Ebola and HIV Narratives in a Colonialist-Capitalist World

In October 2014, Ebola costumes sold out for Halloween. There was the Ebola HAZMAT costume (modeled by a boy in the ads), and two versions of the “sexy Ebola containment suit” (girl’s costume, designed to show leg at the risk of compromising the fiction of its containment properties). Many felt this was “in bad taste,” as Arthur Kaplan, head of the bioethics division at New York University’s Langone Medical Center, put it (cited in Baskas 2014). Doctors of the World, a humanitarian organization, used the opportunity to advertise for donations of protective equipment to be used in the affected countries of Guinea, Sierra Leone, and Liberia, deploying a campaign entitled “It’s more than a Halloween costume” with the accompanying tagline, “Here it’s a Costume; There it saves Lives” (Baskas 2014). In Sacramento, Robert Kirk, a therapist at Sage Psychotherapy, said making a serious situation seem humorous could be viewed in the light of a defense mechanism; people play up the issue to keep genuinely fear-generating situations “at arm’s length, kind of a whistling-past-the-graveyard kind of thing” (cited in Caiola 2014). Why, one might ask, would Americans be so fearful of Ebola?

Contemporaneous news articles claimed President Barack Obama’s affinity with Africa through his grandfather’s Kenyan origins meant that he was prepared to sacrifice American security by refusing to cut off the United States from West African air traffic during the epidemic. Dr. Keith Ablow, of the Fox News’s “Medical A-Team,” claimed that Obama’s “affinities” are with Africa, not the United States: “His affinities, his affiliations are with them, not us. . . . He’s their leader.” Ablow elaborated on what he sees as Obama’s perspective:

In his mind, if only unconsciously, he’s thinking, “Really? We’re going to prevent folks suffering with illnesses from coming across the border flying into our airports when we have visited a plague of colonialism that has devastated much of the world, on the world? What is the fairness in that?” How can you protect a country you don’t like? Why would you? (cited in Hananoki 2014)

This tells us more about Ablow’s fears and preoccupations than about Obama’s; and those are not singular to Ablow. Radio host Rush Limbaugh suggested Obama refused to divert flights from Ebola-infected countries and close down America’s borders because Obama believed the United States “deserves” to be infected with Ebola as retribution for its role in perpetuating slavery (cited in Volsky 2014).

Responding to a caller on his nationally syndicated radio show, Limbaugh launched into a soliloquy: “. . . [the United States] being to blame for things and it’s that kind of thinking that leads to opposition to shutting down airports from various countries,” he explained, referring to the Obama administration’s handling of the crisis. “It leads to opposition to keeping these people out of the country: ‘How dare we? We can’t turn our back on them! They exist because of us. We can’t turn them away!’ ” (cited in Volsky 2014). Limbaugh vocalizes his notion of politically correct liberals, whom he thinks believe that the United States is responsible for the spread of Ebola in Liberia because that nation was established by freed American slaves. “And if it hadn’t been for that they probably wouldn’t have [Ebola]. So there are some people who think we kind of deserve a little bit of this,” he said, before accusing American leaders of purposely leaving the U.S. vulnerable to the virus: “The danger we have now is that we elected people in positions of power and authority who think this or think like this in terms of this country being responsible” (cited in Volsky 2014).

While some may have dismissed Ablow and Limbaugh, both associated with the Fox News network, as extremist voices, what is striking about the Ebola outbreak of 2014 is the complex set of affects attending on its coverage in the Unites States. These cannot be assigned to mere bad taste or what was, before Trump’s election, often described as marginal politics. Such affects include fear of, and fascination with, a nationally conceived power that can ostensibly “save” and “kill”—the kind of biopolitics Giorgio Agamben associates with a sovereign (1998). This amounts to a fetishization of a political power, conceptually aligned with the nation-state, to foster life or disallow it to the point of death, or as Achille Mbembe puts it, revisiting Foucault, involved in “the generalized instrumentalization of human existence and the material destruction of human bodies and populations” (2003, 14). Here I am using the definition of the fetish as an object that is always fantastical to the extent it substitutes for another object or condition perceived to be missing (Suleiman 1990, 48).

This fascination with a (putative) sovereign power is expressed in the Halloween costumes, as well as in rants against Obama as refusing to protect the United States because of his affiliation with African-ness, in a specifically biomedical iteration. This affiliation marks Obama as incapable as a Black man, despite his U.S. citizenship, of exercising that citizenship in favor of U.S. citizens, in an old equation in which Blacks cannot be sufficiently American; but simultaneously, the president of the United States should let Africans die ostensibly to save U.S. citizens. Here Obama is attributed with believing that Ebola marks a retributive justice for the exercise of the slave trade by white Americans against nonwhite ones; and responsibility for Liberians, as citizens of the U.S.-initiated exslave colony, is seen as the revenant of the duties owed to Liberia by those U.S. authorities who literally made the state (possible) in the first instance. Obama is the “object” who is inadequate as fetish because he cannot represent the subjective power of a white president.

Juxtapose this scene with one almost a decade earlier, in 2003, when I was interviewing inhabitants of the Sisonke/Harry Gwala District of KwaZulu-Natal (KZN) about their ideas of how HIV came to be so pervasive in the region, most of which is deeply rural and not easy to access. An older lady in the Underberg area told me that the apartheid government had inflicted HIV on Blacks in South Africa in retribution for the Black majority voting for the African National Congress (ANC) in 1994, which led to the election of the first postapartheid government under Nelson Mandela. A response to such a statement might have been to dismiss her as ignorant. However, this lady spoke a certain truth. The apartheid government was extremely slow to acknowledge and deal with HIV/AIDS while simultaneously ordering HIV-positive agents to infiltrate ANC cadres and infect them. Further, the government funded a program to develop strains of bacteria and viruses that would target the Black population, a project that was predictably a failure, as race is not a category that works in terms of infectious disease perpetration. Sterilization of Black women and HIV-positive women without their consent has been documented in South Africa and Namibia, although racially motivated programs involving disease agents cannot be made to target one race over another.

