| This dissertation analyzes the creation of Botswana's ARV program, which was the first nation-wide, government program in sub-Saharan Africa to attempt comprehensive treatment for HIV, including drug therapy. The initiative was the fruit of a larger partnership between the Botswana government and an internationally funded donor organization named ACHAP, an acronym for the African Comprehensive HIV/AIDS Partnership. ACHAP itself was a collaboration between two main donors, the Merck and Gates Foundations, which joined together to assist Botswana. The dissertation, which is based largely on ethnographic observations from 2002--2004, examines the process by which key actors created and adapted the clinical, bureaucratic, and global health practices that constituted Botswana's ARV program. While popular accounts emphasize the role that international money and expertise had in starting this program, this dissertation tells the story of Botswana's landmark ARV program from within its government health care system. The dissertation examines the politics of knowledge within Botswana ARV program by describing how HIV drug therapy was understood by national bureaucrats, hospital chiefs, HIV clinic nurses, and rural health providers. It focuses on knowledge about HIV clinical care and management developed within Botswana's own health care system, both at the top, among physician-bureaucrats, and at lower levels, among Botswana's nurses, physicians, and other care health workers. Expertise from within the nation played a vital role in creating this lifesaving clinical care program. Further, the dissertation argues that state bureaucrats worked strategically and thoughtfully to use the talents of international health experts for maximum positive effect. Both upper level bureaucrats and workers in the individual hospitals used international health experts as brokers and negotiators, in order to achieve needed changes. Experts' success in their role depended as much on their social status as outsiders as on their knowledge of public health management and HIV clinical care. The dissertation adds to a growing body of scholarship that examines the local social and political context of health care in order to understand global health, and is intended for an audience of medical historians, sociologists, anthropologists, and health policymakers. |
