A tide of populism and authoritarianism on both sides of the Atlantic has facilitated the rise of particular groups to power and underscored that political control of the state can produce significant changes in society. These events highlight that it is people working within the state that control how government institutions operate and produce effects that impact society. Rather than impersonal institutions that reflect normative criteria, these dynamics suggest that people are the state. But what are the implications of conceptually framing the state as people? What might happen if different groups of people were able to transform state policy based on the principles of social justice?

I tell that story in my new book. The HIV/AIDS movement in South Africa—constituted by activists, healthcare workers, NGOs, and others—occupied the state to transform policy, renovate health institutions, and sustain the lives of people living with HIV. The movement leveraged political principles developed by the anti-Apartheid movement to build a broad coalition that changed national HIV policy and increased access to treatment through institutional transformation. The result was a revamped state health system. The HIV/AIDS movement’s struggle shows how the state can enable the representation of different voices in a pluralistic society.

The campaign for treatment access underscores that it is people that produce social effects associated with states, and that activists, NGOs, and other entities can alter policy and transform state institutions to produce dramatic changes in society. The South African HIV/AIDS movement was able to occupy the state to expand treatment access, an outcome that required overcoming the opposition of a powerful group of state elites that stringently limited access to treatment, questioned the scientific link between HIV and AIDS, and actively supported scientifically unproven remedies as treatment. Notably, this clique of “AIDS dissidents” included then president Thabo Mbeki and his serving health minister Manto Tshabalala-Msimang, among others.

Accordingly, the history of the South African HIV/AIDS epidemic necessitates that we consider how afro-pessimistic perspectives distort our understanding of the state and contemporary politics in Africa. Indeed, normative conceptualizations of the state have often been deployed to characterize African polities and political dynamics as failed, deviant, or associated with criminality, and thus requiring external intervention to redirect these processes. Rather than reproduce colonial depictions of African societies, I contend that reframing the state as people enables a new approach to studying the dynamics of state and society that allows one to circumvent the deployment of normative Anglo-European conceptions of the state.

Following people, whether they are HIV/AIDS activists, members of NGOs, or state representatives, allows us to see their lives as they are actually lived. Moving alongside people involved in HIV/AIDS politics allowed me to witness the development of policy and exercise of power as it happened and use this information to study the state, rather than rely on abstract conceptions of power and politics. Employing this methodology facilitates a different understanding of state power as the amplification of particular people’s ideas and actions, rather than the product of a nameless, faceless bureaucracy.

For example, the development of a provincial HIV/AIDS policy was redirected by the politics surrounding a grant renewal with the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria in the Western Cape province. The actions of particular people and organizations redirected a national policy development process that aimed to rapidly expand HIV/AIDS treatment access. The social process that led to this outcome was the result of actions carried out by people working within, and on the margins of, the state. This history shows how the success or failure of activist-led HIV/AIDS policy initiatives did not depend solely on technical issues, but were instead contingent on the constellation of people, organizations, and institutions that interacted and produced power dynamics and policy outcomes at the different levels of the state.

While the HIV/AIDS movement eventually emerged as triumphant in the struggle over treatment access, for many poor and working-class South Africans, including those involved in the movement, the victory has not addressed the socioeconomic conditions that structure their lives and drive HIV/AIDS infection. Analyzing the significance of the campaign for treatment access alongside limited social transformation, my research suggests that limited social transformation, as seen through social, political, and economic conditions, continues to drive the ongoing expansion of the HIV/AIDS epidemic. This conclusion underscores that rights-based social justice activism and access to treatment may not be sufficient to change the social determinants of health and end the HIV/AIDS epidemic in post-apartheid South Africa.