The lady had an embodied, intergenerational knowledge of apartheid biopolitics and their racist aspirations. She would have had no problem comprehending the connections between racism and its effects in terms of structural violence, of the relative vulnerability of Black and Brown people in the United States to Covid-19. It would be a misrecognition to think of her and Ablow and Limbaugh as speaking with the same validity. Ablow and Limbaugh have not experienced a state deploying power against them in the form of racist provisions for separate education, job reservation, racially directed population control, and so on. Their sense of threat is precisely what makes their response to Ebola fantastical.

So how does the fantasy of the Ebola threat play out specifically along racial lines? The response to Ebola manifests a fantasy of containment of the (racialized) threat of exotic disease, wherein the costume acts as a staging of whites both as impervious to disease though proper technologies of protection and as “saving” Blacks, where the doctor/nurse is preconceived of as white, and the patient, missing from the costume but implied by it, is black African. The fact that the disease made it into a Halloween costume is related to the virtual impossibility of getting Ebola in the United Kingdom or America, where the costumes were bestsellers. The racial politics would have played out differently if that were the case. It’s hard to believe a Covid-19-related costume would make it onto the shelves because it “lives” in the United States already, across Black, Brown, and white populations, although the former two groups are differentially negatively affected. Indeed, one of the reasons HIV in America has such a different cultural profile from Ebola is because it, too, “lives” in the United States and is distinguished from the sub-Saharan epidemic by the telling phrase “African AIDS.” (There is, to my knowledge, no North American correlate, such as “American AIDS.”) It is revealing that all the advertisements for the popular 2014 Ebola Halloween costume feature whites sporting their safeguards in various parodies of personal preventative equipment (PPE, the Centers for Disease Control [CDC] term that has become so familiar to us from news coverage of the U.S. response to Covid-19).

The fascination is with the epidermalized white fantasy of the power of healing, of saving from death, while oneself being immune. The unexpressed terror is that of becoming ill, becoming Black, becoming unruly through improper contact with the racialized other who manifests these supposedly negative attributes. One can think of the unspoken element of this fear in the fact that, as I noted above, there is no “pair” costume for the Ebola doctor or nurse. This would have been “for” the Ebola victim, just as there are numerous vampire-and-victim Halloween costume pairs. One could interpret this absence as politically correct, but that has certainly not been the case in other aspects of popular costumes, where fear of social sanction has been notably absent. Rather, the ellipsis of a partner Halloween figure expresses the “impossibility” of a white Ebola victim, even in play. The fantasy of immunity manifests itself in fear of contamination, which is itself not logical, where the figure of the diseased, racialized, and unrulable other threatens citizenry who are the apotheosis of the genre of the human and need to be maintained by a racialized cordon sanitaire. Americans too may “get sick” (contaminated), hence the need for a “wall,” now translated into Trump’s fantasy wall, that will protect Americans. Paranoia and racialized images of the diseased as disposable abound in the performance, rather than the actuality, of Ebola as an exotically constructed threat. These images portray the diseased as surplus to requirements, as that material set of objects (non-animated) that need to be contained. What cannot be contained in the white fantasy of immunity is a set of conjoined effluent subjects whose moniker would be something like Black-diseased-mad-unruly-unrulable-noncitizen, prefigured in the historical figure of the slave and suggested by the very idea of Ebola as a Halloween costume.

The cultural logic behind the adoption of the Ebola costume can be traced to the predominance of the zombie in Halloween costumes. The zombie, originating in Haitian folklore, represents a “walking dead” body, often thought to be contaminated by having been bitten by another zombie, since the zombie is a voracious, flesh-eating being with malevolent intent. The zombie most likely derived from transformations of West African folklore that originated in the seventeenth century when West African slaves were brought to work on the Haitian sugar plantations. The zombie is, in this context, thought to represent the miserable conditions under which slaves labored for their owners. The waking-dead aspect of this suggests the notion that one cannot escape slavery, even in death. However, I propose it also has a persistent meaning, or in the context of this argument, possibly an effluent one: the walking dead may wake at any moment to resist their incarceration, just as the ancestors may advise the living to rebel against structural violence, consisting in slavery, impoverishment, and illness at the behest of colonial capitalism, racist governance, and their intersection. The latter interpretation, it is worth noting, is possible only if one holds the cycle of the unborn, the living, and the ancestors as an ontology of relations that confound the normative Western binary of living–dead.

The constellation of images doing culturally violent work in the 2014 Ebola outbreak challenges us to compose a history of disease and human being coexistence that bears witness to effluent subjects who are pitted against the healthy genre of the human that inhabits the UNDHR. An effluent eye enables comprehension of the genre of the human as linking practices of colonialism and medicine through a shared politics. Both colonialism and medicine tend to see disease and the diseased subject as that which should be confined to objectivity, and consequently be ejected from the modern state or the individual respectively. This is the case despite the facts that constantly vulnerable and debilitated subjects are essential to the survival of the colonialist-capitalist contemporary state, through its dependence on exploitable labor, and that one cannot separate disease from its co-constitutive “host,” or to paraphrase Yeats’s words, in disease, one cannot know the dancer from the dance (see “Among School Children” in Yeats 1989, 64).

