47.

The following day, Selzer talks with physicians and examines a large number of patients with apparent HIV-related illnesses for whom little in the way of treatment is available.

Selzer is carefully nonjudgmental with respect to street life and indeed speculates that the virus may have entered Haiti as an accidental feature of First World exploitation: "Could it have come from the American and Canadian homosexual tourists, and, yes, even some U.S. diplomats who have traveled to the island to have sex with impoverished Haitian men all too willing to sell themselves to feed their families? Throughout the international gay community Haiti was known as a good place to go for sex" (p. 64). Selzer pursues this characterization of Haiti as sexual victim ravaged by Western capitalists. Acting on "a private tip from an official at the Ministry of Tourism," Selzer and guide drive to a once luxurious hotel fifty miles from Port-au-Prince that was a prime vacation spot for gay men. Because the two Frenchmen who own the hotel are out of the country, Selzer and his guide are shown around by a staff member, a man about thirty who clearly

is desperately ill. Tottering, short of breath, he shows us about the empty hotel. The furnishings are opulent and extreme—tiger skins on the wall, a live leopard in the garden, a bedroom containing a giant bathtub with gold faucets. Is it the heat of the day or the heat of my imagination that makes these walls echo with the painful cries of pederasty? (p. 64)

Ill at ease among the tiger skins of a hotel in Haiti, the Western travel writer goes to work on "Third World AIDS." Ultimately, for Selzer, AIDS in Haiti is an unambiguous mor(t)ality tale about the evils of sexual excess: as northern homosexual men ravaged Haitian boys, so does AIDS ravage Haiti. Nostalgia for the observed culture's original innocence gives way to regret at its exploitation by decadent foreigners and speculation about the deadly effects of exotic customs and sexual

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practices. Selzer's account therefore tells us something about his concrete daily activities, his heated imagination, and his strategies for transforming selected experiences into prose, but his desire to bring the country's plight to world attention is as much about language as about AIDS in Haiti.

The status of Selzer's article as a firsthand report of observed phenomena does not rest on our firsthand knowledge about AIDS, the Third World, or Haiti. In certain concrete ways, just as cinematic convention represents scenes viewed through binoculars as two intersecting circles, Western AIDS discourse transforms a culture so that it ceases to recognize itself but paradoxically becomes recognizable in the West. What is needed is to sort out the multiple voices, texts, and subtexts of the AIDS epidemic—which has in part evolved, as Jan Zita Grover puts it, as a "creature of language."^[8]

Jan Zita Grover, "A Matter of Life and Death," Women's Review of Books 5, no. 6 (March 1988): 3. See also Simon Watney, "Missionary Positions: AIDS, 'Africa,' and Race," Differences: A Journal of Feminist Cultural Studies 1, no. 1 (1989): 83-100.

Several elements of Selzer's account of AIDS in Haiti are now virtually obligatory in First World chronicles of Third World AIDS. First, the opening arrival scene, as I have noted, situates the First World observer in relation to the Third World culture—a culture that, in AIDS chronicles, almost always belongs to the fallen world of postcolonial development. Indeed, the term Third World grew out of the perceived confrontation between capitalist and communist interests and hence presupposes an analysis dependent on such concepts as colonialism, industrialization, modernity, and development. Second, the statistics provided by Haitian physicians function in at least two ways: to anchor in objective fact Selzer's more personal observations about the prevalence of AIDS, and to demonstrate the specialized knowledge of expert native informants whose on-the-scene experience equips them to reveal the truth behind the official mask. (In Selzer's story the inside informants assert that AIDS is more widespread than officials admit; but in other AIDS stories insiders also function to accuse the government and the media of exaggerating the AIDS crisis for political gains.) Another element is provided by "the reigning American pastor," a nonnative informant whose unreliability as a cultural informant is demonstrated by his moralistic condemnation of voodoo—a system of practices believed by some to facilitate the spread of HIV. Voodoo, he tells Selzer, is "a demonic religion, a cancer on Haiti" that is "worse than AIDS" (p. 62). In positioning himself against his fellow American, "a tall, handsome Midwesterner with an ecclesiastical smile," Selzer secures his own reliability, much as ethnographers quote descriptions of a given culture by earlier travel writers to repudiate the bias of such unscientific observations.

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Selzer's visits to health care settings constitute another element, revealing a devastated health care system—part of the economic fallen world that parallels his image elsewhere of Haiti as the victim of First World sexual exploitation. A further familiar feature of AIDS stories is "the view from the street," represented by Selzer's talk with the three healthy Dominican prostitutes. Their remarks seem designed to underscore the ignorance and dangerous false security engendered by the government's official silence. One of them, Carmen, scoffs at Selzer's suggestion that prostitutes as a population are sick with AIDS:

"AIDS!" Her lips curl about the syllable. "There is no such thing. It is a false disease invented by the American government to take advantage of the poor countries. The American President hates poor people, so now he makes up AIDS to take away the little we have." The others nod vehemently. (p. 60)

The notion that AIDS is an American invention is, like so-called conspiracy theories, a recurrent element of the international AIDS story. It is one not easily incorporated within a Western positivist frame—in part, perhaps, because it often reveals an underlying narrative about colonialism in a postcolonial world. The West accordingly attributes such theories to ignorance, state propaganda, or psychological denial; or it interprets them as some new global version of an urban legend, like alligators in the New York City sewer system.^[9]

Conspiracy theories of AIDS are reviewed by Robert Lederer, "Origin and Spread of AIDS," CovertAction, no. 29 (1988): 52-67, and are reported regularly in the New York Native, a gay New York City weekly periodical. The function of conspiracy theories in postcolonial settings is discussed by Paul Farmer, "Sending Sickness: Sorcery, Politics, and Changing Concepts of AIDS in Rural Haiti," Medical Anthropology Quarterly 4, no. 1 (1990): 6-27; and Alma Gottleib, "Hot Blood, Vengeful Blood: AIDS and Blood Symbolism in Africa," paper presented at the conference on the Impact of AIDS on Maternal-Child Health Care Delivery in Africa, University of Illinois at Urbana, May 5, 1990.

But Carmen's theory of AIDS invokes two further narratives that reinforce the notion of a global economy changing in ways the West cannot fully control. One is a tale of postmodern scholarship about the difficulty of finding good native informants these days. As Shostak's introduction to her ethnographic study Nisa makes clear, native informants are quite likely to be already wise in the ways of Western inquisitors. Discussing Nisa , Pratt convincingly argues that Shostak is nevertheless able ultimately to transcend the "degraded" ethnographic culture of too-knowing informants and achieve a redemptive resolution for her story. Selzer's framing of Carmen accomplishes something similar, together with a second narrative, to which I have already alluded, concerning the construction of the subject in a fallen world. Pratt suggests that ethnographic characterizations of the !Kung changed in the course of foreign colonization. Precolonial ethnographers rendered them as sly, bloodthirsty, untrustworthy, appetitive, manipulative; after colonization they came to be represented as helpful, friendly, innocent, good, and vulnerable. Carmen's speech takes place at a pivotal moment in the global AIDS drama, and this context encourages us to hear her emphatic

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denial of AIDS as a prelude to tragedy—perhaps as we would hear Violetta in the first act of La Traviata .^[10]

A parallel shift in the course of the AIDS epidemic in the United States is clearly evident in representations of gay men, as illness and death transform a threatening and alien community into a vulnerable one. Pratt (in "Fieldwork in Common Places," pp. 44-50) discusses redemptive endings. Working against them is the ethnographic paradox that the Other becomes worldly-wise through contact with "modern civilization"—often in the guise of ethnographers themselves. In Selzer's encounter, the fact that he pays the prostitutes to talk to him parallels the further irony of ethnographic research in which the privileged investigator enters into a commodity exchange with the native informant—anexchange which, as Pratt puts it, turns the "anthropologist preserver-of-the-culture" into an "interventionist corrupter-of-the-culture."

Selzer finally sums up: "This evening I leave Haiti. For two weeks I have fastened myself to this lovely fragile land like an ear pressed to the ground. It is a country to break a traveler's heart. … Perhaps one day the plague will be rendered in poetry, music, painting. But not now, not now" (p. 64). Here the stance of physician as ethnographer is clearer, the physician's ear pressed to the body of Haiti as he might press it to the body of a patient. But though the diagnosis is grim, the language is utopian: the First World AIDS narrative successfully repels the various threats of postmodern disruption to deliver a message of transcendent, universal humanism.

