**Abstract**

This paper explores the expulsion of an activist from the 2010 International AIDS conference and juxtaposes it with Bill Clinton's plenary talk from the same conference. These two events dramatize the complex and competing discourses circulating within the global AIDS movement. In particular, they illustrate the ways in which governments, NGOs, Big Pharma, medical researchers, and funders constitute a global bureaucratic matrix that promotes new 'truths' about the epidemic. Namely, that the battle will be fought and won through programmatic (economic, biomedical, technological, and pharmacological) interventions. These new 'truths' and affiliated practises render dissent and advocacy a threat to this programmatic rationality, and serve to silence the global AIDS movement's earlier calls for critical resistance and action. Drawing on Foucauldian "biopower" the paper offers a re-articulation of international HIV programs and institutions, and reads the techniques of HIV and AIDS governance, polemically, as a form of "biofascism."

**Key words** activism, Bill Clinton, biofascism, biopolitics, global AIDS, HIV/AIDS, parrhesia

**Global AIDS Governance, Biofascism, and the Difficult Freedom of Expression**

ADRIAN GUTA, STUART J. MURRAY &
ALEX MCCLELLAND

**Introduction**

This paper raises critical questions about the governmental and programmatic focus of the global AIDS response by offering an analysis of two seemingly unrelated events, which two of the authors (Guta and McClelland) witnessed and participated in at the 2010 International AIDS Conference. These two events are examined together to reveal the complex and competing discourses circulating within the larger social, cultural, symbolic, and embodied AIDS movement. In particular, they illustrate the ways in which governments, NGOs, Big Pharma, medical researchers, and funders have formed a global bureaucratic matrix – what

we describe as the global HIV industrial complex – that promotes eradicating HIV and AIDS through programmatic (economic, biomedical, technological, and pharmacological) interventions. This approach privileges particular ways of knowing and renders dissent and activism a threat to this rationality. Through both overt and subtle means, this matrix works to silence activists' earlier calls for critical resistance and action. We intentionally offer this analysis one year after the 2010 International AIDS Conference. To many, this 'anniversary' simply marks the midpoint between bi-annual meetings of international delegates with a shared interest in HIV research, programming, and evaluation. For us, it marks the anniversary of a personal and political call to action, the occasion for a theoretical departure that might foster new ways of thinking and seeing the global AIDS response. We have chosen to write at the one year mark to give other researchers and activists time to prepare for what we hope will be increased critical dialogue and action during the 2012 International AIDS Conference.

Our argument interrogates multiple domains within HIV –
political, legal, medico-scientific, ethical, and embodied – and is structured as follows: We start with a brief historical overview of AIDS activism, international monitoring and surveillance mechanisms, research, and funding. We then introduce Michel Foucault’s understanding of biopower and biopolitics as our theoretical framework, extending the concept of biopolitics and advancing our claims through a discussion of “biofascism.” Having provided an historical context and proposed a theoretical framework, we turn our focus to Bill Clinton’s 2010 keynote address as a site to read biofascism. We then shift our focus back to where we began, and ask if the activism that informed the early years of the epidemic has any place in today’s global AIDS response, or whether this activism has been silenced or co-opted entirely by the burgeoning global HIV industrial complex. The approach taken is fluid, but draws on the techniques of discourse analysis, [1-3] and is at times auto-ethnographic in nature. [4,5] While we intend to interrogate various aspects of the global AIDS response and its relation to the global HIV industrial complex, we implicate ourselves and acknowledge having benefitted in numerous ways. We do not intend to undermine others’ accomplishments or dismiss the impact of programs that have improved millions of lives, but instead offer an insider’s critique of practises which we have come to find concerning and in need of further critical discussion.

## A brief history

> "Someday, the AIDS crisis will be over. Remember that. And when that day comes – when that day has come and gone, there'll be people alive on this earth – gay people and straight people, men and women, black and white, who will hear the story that once there was a terrible disease in this country and all over the world, and that a brave group of people stood up and fought and, in some cases, gave their lives, so that other people might live and be free." [6]

This excerpt from Vito Russo’s “Why We Fight” captures the passion that characterized the HIV and AIDS movement of the 1980s. The Denver Principles marked the turning point when people living with HIV first proclaimed themselves to be *living* and not *dying*, and deserving of the right to be involved in decisions about their own health.[7] Following this, people living with HIV began to organize, most notably in the form of “The AIDS Coalition to Unleash Power” (ACT UP), with chapters across the globe. The AIDS activist movement at the time was largely characterized by civil disobedience and guerrilla tactics, including demonstrations, die-ins, political funerals, marches, and even the public spreading of ashes [8]. Radical activism was necessary, many felt, given the lack of state response to the emerging epidemic – as it affected

people who did not seem to matter, and involved behaviours that many did not want to discuss publicly.