The first fact above (reliance on constantly debilitated and vulnerable subjects) constitutes the foundational contradiction of capitalism in this study: capitalism promises material benefits to all, but simultaneously depends upon exploitative labor practices and global inequity. Effluent subjects in this context are anti-utopian within the settler-state political imaginary, where utopianism acts as a racialized and “healthy” containment strategy. Effluence can and does dwell domestically; and the specter of the improper “citizen,” or of citizens’ contact with disallowed subjects, who are perceived as objects, is insupportable because it reminds the citizenry that effluent subjects are not confined to the exotic. This is spectacularly problematic, as only specialized cohorts of citizens “should” have contact with effluent subjects.

In the case of this chapter, the specialists are humanitarian global health physicians whose job it is explicitly to heal the vulnerable, but implicitly to “take the flak” to keep the citizenry at home safe, in a medical model that uses humanitarianism to feed exotic interest and to stage Western medicine as infinitely superior to Indigenous forms of healing within the postcolonial context. For this reason, I conclude with a critique of the utopianism/neocolonialism of the role of Western medicine in humanitarian interventions in the global South, and by rethinking the figure of the zombie, not as one who simply answers the capitalist call to work-for-money-and-purchase-goods as an end in and of itself, but as signaling the birth of the as-yet-to-be-materialized possibility that productivity can be recognized outside of colonialist-capitalist frameworks. First, however, I trace the histories of utopian attempts to keep out Blackness, to keep out diseases, as colonialist and neocolonialist operations that seek to deny both the fact of effluent subjects within state borders and these operations’ dependence on slave labor and its descendent, an endlessly substitutable labor force. I conclude with a critique of the utopianism/neocolonialism of Western medical practices in interventions in the global South, and by rethinking the figure of the “duppy,” or zombie, as that which simply answers the capitalist call to “work-for-money-and-purchase-goods” as an “ethic” and end in and of itself.2

The kind of vulnerability generated by the fear–aggression matrix evident in Ebola fantasies does not attach to the effluent subject, who lives alongside both the real possibility of and the actuality of illness. Where that illness is accompanied by conditions of colonialist-capitalist structural violence, effluent subjects find ways of naming that violence, as did the lady of rural KZN in her discussion with me. Determining responsibility at an individual rather than structural level is the challenge in naming structural violence in a context of ideological domination by the vocabulary of the genre of the human and its relation to the citizen; the vocabulary makes structural violence invisible as a determinant of health. Think, for example, of all the demonized individuals/nationalities associated with the spread of Covid-19 in the United States, as in “China flu.” Invisible detrimental conditions are assignable to the effluent other in figures of unspeakability, as in the implied but missing partner Ebola costume. What xenophobic naming masks, however, is our connectedness to China through global networks and the fault lines that the virus illuminates domestically, within the United States. In the global postcolony, neither the technologies of Western medicine nor their power to save are untouched by such structural threat.

The term currently used by the National Institutes of Health (NIH) to describe contexts of health debility is the “social determinants of health” (SDH), sometimes expanded to the “social and economic determinants of health” (SEDH). According to the CDC, the term SDH “refers to the complex, integrated and overlapping social structures and economic systems that include the social physical environments and health services. These determinants are shaped by the level of income, power, and resources at global, national, and local levels . . . often influenced by policy choices” (2010).3 The CDC and the NIH base their definition on the U.N. report finalized in 2008, conducted by the WHO Commission on Social Determinants of Health. Interestingly, the places where the term is most employed is in relation to explicitly recognized “vulnerable populations”; so, for example, the websites in which it plays a greater role than elsewhere in the NIH sites include the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention and the National Institute of Minority Health and Health Disparities. This gives the unfortunate impression that the structural violence of inequity can best be addressed through attention to minority health concerns. Yet the absent partner in this picture is the idea of medicine as a key site of corporate profit. Attention is paid to victims of structural violence, but not to its beneficiaries in financial terms, or to intergenerational histories that produce such negative outcomes.

It should come as no surprise, then, that an analogous problem affects the history of relations between settler-colonial enterprises and disease, especially infectious disease, where colonially directed population movements are left out of medical history. In 1998, Warwick Anderson wrote a review of two histories—on the developments of tropical medicine and of colonial medicine in Malaysia—tellingly entitled “Where Is the History of Postcolonial Medicine?,” in which he argues that:

Over the past twenty years or so, a small but growing band of historians of medicine has directed its attention to disease and health care in colonial settings. Previously, medicine and imperialism had been brought together mainly in the recollections of colonial medical officers and in the more wide-ranging social histories of recently decolonized nations. In these accounts, Western medicine was generally presented as one of the few indubitable benefits of European imperialism. Even Frantz Fanon, the Martiniquean psychiatrist who features so prominently in origin stories of postcolonial critique, remained convinced that Western medicine and psychiatry were basically good things, although distorted in a colonial structure of inequalities. But historians of colonial medicine are now more likely to discern a deeper collusion between medicine and empire: the political economists among them describe more plausibly a colonial production of disease, and the more literary of them analyze medicine and public health as technical discourses of colonialism. Accordingly, it seems now that to use Western methods to prevent or treat the diseases spread by colonialism was to colonize the body in a more basic way than Fanon’s nationalist optimism would ever let him admit.

