Sanyu Mojola’s “Love, Money, and HIV: Becoming a Modern African Woman in the Age of AIDS” (2014) presents a compelling, multilayered, processual account of the ways that changing ideas of modernity and the expansion of a gendered market economy combines with the physiological and ecological structure of HIV transmission risk to produce the outrageous inequity in HIV burden borne by women in Africa. She says, “Specifically, I illustrate how consuming young women have been cultivated and produced, in three contexts—communities, schools, and labor markets” (p. 8). For her, the dramatically gendered disparities in HIV burden and experiences can only be adequately explored by tracing the interwoven threads of the structuring market, its shaping force on cultural norms and dispositions, and the implications for young womens’ search for love and desire amidst the specter of HIV. As Mojola describes, women are caught between the culturally and institutionally cultivated demand to consume—products, beauty goods, daily signs of status and modernity—while also being structurally excluded from the vast majority of the formal labor market and consistent income potential. The demand for stable income leads to emergence of various forms of “transactional sexual relationships” that take on different forms in different settings, but all help to satisfy consumptive needs and norms.

Mojola was born in Tanzania but attended college in the UK and graduate school at the University of Chicago. As she as a result her writing has an emotional and intellectual proximity that is unusual. It makes the evidence—qualitative and quantitative—all the more compelling. As she says, “I was Robert Park’s ‘marginal (wo)man”, belonging, yet not quite belonging, understanding yet not quite understanding…Far from an impersonal and purely academic account, then, this book is a study about the young women whose dangerous transitions I might have had to traverse except for the strange turns my life has taken” (p. 27-28). Using a life-course framework to study young people’s transition to adulthood in the context of the HIV epidemic, she mobilized interviews with 185 people (young people, middle-aged adults, and older adults) from the Nyanza province of Kenya; population-based survey data from Kenya; and, ethnographic field work.

Mojola’s central puzzle is: what social forces lead women to be so extremely vulnerable to HIV infection in sub-Saharan Africa, specifically the eastern part of the continent? Research on the issue tends to focus on three broad sets of interrelated causal factors—biophysiological, proximate explanations, and social structural causes. Biophysiological factors include the relationship of female anatomy/physiology and its relationship to HIV transmission potential. Proximate explanations tend to focus on the age at first sex, the number of sexual partners, condom use, the structure of sexual networks, and migration patterns. Mojola identifies one key social-structural cause, which is the central analytic lens of the book: consumption. She explores the how socially produced consumption desires shape behavior and consequent risk for contracting HIV; how consumption operates within networks and institutions (such as schools and labor markets) to shape HIV risk; and, how the structuring dynamics of consumption patterns are similar across high-prevalence settings across Africa.

Mojola begins her substantive argument by tracing the phenomenology of “modernity” as experienced by young women, transitioning to adulthood, in sub-Saharan Africa. Globalized notions of taste, marketing and media enable brands and consumption patters to be extended to even places “remote” from the metropole/former colonial centers. In places marked by significant poverty, “consumption is available used and at a deep discount—through secondhand North Face clothing that has made its way from Western charities, for example, or through cheap pay-as-you-go Nokia mobile phones” (p. 34). This modern (post-modern?) form of consumption has a markedly gendered dimension: “the dominant signifier of modernity for young women is the purchase, consumption, and display of modern goods. Indeed, there is a sense in reading these accounts that transactional relationships as a means for enhanced consumption are an indelible part of the landscape of young African women’s relationships” (p. 36). As has most notably been discussed by Viviana Zelizer and others, money, transactions, gifts, sex, and intimacy are often interwoven within relationships. Women and men engage in “relational work” to maintain culturally appropriate and sanctioned matches between money, media, and morals within intimate relationships. This is no less true in the relationship forms of young African women, and these structures have significant implications for the observed disparities in HIV rates. “In Kisumu, Nyanza, for example, three-quarters of men surveyed reported giving an average of 10% of their monthly income to their nonmarital, noncommercial sexual partners… transaction in intimate relationships was the norm rather than the exception in this setting” (p. 37).