Perhaps most memorable in the Canadian context was the 1989 International AIDS Conference in Montreal, where 300 protesters forced their way into the auditorium waving banners declaring “SILENCE=DEATH”; the protesters then sat in the section reserved for VIP delegates and refused to leave. Intended as a “scientific” forum, conference organizers had previously ignored “community” interests in their high-level discussions. Ron Goldberg[9] identifies the pivotal moment when ACT UP and its Canadian counterparts, AIDS Action Now! and Réaction-SIDA, stormed the stage as marking a pivotal shift in activism to include a role in knowledge production. Previously, he explains, this conference had been “a members-only event for the AIDS establishment ... [and people living with HIV] were presented mainly as abstractions, their lives reduced to statistics on spreadsheets, their needs and desires mere sidelights to the noble pursuit of science.” The exclusionary nature of this and other HIV forums changed following the Montreal conference, and the resulting momentum led to activists and scientists marching side by side to challenge oppressive American HIV policies during the 1990 International AIDS conference in San Francisco.[9] This collective action resulted in a large number of arrests and police violence towards demonstrating delegates.[10] Significantly, the radical advocacy campaigns from this era have been credited with dramatically increasing the profile of HIV and AIDS and changing the ways in which treatment and care are provided.[11]

Activists working during this period deserve most of the credit for pushing forward the development of desperately needed treatments. Steven Epstein[12] details how activists turned their focus to treatment technologies in a way that brought them to the table with scientists, policymakers, and pharmaceutical companies. Despite obvious successes in the form of life saving/prolonging treatments, this shift also resulted in a simultaneous privileging of clinical research and a diversification or splintering of activists in different directions. While we recognize and celebrate the impact treatment activists had on improving conditions for people living with HIV, this had unintended consequences. The shift towards biomedical partnership has served to bring activism within the purview of what Foucault[13] described as the “medical gaze” and made it subject to particular ways of knowing and seeing. Elisabeth Pisani describes the establishment of treatment as the primary advocacy goal of this period; however, this goal became a “sacred cow,” she argues, and those who challenge the benefits of treatment
risk being branded as “monsters” who would deny treatment to people living with HIV.[14]

The emphasis on medical interventions has necessitated a particular organizational milieu for managing AIDS. The early forms of radicalism and mobilizing have been replaced – and largely co-opted – by institutions and structures that require bureaucratic governance. This includes the changing nature of AIDS Service Organizations (ASOs), which initially were formed with activists at the table, but now offer primarily programmatic and formalized outreach and support. What were once communities within themselves have “become increasingly professionalized, bureaucratic and inflexible, leading some PHAs to no longer feel at home or welcome.”[15] Often, many of these organizations are caught in complex relationships with state funders that limit their ability to challenge those who support them financially.[16] Political institutions and structures largely exclude (and often denounce) activism and civic engagement as a threat to the continued existence of this well organized surveillance and treatment system. Three decades into what has become a global pandemic, the political face of HIV in Canada has become almost unrecognizable.

## Politicizing AIDS and the global AIDS response

Although many political leaders initially ignored HIV, especially when its transmission was relegated to bathhouses and “shooting galleries,” there soon emerged focused public health efforts to contain its spread within states. Framed through a discourse of “risk” and “risk-management,” HIV has necessitated complex and multi-level responses through various state and non-state mechanisms.[14,17] What started as a few activists on the streets of New York and San Francisco has evolved into one of the most unique and complex interconnected network of actors and organizations ever to amass in response to a global issue. The current global AIDS movement is made up of activists, medical and allied health professionals, program implementers, researchers, government actors, recipient populations, faith groups, the private sector, unions, and various UN organizations working to leverage funds to address the devastating effects of the epidemic.

We differentiate the global AIDS movement from the global AIDS response, the latter of which has a governmental and programmatic focus. The response is not as obvious as the movement, and is challenging to describe properly within the constraints of this paper. We start by turning to the central role of UNAIDS as a joint effort to conduct global surveillance and monitoring of HIV, ensure countries

are meeting their international obligations, and to work in partnership with key governments, multilateral and private funders, to set the agenda for how the global AIDS response is organized and structured. The primary funding institutions of the global AIDS response form a complex network – often referred to as the Global AIDS Funding Architecture – that includes the Global Fund to Fight AIDS, TB and Malaria; the Bill and Melinda Gates Foundation; the Clinton Foundation; and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) program. These organizations share a commitment to funding biomedical and technological innovations and interventions to curb the tide of the epidemic, and have a central role in determining the thrust of the global AIDS response. An argument has been made that the philanthropy that underpins some of these organizations is implicated in empire building,[18] and may serve to govern people around the world.[19]

Over the course of the 30 years of HIV response efforts, the increasing role of the state and of high-powered funding bodies that form the Global AIDS Funding Architecture has resulted in the increasing institutionalization, bureaucratization, and construction of “appropriate” forms of intervention and research. The competing complex interests of actors in the global AIDS movement result in a response that prioritizes the needs of those who control the funds, namely, state and neoliberal interests. What started with the global community acknowledging that AIDS constitutes a threat to “prosperity and growth in developing countries” in the 1994 Paris Declaration,[20] evolved over the following decade into the realization that HIV poses a larger threat to the capitalist goals of growth and globalizing free market expansion.[17,21,22] We went from governments monitoring HIV internally to international bodies whose role is conceived in the first instance as economic, with the goal of maintaining political equilibrium between states, safeguarding the health of “developing” markets, and ensuring continued economic growth globally.