What are we to make of this? I am not suggesting that Selzer's account is not "true," or that we should exonerate the government of Haiti on its AIDS policies. I wish rather to point out how narrative conventions establish and sustain our sense of what is true. Visual representations reinforce the illusion of truth, in part because they reproduce familiar representations of the Third World and reinforce what we think we already know about AIDS in those regions. Thus, the color photographs in Selzer's Life story show us frail, wasting bodies in gloomy clinics; small children in rickety cribs; the prostitutes in red. One of the Dominican prostitutes, for example, is glamorously photographed, the full skirt of her red dress fanned out across a bed. Similarly, an April 1988 news account of the fear of AIDS in Mombasa, Kenya, reports an exchange between a U.S. sailor and a prostitute, a "23-year-old Ugandan woman in red shorts"; and a Newsweek photograph of a woman in red leggings and a skirt is captioned: "'Avoid promiscuity': Prostitute with men in Zaire." Photographs in a 1986 Newsweek story on AIDS in Africa depict the "Third Worldness" of its health care system: in Tanzania a man with AIDS lies hospitalized on a plain cot with none of the high-tech paraphernalia of U.S. representations; a widely reprinted photograph shows six "emaciated patients in a Uganda AIDS ward," two in cots, four on mats on the the floor; rarely are physicians shown. A story on Brazil carries similar low-tech images. In contrast, publications originating in these countries do not omit technical images: African publications often show African scientists and physicians, and among the photographs in a 1987 story on AIDS in Veja, the Brazilian equivalent of Newsweek, are an enormous fully equipped modern hospital and masked and gowned physicians and nurses.^[11]

See photographs in Nordland et al., "Africa in the Plague Years," and Kenneth M. Pierce, "Nowhere to Run, Nowhere to Hide," Time, September 1, 1986, p. 36. Images of AIDS in Brazilian magazines like Veja, first brought to my attention by Elisabeth Santos, are further analyzed in Haydée Seijo-Maldonado and Christine A. Horak, "AIDS in Latin American Newsmagazines: A Contest for Meaning," unpublished manuscript, 1991. Odd linkages among photographs, captions, and text do not only occur in Third World contexts, of course. A story on AIDS in the Canadian journal Macleans, for example, includes a photograph of pedestrians on a crowded Toronto city street; shot from behind so that the pedestrians are moving away from the camera, the photo appears to illustrate the caption: "Toronto sidewalk traffic: Growing fear on AIDS virus spreads to general public" (Macleans, August 24, 1987, p. 31).

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A different problem occurs in a 1988 National Geographic story called "Uganda: Land beyond Sorrow." The story's portrait of unrelieved despair is oddly challenged by the magazine's characteristically stunning photographs. A young woman with AIDS in a long, flowing dress, for example, stands supported by her mother, who is wearing vivid pink; the caption tells us that the woman, Jane Namirimu, is pregnant and already too weak to stand alone. Yet the beauty of the composition, even the adjacent photograph of her grave taken when the photographer returned three months later, transforms the text's bleak assertions into an almost utopian narrative of elegiac fatefulness in which aesthetic universality redeems individual suffering.^[12]

Robert Caputo, "Uganda: Land beyond Sorrow," National Geographic 173, no. 4 (April 1988): 468-74; the Caputo photo of Jane Namirimu and her mother is on p. 470. Pratt (in "Fieldwork in Common Places," p. 40 and p. 45) discusses respectively the fallen postcolonial world of ethnographic writing and the trope of utopian universality.

A final problem is the literal appropriation of images. J. B. Diederich's photographs for the Selzer story were at least original for Life; but some AIDS photographs are familiar not simply because they invoke a familiar tradition but because precisely the same images circulate among diverse publications. In one of Diederich's photographs, a large, striking study in brown and white, an emaciated Haitian woman in a white dress sits gracefully on a wooden bench and looks out at the camera. The caption reads, "Tuberculosis is but one of the wasting infections of what Haitians call maladi-a ." Selzer's article does not define maladi-a or tell us whether tuberculosis is counted in Haiti as a disease that signals AIDS or is, like AIDS, simply one of many wasting diseases; nor is it clear that the woman in the photograph has actually been diagnosed with AIDS. But reproduced months later in the Canadian newsmagazine Macleans, the identical photo, no longer ambiguous, is captioned "Haitian AIDS victim: a former playground for holidayers."^[13]

Selzer, "Mask on the Face of Death," p. 63. The Diederich photograph is reprinted in Macleans, August 31, 1987, p. 37. To take another example, the Newsweek photographs accompanying Nordland, "Africa in the Plague Years," have been widely reprinted. One (p. 44) shows an emaciated woman framed in the doorway of her home, holding a small thin baby in her lap. The Newsweek print is captioned "Two victims: Uganda barmaid and son," and is credited to Ed Hooper—Picture Search. Appearing on the cover of the May 24, 1988, issue of the Washington Post's weekly journal Health (vol. 4, no. 21) is a photograph of the identical woman shot at a slightly different angle; accompanying Philip J. Hilts's featured story "Out of Africa" (pp. 12-17), the photograph is now captioned as follows: "In the Ugandan village of Kinyiga, Florence Masaka, 22, and her 2-month-old daughter have both tested positive for the AIDS virus." The byline accompanying the story incorrectly credits the photos to "Al Hooper." Hilts's article and the photographs were reprinted in Africa Report, November-December 1988, pp. 26-31, to accompany "Dispelling Myths about AIDS in Africa"; the photos were captioned only with text from the story. The Hooper photographs also accompanied Catharine Watson's "Africa's AIDS Time Bomb: Region Scrambles to Fight Epidemic," The Guardian, June 17, 1987, pp. 10-11; and the Weekly Review (Nairobi), June 24, 1988, p. 18, reprinted the mother and child photograph with the caption "Ugandan AIDS victims" and no picture credit. Most recently it appears in Hooper's book Slim: A Reporter's Own Story of AIDS in East Africa (London: The Bodley Head, 1990), where the caption reads: "Florence and Ssengabi, sitting outside their hut in Gwanda. Florence died one month after this picture was taken; her baby, Ssengabi, died four months later." (Picture follows p. 170.)

Hence, our understanding of the situation in Haiti is based on a series of filtering devices, a layering of representational elements, narrative voices, and replicating images. These mediating processes are not, of course, a simple function of high-tech Western representation. Firsthand experience is not unmediated either, so one cannot get off a plane in Port-au-Prince or Nairobi, look around, and determine who is correct. Within these countries there are also differing constructions: there are people who agree with the Western media's account that AIDS is devastating the whole region; there are people like Carmen, who believe the disease is largely imaginary, the latest Western trick to reduce the Third World's population in the wake of failed birth control strategies in the past; there are others, including scientific investigators, who believe the disease exists but is a "white man's disease"; and there are still others who point to serious flaws in most existing data about the prevalence,

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incidence, epidemiology, chronology, and social history of AIDS and HIV infection in the Third World.^[14]

Sabatier quotes a Nigerian prostitute named Juliet as follows: "Although white clients generally pay better than their African counterparts, I will never go to bed with a white man unless he wears a condom. As far as I am concerned, AIDS is a white man's disease" (René Sabatier, Blaming Others: Prejudice, Race, and Worldwide AIDS [Washington, D.C.: Panos Institute; Philadelphia: New Society Publishers, 1988], p. 96). Similarly, a letter to the editor of the Weekly Review in Nairobi even inverted the Western argument for gender-neutral transmission to argue that AIDS in Africa could not really be affecting men and women equally because why should a disease that is homosexual in one country be heterosexual in another?

Discrepancies between doomsday predictions by the Western media and official denials by Third World governments introduce another complicating factor: every state has a "social imaginary," something it dreams itself to be, and its explicit declarations and official statistics are likely to be pervaded by this implicit social dream.^[15]

Ann S. Anagnost, "Magical Practice, Birth Policy, and Women's Health in PostMao China," paper presented at the Unit for Criticism and Interpretive Theory Colloquium, University of Illinois at Urbana, December 7, 1988.

The dream of controlling the AIDS epidemic—whether controlling the blood supply, statistical and epidemiological knowledge, media coverage, biotechnology, or moral and sexual behavior—may well declare itself in a Western tongue. The photograph of the Brazilian hospital may accurately document the existence in Brazil of sophisticated medical capabilities. But as a representation of "the AIDS epidemic," it may be as bogus as the "Haitian AIDS victim." Symbiosis is self-perpetuating: while Third World representations function as elegiac icons that can be seamlessly decontextualized and appropriated by the First World narrative voice, the Third World media, dependent in varying degrees on First World sources and technology, recontextualize these images as their own. As Edward Said argues, modern representation in the decolonized world depends increasingly on a concentration of media power in metropolitan centers; this contributes to the monolithic nature of Third World representations, which are in turn a major source of information about Third World populations not only for the "outside world" but also for those populations themselves.^[16]

Edward Said, "In the Shadow of the West," Wedge 7-8 (Winter-Spring 1985): 4-11, at p. 5.

There is, however, another way of confronting the epidemic. If we relinquish the compulsion to separate true representations of AIDS from false ones and concentrate instead on representation and discursive production, we can begin to sort out how particular versions of truth are produced and sustained, and what cultural work they do in given contexts. Such an approach illuminates the construction of AIDS as a complex narrative and raises questions not so much about truth as about power and representation. Richard Selzer's essay on AIDS in Haiti provides useful information—not necessarily about the true nature of AIDS in the Third World but about the power of individual authors and Western mass print media to produce and transmit particular representations of AIDS according to certain conventions and, in doing so, to sustain their acceptance as true.^[17]

Jean William Pape, a leading AIDS researcher in Haiti and one of the physicians Selzer consulted, expresses disenchantment with the Western press for consistently ignoring "the efforts of the Haitian people to fight, with almost no resources, the most devastating disease of this century." He told the Panos Institute: "I have given over 60 interviews to American and other reporters about AIDS in Haiti. It is very time-consuming and exhausting, and takes energy I would like to put into my work. Of all those interviews there are only one or two that recorded what I said, and the context in which I said it, accurately. The others often painted a picture of AIDS in Haiti that was unrecognizable to me" (quoted in Sabatier, Blaming Others, p. 90). (Selzer also consulted Pape, but I have no evidence that Pape found his report objectionable.) But negative reactions to Western media reports do not necessarily disrupt the cycle of representation. Some African governments, for example, angry at what they believed to be inflations of their statistics or simply wishing to deflect focus on the AIDS problem, prohibited AIDS researchers and physicians from giving interviews to the Western press. "One result of such attempts at control," said James Brooke, West Africa correspondent for the New York Times, in an interview with the Panos Institute in November 1987, "has been to force foreign reports to rely more heavily on foreign researchers working in those countries, making it more difficult than before to convey an authentically African point of view" (quoted in Sabatier, Blaming Others, p. 95). See also James Kinsella, Covering the Plague: AIDS and the American Media (New Brunswick, N.J.: Rutgers University Press, 1989). A series in the New York Times entitled "A Continent's Agony" ran from September 16 to 19, 1990 (see note 30 for a listing of lead articles). I discuss this series in "AIDS, Africa, and Cultural Theory," in Transition 51 (1991): 86-103.