So have we, then, developed a truly postcolonial historiography of Western medicine, our own postcolonial literature? I do not think so. Rather, it seems to me that we are successfully building a disciplinary enclave of implicitly nationalist historians of medicine. We are more likely to ask what is distinctive about Western medicine in a particular colonial, or protonational, setting than to look for what is colonial about Western medicine in any setting. We are still writing a minor literature. (522–23)

To take up Anderson’s challenge, I look for what might be colonial about Western medicine through an explicitly nonnationalist history involving Ebola and HIV/AIDS. These diseases, as I noted earlier, are thought of within nationalist imaginaries as African, where “Africa” is not (even) yet acknowledged to have states, even though those states were in the first instance determined by Europeans at the 1885 Berlin Conference. First, I connect the concept of the state-as-healthy to the human subject, to illustrate the ubiquity of the genre of the “healthy human” subject in its enmeshment in practices of human-rights violations through colonization and slavery and through the instrumentalization of some human beings. I associate this with an essentially vulnerable utopianism, one whose weakness lies in its addiction to the state-as-healthy and its projection of the unhealthy onto noncitizens who are then cast as enemies, standing in for the oft-imagined danger of “the” (usually “an,” meaning the handiest politically at the time) infectious disease with pandemic “street cred,” the infectious disease that’s trending, one might say. When I have demonstrated the challenge the elision of nonnationalist, postcolonial histories of medicine4 poses to rendering structural violence in terms of SEDH, I move, albeit tentatively, toward explication of an effluent subject: an explication that distinguishes between biological disease agents and the structural violence that enables them to flourish.

I embark on a brief, comparative history of the heavily burdened postcolonies of Liberia, Sierra Leone, and Haiti to begin filling the gap Warwick has outlined. While recent feminist thought has begun to understand that autonomy must, of necessity, entail vulnerability in terms of constructive interdependence, I describe forms of sovereignty that seek to deny vulnerability in fantasies of absolute domination at the very birth of nation-states.5 That is to say, I identify within the very ideation of the nation-state a utopian will to power that is mystified by the independent agency of potentially damaging but entirely nonintentional forms of threat to state governance, such as is the paradigmatic case in this chapter, infectious disease. I pay particular attention to the material realities of the ebbs and flows, crossings and recrossings, of trade in persons and diseases and their shared materiality, attempting to place this history of material exchanges within an understanding of settler-colonial and late-capitalist utopian dreams of sovereignty, where the utopia must, by definition, exclude any ideation of vulnerability. Unlike this utopian will to power, whose goal is an impossibly consistent invulnerability, the effluent subject accepts vulnerability as a condition of being, without the anthropocentric attribution of self-denial (“I am invulnerable”) or masochism (“I am always a victim”). The acceptance of vulnerability as ontological is frequently interpreted in global capitalism as self-victimization (the “pull yourself up by your bootstraps” approach to structural violence). While one can attribute a politics to the intentionality of human forces driving population ebbs and flows in a colonial context, taking a decentered approach to the agency of disease involves entangling histories of human intentionality in a new sociality with histories of disease, while scrupulously avoiding assigning agency to diseases such as AIDS and Ebola outside of their hardwiring to reproduce and thrive at the material level. This kind of history begins to answer Anderson’s call for postcolonial medical history through a decolonial critique. The vexed question of how to write postcolonial medical history with decolonial vision requires writing medical history outside of the genre of the anthropocentric human, portrayed either as “savior” (the desire behind the Ebola containment suit) or “victim” (the absent and feared Ebola sufferer).

My refusal to assign agency to diseases outside of their biological hardwiring is not to deny that such diseases play a role in vast symbolic imaginaries of humans, such as those that locate AIDS as a sign of moral failure and Ebola as racialized proof of an inherent weakness or inability to thrive. Such inability precedes the onset of the disease and is made explicit by the disease, under the sign of impropriety, in which the disease becomes the outward manifestation of the mistake of improper, unapproved contact with effluent subjects. Such impropriety is true for the Black subjectobject, as well as for that often unnervingly, indeterminate subjectobject, the yet-to-be-out-as-HIV-positive person whose “preexisting condition” of disease masquerades as the healthy citizen.

It is, however, crucial to separate these imaginaries from an understanding of the agency of the diseases themselves, to “reverse engineer” disease history to see diseases as “companion animals,” so to speak, to colonial and capitalist enterprises of accumulation through dispossession. I invoke companion animals in the same way in which Donna Haraway speaks of dogs as companion animals to humans in her 2003 Companion Species Manifesto. To paraphrase her key questions about dogs and humans (3) in terms of humans and viruses: How might an ethics and politics of significant otherness be learned from taking the human–disease agent relationships seriously? And how might stories about disease–human worlds finally convince Americans that history matters in naturecultures?6 Here “naturecultures” is a description of an effluent subject that refuses to separate human-as-cultural from nonhuman-as-natural, or “primitive,” resulting in the telltale conjoined subject that is impossible within the Enlightenment imaginary that separates (white) Human Subject from (Black) nonhuman object.

The bare facts of the history I reprise below concerning an array of transatlantic crossings, and indeed crosshatchings, involving the colonial management of (quasi) subjects (that is, colonially ruled peoples) are not new.7 My contribution aims to contextualize these facts within a nexus of hyperimages of slavery, disease, “race,” zombification, and nationalism around which the fear and fascination I referenced above in relation to the figure of the Ebola Halloween costume coalesce. These are hyperimages in the same way that Timothy Morton describes his “hyperobjects” as such enormously and variously inflected images that we have trouble tracing their implications comprehensively because we live within them, rather than look at them (2013). These implications escape articulation within the framework of individual or even collective human subjectivity and agency. That is to say, they are inarticulable within frameworks driven purely by the bildungsroman/human-rights aspiration of man-as-sovereign, His intentions and their consequences as controlled and effective, and the nation-state as the primary mechanism of communal expression of those intentions and their consequences.