## From biopower to “biofascism”: Making live and letting die

In this section, we try to understand the shift that has occurred, from governments largely ignoring the HIV epidemic to what is now a complex system of state involvement across multiple socioeconomic, technological, and political spheres. Our purpose is also to begin to explore what such complex state involvement entails, and how the perception of radical advocacy and activism has itself shifted, from the early power of community activism to mobilize researchers and
governmental bodies alike, to that which today is thought
to threaten research and the state, and to thwart scientific
development. Here we draw on Michel Foucault's concept of
biopower, which he used to explain the historical "explosion
of numerous and diverse techniques for achieving the
subjugation of bodies and the control of populations."[23]
The two axes of biopower, anatomo-politics and biopolitics
– which treat the individual and the population, respectively
– help to explain how the management of disease became an
important target for state intervention to maintain the security
and productivity of the political body, simultaneously
disciplining bodies and regulating populations. Stefan
Elbe[24] explains that biopolitics is crucial for understanding
the securitization of the response to HIV and AIDS, describing
it as "a powerful international intervention targeted directly
at the level of population" and "undertaken with the active
and willing participation of a whole host of wider social
and political actors." Within the global AIDS response, we
observe an extension of biopower to harness the potential
of the global body. As the gaze of HIV monitoring systems
extends to the global stage, there occurs a simultaneous
restricting of options for people living with HIV and AIDS
(and their allies). Foucault[25] may have understood this
as the systematic reduction of opportunities for dissent or
"counter-conduct" and the sublimation of already subjugated
knowledges[26] through the imposition of highly regulated
systems of thought and action, choreographed through diffuse
but pervasive networks of power-knowledge. Our goal is to
contribute to this debate by moving beyond securitization
(at the state or intra-state level), to include additional actors
and to attempt to account for systems and processes that
converge to produce the new 'truths' that characterize the
global HIV industrial complex.

Our use of the term *fascism* is bound to be a controversial
and polemical gesture; it is intended to trouble the field of
discourse, to upset its reigning logics, and to incite fresh
debate about the politics of the production of knowledge, state
biomedical intervention, and the delivery and management
of health care. It is a rhetorical form of activism, one
remaining tactic for activists and researchers who, however
marginalized by State Science, seek to sway public opinion
and to expose the workings of power at play. We hope to
politicize what is too often swept up by the unreconstructed
rhetoric and inertia of "development" (scientific, economic,
moral, etc.). To be clear, when we speak of fascism, we do
not mean in any straightforward sense the fascism of regimes
such as those led by Hitler and Mussolini. As Foucault writes
in his Introduction to Deleuze and Guattari's *Anti-Oedipus*:

the major enemy, the strategic adversary is fascism.... And not only historical fascism, the fascism of Hitler and Mussolini – which was able to mobilize and use the desire of the masses so effectively – but also the fascism in us all, in our heads and in our everyday behavior, the fascism that causes us to love power, to desire the very thing that dominates and exploits us.[27]

What is perhaps most unsettling, and not least of political
concern, is not simply the question of enjoyment, as
if fascism were rooted in the complex economy of an
individual's desire. The subtle tendrils of the fascist impulse
extend further still, in the justificatory rhetoric that defends an
action, or promotes it as necessary or natural, in the name of
a greater – if not transcendent – good. Our term "biofascism"
is meant to suggest the myriad political dimensions of the
bios – of "life itself" – as this term circulates in the global
AIDS response, and as the very meaning of "life" is fashioned
almost unilaterally, co-opted by State Science and the global
HIV industrial complex as their ultimate raison d'être, an
unquestionable good.

Biofascism is, then, an extension of Foucauldian biopolitics.
For Foucault, biopolitics regulates populations, rather than
individuals. Under biopolitics, the function of medicine is
regulatory, and concerns "public hygiene, with institutions
to coordinate medical care, centralize power, and normalize
knowledge."[26] What emerges is "a new body, a multiple
body, a body with so many heads that, while they might not
be infinite in number, cannot necessarily be counted."[26]
In Foucault's terms, the formula or slogan of biopolitical
power is the state's power "to make live and let die."[26]
This power no longer targets the individual body; rather,
this is a decentralized and polymorphic power – multi-
headed – that regulates the masses, the population, man-as-
species, the "race." The power to "make live" is conceived
as the power to bestow life, to foster it, to protect it, by
regulating human reproduction, fertility, productivity, public
health and hygiene, accidents, medicine, and the like. In
sum, biopolitics does not treat individual bodies; bodies
are "massified," bodies are "regularized," and "bodies are
replaced by general biological processes."[26]