This is what Michel Foucault refers to as a regime of truth.^[18]

"Regime of truth" is Michael Foucault's term. See "The Political Function of the Intellectual," Radical Philosophy, no. 17 (1977): 13-14. See also Treichler, "AIDS, Homophobia, and Biomedical Discourse."

Other forms of representation, drawing on different conventions, different rules, may make claims to truth in different ways.

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The Country And The City: Dreams Of Third World AIDS

It is not impossible that in the future, as in the past, effective steps in the prevention of disease will be motivated by an emotional revolt against some of the inadequacies of the modern world. … Knowledge and power may arise from dreams as well as from facts and logic.
Dubos, Mirage of Health^{[ 19]}

René Dubos, Mirage of Health: Utopias, Progress, and Biological Change (New Brunswick, N.J.: Rutgers University Press, 1987), pp. 218, 219. Originally published 1959.

A regime of truth is that circular relation which truth has to the systems of power that produce and sustain it, and to the effects of power which it induces and which redirect it.
Tagg, Burden of Representation^{[ 20]}

John Tagg, using Foucault to analyze the function of photographs in representing "the true," in The Burden of Representation (Amherst: University of Massachusetts Press, 1988), p. 94.

You'd be surprised: They're all individual countries.
Ronald Reagan^[21]

Ronald Reagan, press conference after returning from a Latin American trip, December 15, 1987.

"The statistical mode of analysis," argued Raymond Williams in The Country and the City, was "devised in response to the impossibility of understanding contemporary society from experience." Characterizing preindustrial English society as knowable through experience (if only partially so), Williams contrasted this "knowable community" with the "new sense of the darkly unknowable" produced by urbanization and industrialization. The metaphor of darkness was routinely invoked in discussions of the rise of cities: the East End, for instance, was called "Darkest London." Statistical analysis was one of the new forms of knowledge "devised to penetrate what was rightly perceived to be to a large extent obscure."^[22]

Raymond Williams, Keywords: A Vocabulary of Culture and Society, rev. ed. (New York: Oxford University Press, 1985); in discussing the word experience in Keywords, pp. 126-29, Williams refers to his earlier analysis in The Country and the City of experience and statistical analysis as different ways of producing knowledge (London: Chatto and Windus, 1973), especially pp. 215-32.

Given this historical mission, it is not surprising that statistical analysis is widely seen as a powerful way to understand the latest incarnation of the "darkly unknowable": AIDS in the Third World. Statistical data, at the least, are seen as the necessary foundation for other knowledge. The ability to produce statistical information is used to measure a nation's degree of development, predict its ability to cope with the AIDS crisis, and in some cases determine its eligibility for external aid.^[23]

See, for example, the testimony of Bradshaw Langmaid, Bureau of Science and Technology, USAID, on funding criteria for AIDS aid to African countries, in AIDS and the Third World: The Impact on Development, Hearing before the Select Committee on Hunger, U.S. House of Representatives, 100th Cong., 2d sess., June 30, 1988, Serial No. 100-29 (Washington, D.C.: U.S. Government Printing Office, 1988), pp. 33-34.

Even if a country cannot produce its own statistics internally, it can demonstrate its ability to cope by cooperating with external studies.^[24]

Most studies depend on some degree of cooperation between the First and the Third World and are thus influenced by the scientific and political commitments of given agencies and their ability to find common grounds of inquiry as well as resources. Scarce resources have created wide variation in scientific research in Africa; yet much more research goes on than stereotypes about Africa would suggest. Needless to say, views on cooperation with Western scientists are also highly variable, reflecting in some respects the ideological commitments of the state as a whole. See Sabatier, Blaming Others, pp. 108-9, on the distinction between the many long-term collaborative projects that predate AIDS and what African commentators call "parachute research" or "tourist research," in which foreign researchers drop in "to collect blood samples, data or clinical observations, and just quickly [take] off again, to write up their findings for a (Western) scientific journal."

But more obviously, the international discourse on AIDS and HIV infection in the

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Third World is shaped on a day-to-day basis by statistical findings and projections. Once numbers are generated and publicized, they take on a life of their own. Because they may generate calls for action (and therefore time, money, and organization), AIDS estimates may be initially resisted. But though specific numbers may be questioned and even denounced in given instances, the use of numbers as a fundamental measure of the reality of AIDS is not.

Data with regard to AIDS/HIV in Third World countries are regularly generated by several sources, including the U.S. Public Health Service Centers for Disease Control (CDC) and the World Health Organization's (WHO) Global AIDS Program (GPA); the GPA's AIDS Surveillance Unit is widely regarded as a legitimate producer, synthesizer, and interpreter of international numbers. By January 31, 1989, the number of countries reporting to the GPA was 177, of which 144 had reported one or more cases of AIDS (up from 175 and 138 in three months): a total of 139,886 cases worldwide had been reported to WHO, though WHO considers a more realistic total to be 250,000 to 500,000; WHO estimates that 5 million are infected worldwide, with a million or more infected in Africa alone. These totals mean that at least one new case of AIDS is being reported somewhere in the world every minute, or 60 new cases every hour and 1,440 each day. Projections about the worldwide distribution and future prospects of AIDS and HIV infection led Jonathan Mann, then director of the GPA, to conclude that "the global situation will get much worse before it can be brought under control."^[25]

Jonathan M. Mann et al., "The International Epidemiology of AIDS," Scientific American, October 1988, pp. 82-89, at p. 82. See also Peter Piot et al., "AIDS: An International Perspective," Science 239 (1988): 573-79. Monthly statistical updates are available from the Pan-American Health Organization in Washington, D.C., WHO's regional health office for the Americas. Though the worldwide estimate of HIV infection is often given in the press as five to ten million, official estimates are somewhat lower: six to eight million was the estimate given at the Sixth International Conference on AIDS in San Francisco by Dr. Michael Merson, Mann's replacement as head of WHO's Global AIDS Program (Roland De Wolk, "Parley Opens with a Bleak Prognosis," Oakland Tribune, June 21, 1990, pp. A1, A4).

WHO did not officially acknowledge AIDS as a global health problem until late 1986—some five years into the epidemic for some countries. By the end of 1987, however, WHO's surveillance reports and seroprevalence data were sufficient to suggest three broad global patterns of AIDS:^[26]

Mann et al., "International Epidemiology of AIDS," p. 84; Piot et al., "AIDS: An International Perspective," p. 576.

Pattern I, typical of industrialized countries with large numbers of reported cases (the "First World," roughly, including the United States, Canada, Western Europe, Australia, and New Zealand), is characterized by the initial appearance of HIV infection in the late 1970s; rapid spread primarily among gay men, bisexual men, and IV drug users in urban coastal centers; and recipients of blood products. HIV infection and illness are at present slowly increasing in the heterosexual population but at highly variable rates, with perinatal transmission (from mother to infant) likewise increasing but not uniformly widespread; infection in the overall population is estimated to be less than 1 percent. In Pattern II countries (typically in sub-Saharan central

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Africa, the Caribbean, and Latin America), HIV infection may have appeared in the late 1970s but was not widely identified as AIDS-related until 1983; heterosexual transmission is the norm, with males and females often equally infected and perinatal transmission therefore common; transmission via gay sexual contact or IV drug use is believed to be low or absent. A Pattern III profile is attributed to the Second World countries of the Soviet bloc as well as to much of North Africa, the Middle East, Asia, and the Pacific (excluding Australia and New Zealand): HIV is judged to have appeared in the early to mid-1980s, and only a small numbers of cases have been identified, primarily in people who have traveled to and engaged in some form of high-risk involvement with infected persons in Pattern I or II areas.^[27]

Mann et al., "International Epidemiology of AIDS," p. 84. The Soviet Union did not report its first official "indigenous" death from AIDS until September 1988—a pregnant Leningrad prostitute named Olga Gaeevskaya; "Epidemiologists were incensed that the woman's doctors failed to diagnose AIDS before she died" (Edmonton Journal, October 11, 1988, p. A2). Another "outbreak" of HIV infection (the headline says "AIDS") occurred among twenty-seven babies and five of their mothers in a hospital in Elista, capital of a region along the Caspian Sea. Some authorities blame unsterilized needles for the babies' infection and suggest that the mothers' infection was contracted while they were breast-feeding the infected babies (John F. Burns, "Outbreak of AIDS Triples Testing in a Soviet City," New York Times, February 5, 1989, p. 29).