As has been demonstrated in research on “sugar daddies” and other forms of explicit and non-explicit forms of transactional intimate relationships (in the U.S. and elsewhere), “when access to money and resources is structurally constrained, transactional sex emerges as a way of ‘redistribution and reciprocity in an unequal and uncertain world,’ where men’s dominant access to wealth and resources ‘compels them’ to have concurrent sexual partnerships involving transactional sex” (p. 42). Market demands for consumption are therefore intimately tied to the gendered risk of contracting the all consuming illness of HIV/AIDS (“Ayaki [Luo word for AIDS] came from the root word yako, which means to consume very fast, in such a way that displays greed” (p. 51)). An interesting aside is the parallelism in the discussion of consumption in HIV and the history of tuberculosis as a consumptive disease. The entanglement of aesthetic, ethical, cultural, and market demands for consumption are structuring for the experience of infectious disease transmission risk. The pursuit fo the raha—the good life of enjoyment and consumption—shaped the HIV epidemic which was “not just consuming anyone; it was consuming young women” (p. 59).

Mojola describes the “great transformation” of colonial/post-colonial settings in a Polanyian way: relationships, particularly intimate ones, are embedded within a complex, historically rooted matrix of moral, ethical, and social meanings and commitments. “It was not money that alienated or ‘ushered in moral confusion’ or that created alienated social exchange. Rather… ‘it is important to understand the cultural matrix into which it is incorporated” (p. 75). Money and the consumptive market economic logic imbricated with existing historical norms of kinship, marriage, relationship, and sexual norms. Mojola indicates two primary forms of transactional relationships that have emerged: relationships for education and relationships for sex. The former, however, often evolved into the later. “For many young men, the only fair exchange or reward for the gift of money was having sex in return. Boy did not necessarily need to be wealthy, but needed to have the ability to get or earn money to help their girlfriends” (p. 83). In Zelizerian terms, gifts of cash and consumptive products (beauty and other types) [the media] were matched with evolving transactional relationships which were not poisoned, or “tainted” by such cash and “economic” transactions, but were actually imbued with additional meaning and moral significance as a result. “Both sex and money expressed love. In other words, love = sex + provision” (p. 87).

These dispositions were actively cultivated in young women, as explored by Mojola, in two primary institutions: the school and the labor market. Puzzlingly, women with more education are observed to have higher rates of risk for contracting HIV. “The thinking goes, if education has such dramatic effects on one sexually transmitted condition—fertility—why not on HIV/AIDS?” (p. 114). Her explanation hinges on the ways that structural processes and norms, refracted through gendered practices, shaped the notion of a “modern schoolgirl” as “Consuming young women [that] had desires that could only be satisfied by consumption, desires that were considered necessities and integral to schoolgirls’ transformation” (p. 132). This culturally disciplining nature of the demand for becoming a modern, consuming, young woman combined with the norms of engaging in transactional relationships with working-class men to get money to pay for those needs, is Mojola’s main explanation for the linkage between increased education and increased HIV risk.

Finally, the gendered nature of the economy and the structure of the labor market was another way that the embedded forms of economic and meaning making became entangled in and produced the risks of contracting HIV. As she states, “In particular, the predominantly one-way transfer of money and gifts—from men to women—in transactional relationships reflect the fact that in most settings, men have relatively greater access to money and resources due to the gendered structure of local economies” (p. 151). This gender-structured labor market exacerbated the sociocultural/economic structures that produced unequal HIV transmission risk. The structural disconnect between the cultivation of young, modern, consumptive young women in the emerging mass education system and the exclusion of women from the labor market and formal income-generating mechanisms that would be necessary to finance this consumptive demand, produced the need for transactional sexual relationships with men. “They had to be continual consumers and thus continual transactors” (p. 169).