Two things are of immediate note in this formulation, “to
make live and let die.” First, who are those who are “allowed
to die,” and what is the relation between their dying and
a state-sanctioned “making live”? Who will decide, for
instance, which or how many HIV-positive people have
access to ARV therapies? If the business of pharmaceutical
corporations is to “make live,” in this respect, those who
cannot afford treatments, across poorer regions of the globe,
will be “allowed to die.” Arguably, this is a form of killing, a passive or indirect form; it is a preventable death, but it is one that does not count under the logic of biofascism. As Foucault writes, “When I say ‘killing’, I obviously do not mean simply murder as such, but also every form of indirect murder: the fact of exposing someone to death, increasing the risk of death for some people, or, quite simply, political death, expulsion, rejection, and so on.”[26] Indeed, in military terms these deaths might be dismissed as “collateral damage”; in economic terms, they might be called “negative externalities.” But they are deaths all the same, and this raises an ethical conundrum about the limits of individual autonomy and responsibility – for we are part of a system, it would seem, that sanctions death as the unavoidable cost of our own living and livelihood: economically, medically, geopolitically, in war, under global capitalism, and so on. Often entire populations are marked out and “allowed to die” – perversely, in the name of life itself, since these populations are deemed to pose a threat to health, security, wellbeing, prosperity, etc. These words will likely ring true to those who watched a generation of gay men – friends, brothers, children, lovers – die at the beginnings of an epidemic in which political leaders refused to acknowledge a problem until it affected people who mattered. And as Foucault suggests, such “indirect murder” goes hand in hand with what we might call the “softer” or more symbolic forms of death – political death, when someone no longer counts politically, when someone loses his or her rights; or when someone is expelled from society, or is otherwise silenced. This is often what happens to those who speak out against and expose the system of “indirect murder.” They find themselves within a system that has the power to silence them, to discredit them, to stigmatize and disenfranchise them. This is the fate of many activists today.

The second concern is directly connected with the first. Under biofascism, “life” is the hidden pretext, the greatest good, the animating logic in the name of which some must be “allowed to die.” But the meaning of “life” itself is slippery: it operates as a transcendental signifier which has no concrete referent, but which can be filled with whatever justificatory fantasy one wishes. Is “life” something biological? And if so, is this histological or homeostatic? Does it mean health? The absence of disease? Can we speak of viral “life,” for instance? Does it mean the life of the individual or the population? Does it imply a *quality* of life? Does it mean wealth? Is it “human capital”? Or perhaps it is a spatiotemporal event? A gift from God? The mere absence of death?

Rhetorically, the term, and its associated values, commingle and trade simultaneously on multiple registers. But it is fair to say that its meaning – and the effect of this meaning – is sometimes a matter of life and death, marking out those who will live from those who will die. The biofascist impulse steadfastly refuses to question such things: if “life” moves the gears of an apparatus that actively or passively kills, it is best to remain silent, for “our” lives are improved to the extent that “their” lives are exposed and revoked, as it were.

In an earlier work, Murray[28] identifies three interrelated ways that “life” is defined and mobilized within the biofascist impulse, and we draw on this here to demonstrate some of the ways that seemingly disparate elements of the global HIV industrial complex function as biofascism:

(a) **Bioeconomics**, the “monetization” of life where neoliberal political economic policies and biomedical, pharmaceutical, and state discourses intertwine, affirming their respective dominance, and demanding “greater efficiency” in the “business” of life.

(b) **Biomedicalization** more generally, the “tangled web” that includes multinational pharmaceutical companies, government agencies, policy makers, academia and its research sponsors, the convergence of research and business, public-private partnerships, “evidence-based” medicine, and the resulting medicalization of everyday life.

(c) **Biocultural** discourses, where biomedical and bioeconomic discourses work together to inform wider cultural and popular perceptions of health and the individual’s relation to his or her body, the population, and to the healthcare systems and industries.

The narrow understanding of “life” that emerges here seems to leave little space for other, divergent conceptions. This “life” constitutes a convergence of forces that operates as a moral orthopaedics, a convergence that has become naturalized, i.e., made to *appear* natural, normal, logical, and good. Nevertheless, those who are “made to live” in this way might find that the terms of such a life are hard to live with. Some might not care to embody this narrow understanding of “life,” a life that may not reflect the lives of infected persons, a life that, for some, might feel unliveable, a life whose value will reflect myriad interests and “stakeholders” – often stockholders – but which must at times seem far from the values and interests of those who live with HIV and AIDS and those who love and support them.

In what follows, we apply this theoretical framework to
make sense of two ostensibly unrelated events from the 2010 International AIDS Conference, and to illustrate the complex and competing discourses circulating within the global AIDS response. Within the global HIV industrial complex, governments, NGOs, Big Pharma, biomedical researchers, and funders constitute a global bureaucratic matrix that is committed to promoting biomedical and technological innovations to curb the tide of the epidemic; the interrelated phenomena above work to inform – and to limit and police – much of what we understand to be the global AIDS response today. We hope that our reading will serve to galvanize activists and critical researchers in the global AIDS response, and to foster a culture of debate and dissent.