The truths spoken by these hyperimages begin to become more visible only in a rendering of them in which sovereign/colonizing Man is visible in the center of a structural violence, colonial capitalism, that reflects the narcissism of an anthropocentric world.8 The hyperimages, the expression of fused desire and terror that accompany sovereign fantasy, have identifiable historical roots and deeply important effects on current global biopolitics. Further, their entanglements extend into negative public-health outcomes. I frame these outcomes as the materialization of racist utopia/dystopia fantasies, characterized by their inability to face the vulnerability the supposedly nonhuman other (Black, African, slave, disease) presents to the human. In effect, I describe how the human that exceeds the normative intentionality attributed to Him in the genre of the human, manifest in the UNDHR, sets panic to work in the administrative heart of colonialist-capitalist “rationality,” as evidenced in Ebola Halloween costumes explicated above.

Slavery as the Instantiation of Capital at the Founding of the Nation-State: Sierra Leone, Liberia, Haiti

The three countries most deeply affected by Ebola in 2014—Sierra Leone, Liberia, and Guinea—were profoundly influenced by precolonial and colonial slave trading. Specifically, Sierra Leone and Liberia were founded by freed slaves. That is to say, some white abolitionists and freed Black allies held the view that having slaves freed in the United Kingdom and the United States settle “back” in West Africa was ideal. These freed slaves were part of the intergenerational displacement of the slaves from Africa in the transatlantic slave-trade practices of forced removal and abduction. As such, the origins of the freed slaves could not accurately be traced in most instances even to or via the Caribbean, let alone to specific areas of West Africa itself. “Return” would not be an appropriate description of the founding of the colonies of Sierra Leone and Liberia in West Africa in this sense. Further the state-making vision of the “returned” freed slaves was profoundly colonial.

The less expressed sentiment behind the vision that all freed slaves should live elsewhere than in the United States and United Kingdom is that the Blacks should be outside of the imperial territory unless they are enslaved: a manifestation of the nation as a white utopia. The freed slaves’ presence “at home” in the settler colony is an untimely reminder of the key subvention capitalism required from the slaves themselves to get it going, which is free labor, just as it required “free” land from Indigenous peoples. The settler state, as a colonialist-capitalist Subject par excellence, does not admit to visible evidence of its dependence on exploitative labor practices with any grace.

The Practice of “Rescue” Medicine in the Global South

In spite of the fact that Anderson wrote “Where Is the Postcolonial History of Medicine?” over two decades ago (1998), it would seem we are still “writing a minor literature,” which has deeply problematic, actual effects, as Western medicine is assumed to be both normalized and superior to Indigenous traditions and cultures of healing and wellness on all counts, as Alan Bleakley, Julie Brice Browne, and John Bligh point out:

Western medicine and medical techniques are being exported to all corners of the world at an increasing rate. In a parallel wave of globalization, Western medical education is also making inroads into medical schools, hospitals and clinics across the world. Despite this rapidly expanding field of activity, there is no body of literature discussing the relationship between postcolonial theory and medical education.

We need to develop greater understanding of the relations between postcolonial studies and medical education if we are to prevent a new wave of imperialism through the unreflecting dissemination of conceptual frameworks and practices which assume that “metropolitan West is best.” (2008, 266)

Add to this, first, the current focus in medical education on “cultural competence” as a means of communicating effectively with communities from cultures other than the Western scientific and, second, the current rage for global health experience among medical students. Firstly, “cultural competence” has nothing to do with cultural competence in the sense that it constitutes an instrumentalist set of tools for more efficiently conveying the authority and superiority of Western medicine in contexts in which such superiority could be questioned by Indigenous and postcolonial communities. The CDC takes its definition of cultural competency from the U.S. Department of Health and Human Services, Office of Minority Health, which assumes that the patient is defined above all as a “consumer” of Western health services, despite the document’s apparent concern with identifying the health provider’s own beliefs as a potential barrier to positive outcomes in situations where the aforementioned “consumer” is of a minority.14 Following Anderson, cultural competence pedagogies do not ask, “what is colonial about Western medicine in any setting?,” and they assume that the Western-trained healer is able to develop competence in the culture of the other, or at least, able to develop sufficient “skill” to impose Western medicine authoritatively in the cultural setting of the other under the sign of “cultural competence.”

As I have noted elsewhere, the practice of medicine in conjunction with the allures of the postcolonial exotic creates a fatal medical neo-imperialism. I spent three years of my childhood in Lesotho, an independent nation enclosed by South Africa, in a mission hospital where my father was the only doctor for forty thousand square miles, and we lived in the geographical center of the country along the infamously dangerous “Mountain Road.” We would get well-meaning donations to the hospital that made us laugh and cry at the same time: an unbelievably expensive piece of a heart transplant machine, which we then had to find a buyer for to garner the income for the hospital’s needs, and hundreds of disposable needles that had already been used. The postage expended to get them to us we could well have deployed for real needs. Who, one wonders, thinks that one can reuse disposable needles? And what population “deserves” such “care”?

Lesotho depends on charity, migrant labor, and garment work, as well as subsistence farming. The country is among the group of “Low Human Development” countries (ranked 168 of 191 on the Human Development Index as classified in the United Nations Human Development Insights in 2023). The current 2023 life-expectancy figure is 55.65 years, and while adult literacy rose as high as 81.02 percent in 2021, the infant mortality that year was still high, with 55.183 deaths per thousand babies (Macrotrends 2023). According to 2021 estimates, the prevalence of HIV was about 20.9 percent, one of the highest in the world, with 290,000 living with HIV, 74,000 new HIV infections, 4,500 deaths, and 81 percent of infected adults on highly active antiretroviral drugs (HAART) (UNAIDS 2021).

