The idea of clientship comes also out of half-remembered theoretical arguments and our own experience of listening to people, the way they address each other, of being together with people. What is important for us is position, being aware of the fact that researchers are positioned in a social world and that the people we meet are too: this is the basis of ethnography and by definition this is radically unreplicable. Not falsifiable. It is an additive exercise. The test of validity of what you do is not whether someone can reproduce it, but how well you explain what you have done. It is not experimental.

I want to push back on this point that ethnography is not replicable. I think that if we make our arguments in those terms we will never get a voice. Just because we are interested in particularities and context does not make this any less rigorous. On the contrary, it raises the bar. Ethnographic vignettes provide a structure and allow us to do various kinds of counting. We don’t reproduce ethnography but case studies do re-read old texts, build on them and critique them.

I also have a question on how “health care seeking,” a traditional medical anthropological term, links up to political citizenship. Your field is a terrain booming with projects or littered with projects. I am reminded of Fassin’s account of the experiences and politics of AIDS in South Africa, where you also have all these multiple actors. How does the booming chaos of the chart of multiple rollout projects you showed link up, and by what principle? Where is the notion of public disclosure? I am thinking here of Marx’s observations about peasants, that they had potatoes in a sack not because they were dumb but because of structural conditions. And what happens to all the doctors in the chart? There has been extreme burnout in Tanzania and elsewhere, and pushback from medical organizations.

I agree with your comment on the overwhelming burden ethical review boards place on anthropological research which is fundamentally relational. We have to stop the mission creep. What started as protection for medical subjects is now mostly about liability control for big institutions. We should fight for separate IRBs that provide some oversight but that don’t apply false categories of oversight.

On the projectified landscape. I’m thinking about how to reconcile Joe Amon’s point about the potential criminalization of AIDS transmission in Uganda with the reality of therapeutic clientship. To what extent are people aware of these changes in law? To what extent are national legislators in touch with the realities you describe? Are these two separate worlds? You also identify a major shift in perspective in Africanist ethnography, from the contingent “why me?” question to pushing forward with life. What about this change in subjectivity?

On the classic studies of patronage and clientage in African studies. Some of the most interesting studies relate to the networks of patrons and clients at multiple levels of power. What your study is doing is starting at the most local level. A standard survey instrument would ask about the relative wealth of people in this therapeutic landscape, but would not have a method for asking how much social capital they have in this network. How much money you have is no more important than how many people you know and who they are. A Study in eastern Kenya, for example, showed that if the person who owns a drug shop knows that clients have a rich social network, they are able to receive a loan. But we don’t have systematic ways of asking about this. Also, the way that what you are describing plays out in Uganda has to do with the fact that the medical community there is much richer and deeper than others in East Africa. Clientship is in fact at the core of the historical cultural style of southern Uganda (i.e., Holly Hanson’s book about clientship being at the core of southern Uganda “style”).

I see a parallel in your work to corporate citizenship programs. Agents of neoliberalism push the language of citizenship, but they mean clientship. They are creating clients in the old sense. Patients don’t call themselves clients, but healthcare workers call them that. Also, what happens when things are given away for free? There is an expectation that if medicines are given for free, “clients” will say good things about the organization in return.

There is not a “population” in this diagram/mosaic. We need to name these collectives. What are the units of people and of populations we see here? What kind of ambiguous political subjects are they?

What you present is evidence of a different kind that is just as powerful as RCT. I love the idea of clientship as a way of thinking of the relationship to healthcare. Clientship is bound up with exchange. These encounters create changes not only in subjectivities/selves, but in forms of sociality. I am interested not just in how the subject is changing but also something going the other way. The antiretroviral therapy supply chain might be thought of as a new kind of kinship chart. I am interested in how research subjects and other social formations are displacing families and other forms of sociality.

Regarding anthropology and Mike Fischer’s point, I was getting at the fact that ethnography cannot be replicated and falsified and that this is what the models seem to want. Arguments about validity explain how you got where you are, but two people will take very different journeys starting from similar places. Anthropological knowledge is additive, cumulative. And this is the real contrast with the evidence-based model. Evidence-based is a contradiction, a tautology. What is true is apparent, what is apparent is true. About ethical review boards: When we draw on pictures, quote people, and share feelings that were entrusted to us are we being unethical? Obviously not, but we always have to make an argument for it. Most of our subjects, when we show them what we’ve written, go looking for their names, and are upset when they see that they have pseudonyms which is a result of IRB demands. Many do not want to be anonymous. The blanket “anonymity always” has to be questioned.

Regarding the comment that the focus on healthcare seeking is traditional medical anthropology—yes, and that is important. The material that we have allows us to look at health-care seeking, but also at how the landscape in which people are making their decisions is changing and has changed over time. It is about the overall mapping of the changes while not forgetting that there are people who would like to continue living.

How to link therapeutic clientship and citizenship, and what kind of population we are talking about here? All of the different projects offer treatment. In order to have that second chance and be able to survive, you have to join. There is a kind of social organization of people visà-vis the projects. It is not that easy to switch from one project to another. Once you join, you’re supposed to stay and stay loyal to your project. Programs have their health workers and providers who are funded for running the program and they have their patrons. These are people whose jobs depend on being able to satisfy their donors. The people who are the real advocates for rights for health are, by and large, the doctors, who are most active in the name of therapeutic citizenship. And then there are the “AIDS stars,” who also attract support from patrons. But most people don’t want to do that, they just want to get their drugs.

The intention of the chart is to show how confusing everything is. This is nobody’s guide for action. It just demonstrates how chaotic the situation is. It’s also not the hidden structure, it is the part of structure that could be discovered last year in Uganda. It may resemble a kinship diagram but it is a very different representation; actors are not aware of most of these organizations.