## Where systems converge: Bill Clinton's keynote address

At each International AIDS Conference, Bill Clinton is given a unique platform received by few others, and often garnering the most press attention, where he tells delegates from around the world what they need to know about HIV prevention, research, programming, and care. This is one powerful means by which the global HIV industrial complex delivers its message. While the fight against AIDS is fought on the ground – in clinics, schools, communities, bathhouses, and street corners – we focus on the conference for reasons identified by Altman:

> The conference circuit becomes an arena where far more than “objective” information is exchanged. It becomes a focus where dominant paradigms and individuals are established, where contacts are made and where a new class of international AIDS “experts” reinforce each other’s importance. Most significantly, the Conferences reinforce a particular “scientific” approach, as discussion is squeezed into predetermined categories. What has become a regular division of discussion at both international and national conferences into four tracks – Basic Science, Clinical Care, Epi, Social Response – has come to suggest that this is the natural way of conceptualizing the epidemic … which has the effect of other topics, particularly with political or cultural content, appear[ing] peripheral.... [29]

We present and discuss key excerpts from Clinton's 2010 keynote address[30] as one instance, a representative example, of the biofascist impulse. We do not claim that Clinton speaks on behalf of the actors that comprise the global AIDS movement or even that the global AIDS response is monolithic; indeed, we hope to encourage a plurality of perspectives within this movement, but argue that Clinton's perspective offers a unique insight into the hegemonic evolution of HIV discourse and knowledge production. Although we attempt to tease out the boundaries between

the three faces of biofascism, above, the lines between the biomedical, economic, and cultural aspects overlap.

Clinton's talk is predominantly informed by biomedicalizing discourse, which he quickly invokes by mentioning a group of Cambodian children he just met, who he says are alive today "because of people like you." Much of his talk focuses on the cost of antiretroviral drugs (ARVs), and the tireless work of reducing the cost of these therapies. The next hour is peppered with references to work being done with Bill Gates, political leaders, and the heads of multinational pharmaceutical corporations. In particular, he recounts an exchange with the President of Pfizer who released a drug to market with a 60-percent reduction in cost. Clinton describes the exchange as follows:

> So I ask the new president of Pfizer, Jeff Kindler, I said why are you doing this? And I could tell he didn't expect to be asked that and he smiled and he said, first of all, it's the morally right thing to do, but he said, secondly, we don't have a sustainable business model. We cannot possibly go out 50 years just marketing all our products to 10 to 15-percent of the world. We ought to sell to 100-percent of the world and in order to do that our unit costs have to go down.

Clinton responded, "That was the best news I'd heard in a long time." Though he does not ask if a 60-percent reduction in cost will make this drug affordable to 100-percent of the world, and he does not question how the "morally right thing to do" is convergent with marketizing forces and business models. Clinton then begins to marvel at recent prevention technology innovations, telling us:

> Well we now know things we didn't know two years ago. We know circumcision reduces transmission in excess of 50-percent. We know treatment can reduce transmission by 90-percent. We know we have new tools that just two years ago we didn't have. New drugs and point of care technologies that bring care closer to people who need it. [Later, he describes] A simple hand-held machine that can tell someone in any remote rural village, right then and there, what their CD4 count is. If we're going to use the CD4 count for determining when to start treatment early, we need these machines in every rural place in the world that can have it. [Applause].

The goal to medicate people with HIV as soon as possible and to therefore reduce their viral load and infectiousness to others has been promoted by health economists, the United Nations, the World Health Organization, and the International AIDS Society. Termed "treatment as prevention," this response is believed to reduce the number of new infections from HIV-positive individuals.[31-37] Canada's own B.C. Centre for Excellence in HIV/AIDS has employed it with a focus on "hard to reach" communities in a "seek and
treat” approach.[38] And yet, Cindy Patton, among others, has raised concerns that the statistical modelling used to support these initiatives ignores the realities of living with HIV and managing a drug regimen. Patton notes that, “treatment-as-prevention programs require testing and mandatory treatment on a scale seen only in dictatorships.”[39]

Secondly, Clinton invokes what we have called a bioeconomic discourse when he acknowledges the recent global economic downturn, which has posed a threat “to keep[ing] the AIDS movement going.” But he offers hope in the form of new private-public partnerships – encouraging us to purchase products that donate a small portion to pharmaceutical research. Offering an example of the transformative potential of small scale economic investments, he tells the story of a woman he met on his annual trip to Africa, saying:

> So I met with all these farmers, but one who was the chosen spokesperson was a woman whose husband had died and she had only one child and her sole source of income was a quarter acre of land on which she grew soybeans. Last year she earned $80. So we gave her better seed, better fertilizer, a way to get rid of the pests, she increased her yield two-and-a-half fold. Then, we directly marketed her soybeans to the processor so that she didn't have to go through an agent, that doubled that income, so instead of $80 on this little quarter acre, she made $400 this year. A fivefold increase. Why? She didn't do anything

different. She had a system that worked for her.

The business of life, we are told, can be managed through science and technology delivered by corporations and their “systems.” But clearly, not all “Africans” have access to agricultural biotechnology, to fertilizers and pesticides, or to Clinton’s celebrity as the means by which to obtain them. Some may be suspicious of corporate “altruism” or of other international bodies, such as the IMF and World Bank, since the interests they serve are rarely the interests of those they “save.” Turning his attention from this individual, he later addresses the donors in the room, encouraging them to “say from now on, I’m only going to support organizations that do things better, faster, and at a lower unit cost.” He reminds us that, “Healthcare is not just a right, it’s basically an extraordinarily good economic investment with a very high rate of return.” In these two examples, Clinton offers up a particular vision of *homo economicus* as “active citizen” and entrepreneur.[40-42] Health is promoted through market ideology as something to buy, to sell, and to profit from.