What will be the material effects of the global epidemic? Again we can identify a widely accepted set of predictions. In developed countries such as the United States, where 13 percent of the gross national product is spent on health care, AIDS and HIV-related illnesses are already straining the health care system; in many developing countries, where annual expenditures on health care are often less than five dollars per person and inadequate even for current needs, future prospects are grim. The epidemic will almost certainly jeopardize the World Health Organization's ambitious global goal of Health for All by the Year 2000. Further, despite the widespread stereotype of people with AIDS as the disadvantaged of society, the twenty-to-forty age group is the most vulnerable worldwide—the age group most central to the labor force, to childbearing, to caring for the dependent young and old, and, ironically, to marshaling and managing the resources for addressing the AIDS epidemic.^[28]

For assessments of the impact of AIDS on the Third World, see testimony in AIDS and the Third World: The Impact on Development; AIDS Prevention and Control: Invited Presentations and Papers from the World Summit of Ministers of Health on Programs for AIDS Prevention (Geneva: World Health Organization; Oxford: Pergamon Press, 1988) [Jointly organized UK government and WHO; held at Queen elizabeth II Conference Centre, Westminster, London, on January 26-28, 1988]; Panos Institute, AIDS and the Third World (London: Panos, in assoc. with Norwegian Red Cross, 1989; Philadelphia: New Society Publishers, 1989 [trade edition of nontrade dossier published 1986, 1987]; Sabatier, Blaming Others; Cindy Patton, Sex and Germs: The Politics of AIDS (Boston: South End Press, 1985); Norman Miller and Richard C. Rockwell, eds., AIDS in Africa: The Social and Policy Impact (Lewiston, N.Y.: Edwin Mellen Press, 1988); R. M. Anderson, R. M. May, and A. R. McLean, "Possible Demographic Consequences of AIDS in Developing Countries," Nature 332 (1988): 228-34; Robert J. Biggar, "Overview: Africa, AIDS, and Epidemiology," in AIDS in Africa, ed. Miller and Rockwell, pp. 1-8; Raymond W. Copson, AIDS in Africa: Background/Issues for U.S. Policy (Washington, D.C.: Congressional Research Service, Library of Congress, 1987 [17 pp.]); Christine Hawkins, "AIDS Expected to Slow Population Growth," New Africa 251 (August 1988): 25; Charles Hunt, "Africa and AIDS," Monthly Review 39, no. 9 (February 1988): 10-22; Institute of Medicine and National Academy of Sciences, Confronting AIDS: Update 1988 (Washington, D.C.: National Academy Press, 1988); Nancy Krieger, "The Epidemiology of AIDS in Africa," Science for the People, January-February 1987, pp. 18-21; M. Over et al., "The Direct and Indirect Costs of HIV Infection in Developing Countries: The Cases of Zaire and Tanzania," paper presented at the International Conference on the Global Impact of AIDS, London, March 8-10, 1988; Kenneth Prewitt, "AIDS in Africa: The Triple Disaster," in AIDS in Africa, ed. Miller and Rockwell, pp. ix-xv; Jane Perlez, "Africans Weigh Threat of AIDS to Economies," New York Times, September 22, 1988, p. 16; Al J. Venter, "AIDS: Its Strategic Consequences in Black Africa," International Defense Review 21 (April 1988): 357-59; Gloria Waite, "The Politics of Disease: The AIDS Virus and Africa," in AIDS in Africa, ed. Miller and Rockwell, pp. 145-64; Catharine Watson, "Africa's AIDS Time Bomb: Region Scrambles to Fight Epidemic," The Guardian, June 17, 1987, pp. 10-11.

Synthesizing many studies on AIDS in Africa, Miller and Rockwell spell out in further detail the demographic, economic, and medical consequences of the epidemic. Education and prevention, they point out, still the best resources for controlling the spread of the virus, are difficult enough in media-rich Western countries; the task of communicating complex health messages to the diverse populations and geographical sites of Third World countries is formidable.^[29]

Miller and Rockwell, "Introduction," in AIDS in Africa, pp. xxiv-xiv.

These predictions have combined to bring about widespread international agreement about the significance of the epidemic; and as experience increasingly documents the futility of closing boundaries to the virus, so also are global leaders coming to agree with the WHO doctrine that "AIDS cannot be stopped in any country until it is stopped in all countries."^[30]

Quoted in Marilyn Chase, "Rich Nations Urged to Help Poor Lands Fight AIDS by Backing WHO Program," Wall Street Journal, June 17, 1988, p. 4. On the evolution of the epidemic in Third World countries, see Lawrence K. Altman, "New Support from Africa as WHO Plans Effort on AIDS," New York Times, December 22, 1985, p. 11; Erik Eckholm, "AIDS, an Unknown Disease before 1981, Grows into a Worldwide Scourge," New York Times, March 16, 1987, p. 11; Thomas W. Netter, "AIDS Spurs Countries to Act as Cases Rise around World," New York Times, March 22, 1987, p. 18; Steven V. Roberts, "Politicians Awaken to the Threat of a Global Epidemic," New York Times, June 7, 1987, sec. 4, p. 1; "AIDS Now Is a Global Public Health Crisis, Harvard MD Stresses," American Medical News, June 12, 1987, p. 19. On international cooperation see Simon Watney, "Our Rights and Our Dignity," Gay Times, March 1988, pp. 32-34; Sabatier, Blaming Others; Amadou Traore, "Meeting Point: Dr. Gottlieb Monekosso, WHO Regional Director for Africa," The Courier [Africa-Caribbean-Pacific-European Community] 105 (September-October 1987): 2-5. A cooperative international policy is outlined in the document Concerning a Common European Public Health Policy to Fight the Acquired Immunodeficiency Syndrome (AIDS), Council of Europe Committee of Ministers Recommendation No. R (87) 25; adopted at the 81st session, November 26, 1987. Jonathan Mann, former director of the Global AIDS Program, advocates aggressive, activist strategies to achieve global cooperation; in an "AIDS Monitor" column on the January 1988 global summit (New Scientist, February 4, 1988, p. 32), Mann states that the international declaration reached at the summit represents "an extraordinary consensus." The impact of the epidemic at decade's end is assessed in a four-part series in the New York Times which ran from September 16 to 19, 1990: Erik Eckholm with John Tierney, "AIDS in Africa: A Killer Rages On," September 16, pp. A1, A11; John Tierney, "AIDS Tears Lives of the African Family," September 17, pp. A1, A6; John Tierney, "With 'Social Marketing,' Condoms Combat AIDS," September 18, pp. A1, A6; Erik Eckholm, "Confronting the Cruel Reality of Africa's AIDS Epidemic," September 19, pp. A1, A14.

The power and centrality of numbers to these constructions of AIDS are obvious. Without the sophistication and authority of statistical

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methods, the epidemic as a global issue could not have been articulated at all. Yet while this First World numerical chronicle of global AIDS may appear to be unfolding smoothly as our knowledge grows, in fact it is problematic. Consider the following judgments about Africa, all published in 1988:

1. "The continent hardest hit by the AIDS pandemic is Africa where all three infection patterns can be found." (WHO)

2. "Medical experts consider the epidemic an accelerating catastrophe that, in the words of one, 'will make the Ethiopian famine look like a picnic.'" (Congressional Research Service)

3. In many of the urban centers of Congo, Rwanda, Tanzania, Uganda, Zaire, and Zambia, "from 5 to 20 percent of the sexually active age-group has already been infected with HIV. Rates of infection among some prostitute groups range from 27 percent in Kinshasa, Zaire, to 66 percent in Nairobi, Kenya, and 88 percent in Butare, Rwanda. Close to half of all patients in the medical wards of hospitals in those cities are currently infected with HIV. By the early 1990s the total adult mortality rate in these urban areas will have been doubled or tripled by AIDS." (WHO)

4. "A Newsweek cover story claimed one Rakai village [in Uganda] had seven discos and 'sex orgies.' In reality it has 20 mud huts, a handful of fishing boats, and no electricity." (The Guardian )

5. "The tale of AIDS in Africa is not one of widespread devastation and the collapse of nations. There are 53 countries in Africa and AIDS exists substantially in only a few of them." (Washington Post )

6. "Like the tenacious theories put forward as explanations for the heterosexual spread of HIV in Africa, the whole AIDS pandemic is shrouded in mystery and uncertainty. There is no reliable information on AIDS and by the time one message has percolated its way down to the general population, it is out of date and a new one is already on its way to replace it." (West Africa )^[31]

(1) Mann et al., "International Epidemiology of AIDS," p. 84; (2) Copson, AIDS in Africa, p. 9; (3) Mann et al., "International Epidemiology of AIDS," p. 84; (4) Watson, "Africa's AIDS Time Bomb," p. 10; (5) Hilts, "Out of Africa," p. 12; (6) Mary Harper, "AIDS in Africa—Plague or Propaganda?" West Africa, November 7-13, 1988, pp. 2072-73, at p. 2072.

Given the statistics cited above, how can it be that the most fundamental meaning of the narrative remains contested?

Several sources of confusion and contradiction can be identified. Estimates of infection and actual cases of AIDS for entire populations may be derived from inadequate data: too few studies, studies of too small a sample size, nonrepresentative samples, and so on. Rates estimated for all Africans are often based on small studies in urban areas; studies of "prostitutes" may in fact classify all sexually active single women as

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prostitutes. Chronological claims (about when AIDS first appeared) are primarily based on flawed blood-testing procedures and other problems of diagnostic method. In Africa "underreporting" is taken for granted and estimates corrected upward; at the same time, the number of positive cases actually diagnosed may be too high or too low, depending on the procedure used. Research cited as evidence may be unpublished, based on conference papers unavailable for detailed scrutiny, or sloppily interpreted; and many published papers do not report important data. Moreover, interpretations of the epidemic may be based on divergent and not mutually understood paradigms and forms of evidence. Testing blood samples in a laboratory involves different practical operations and generates knowledge different from that produced by a clinician examining patients or a journalist interviewing people on the street. Experienced medical experts in Africa, who tend to make lower estimates of cases, claim that their knowledge is discounted as clinical and experiential by Western and European academic scientists.^[32]

For an overview of problems associated with diagnosis and testing, see Albert E. Gunn et al., AIDS in Africa (Washington, D.C.: Foundation for America's Future, 1988); R. Sher, "Seroepidemiology of HIV in Africa from 1970-1974," New England Journal of Medicine 317, no. 7 (August 13, 1987): 450-51; I. Wendler, "Seroepidemiology of HIV in Africa," British Journal of Medicine 293 (September 27, 1986): 782-85; World Health Organization and Centers for Discase Control, "HIV Not Related to Monkeys," WHO-CDC AIDS Weekly Report, July 25, 1988, p. 8. See also Dieter Koch-Weser and Hannelove Vanderschmidt, eds., The Heterosexual Transmission of AIDS in Africa (Cambridge, Mass.: Abt Books, 1988), especially Felix I. D. Konotey-Ahulu, "AIDS in Africa: Misinformation and Disinformation," pp. 24-25.