Mojola ends this book with a call to action: “The large number of young women currently beginning their sexual lives in high HIV-prevalence environments suggest that policy actions (or nonactions) undertaken in the next five to ten years may very well determine the course of the HIV pandemic in Africa” (p. 183). She calls for continued individual-level interventions such education and awareness raising, but also claims that this will be insufficient. As is the topic of this book, change will only occur with changes in the socio-structural determinants of HIV transmission: changing the school environment, cracking down on sexual relationships between teachers and students, legislating and making paying jobs more available to young women. Most promising is her brief summary of the potential of conditional (and unconditional) cash transfers to schoolgirls for HIV prevention. By reducing the structural/economic pull that young women feel in their pursuit of accomplishing the role of being successful young, consuming, modern women, perhaps the trajectory of the HIV pandemic can be altered.

Some key questions that come up for me:

• Mojola seems to base her theoretical contribution building off of a combination of Zelizer and Granovetter: networks and institutions structurally shape the networks of relationships (the circuits) through which HIV is transmitted, but also reinforce the cultural feel, aesthetic view, and moral meanings associated with these transactions, interactions, and at times loving/intimate relationships. While this does seem like a powerful case example of embeddedness and relational work in an understudied setting/population—with important policy implications—what does it add to sociological theory?
• While she clearly engaged with young women who were in difficult straights, her respondents / sample does seem to be relatively well off, urban, school-bound women. She explicitly says on several occasions that these were not transactional relationships of necessity (in order to eat, have shelter), but rather the needs expressed by the young women were structured by the demand to consume along the lines dictated by the cultural pursuit of modernity. I wonder if this presents a limitation or simply a purposeful focus for the structure of her research design?
• A question that rises for me after having read this study is how the formal healthcare system shapes / impacts these cultural norms any of these socio-cultural structural determinants? If the school system (which arguably has a much more powerful shaping function) shapes and transmits norms, how could the healthcare system be present in schools, or more available in contexts where their prevention activities could be improved?
• How does this research intersect with James Ferguson’s (and others) work on cash transfers? Would love to talk about this in the context of “Give a Man a Fish.”

Andrew Lakoff’s “Unprepared: Global Health in a Time of Emergency” (2017) explores the assemblage of practices, knowledge forms, and politics that underlie the production of preparedness for the unquantifiable risk of catastrophic pandemic disease under the current global health security regime. It tells the story of how “the machinery of global health security was cobbled together over a two-decade period, beginning in the 1990s… it is a story of the assemblage of disparate elements—adapted from fields such as civil defense, emergency management, and international public health— by well-meaning experts and officials and of response failures that have typically led, in turn, to reforms that seek to strengthen or refocus the apparatus.” (p. 7).

Lakoff takes the approach of “historical ontology.” In the spirit of Ian Hacking and Michel Foucault, Lakoff seeks to unmask how “taken-for-granted objects of existence—whether the economy, the psyche, or the population—are brought into being through contingent and often-overlooked historical processes.” (p. 7). This approach enables him to observe “two [current] regimes for governing global health problems: global health security and humanitarian biomedicine.” (p. 10). For him, global health security focuses on the logic of protection of powerful nation-states, particularly maintaining the smooth flow of global capital and trade that disproportionately benefits wealthy capital holders. Humanitarian biomedicine, on the other hand, takes on the “need to save all lives, regardless of political boundaries, from treatable maladies such as malaria, tuberculosis, and HIV/AIDS.” (p. 10). The distinction and relationality between these two approaches to governing global health is a central theme of this book.

How did the notion of “preparedness”—the never-ending process and series of practices of developing skills, knowledge, plans, etc. to governmentally approach managing perceived threats—come in to existence? Lakoff links the techniques of preparedness to a response to the political demand posed by the contemporary category of “emergency.” (p. 15). Different from notions of “risk” (under which probabilities of different outcomes are thought to be relatively well-known and stable, thus capable of being calculated and sufficiently technically managed) preparedness hinges on a state of emergency under which “a catastrophic occurrence… may not be avoidable and so generates knowledge about its potential consequences through imaginative practices like simulation and scenario planning. Such practices make it possible to gauge vulnerabilities in the present, which can then be the target of anticipatory intervention.” (p. 19). A strategy of government, preparedness encompasses a series of practices and techniques that are meant to support the preservation of life in a future time of emergency and includes activities such as “early warning systems, scenario-based exercises, stock-piling of essential supplies, and the capacity for crisis communication.” (p. 19).