Finally, *biocultural* discourses seek to normalize and extend biomedical and economic interventions as a normalized part of everyday life. This might include the formation of individuals who are willing to have their CD4 count read on the street, or those who are encouraged to become an

<figure><img src="image_1.png" /></figure>
entrepreneur following the loss of a partner to disease. Changing cultural attitudes towards circumcision is another example: "We also have indisputable evidence ... that all these cultural things we were told about how African men will never show [to be circumcised as part of randomized controlled trials] turn out to be flat out wrong, that there's more demand for it than we thought, but there's not enough supply yet.... So we have to do more of it and we should invest more money in it." Certainly, mass circumcision, biotechnologies, and biomedical interventions would require a massive and coordinated infrastructure in order to be effective, but this is not discussed. Clinton confirms the power of these discourses, to shape hearts, minds, and bodies to fit the new 'truths' that he offers on behalf of a complex of vested interests all working, we are told, in the name of "life."

Clinton's plenary was not a debate. There was no room for discussion on any of these points. We as audience members are expected to take them all to be good, all signs of development or progress. We feel coerced to join the applause. We need not ask tiresome questions about how

these global conditions came to be, or who profits. To raise claims concerning neo-colonialism, biomedical imperialism, or simple profiteering would detract from the importance of the work being done. The people leading these initiatives are heroes. Clinton tells us the director of PEPFAR is in the room, and asks him to stand up, and suggests that "he ought to get some kind of Purple Heart for showing up" and that "This man is [our] friend" and that "He is a good man." Clinton presents ideas and invokes images that are compelling, exciting, and revitalizing for those who continue to fight. Who could challenge what appears to be a perfect system?

## The expulsion of an activist

On the same day as Clinton's keynote, but relegated to the "global village" (a community space open to the public), there was a panel whose title asked "Is AIDS Activism Dead?" The global village serves as a way of symbolically opening up the conference to those who cannot afford the substantial registration fee, while still separating the worlds of science and community with an army of volunteers who diligently scan delegate badges. Included on this panel

<figure><img src="image_2.png" /></figure>

<figure><img src="image_3.png" /></figure>
was Dr. Robert Carr, then director of policy and advocacy at the International Council of AIDS Service Organizations (ICASO), who recently passed away. Reflecting on the state of activism, Dr. Carr said:

> But I also think that, at the global level, in terms of the structure to support activism that the environment is changing and it's not particularly supportive of activism. There's a lot of money, for example, if you really look concretely at what the HIV response is funding. What you see is a lot of workshops, for example, and a lot of documents being produced. Very often what's really needed is a different kind of strategy, a different kind of response: The ability to confront, the ability to be confrontational, but be supported in your confrontation, financially, for example, so more human rights based activism. The way in which the global environment structures the resources to support you at your country level, really encourages you towards certain kinds of activities that more or less leave the status quo intact, perhaps meddled with but intact. Whereas I think really what we need is to be able to support people who want to push the system more strongly. And that's the gap that prevents us, I think, from moving forward more powerfully than we do.[43]

Dr. Carr explains that much of the supposed investment in the HIV response, outside of biomedical interventions, is limited to educational materials. What is needed, he claims, is a strategy that includes confrontation tactics. We imagine

this confrontation to be in the tradition of ACT UP NYC/ Paris, AIDS Action Now! and Réaction-SIDA. However, confrontation tactics such as these are not tolerated in today's climate. What is the future of activism, of debate and dissent? And what would it look like if someone attempted to disrupt the status quo at one of these events?

During the second day of the conference, two Toronto-based HIV and harm reduction activists, Alex McClelland and Zoe Dodd, attended a speech delivered by Canada's federal Minster of Health, Leona Aglukkaq, at a reception aimed at praising the Conservative government's ongoing commitment to HIV. This commitment can be seen in the estimated 65,000 Canadians living with HIV,[44] 250,000 living with Hepatitis C,[45,46] and a high proportion co-infected with both HIV and Hepatitis C.[47] HIV continues to rise among Aboriginal peoples, people who use injection drugs, newcomers to Canada, the incarcerated and gay and other men who have sex with men.[44] Despite these alarming trends the federal Conservative government has reneged on promised funding for HIV in recent years[48] and has brought legal challenges against harm reduction initiatives like Vancouver's safe injection site.[49] The Conservative government denies the provision of comprehensive harm reduction services for people who use drugs, especially for those in prisons.[50-52]

<figure><img src="image_4.png" /></figure>
The denial of such services has been described as a human rights violation, which makes it more difficult to curb the epidemic.[53,54]