Rumor and fantasy play their part as well. Cultural practices are taken out of context, exaggerated, distorted, or invented. Voodoo continues to animate accounts of HIV in Haiti, with grizzly descriptions of Voodoo sorcerers biting off the heads of infected chickens and sucking the bloody stumps. African tales often involve the notorious African green monkey, whose photograph keeps circulating long after his role in AIDS has been discounted. Africans are said to have sexual contact with these monkeys, or eat them, or eat other animals they have infected (Haitian chickens?), or give their children dead monkeys as toys. Purporting to explain why HIV transmission is heterosexual in Africa, reports hypothesize radical differences between African and Western bodies based on physiological, behavioral, cultural, moral, and/or biological factors. As Sander Gilman has comprehensively documented, these rumors are tirelessly fueled by historically entrenched myths of the exotic.^[33]

Sander I. Gilman, Disease and Representation: Images of Illness from Madness to AIDS (Ithaca, N.Y.: Cornell University Press, 1988). An influential anthropological source for rumors about exotic behaviors has been Daniel B. Hrdy, "Cultural Practices Contributing to the Transmission of HIV in Africa," Reviews of Infectious Diseases 9, no. 6 (November-December 1987): 1109-19. The rumors preserve bits and pieces of such anthropological research without its larger cultural context. The first major study of prostitutes is Joan K. Kreiss et al., "AIDS Virus Infection in Nairobi Prostitutes: Spread of the Epidemic to East Africa," New England Journal of Medicine 314, no. 7 (February 13, 1986): 414-18. A detailed critique of many studies can be found in Richard C. Chirimuuta and Roaslind J. Chirimuuta, AIDS, Africa, and Racism (London: Free Association Books, 1989), who also suggest that "underreporting" is no more a problem than "overdiagnosing." See also Cynthia Haq, "Data on AIDS in Africa: An Assessment," and Barbara Boyle Torrey, Peter O. Way, and Patricia Rowe. "Epidemiology of HIV and AIDS in Africa: Emerging Issues and Social Implications," both in AIDS in Africa, ed. Miller and Rockwell, pp. 9-19 and 31-54. A general critique of studies on AIDS in Africa is provided by Margaret Cerullo and Evelynn Hammonds, "AIDS in Africa: The Western Imagination and the Dark Continent," Radical America 21, nos. 2-3 (March-April 1987): 17-23, and Krieger, "Epidemiology of AIDS in Africa." An attempt to place AIDS statistics within a broader political and economic perspective is presented in Carol Barker and Meredeth Turshen, "Briefings: AIDS in Africa," Review of African Political Economy 27, no 105 (January-March 1986): 51-54. An elaborate web of speculation about Haiti can be found in Alexander Moore and Ronald LeBaron, "The Case for a Haitian Origin of the AIDS Epidemic," in The Social Dimensions of AIDS, ed. Douglas Feldman and Thomas Johnson (New York: Praeger, 1986), pp. 77-93. The historical debate over "the Haitian origin of syphilis," of course, goes back centuries, a debate noted in his critique of Moore and LeBaron by Paul Farmer, "The Exotic and the Mundane: Human Immunodeficiency Virus in Haiti," Human Nature 1, no 4 (1990): 415-45.

While increased international scientific dialogue has answered some questions about global AIDS and HIV, it has confirmed the difficulty of answering others and has underscored the need for thick description—complex, multileveled, multilayered research. Jay A. Levy's 1988 state-of-the-art collection on AIDS, for example, includes detailed review chapters on AIDS in Haiti and in Africa. Both demonstrate the diverse and very different clinical manifestations of HIV infection in those settings and emphasize the need for revised diagnostic and reporting systems. Treated at length in the Haiti chapter are the complex interaction

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of HIV infection with tuberculosis (alluded to by Selzer), while the Africa chapter reviews controversial origin questions as well as various explanations for the high rate of heterosexual transmission; both chapters emphasize remaining questions and the need for continuing investigation.^[34]

Nathan Clumeck, "AIDS in Africa," in AIDS: Pathogenesis and Treatment, ed. Jay A. Levy (New York: Marcel Dekker, 1989), pp. 37-63. Existing studies are summarized by Clumeck; by Hilts, in "Out of Africa"; and by Torrey et al., in "Epidemiology of HIV and AIDS in Africa." On the clinical manifestations of AIDS in Haiti, see Warren D. Johnson, Jr., and Jean W. Pape, "AIDS In Haiti," in AIDS: Pathogenesis and Treatment, ed. Levy, pp. 65-78; interactions of AIDS with tuberculosis are discussed on pp. 72-77.

The overwhelming difficulty of even characterizing the diversity of the epidemic, let alone containing it, suggests that statistical measures—numbers—may once again be functioning as Williams says they did in the late nineteenth century: to offer us the illusion of control. As these numbers are taken up and deployed for various urgent purposes, however, they may take on a life of their own and reinforce a view of HIV disease as an unmediated epidemiological phenomenon in which cultural differences (such as differences in sexual practices) can simply be factored into a universal equation. But the local interacts with the global, AIDS continually escapes the boundaries placed on it by positivist medical science, and its meanings mutate on a parallel with the virus itself. Added to the medical, epidemiological, social, economic, and educational challenges of the AIDS crisis is its inevitably political subtext. AIDS is not a precious national resource; it is something nobody wants. Wherever it appears, AIDS discourse quickly becomes political as it is articulated to preexisting local concerns. To begin to identify these concerns, it may be useful to retreat from the power of numbers and see what other forms of knowledge tell us.

In Africa analysis of AIDS must inevitably confront questions of decolonization, urbanization, modernization, poverty, endemic disease, and development: in Uganda, for example, the legacy of civil war is significant in assessing the AIDS situation, as is the influence of the church in discussions of health education; in Kenya, for the independent press at any rate, AIDS is used as an ongoing test of the central government's ability to acknowledge and resolve conflict.^[35]

See, for example, Caputo, "Uganda: Land beyond Sorrow"; Lloyd Timberlake, Africa in Crisis: The Causes, the Cures of Environmental Bankruptcy, ed. Jon Tinker (Philadelphia: New Society Publishers, 1986); and ongoing coverage in the Nairobi Weekly Review.

In France Jamie Feldman found in interviews that for French AIDS researchers the AIDS epidemic "reveals the impact that France's colonial past and present African immigration have on French life."^[36]

Jamie Feldman, "Identity, Illness, and the Process of Giving Meaning: French Medical Discourse on AIDS," unpublished manuscript, University of Illinois at Urbana-Champaign, July 1988. See also Michael Pollack, Les homosexuels et le SIDA: Sociologie d'une épidémie (Paris: Éditions A. M. Metailie, 1988).

In his ethnographic study of AIDS in urban Brazil, Richard Parker suggests that the epidemic needs to be linked to "the social and cultural construction of sexual ideology," or what he calls the "cultural grammar" of the Brazilian sexual universe.^[37]

Richard Parker, "Acquired Immunodeficiency Syndrome in Brazil," Medical Anthropology Quarterly 1, no. 2 (1987): 155-75, at pp. 158, 159.

In both the United States and Great Britain, AIDS intensifies stress on health care systems already in crisis. In South Africa apartheid is seen to reproduce itself in the government's public health campaign: a post-campaign survey of black attitudes in the Johannesburg area found that

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many believed there were "two totally different kinds of AIDS. The one that only affected blacks was acquired through sexual and ritual contact with baboons in central Africa. The other was acquired by sexual contact with homosexuals—white AIDS."^[38]

David Seftel, "AIDS and Apartheid: Double Trouble," Africa Report (November-December 1988): 17-22, at p. 21.

In Cuba mandatory HIV testing of the general population has identified a small number of infected people, who have been placed under indefinite quarantine. Placed in AIDS sanitoria, they receive air conditioning, color television, regular health checkups, and other amenities not generally available to the population at large. This treatment is variously interpreted by Western commentators as a manifestation of Cuba's progressive health care policies (one can certainly argue that Cuba is providing more support and resources for its infected citizens than many other countries) or as totalitarian and homophobic repression in a police state.^[39]

See Elizabeth Fee, "Sex Education in Cuba: An Interview with Dr. Celestino Alvarez Lajonchere," International Journal of Health Services 18, no. 2 (1988): 343-56; Nicholas Wade, "Cuba's Quarantine for AIDS: A Police State's Health Experiment," New York Times editorial, February 6, 1989; p. A14; Richard Goldstein, "AIDS Arrest: The Cuban Solution," Village Voice, February 14, 1989, p. 18.