I once had a discussion with a colleague who was taking groups of students over to a Canadian-sponsored HIV clinic in Botswana; he figured he could keep the clinic going through rotations of medical students and locums from Canada indefinitely. He was mirroring the approach of Philip Berger, who worked under the auspices of OH Africa (an NGO associated with the Ontario Hospital Foundation) at the Basotho clinic he had set up in late 2004. The clinic was due for a normal transfer from foreign to Basotho government control, as was recognized by the Canadians themselves. However, as the takeover loomed, Berger and OH Africa warned of a “life or death” crisis at the clinic, due to the withdrawal of the Canadian staff, a refusal of the Basotho national government to pay for fifteen local workers, and fear that integration of the clinic into the hospital would lead to stigma-related avoidance and a diminishment in care standards.

The clinic at one point boasted of having attracted fifty Canadians to its locale. This raises the questions of what programs were in place for the transfer of skills from the Canadians to the local medical staff and what plans were made by the clinic for its eventual transfer to the central government, a condition by which the clinic had operated with the Basotho government’s permission. HAART administration becomes a complicated business only when rarer forms of resistance to regimes appear. However, this is used as a form of threat in an instantiation of Canadian superiority in the language of the letter written to the Basotho government by the OH Africa and Dr. Berger:

Now, after a dispute with the Lesotho government, the Canadian donors are warning of a nightmare scenario. Patients could die, they say, and the clinic could spark a public-health crisis by spreading drug-resistant HIV strains across the border to South Africa.

Health professionals at the clinic are already beginning to leave, and key programs are disintegrating. “This is a life-and-death urgent matter for the people of the region, said Philip Berger, a Toronto doctor who specializes in AIDS treatment and has worked at the Lesotho clinic as recently as December. (York 2010)

This implies that new strains of resilience are not spreading within South Africa itself and do not often come from there, a patently empty claim: indeed, I’d be more worried about such strains coming into Lesotho, not going from there into South Africa, as South Africa has a far more advanced HIV/AIDS system for detecting and dealing with such strains, and a far larger population in which to develop them. Further, we have considerable experience now of how to destigmatize HIV clinics within a hospital setting, such as making sure they are integrated with pre- and post-natal care, and are not “stand alone,” so that patients visiting them cannot be identified as HIV-positive or not.

My main point, not a new one, but not a persuasive one, apparently, is that intercultural skills transfer to local professionals should be part and parcel of the plan. I understand that there would be resistance on the part of clinic-goers to the change in care, which may be less personalized, require further travel (a huge problem in the service of the highlands in Lesotho in particular), seem less “high tech,” and therefore be perceived to be less effective. Working within a hospital administration poses barriers not encountered in individual, specialized clinics—no question—as I experienced in my own attempts to integrate NGO rape-crisis clinics into hospitals in rural KZN. But what does it mean to develop clinics in Lesotho and Botswana that effectively depend on rotating medical staff trained in Canada to do locum and fixed-term work at the clinics? As the minister of health of Lesotho, Mphu Ramatlapeng, put it in an e-mail to The Globe and Mail: “They experienced a very high turnover of staff and they failed to meet certain targets. . . . They failed to integrate the clinic services with the services of the main hospital. They also failed to assist us with decentralized services to the clinics” (cited in York 2010).

The most important services communities need when members are on antiretroviral (ARV) treatments are the complex but nontechnical skills to: persuade a mother not to give her drugs to her husband or another family member because they won’t go for testing; ensure that the family (however constituted) has access to the right kinds of foods and good quality water to sustain taking ARVs (both food and water are a problem in Lesotho); explain the importance of condom usage to discordant couples and those at risk of cross-infection of different strains; prevent mother-to-child transmission; negotiate traditional healer integration with ARV regimes, and appraise patients of the possibility of resistance and its symptoms and postresistance options. These are all public health and interpersonal skills services best offered in Sesotho in the context of its extremely high poverty and unemployment rates, and with an understanding of the modern history of the country as, until recently, a men’s (and now, increasingly) women’s labor camp for South African industry.

Canadians and other Westerners founding clinics in the global South are often not attentive to the repetition of the hubris of colonialism and the cost of that hubris to local populations. At issue is the lack of the sustainability of foreign interventions, just as it was when the Belgians failed to train successors when they pulled out of the Congo on June 30, 1960. The ensuing development of the postcolonial state, in part by expatriate Haitians, is the factor to which Peter Piot and others, such as Oliver Pybus, infectious disease specialist and evolutionary biologist at the University of Oxford, attribute the introduction of HIV to Haiti. Returning expatriates brought the genetic forerunner of the current epidemic back to Haiti with them from the DRC (Faria et al. 2014). As Pybus, Andrew J. Tatem, and Phillipe Lemey point out, “the effects of global mobility upon the genetic diversity and molecular evolution of pathogens are under-appreciated and only beginning to be understood” (2015). Also at stake are postnatal care units and other physical areas of the hospital that offer highly unstigmatized and long-standing services, including Tuberculosis services, which have a long history in Lesotho owing to the migrant mineworkers. HIV drug resistance (HIVDR) is an increasing threat to treatment globally. The development of laboratory capacities for testing goes hand-in-hand with country ownership and governance mechanisms to ensure sustainable responses to HIVDR (WHO 2017a; note objective 4). Further, there are community resources that go unrecognized in the enshrining of Western medicine as the gold standard. Before the availability of ARVs in South Africa, Sangoma (traditional healer) Benghu reminded me once, the folks at King Edward VIII Hospital in Durban used to tell HIV-positive patients from the Valley of a Thousand Hills to “go home to die.” It was the traditional healers who supported them in their quest as to how to live with the disease. Conceiving the ill postcolonial citizen as purely a victim is rife with fantasies of humanitarianism, technological superiority, and the zeal of Western medicine to practice under the sign of the exotic tropic.

What might a way out of this conundrum be?