Practices of preparedness have their historical roots in the Cold War-era national security strategies of the United States. Lakoff writes, “Given these concerns about American susceptibility to a sudden and devastating attack, Cold War national security strategists sought to ensure that the nation could rapidly put into motion an efficient military production apparatus in the midst of a future emergency.” (p. 22). Although this as a national-level civic defense strategy, Lakoff makes the argument that the normative rationality underlying these scenario-planning and preparedness exercise techniques were eventually taken up as the basis for a more general approach to health and security threats, within the United States and globally. This shift, a part of Lakoff’s historical ontology approach, is distinguished from other past regimes of governmental sovereign power. He makes the distinction between sovereign state security, population security, and vital systems security: sovereign state security being the 17^th century efforts of monarchs and rulers to deploy military force to combat opposing extra-territorial forces; population security as the nineteenth century modern state’s deployment of population-level statistics to distribute risk and promote particular forms of life; and finally, vital systems security targeting the distinctive type of threat of the event “whose probability cannot be calculated but whose consequences are potentially catastrophic.” (p. 38).

The practices of stockpiling vaccine serum in preparation for potential “Swine Flu” pandemic influenza is a case example explored in in-depth by Lakoff. Under the specter of the catastrophic 1918 influenza pandemic which killed more than half a million people in the United States, President Ford made the decision to stockpile and subsequently immunize the entirety of the population of the U.S. The strategy “defied actuaries”, as no policy like this had ever been deployed and the risk of serious side-effects of the immunization were not known. Despite these various setbacks, by December 1976, forty million people had been immunized. But, because of a handful of cases of serious Guillain-Barre syndrome and no evidence of an impending pandemic, the New York Times editorialized this as the “Swine Flu Fiasco.” Rather than leading governmental leaders to question the logics ongoing preparedness in the face of unknown risks, they chose to double down instead. Failure was attributed to “administrators’ lack of foresight. The Federal health officials did not have contingency plans in place and so reacted in an ad hoc manner as unexpected events occurred. Going forward, public health authorities coalesced around the changed notion of what type of knowledge ought to be ascendant in times of emergency: “rather than statistical calculation of risk based on historical patterns of disease incidence, the emphasis of experts [should] be on knowledge of system-vulnerabilities gathered through the imaginative enactment of singular events.” (p. 65).

These logics moved to the global sphere amidst the next global pandemic threat: the so-called H5N1 influenza virus, also dubbed “avian flu.” Specifically, this situation brought to the fore the geopolitical tensions inherent in sharing biological data about viral strains, accurate epidemiological data, and other forms of knowledge necessary to assess the risk of a deadly global pandemic. Specifically, Indonesia refused to share samples of influenza virus with the Global Influenza Surveillance Network (GISN) under the—rather reasonable—assumption that this knowledge sharing (and the potential pandemic prevention it could enable) would benefit them less than the wealthy countries of the world. This example is a case study of the challenges and tensions inherent in the modern regime of “global health security” which focuses “on ‘emerging infectious diseases,’ whether naturally occurring or manmade, which are seen to threaten wealthy countries and which typically (although not always) emanate from Asia, sub-Saharan Africa, or Latin America. [Global health security] develops techniques of preparedness for potential events whose likelihood is incalculable but that threaten catastrophic political, economic, and health consequences. Its advocates seek to create a real-time, global disease surveillance system that can provide early warning of potential outbreaks, and to link such early warning to systems of rapid response designed to protect against their spread to the rest of the world.” (p. 71).