These examples and others suggest that the reproduction in AIDS discourse of existing social divisions appears to be virtually universal, whether it is white or black AIDS, gay or straight AIDS, European or African AIDS, wet or hot AIDS, East or West German AIDS, central African or western African AIDS, foreign or native AIDS, guilty or innocent AIDS.^[40]

Though these dichotomies are primarily social, the differentiation among types of AIDS and strains of HIV is also a scientific and clinical question. See, for example, Clumeck, "AIDS in Africa."

A First World/Third World dichotomy manifests itself in diverse ways. In Africa people with AIDS are sometimes described by those in their own countries as having sexual practices as strange as those of gay white men in San Francisco.^[41]

Hilts (in "Out of Africa," p. 12) notes the incredulity that greeted the appearance of AIDS in Africa. He quotes a pulmonary specialist in Uganda who first saw AIDS there in 1983: "It looked like the new American disease. But none of us could believe it." But before too long, AIDS began to be blamed on the loose morals of African people—always those in other countries, classes, or ethnic groups. Thus, an editorial in the Kenya Times (Nairobi), May 26, 1987, blamed Uganda for lax sexual behavior, noting that "nature has its own law of retribution." See discussion in Sabatier, Blaming Others, p. 105. In contrast, see Frank Browning, "AIDS: The Mythology of Plague," Tikkun 3, no. 2 (March-April 1988): 69-71. Browning says that most descriptions of U.S. subcultures involved in AIDS make them sound "as strange as those of Bantu twig gatherers" (p. 70).

In Japan officials believed initially that transfusion-related HIV infection among Japanese would not be a threat thanks to procedures for sequestering the national blood supply; while this Japanese/foreign division remains an animating feature of AIDS discussion and policy, statistics make clear that it can no longer be considered a safeguard.^[42]

Clyde Haberman, "Japan Plans to Deny Visas over AIDS," New York Times, April 1, 1987, p. A18. According to a report in the Independent (London), February 14, 1987, when the death of a Japanese prostitute in Kobe was attributed to AIDS, the immediate conclusion was that she had been infected by sexual contact with a foreigner; as one Japanese newspaper put it, "Her death was the result of an infatuation with Europe." Sabatier (in Blaming Others, p. 114) notes that "in the red light district of Tokyo warning signs suddenly appeared: 'Gaijin [foreigners] off limits.'" For a more extended discussion, see James W. Dearing, "Foreign Blood and Domestic Politics: The Issue of AIDS in Japan," in this volume.

Richard Parker identifies a similar dichotomy in the Brazilian medical community's transition from conceptualizing AIDS as a "foreign import" to accepting it (from 1985 on) as a disease that has "taken root."^[43]

Parker, "Acquired Immunodeficiency Syndrome in Brazil," p. 157; and Alan Riding, "AIDS in Brazil: Taboo of Silence Ends," New York Times, October 28, 1987, p. 8.

Great Britain's announcement that HIV-positive applications for visas from high-risk countries would be denied entry provoked accusations of racial imperialism when central African countries were classified as "high risk" but the United States was not.^[44]

Sabatier, Blaming Others, pp. 106-7. See also Robert Pear, "U.S. Seeks to Bar Aliens with AIDS," New York Times, March 27, 1987, p. A18; and Serge Schmemann, "Calls of 'Hi Sailor' Get the Heave-Ho," New York Times, May 14, 1988, p. 4.

These divisions are, at least in part, produced by what Dubos calls the inadequacies of the modern world—that is, by a set of historically produced social arrangements. When AIDS in Africa or Brazil is termed "a disease of development," it is precisely the intractable social topography of recent history that is invoked, the problematic contours of development—environmental devastation, malnutrition, war, social

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upheaval, poverty, debt, endemic disease—now unavoidably illuminated and scrutinized in the international light of the AIDS crisis. As Rudolph Virchow wrote in 1948, "Epidemics correspond to large signs of warning which tell the true statesman that a disturbance has occurred in the development of his people which even a policy of unconcern can no longer overlook."^[45]

Dubos, Mirage of Health, p. 218; many researchers characterize AIDS as a "disease of development," among them Marc H. Dawson, "AIDS in Africa: Historical Roots," in AIDS in Africa, ed. Miller and Rockwell, pp. 58-69. Virchow is cited in Paul Epstein and Randall Packard, "Ecology and Immunology," Science for the People (January-February 1987): 10-17, who also discuss AIDS and development.

Even the seemingly simple message to "use a condom" is actually a complicated drama that must incorporate competing scripts, play to hostile audiences, and ultimately raise as many questions as it answers. Already it has returned to the world stage such stock characters as the Ugly American who, in the guise of the U.S. Agency for International Development, distributed in central Africa condoms that were too small and inelastic.^[46]

Brooke Grundfest Schoepf et al., "AIDS and Society in Central Africa: A View from Zaire," in AIDS in Africa, ed. Miller and Rockwell, pp. 211-35, at p. 218.

But the larger point is that, as Brooke Grundfest Schoepf and her colleagues argue, the adoption of condoms involves "much more than a simple transfer of material culture."^[47]

Ibid., p. 228; the authors observed (as USAID, apparently, did not) that condoms "which hurt their wearer or break during normal use may limit the effectiveness of AIDS prevention efforts." See also Hooper, Slim

Describing their experience with Project CONAISSIDA (an AIDS education and research program in Zaire), these researchers identify myriad ways that the condom question puts stress on the entire fabric of social relations. They point out, too, that the AIDS crisis is embedded in a continuing economic crisis that affects men and women differently: married women in plural households may take up prostitution as a means of economic existence when their husbands can under current conditions no longer support the traditional plural households. Women's groups with whom CONAISSIDA has contact express interest in information about AIDS, and about condoms; but they also articulate resistance to the view that information and condoms offer a total solution, emphasizing the role of deepening poverty and the need for income-generating activities for women to provide alternatives to multiple-partner sex.

A different sort of complication is raised in Africa by the important role of nongovernmental organizations (NGOs). While these organizations may be reluctant to shift their agendas for AIDS or to ally their already fragile causes with a yet more stigmatized one, they nevertheless often have excellent international and community networks. The International Family Planning Agency has prepared and distributed a well-received manual on AIDS for local as well as national use; such efforts are likely to bring about increased U.S. aid for family planning.^[48]

Gill Gordon and Tony Klouda, Preventing a Crisis (London: International Planned Parenthood Federation, 1988). Reviewed by Harper, "AIDS in Africa—Plague or Propaganda?"

But as Schoepf and her colleagues point out,

Ideological issues also need to be addressed. In Zaire nationalist sentiment currently links contraception and condom use to western population control strategies, which are viewed as a form of imperialism. Some husbands also

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view contraception as an encouragement for wives' extramarital sexual relations. … These considerations suggest that it may be preferable to separate AIDS prevention from birth control efforts, rather than to place responsibility for AIDS interventions within family planning programs.^[49]

Schoepf et al., p. 219. Few alternatives to the condom exist. At the Fifth International Conference on AIDS in Montreal, there was for the first time discussion of a female condom and of the use of spermicides without the use of condoms; but at the Sixth International Conference in San Francisco, some data suggested that for some women the use of spermicides might increase the risk of HIV transmission by causing inflammation and breakdown of the vaginal mucosa.

But fruitful acknowledgment of division is not accomplished by formula. To take one final example, the system of sexual classification that dominates discussions of AIDS internationally—heterosexual, homosexual, bisexual—is not universal. Criticisms of this system applied to AIDS discourse in Western industrialized countries are all the more valid in other cultures; for not only is sexuality complicated for individuals, with no fixed correspondence among the components of sexual desire, actual practice, self-perceived identity, and official definition; it is culturally complicated as well. Richard Parker argues that the hetero/homo/bi classification is seriously, conceptually, at odds with "the fluidity of sexual desire" in contemporary Brazil.^[50]

Parker, "Acquired Immunodeficiency Syndrome in Brazil," p. 161.

While the medical model's distinctions clearly exist in Brazilian society and are increasingly familiar as a result of media dissemination, they remain largely part of an elite discourse introduced to Brazil in the mid-twentieth century. The traditional classification relates sexual practices to gender roles , with both gender and sex constructed by a fundamental division between a masculine atividade (activity) and feminine passividade (passivity). Two males engaged in anal intercourse would be distinguished by who was the active masculine penetrator, who the passive feminine penetrated. Neither would necessarily perceive his behavior as "homosexual," nor would everyday language readily furnish him with the lexicon to do so. As Parker suggests, this different perception of same-sex behavior has obvious and dismaying implications for conventional notions of "risk group" identification and "safer sex" education.^[51]

Ibid., pp. 160-63. I have greatly oversimplified Parker's intricate representation of Brazilian sexuality, which, as he emphasizes, is not the mere overlay of a Western ethnographer but permeates language, slang, informal discussion, and ongoing open debate about sexuality as an essential aspect of cultural identity and "Brazilianness." But the penetrator/recipient and other distinctions that construct masculinity/femininity between same-sex partners occur elsewhere, including the United States. See Charles F. Turner, Heather G. Miller, and Lincoln E. Moses, eds., AIDS: Sexual Behavior and Intravenous Drug Use (Washington, D.C.: National Academy Press, 1989), pp. 73-185, for an illuminating review of recent research on "same-gender sexual behaviors" in several cultural settings. See also Ralph Bolton, "A Selected Bibliography on AIDS and Anthropology" (forthcoming in Journal of Sex Research). For an analysis of sexuality from a different perspective, but one potentially helpful in articulating women's concerns, see the conclusions and recommendations "adopted by the group of experts" at a UNESCO conference in Madrid, March 12-21, 1986 ("UNESCO: On Prostitution and Strategies against Promiscuity and Sexual Exploitation of Women," Echo [Newsletter of the Association of African Women for Research and Development] 1, nos. 2-3 (1986): 16-17).