The Zombie as Revenant

The absent figure in the Halloween costume is that of the unspeakable Ebola victim. Thus, while biohazard containment costumes abounded in popularity in October 2014, their twin costume, so to speak, was (thankfully) absent, as noted above. The Ebola victim, despite the potential of the stereotype of Ebola as a (misnamed) hemorrhagic fever to offer Halloween costumes of gruesome creativity matched only by inexorable bad taste, was present by her/his spectacular, racialized absence. If there were instances of Halloween makeup verging on the popular notion of Ebola as a spectacular hemorrhagic fever inaccurately perpetuated by texts such as Richard Preston’s 1994 The Hot Zone, these occupy a pleasurable distance from the actual fact of the person who dies from Ebola.15 Makeup itself suggests containment through its manipulation of a stable face, a stable body in costume, rather than the unpredictably effluent body of the dying person, in which the actual moment of death is buried in days and hours of deep suffering. If this absent figure has an actual correlative, it would perhaps be Thomas Eric Duncan, a Black American with a reportedly thick West African accent who became infected on a visit to West Africa and later died in a Dallas hospital, having been neither treated with the drug cocktail offered to white survivors nor transfused with the blood of a survivor, both interventions demonstrated to improve the victim’s chances of survival (Karimi and Shoichet 2014). Ironically, despite the panic in the Unites States over Ebola, the failure to recognize the disease “on home turf” and the related failure of provision of services killed Duncan.

It is with the absent figure of the Ebola zombie that I wish to conclude. The zombie becomes tied in with the Ebola victim in the strange reports of Ebola victims who come back to life after they are dead, notably two women from the Nimba Country of Liberia. While this is obviously “fake news,” so to speak (they were likely falsely pronounced dead in the height of the epidemic), what is notable is the facility with which citizens latched onto Ebola hysteria in the United Kingdom and the United States. I argued above that the Ebola-containment Halloween costume and its absent other, the racialized Ebola victim, speaks a certain history, that of a colonialist-capitalist regime in which biomedicine prevents whites being harmed (and, one might argue, from “susceptibiltiy” to nonheteronormative gender formations, considering the gendered nature of the outfits), while consigning actual victims in need of help to the speculative region of an invisible, unspeakable, fantastically dystopian, and disease-riddled, and indeed a disposable, “Africa.”

In the engaging, telling, and often meticulous genre of zombie studies, the zombie is traced through its Haitian original in voodoo, through its appearances in the rampant genre of the zombie movie via George Romero, through to its appearance not as the living dead, but those who live as if they were dead: those who stave off a sense of limited subjectivity, for example, through rampant consumerism. Here the zombie is not the Ebola victim per se, but its supposedly privileged other, the consumer who buys the Halloween costume in a putative but genuine attempt to stave off threats to an absolute sovereignty. This desire has its adult expression in the survivalists who bought real Ebola/hazmat-containment suits to the tune of thousands of dollars, despite the fact that their potential exposure to Ebola was nil.16

This phenomenon speaks to the mixture of desire and fear we see in such costuming against a future threat that comes from a racialized elsewhere. The telling aspect of this scene lies, as rehearsed previously, in the fear of diminished white sovereignty, of diminished consumer colonialism, of the failure of rationality in the history of the West, and of the retreat of colonial capitalism in the face of a history of the Black/slave/debilitated/sick subject as revenant. The figure of the zombie comes to us as revenant in the spectral politics of Ebola through the sufferers “raised from the dead” and through the smiling faces of apparently perfectly healthy subjects wearing Ebola makeup, as in the Dutch campaign for Doctors without Borders that sought to raise awareness of the disease through celebrity “Ebola selfies.”

Bringing an effluent eye to the persistent figure of the zombie enables us to see a weakness in Roberto Esposito’s immunological biopolitics. Esposito views modernity and biopolitics through the lens of immunity, which he opposes to community. In modernity, he argues, the need to defend against others rather than build community expansively reigns: As Nietzsche saw clearly, he argues, “what we call ‘modernity’ is nothing but the meta-language that allowed [us] to respond in immunitarian terms to several demands of preventive protection, . . . when the promises of transcendent salvation were failing” (2013, 97). That is to say, when secularism threatens the afterlife as it is conceived in Judeo-Christian terms, technology offers the promise of survivability in this life through immunization, not simply as medical practice, but as a foundational paradigm for sovereign human life in a secular field. If in premodern times the sovereign never dies—only the king, who occupied the position of the sovereign, dies—in secular modernity, the Human can be resurrected as actual sovereign, not just as occupying the position of the sovereign, through the paradigm of immunization.

As the paradigm of immunization helps us to grasp the structural link between modernity and biopolitics, the paradigm of autoimmunization lets us establish the relation, as well as the element of discontinuity, between modern biopolitics and Nazi thanatopolitics, where thanatopolitics is “a politics of death . . . stand[ing] in opposition to biopolitics and its affirmative instantiations of life itself”:

Regarding [thanatopolitics], . . . not only the racial politics of the German people became the principle aim of German politics—in a way that affected their survival to the death of its external and internal enemies—but at some point, when defeat seemed inevitable, the order of its self-destruction was given. In this case the immunitarian system assumed a fully auto-immunitarian connotation and biopolitics came to perfectly coincide with thanatopolitics. (Esposito 2013, 87)

As Esposito also characterized thanatopolitics, it is “operationalized as the progression of life through increasing the ‘circle of death’ ” (2008, 110).