McClelland and Dodd openly challenged the health minister on the Canadian government's ideological stance on harm reduction, asking questions she was unable or unwilling to answer, and calling for her to sign the Vienna Declaration. The next morning, still outraged by the Canadian government's inaction, McClelland and Dodd - with the help of ACT UP Paris - organized a group to surround the Canadian exhibition booth in the exhibit hall of the conference. Despite being staffed by the Canadian AIDS Society, the booth was funded by the government ministry Health Canada, with all materials having been vetted by the Canadian Prime Minister's Office. These activists covered the booth in copies of the Vienna Declaration and slashed a number of banners emblazoned with an image that combined the Canadian maple leaf and the AIDS ribbon, and which read, "Respect/Respecter," "Promote/Promouvoir," and "Fulfill/Réaliser." Activists affixed signs reading, "Harper = Death, Save Insite [the safe injection site in Vancouver that the Conservative government is seeking to shut down]" and "Harper's Policies Are Killing Us!" The overall theme of the public relations exhibit booth was "Canada: Moving Forward / Le Canada va de l'avant." The action made national news[55] and Dodd was cited in the *Globe and Mail* saying, "Canada has missed an important opportunity to show leadership in the struggle against HIV and AIDS and people are dying because of it."[56]

In these banners, the Government of Canada co-opted the iconography of the global AIDS movement and rhetorically aligned itself with the purpose and goals of this movement – while the statistics and official government policy contradict these purposes and goals. The action of slashing banners was typical of earlier activist strategies; in 2010, however, it was deemed shocking and violent by the organizers of the conference, and resulted in McClelland being expelled from the conference, threatened with arrest and with being barred from future IAS conferences – an action that is normally reserved for “AIDS denialists” who maintain that HIV does not cause AIDS. Ironically, perhaps, the Canadian government itself might be accused of denialism, since it has ignored the ‘evidence’ on harm reduction interventions and cut funding to such programs. Despite ‘evidence’ being the supposed currency of policymakers, it does not appear to be followed in this case.

The actions by Dodd and McClelland were aimed at focusing international attention on the hypocrisy of the Canadian government and were in-line with an activist

tradition of similar actions. As a result of such earlier actions the International AIDS Conference developed a policy prohibiting the destruction of exhibitor "property," equating it with personal violence.[57] Indeed, these conferences could not happen without the support of governments and pharmaceutical companies. Yet, Altman has observed that "while its organizers promote these conferences as scientific meetings they seem to me better understood as trade fairs in which the stands of the pharmaceutical companies are as significant as the delivery of papers...."[29] We are critical of the privileging of private property and angered that economic support from country exhibitors is deemed more important than the lives affected by those same countries' antiquated policies. This does little to challenge the perception that AIDS has gone from being a movement to a business.

Returning to Clinton's speech in light of these events, we now understand the subtle and insidious implications of his words. Clinton's speech forecloses upon such debate or dissent; it implies that such activists are illogical or immoral, that they do not love life; and it supports, one might say, the forcible expulsion of anyone who challenges the logic of "making live." In the tireless and imperious business of "making live," it would seem that activism must be "allowed to die," buried in silence, and that it has died a natural and necessary death, because its message is made to seem irrelevant, petty, and an impediment to all that is good - to life itself, to health, and to progress, no matter how narrowly these terms are defined.

## Conclusion: The difficult freedom of expression

The question we would like to raise here concerns academic freedom, freedom of expression, and the place of activism. We are reminded that at the beginning of the epidemic activists and critical scholars were some of the loudest voices. It is obvious to us that activists and critical scholars need to raise their voices in the post-HAART era in response to the failed promise that providing treatment can wash away all the injustices and forms of structural violence that lead to new HIV infections.[58,59]

We understand that producing critical work is increasingly difficult when researchers are forced to rely on government funds to support their work. We commend our Canadian colleagues who have continued this work,[39,60-62] and acknowledge efforts to revive critical social science perspectives in HIV studies.[63-65] Yet, as Andrea Smith has stated, we may have to "think beyond the non-profit and the academic industrial complexes when doing social-justice organizing while working in the academy."[66] Government holds an increasingly tight grip on what knowledge will be
produced and shared, though this control is by no means
limited to the work of critical scholars. The focus of research
funding is well orchestrated,[67] and there are documented
cases of scientists being silenced in the public sphere [68-
70]. We could argue that HIV is different, since the evidence
is not exactly censored, but there remains the question of
access (knowledge mobilization), as well as the basic tenets
of “respect,” “promotion,” and “moving forward” – noble
things that we read on government public relations materials
that nevertheless belie a reality that is less well known,
propaganda that replaces fiction for fact. Finally, we might
say that the human element is lost in debates about quality
and cost effectiveness.[71] These are some of the ways of
“making live” at the cost of those who are “allowed to die.”

What are the means, today, for activists and critical
researchers in the global AIDS movement to critique the
global HIV industrial complex, its programs, policies, and
effects? What happens when the global AIDS response
becomes an arm of – the entire body of – the global HIV
industrial complex? In whose name do we speak, and how
can we speak, for those persons who live with HIV and AIDS,
and their allies? Here, we hope to trouble the category “ally.”
For it is clear, for many activists and critical researchers, that
those who speak, and who act, in the name of the global HIV
industrial complex, do not speak for, do not represent, those
who live with HIV and AIDS or their allies, but rather, act
foremost in the interest of profits, shareholders, and others
whose interests lie elsewhere.