Parker's work, like other projects noted here, demonstrates the contributions of interpretive cultural analysis. The provisional nature of science is very difficult for policy and funding agencies to live with. Rather, there is pressure to produce a coherent narrative in which qualifications and ambiguities, if they must be mentioned, become simply routinized features of the story, to be quickly forgotten; problems of data are perceived to be mere temporary impediments to a refined and comprehensive analysis. Western medical science is conceived as a transhistorical, transcultural model of reality; when cultural differences among human communities are taken into account, they tend to be enlisted in the service of this reality, but their status remains utilitarian. This utilization may effectively accomplish specific goals: it is reported

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that some native practitioners (e.g., of voodoo) have successfully overcome men's traditional resistance to the use of condoms by describing AIDS as the work of an evil spirit who uses sexual desire and the virus as secret weapons; condoms provide a means to trick the spirit and escape its lethal designs.^[52]

Sabatier, Blaming Others, p. 134.

One can certainly support a global anti-AIDS strategy that mobilizes the scientific model of AIDS in culturally specific ways, yet acknowledge imperialist aspects of a strategy that valorizes itself as universal rather than culturally produced. As the foregoing examples suggest, ethnography and other forms of interpretive research are neither better nor less mediated than statistical approaches or other "objective" ways of knowing a culture, but they are different and produce unique insights. Nor are they incompatible with theoretical sophistication.

Research of this kind is not, however, the currency of the First World/Third World transaction. Expert advising is now a major Third World industry: more than half of the $7–8 billion spent yearly on aid to Africa goes to European and North American professionals trained to provide expertise to the Third World.^[53]

Timberlake, Africa in Crisis, p. 8.

Gathering information, reporting facts, and advising the Third World are also mediated activities, permeated by history and convention. In Blaming Others , the Panos Institute's immensely useful 1988 sequel to and self-critique of its indispensable 1986 dossier AIDS and the Third World , Renée Sabatier observes how ironic it is that in the information age, information should be such an elusive resource.^[54]

Sabatier, Blaming Others, p. 4.

But a second irony explains the first. It is not, precisely, a question of obtaining and disseminating "information" but, rather, of acknowledging what information entails: acknowledging how language works in culture, how stories contradict one another, how narratives perform as well as inform, how information constructs reality. Cultural analysts in many fields are acknowledging the inevitability and indeed even the necessity of such multiple and contradictory stories. Yet, having recognized the theoretical complexity of communication, we are pressing communication into a purely pragmatic role that subordinates complication and contradiction to unequivocal assertion and scientific harmony.

Different accounts of truth produce differing material consequences. Tracing the historical relationship between the "country" and the "city" and their evolution in English literature and social thought, Raymond Williams argues that in the course of nineteenth-century imperialism these two ideas became a model for the world, dividing not only the rural from the urban within a single state but the undeveloped world

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from the developed one. Underlying this model is the notion of universal industrialization, underdeveloped countries always on their way toward becoming developed, just as the poor man is always assumed to be striving to become rich. "All the 'country' will become 'city': that is the logic of its development."^[55]

Williams, The Country and the City, p. 284.

Though this linear progression is largely a myth of late capitalism, that does not impede its deployment as an agenda item for the Third World.

For the new possibilities arising out of the AIDS epidemic, the "country" is a very fertile field. As of 1986, according to a reference work called Emerging AIDS Markets , 1,119 companies and other organizations are involved in AIDS-related activities: only 20 to 30 of them are based in Third World countries, but at least 200 of them are engaged in research on AIDS in Africa and other projects likely to entail the use of Third World populations as trial subjects in the development of diagnostic products and vaccines.^[56]

Emerging AIDS Markets: A Worldwide Study of Drugs, Vaccines, and Diagnostics (New Haven, Conn.: Technology Management Group, August 1986). See also Vicki Glaser, "AIDS Crisis Spurs Hunt for New Tests," High Technology Business 8, no. 1 (January 1988); and Manny Ratafia and Frederick I. Scott, Jr., "AIDS: A Glimpse of Its Impact," American Clinical Products Review (May 1987): 26-29; this article also makes clear the size and diversity of the "AIDS market" for the development of clinical products.

Recent reports about vaccine trials make explicit the need for test populations that are "pharmacologically virgin" and, further, are still becoming infected at high rates. Gay men and IV drug users in the First World do not fulfill these criteria, not only because infection is leveling off in the first group and pharmacological virginity is not characteristic of the second, but also because any First World population is too educated, too exposed to the media, and too likely to take steps (including alternative treatments) to avoid infection or reduce clinical illness. In the mind of the city, only the country can furnish the unspoiled virgin material that the market needs, the naive informant still too ignorant to contradict instructions.^[57]

See Gina Kolata, "Africa Is Favored for AIDS Testing," New York Times, February 19, 1988, p. 7; the "AIDS Monitor" column in the New Scientist, February 18, 1988, p. 36; and Jane Perlez, "Scientists from Western Countries Pressing for AIDS Studies in Africa," New York Times, September 18, 1988, p. B5. Perlez, reporting vaccine discussions at a conference in Tanzania on AIDS and Africa, writes: "In Africa, unlike the United States, the virus is most commonly spread through heterosexual contact. Officials believe that, despite warnings to use condoms and avoid multiple partners, further spread of the virus is inevitable. ... Because of behavioral changes brought about by extensive education about AIDS, the spread of the infection among gay men in the United States has slowed. Thus, there would be few new infections in a study group, whether or not its members took the vaccine, the scientists said. The scientists said they regarded intravenous drug users, a group that continues to have a high incidence of AIDS in the United States, as unreliable for the necessary follow-up that is needed for a study group." A WHO committee developing ethical guidelines for vaccine testing said the decision to go ahead should be made by three groups: scientists developing the vaccine, scientists knowledgeable about vaccine development but with no academic or commercial stakes in it, and "government officials and their scientific advisers from the population where the vaccine is to be tried." No representatives of the population to be tested are mentioned.

First And Third World Chronicles

History is a legend, an invention of the present.
Mudimbe, Invention of Africa^{[ 58]}

V. Y. Mudimbe, The Invention of Africa: Gnosis, Philosophy, and the Order of Knowledge (Bloomington: Indiana University Press, 1988), p. 195.

The ethnographer's trials in working to know another people now become the reader's trials in making sense of the text.
Pratt, "Fieldwork in Common Places"^[59]

Pratt, "Fieldwork in Common Places."

But there is always another story, and a continuing one in the AIDS epidemic involves the untrustworthiness of other stories—their sources, motives, data, presuppositions, methodology, and conclusions. In January 1985, for example, the Nairobi Standard publicly reported the

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presence of AIDS in Kenya for the first time in stories headlined "Killer disease in Kenya" and "Horror sex disease in Kakamenga."^[60]

Nairobi Standard, January 15 and 18, 1985. For the development of research on AIDS in Africa, see Ruth Kulstad, ed., AIDS: Papers from Science, 1982-1985 (Washington, D.C.: American Association for the Advancement of Science, 1986); and Koch-Weser and Vanderschmidt, The Heterosexual Transmission of AIDS in Africa.

Subsequent accounts in state-owned newspapers repudiated the report, claiming that the deaths were from skin cancer rather than AIDS, but Western press accounts speculated increasingly on the frightening implications of the presence of AIDS in central Africa. Then in November 1985 Lawrence K. Altman's multipart series on AIDS in Africa in the New York Times reported not only that the epidemic was spreading rapidly in Africa but also that prominent U.S. researchers were convinced the disease started there. Altman's opening sentence dramatically presented the thesis that was to become most controversial: "Tantalizing but sketchy clues pointing to Africa as the origin of AIDS have unleashed one of the bitterest disputes in the recent annals of medicine."^[61]

Lawrence K. Altman, "Linking AIDS to Africa Provokes Bitter Debate," New York Times, November 21, 1985, p. 1.

Altman went on to say that these "sketchy clues," including blood samples, "have led to what has now emerged as the prevailing thesis in American and European medical circles that the worldwide spread of acquired immune deficiency syndrome began in Central Africa, the home of several other recently recognized diseases."

But, as Altman conceded, not everyone accepts this designation of the virus's homeland: "The Africans vigorously disagree, and there is some criticism of the validity of the studies on which the theories are predicated. Indeed, controversial new results point both to and against AIDS originating in Africa, a fact that is fueling the international furor."^[62]

Altman, "Linking AIDS," p. 1. On the "international furor" see especially Chirimuuta and Chirimuuta, AIDS, Africa, and Racism; and Richard C. Chirimuuta, Rosalind Harrison, and Davis Gazi, "AIDS: The Spread of Racism," West Africa, February 9, 1987, pp. 261-62.

Two effects in the West of the Times series were to establish AIDS in Africa as an important scientific question and to place Africa firmly on the national agenda for AIDS media coverage, culminating in the journalistic frenzy of late 1986, which represented Africa as "devastated" by AIDS and AIDS-related illnesses. In Africa the effect was different. When Altman's series began to run in the International Herald Tribune in November 1985, for example, outraged Kenyan officials confiscated the entire shipment. The African offensive against the "African origin" theory was launched with an editorial in Medicus , the official publication of the Kenya Medical Association, which hypothesized that tourists from around the world had introduced AIDS into Africa.^[63]

In the Western media AIDS in the Third World is used to draw conclusions about the West. Thus, Selzer's view that Haiti is "devastated" is intended to serve as a cautionary lesson about gay excess. Stories about Africa may likewise serve to warn Western readers about themselves. "FUTURE SHOCK," proclaimed the cover of Newsweek in December 1986, citing new worrisome projections of AIDS increases in the United States; a related cover headline was titled "AFRICA: THE FUTURE IS NOW." On AIDS and the media in general, see James Dearing and Everett M. Rogers, "The Agenda-Setting Process for the Issue of AIDS," paper presented at the International Communication Association, May 28-June 2, 1988; and Kinsella, Covering the Plague.