However, first let us remind Esposito that the modernity of which he speaks is inflected with colonialism, without which Esposito’s modernity is unthinkable (as is Foucault’s, although Foucault is far more aware of the fact). Then let us return to the fact that the refusal of the opposition between zoe and bios under the sign of contemporary global capitalism is negotiated by the mobilization not of mass death to enable biopolitical life, but mass debility: the debilitation of the other is not incidental to the colonialist-capitalist. The quality of life of the latter actually depends on the debility of the former, as I rephrased Puar earlier. The zombie as the one who consumes without awareness of its state of unawareness in this scenario would reflect the disability of colonialist-capitalist citizens. What can we “let be born” if we conceive as reflexive rather than undirectional the connection between the Subject who lets the “object” live debilitated and the objectsubject who lives debilitated? And what if the form that reflexivity takes is that of the zombie? Rather than a binary opposition between racialized utopias supported by capitalist biomedical regimes and their dystopian others, the literally disarticulated biopolitical regime of systemic debility in the postcolony, we could attend instead to the zombie as a figure that itself disarticulates the binary between the citizen and the debilitated, defined as available for disablement and death. The disarticulation of the citizen–zombie binary and the disposable has the potential to lead us to some preliminary understanding of Esposito’s politics of immunity as potentially reciprocal, and therefore not a politics of immunity at all, but one of a materially presented discursive possibility of eluding the immunity–community binary, in Esposito’s terms: a fragile opening onto a positively co-constituted community of effluence comprising the citizen-subject and the effluent-subject, the latter of which is not defined by an availability for further debility, but embodied self-knowledge of how to read both the separation and the interaction of biological disease vectors and sociopolitical vectors. To put it bluntly: how does one take the observation of the isiZulu lady I interviewed in KZN seriously? How does one listen to her with an effluent ear?

The kind of sovereign Foucault appeals to is a historical reality but a current fiction: very few sovereigns are left who singularly have the power to make die and let live in an uncomplicated gesture of power, as Mbembe points out. More relevant, however, is the material presence of utopian nationalisms playing themselves out over history in the face of the hypersovereignty of multinational capital. In this respect, the inheritors of the white utopian dream of colonialist-capitalist triumphalism—some of whom are not white, of course—are indeed haunted by the specter of the slave. For, in making the human a commodity, the irrevocable decision to commit to the law of commodification, rather than the value of extramaterial meanings, was made, and the human-who-does-not-produce (or oversee production) was rendered available for debility; as David Harvey argues, “sickness is defined broadly under capitalism as inability to work” (2000, 106).

The refusal to respond to the call of Haiti for reparations for slavery thus speaks both to the hypocrisy of the nation-state (France and the United States, in this case), with its commitment to humans as commodities (not making amends for slavery) even as it claims publicly to be against the idea, and to the nation-state’s own diminishment of its supposedly sovereign subjectivity in the face of the disarticulation of colony and capital, as global economic power moves away from its traditional western European and North American shores and financial exchange migrates out of the power of the state under the sign of capitalism. This disarticulation of nation-state and capital can be seen as systemic debility only from the perspective of the colonialist-capitalist zombie, filled with the fantasy of a good life with no repercussions or debts, financial or ethical: a perfect, walled, politics of immunity. But, for those living in actual conditions of colonialist-capitalist-induced debility, not all of them in the traditionally recognized settler colonies, the diminishment of colonialist-capitalist sovereignty is not necessarily a marker of a new vulnerability. It offers an opportunity, perhaps, for a more equitable sharing of vulnerability across nations and races, a more equitable cohabitation in conditions of effluent community; but this outcome is uncertain and deeply fragile, analogous to but not the same as the fragility of the Musselman in its ebb and flow.

In any event, one difference between the agency of Ebola and the agency of the biopolitical human remains: Ebola may often kill its victims in places of colonial capitalism, through underdeveloped medical systems and supports; but it is not the kind of subject that does so in acts of racialized, biopolitical violence that depend on the sustaining of debility, the kinds of acts with which my interviewee is so familiar and of which she has an embodied knowledge. As long as the postcolony remains host to colonialist-capitalist legacies of human agency, a productive infrastructure of postcolonial debility serves the racialized ends of neocolonialist, “utopian”/immunitarian politics. Indeed, factors in being infected by Ebola and dying from it are colonialist-capitalist in nature, having to do with the structural violence of the underdevelopment of health infrastructures in West Africa. Yet, as I demonstrate in the next chapter, subjects in excess of the state are not bound to the immunitarian injunction to create community only through exclusion, and thus can enable persistence against the politics of immunity that Esposito so claustrophobically describes, in which what is feared must be immunized against, pitting the Subject against the other and framing subjectivity as, tellingly, impossibly against community, to the extent that the threatened community offs itself before it is defeated, as in the example of Germany given by Esposito.

In the following chapter, I discuss two novels from the perspective of an effluence-inspired critical ear, as a kind of listening to the isiZulu gogo (older lady), my Underberg-based interlocutor. Jennifer Haigh’s novel Heat and Light is expert at describing Esposito’s immunitarian politics in fictional terms, while Masande Ntshanga’s The Reactive describes an effluent alternative. In The Reactive, Lindanathi, the narrator, assigns a deep value to the inability to help the other in certain situations on the grounds of, first, a lack of knowledge of the situation, where such lack of knowledge is not registered as fear and, second, the notion that the desire to help the other is more often than not a fleeing from attention to the inadequacies of the self. While this plays out on an interpersonal level in relation to the characters in Lindanathi’s narrative, it is also structurally connected to the dangers of humanitarian investments within the violence of a system in which medicine is privatized, and therefore offered in enormous acts of “generosity” rather than provided as a common good. The transactional quality of both financial and humanitarian exchange, we discover, are part of an economy to which effluent communities can show signs of persistence, not in a mass utopian vision that comes under the sign of Resistance with a capital “R,” but in fragile, patchy, but consistent production of evidence of how one might envision living outside colonialist-capitalist value. This practice has intermittent success, where success is defined as the ability to live on the margins in a state of persistence against colonialist-capitalist structural violence, not in the white-zombie terms of the ability to accrue material value from the margins.