We question the possibility of speaking freely and resisting
within the global HIV industrial complex. We fear that
the convergence of biomedical, economic and cultural
discourses will not allow for dissent and will work towards
further silencing the movement's earlier calls for critical
resistance and action. The treatment activists who promoted
the development of the existing architecture were doing
so with their own lives hanging in the balance. When they
challenged scientists and policymakers to care they were
participating in a critical counter-conduct. However, 30 years
into the epidemic the emphasis on treatment and privileging
of biomedical knowledge requires a critical reappraisal. This
system now works to subjugate us all, people living with HIV
and researchers alike.

To conclude, we turn to Foucault's final lectures on ethical
self-governance and truth telling practices.[72] Here,
Foucault invokes the historical concept of *parresia* (sometimes
spelled, *parrhesia*), which is etymologically “the act of telling
all (frankness, open-heartedness, plain speaking, speaking
openly, speaking freely).”[73] Foucault explains, “with

*parresia* we have a notion which is situated at the meeting
point of the obligation to speak the truth, procedures and
techniques for governmentality, and the constitution of the
relationship to the self.”[72] The *parresiast* is “someone who
tells the truth and consequently distinguishes himself from
any untruthfulness and flattery.”[72] Unlike other forms of
speech, like flattery and “mere” rhetoric, *parresiasts* can be
distinguished as “those who undertake to tell the truth at an
unspecified price, which may be as high as their life.”[72]

Here we must distinguish activist tactics like those just
described, from examples like the murder of David Kato.
Kato was a Ugandan LGBT activist who spoke out against his
country's proposed anti-homosexuality bill and draconian
stance on HIV. Stories like that of David Kato, FannyAnn
Eddy,[74] and others who fight tirelessly for the rights of
LGBT and other marginalized, colonized, and exploited
peoples, seem almost impossible in their courage and
veracity. We cannot know if they truly understood the risk
to themselves, and that their speech would cost them their
lives. We do know that against the tide of increased pressure
to remain silent, they chose to tell their truth. By contrast,
we acknowledge that we write from a place of academic
privilege, and from within the global AIDS movement. We
do not risk our lives by sharing these ideas, and even if our
reputations become tarnished in some circles they may
be enhanced in others. Still, there is a difficult freedom of
expression, a choice weighed against what is experienced as
an ethical duty.

This paper, along with the actions of its activists, stands
as a form of cynical academic activism in the *parresiastic*
tradition. As Foucault remarks, the *parresiastic* tactics of
the Cynics employed 1) critical preaching, 2) scandalous
behaviour, and 3) “provocative dialogue” bordering on
transgression.[75] We have offered a brief overview of
AIDS activism, international monitoring and surveillance
mechanisms, the global AIDS funding architecture, and
those who speak – or are silenced – in its name. We have
attempted to apply “biofascism” to expose the convergent
mechanisms of biomedicine, economics, and culture,
which too often serve to form a singular vision and ‘truth’
in a movement previously characterized by divergence and
diversity. Our goal has been to open up a dialogue about
what we consider to be increasingly taken-for-granted
practises within the global AIDS response, many of which
operate outside any system of accountability. We do not
wish to return to a time in the fight against AIDS when
confrontational tactics were the only answer. Indeed, we
acknowledge that this has been made less necessary in many
parts of the world because of advancements in treatment. Yet, we are concerned by the complacency of many in the global AIDS movement, including ourselves, who are pulled by the sway of biofascism. Foucault asked, “how does one keep from being fascist, even (especially) when one believes oneself to be a revolutionary militant?”[27] We wish to end by acknowledging that those who we believe are promoting a kind of fascism may themselves understand their work as being embedded within a revolutionary call, and that they may see our critique as a different kind of fascism. Nevertheless, given the reigning culture of compliance, we hope that this paper helps to mobilize a productive culture of dissent, and to answer the difficult freedom and responsibility of critique. And, once more in a Foucauldian vein, we hope that those in the global AIDS movement might begin (again) to see the ways that critical scholarship and activism might help us all to imagine otherwise.

## Notes

The Kaiser Institute provided a transcription of Bill Clinton's speech. Where we suspected errors, we reviewed the audio file and made changes based on our perception of the audio.

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Acknowledgements

The authors would like to acknowledge Elizabeth Manning, Gillian Kolla, and Marilou Gagnon for reviewing earlier drafts of this manuscript. We would also like to thank Daniel Grace for providing photos from the demonstration in Vienna.

Adrian Guta would like to acknowledge the support of the Ontario HIV Treatment Network studentship award program.

Stuart J. Murray would like to acknowledge the support of the Social Sciences and Humanities Research Council of Canada as well as the Canadian Institutes of Health Research.

Alex McClelland would like to acknowledge the support of the Canadian Institutes of Health Research graduate fellowship award program.

Contact Information for Author:
Adrian Guta, MSW, Ph.D.(c)
University of Toronto
Dalla Lana School of Public Health
155 College Street
Health Science Building, 6th floor
Toronto, Ontario, M5T3M7
Canada
Email: adrian.guta@utoronto.ca

Stuart J. Murray, Ph.D.
Associate Professor of Rhetoric
Ryerson University
Department of English

Alex McClelland, M.ES. (Student)
York University
Faculty of Environmental Studies