At this point the Kenyan newsmagazine Weekly Review , published and edited in Nairobi by Hilary Ng'weno and widely considered one of the best newsmagazines in Africa, took on the responsibility of keeping the public informed about AIDS reports in the African and international press. In the face of increasingly vocal controversy and government

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silence, the magazine took the general position that developing adequate public health measures was more important than countering Western propaganda. Thus, the Weekly Review began providing summaries and analyses of scientific and press reports printed in the West, citing the numbers of AIDS patients reported in Zaire, Rwanda, Uganda, and Kenya. Although itself often critical of the Kenyan government's mode of responding to the AIDS epidemic, the Weekly Review has also been critical of Western reporting. What Africa needs, Ng'weno told the Panos Institute, is concrete assistance, not "a never ending siren recounting a litany of disasters about to engulf the continent."^[64]

Quoted in Sabatier, Blaming Others, p. 97.

An insightful analysis of the AIDS situation in Kenya is provided by the political scientist Alfred J. Fortin. Although Fortin criticizes the actions of the African government, he is primarily critical of what he has elsewhere called the "aggressive bureaucratic and careerist politics" of the "development establishment"; unless development agencies remain under fire, he argues, the AIDS epidemic will allow them to reproduce the power relations of dominance and dependency already in place. In "The Politics of AIDS in Kenya," Fortin argues further that the dominance-dependency relationship of development guarantees English as the international language of AIDS discourse, a language that is necessarily "blind to the African world of meaning." He concludes that, despite Kenya's "comparatively well-developed medical infrastructure and working coterie of Western scientists, its efforts have fallen short of even the minimum requirements suggested by its statistics."^[65]

Alfred J. Fortin, "The Politics of AIDS in Kenya," Third World Quarterly 9, no. 3 (July 1987): 906-19, at p. 907. See also Alfred J. Fortin, "AIDS and the Third World: the Politics of International Discourse," paper prepared for the 14th World Congress of the International Political Science Association, Washington, D.C., August 28-September 1, 1988.

However much the Weekly Review may itself be skeptical of "the development establishment" as well as Kenya's response to the AIDS epidemic, it does not buy Fortin's position either. Calling his paper "a hard-hitting and indictive, if lopsided, criticism of the Kenyan government, the ministry of health and the local press," the editor goes on to contest a number of points of Fortin's analysis—for example, Fortin's point about language:

[Fortin's] paper questions the language of discourse at discussions on AIDS in Africa. It argues that Africans have chosen to use the Western language when talking about the disease and since the language is transplanted, Africa is dependent on the West for its meaning and its continued development. Since the language is not indigenous to Africa, Fortin says, hence it is "blind to the African world of meaning."

Students of African history have long argued that most of the diseases prevalent in Africa today were first witnessed with the advent of the foreigner on the continent and most of the terminology used by the medical practitioners in Africa [is] also borrowed from the developed world.

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African government and researchers have also been emphatic that the AIDS virus was first diagnosed in the United States and, therefore, it would follow automatically that the language used in reference to the disease should be that developed by those who diagnosed it first.^[66]

Hilary Ng'weno, "The Politics of AIDS in Kenya," Weekly Review, September 4, 1987, pp. 11-13.

As I understand it, Fortin's argument about discourse was intended to challenge—as Parker's is with regard to Brazil—the entire discursive formation of international AIDS discussions applied unthinkingly and hence in some sense imperialistically to diverse cultures; it is a position most discourse analysts would share. Ng'weno, however, rejects the corollary implication of this view: that English is somehow "foreign" to Kenya and Kenyan leaders. Though English is indeed a colonial legacy, it plays many roles in Kenyan activities today. Hence, Zairean philosopher V. Y. Mudimbe argues that Western discourse has contributed to but not monopolized what he calls "the invention of Africa"; rather, the objects of that discourse are also subjects who have produced an intricate interweaving of European and African commentary, rendering the notion of a "purely African discourse" an impossible dream.^[67]

Mudimbe, The Invention of Africa.

At the same time, Ng'weno makes the political point that language marks nationality and origin: to use English with regard to AIDS helps sustain its identity as a Western disease. Ng'weno's position acknowledges the power of linguistic constructions of reality, and demands the right of Africans to participate in that construction process. This resistance to adopting AIDS, to giving it—in the words of the Altman story—a home, is reflected elsewhere in the Weekly Review , where supposedly indigenous African terms for AIDS and AIDS-related terms (like "slim disease" and "AIDS belt") are placed in quotation marks and often explicitly rejected; the term magada , cited by Fortin as the name for AIDS in Swahili, is never used in the Review .^[68]

The naming of AIDS internationally is addressed by Sabatier, Blaming Others; Hooper, Slim; and Farmer, "The Exotic and the Mundane."

The juxtaposition of these two complex and interlocking analyses makes clear that the chronicle of AIDS in the Third World cannot be understood monolithically. It must be understood not only in terms of the "rich history and complex political chemistry" of each affected country but also as a heteroglossic series of conflicted, shifting, and contradictory positions.^[69]

Miller and Rockwell, AIDS in Africa, p. xxiii.

Even "AIDS" and "the AIDS epidemic" and "HIV disease" must be understood this way. We are talking, after all, about an epidemic disease with more than forty distinct clinical manifestations, some of which consist of the absence of manifestation, some of which are unique to particular regions of the world, and some of which apparently have nothing to do with a deficiency of the immune system. When we talk about the Third World, we are talking about more than

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one hundred countries of the world. In Africa alone, we are talking about a continent four times as large as the United States, which has more than 50 countries, 900 ethnic groups, and 300 language families (Zambia alone has 74 languages). As Miller and Rockwell argue, it is absurd to talk about "the AIDS problem in Africa" except for specific and well-defined purposes.^[70]

Ibid., p. xxiii.

The international AIDS narrative is hence neither complete nor fully accessible. The present invents the past, but the present itself has not yet been invented; accordingly, this is a narrative necessarily in process, which we must read with all our critical faculties at work. A crisis serves as a point of articulation for multiple voices and interests, and the AIDS crisis in the Third World is no different. My goal has been to demonstrate that, as in the First World, (1) diverse interests are articulated around AIDS in ways that are socially and culturally localized and specific; (2) institutional forces and cultural precedents in the First World prevent us from hearing the story of AIDS in the Third World as a complex narrative; (3) understanding this complexity is a necessary if not sufficient condition for identifying the material and conceptual nature of the epidemic; and (4) such an identification is necessary to effectively mobilize resources and programs in a given country or region.

In the course of this essay, I have identified several analytic strategies through which we may explore these questions and tried to suggest areas of discourse where better understandings may be particularly valuable: the conventions of mass media stories; the discursive traditions and modes of representation that figure in the AIDS narrative of the sciences and social sciences (including tropes, stereotypes, linguistic structures, and pervasive metaphors); the emergence of a dominant international AIDS narrative and its role in the linguistic and professional management of the epidemic; the processes through which AIDS is conceptualized within given institutions for everyday use; and the very terms through which we identify what chronicle we think we are telling. The checks and balances provided by the warring voices at each of these multiple discursive points render it impossible to refuse contradiction—that is, to argue that any single unchallenged account of AIDS exists in the Third World, any more than it does in the First World.

To hear the story "AIDS in the Third World," we must confront familiar problems in the human sciences: How do we know what we know? What cultural work will we ask that knowledge to perform? What are our own stakes in the success or failure of that performance? How do we document history as it unfolds? In concrete terms, we certainly

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need to forsake, at least part of the time, the coherent AIDS narrative of the Western professional and technological agencies and listen instead to multiple sources about and within the Third World.^[71]

Nancy Schmidt, "African Press Reports on the Social Impact of AIDS on Women and Children in Africa," paper presented at conference on the Impact of AIDS on Maternal-Child Health Care Delivery in Africa, University of Illinois, Urbana-Champaign, May 6, 1990.

When we do so, we may find it less instructive to determine whether a given account is true or false than to identify the diverse rules and conventions that govern whether and where a particular account is received as true or false, by whom, and with what material consequences.

The performative work that such narrative structures do can be identified, challenged, recuperated, reassigned; it cannot be eradicated. Language about AIDS, illness, and epidemics is already informed with metaphor (influenza got its name because illnesses were believed to be under the influence of the stars; infect means "to contaminate," "to communicate," and "to stain or dye," a connotative web even the most vigilant housekeeping cannot sweep away). To believe that information and communication about AIDS will separate fact from fiction and reality from metaphor is to suppress the linguistic complexity of everyday life. Further, to inform is also to perform; to communicate is also to construct and interpret. Information does not simply exist; it issues from and in turn sustains a way of looking at and behaving toward the world; it shapes programmatic agendas and even guides capital investments.

Diverse voices, then, represent not diverse accounts of reality but significant points of articulation for ongoing social and cultural struggles. Further, once we adopt the view that reality is inevitably mediated, we become ourselves participants in the mediation process; such voices may then provide important models for challenging existing regimes of truth and disrupting their effects—in the Third World, as in the First.