The global health security regime of global health governance is set against the regime of global health humanitarian biomedicine, which is meant to alleviate the suffering of individuals, independent of national and social identity. “Whereas global health security develops prophylaxis against potential threats to the populations of wealthy countries, humanitarian biomedicine invests resources to mitigate present suffering in other parts of the world.” (p. 72). Perhaps exemplified by Medecins sans Frontieres (MSF) and the Bill and Melinda Gates Foundation (I actually don’t completely agree with this typification, and would like to think about this more) and artfully described by Peter Redfield as having a “secular commitment to the value of human life,” it is a logic that is practiced through medical intervention. Also subsumed under this banner are the primary health care movements who have strived for a “right to health for all,” which has primarily been driven by philanthropic organizations and development aid. Lakoff links the emergence of humanitarian biomedicine to the efforts and social movements that surrounded the emerging infectious disease of HIV/AIDS.

Alongside the humanitarian biomedical response to HIV/AIDS though, was the nagging fear of the specter of continued viral and other novel infectious-agent emergence. With the advent of new tools like the internet-based reporting systems (ProMED and the Global Public Health Intelligence Network) and the outbreak of severe acute respiratory syndrome (SARS) in 2002, there was a need to govern and control the rapid circulation of information about infectious disease outbreaks across national borders: a new form of global disease surveillance was needed.

Enter the International Health Regulations. “According to legal scholar David Fidler, the 2005 IHR revision was ‘one of the most radical and far-reaching changes in international law on public health since the beginning of international health co-operation in the mid-nineteenth century.’” (p. 84). For Lakoff, these revised regulations created a new legal framework of obligations and duties—as well as obligation to accept global intervention—in a world viewed to be “under threat from ominous Emergency.” (p. 85). Central to the changes was the technical assemblage of knowledge and practices that formed the new instrument called the public health emergency of international concern (PHEIC). “This technique of classification is a way of bringing a singular event—the outbreak—into a more general category, which in turn puts into motion a machinery of action steps that guide institutional actors and limit the scope of interpretation and debate.” (p. 87). This is, purely, a mode of global governance and relocated sovereignty. “As Fidler put it, ‘the strategy of global health security is essentially a defensive, reactive strategy,’ given its narrow emphasis on detection and response to outbreaks of emerging disease. ‘The new IHR are rules for global triage rather than global disease prevention.’” (p. 94).

All told, Lakoff’s historical ontological study of changing notions and regimes of governance for managing threats of existential proportion amount to typifying the forms that biopolitics take at the world-level. As techniques of governance have moved from the relatively small-scale territories of 17^th century fiefdoms and monarchies, to the post-war modern welfare nation state, to the new post-modern landscape of decreasing state-level sovereignty and fragmented/decentralized reason and authority, how does governmental power sediment and crystalize into different forms, techniques, technologies, tools, policies, and procedures? I found this book quite useful to explore these concepts through the lens of assemblages: “a grouping of heterogeneous elements that have been brought together contingently to address what is, at least in principle, a common scientific and governmental problem” (p. 122).

My interests in the notion of Bourdieu’s (and other variants) field theory runs deep. A challenge, as I’ve learned and thought more a field theory, is its, at times, lack of “materiality.” I mean that sometimes it seems as if fields of practice are theorized as purely “social” in the sense that they are a “free market” of competition between different forms of field-specific capitals. I’m not sure Bourdieu well accounts for the types of power-sedimenting/crystalizing, field-distorting effects of things like material/technical assemblages developed and deployed by powerful actors attempting to govern in contingent and uncertain situations. So, some questions that emerge for me:

• Assemblages are contingent and “sticky” techniques of government that bring together knowledge, tools, people, and procedures to manage emerging and uncertain situations. How do the conditions of their development linked to their functioning? For instance, while Lakoff does an amazing job describing the historically contingent nature of assemblages that mark our current regime of global health security governance, could fields be useful in thinking about the shaping forces of various assemblages?
• Leadership: there is some creativity and agentic leadership involved in the creation of new governance assemblages. Could leadership (or McAdam/Fligstein’s ‘social skill’) be viewed as the field-positioned ability for an actor to assemble politically potent-assemblages?
• Lastly, the typology of “two regimes of global health” seems overly simplistic and I’m not sure what it adds to the discussion. There seems to be more ways to view it: purely profit-driven market orientation to global health, a “developmentalist” orientation, citizen-driven popular politics, etc. Could a field-based perspective here lend nuance to his argument?