A review of Living with Globalization: The Intersection of Intimate Partner Violence and HIV Infection in Uganda, by Margaret Winchester.
In her dissertation, Living with Globalization: The Intersection of Intimate Partner Violence and HIV Infection in Uganda, Margaret Winchester provides the reader with an illuminating and effective account of the ways in which the lives of women with HIV/AIDS in Uganda are shaped by complex flows of local and global practice, which combine to shape the daily, lived experiences of the disease. It is now more than thirty years since the presence of the HIV virus first began to impact towns and villages across the East African region, with Uganda being one of the earliest and most heavily affected countries. The history of HIV/AIDS, as Winchester highlights, has always been intertwined with global phenomena such as trade, travel, war, migration and other forms of movement, including that of capital, medical technology and ideology. This invaluable dissertation is divided into ten clear chapters, providing detailed literature review and background on the Ugandan contexts (Chapters 1-3), methodology (Chapter 4), policy environment and service provision (Chapters 5-6), survey and ethnographic data on marriage practices, gender norms, domestic violence, lived experiences of HIV (Chapters 7-8), discussions and conclusions (Chapter 9-10).
In Africa, there are currently estimated to be more than 25 million HIV+ persons living on the continent, with over 2 million living in Uganda alone. In the southern and western parts of Uganda, where Winchester mostly conducted her PhD research, approximately 1 in 10 of the population currently carry the disease. Moreover, for every person infected there are tens, even hundreds, of others, including children, spouses, family, friends, colleagues, acquaintances, neighbors and medical staff, whose lives are affected on a daily basis, thereby forming a massive population of infected and affected persons that crosses genders, religions and cultures, and constitutes a substantial proportion of the entire national population and their interpersonal relationships.
By offering an overview of the social, cultural and political history of HIV/AIDS in Uganda, and providing a closer ethnographic examination of how people’s experiences of living with the disease cannot be understood outside of social phenomena, such as domestic or intimate partner violence, the thesis examines some of the key issues that inform women’s experiences and understandings of being HIV+. On the one hand, this allows Winchester to investigate the various social, cultural and moral practices (or what anthropologist Arthur Kleinman describes as “local moral worlds”) that help shape women’s daily lives and define their struggles in the Ugandan context. While on the other hand she shows how these cannot be properly understood without accounting for the wider global forces that are equally constitutive of people’s experiences disease.
Most significantly, as the author highlights, approximately half way through the HIV/AIDS pandemic, highly effective, life extending, combinations of antiretroviral medications radically changed the potency and character of the disease in western countries, causing a massive shift of mind, body and emotion away from death and back towards life. Millions of people living in North America and Europe, having previously faced the prospect of death and often having made irreversible life decisions, found themselves having to learn how to live again and were required to plan for life in a future they never imagined they would see. However, in countries such as Uganda, antiretroviral medications were available but not accessible. At the cost of around 800,000 shillings a month (or to put that in perspective around five or six times the entire monthly salary of a teacher at the time), antiretroviral treatments were placed out the reach of the vast majority of the population with only the very wealthy able to access them.
Antiretroviral medications cost little to manufacture but were sold at hugely inflated price, and as a consequence many persons and families continued to confront illness and impending death, only now it was in the knowledge of a “cure” that was freely available elsewhere in the world but was denied to them due to their economic position, ethnicity and national identity. Accordingly, the advent of antiretrovirals fundamentally altered and exacerbated differences between persons, reinforcing Margaret Winchester’s point that experiences of illness cannot be understood unless placed in a global comparative context.
Persons around the world have long been interconnected through global flows of trade, migration, colonialism and so forth but perhaps never with the same intensity as over the last thirty years in which both HIV/AIDS and neoliberalism emerged as significant global forces. Countries such as India offered to manufacture and distribute medications at cost price to Uganda and other poor countries and at less than a dollar per day, would have brought them into the reach of millions world wide. However, as Winchester notes, “the international TRIPS (Trade Related Aspects of Intellectual Property Rights) agreement has placed restrictions on the ownership and manufacture of pharmaceuticals, inhibiting the manufacturing of generic life-saving drugs in the developing world” (p. 27).
Partially as a consequence of decisions made in other parts of the world, by the Brazilian and South African governments, to contravene such trade agreements on the grounds of human rights and national emergency, the road was paved for the manufacture and distribution of antiretrovirals in countries such as Uganda. By focusing on the critical period in which anti-retrovirals eventually became available to the general population in Uganda, around 2005, Winchester documents how access to medication now allows for extended living and how HIV/AIDS is now experienced as a long-term rather than acute disease insofar as: “The women in this study are part of an emerging era of HIV, in which HIV can be lived with as a chronic disease. Globalization impacts their daily experiences through the availability of life-saving treatment” (p. 10).
By investigating and illustrating how HIV/AIDS as a long term, chronic illness is situated locally and globally, the thesis offers us a reminder of how the anthropological project itself “reflects the messy reality of life in a global context” (p. 20) and how “medical anthropologists working across various settings have adopted methods to complement the local-level expertise of traditional ethnography to incorporate broader social influences in the construction and experience of health” (p. 20). From this platform Winchester then explores the twin forces of the local and the global by showing how intimate partner violence that is frequently concomitant with HIV in the Ugandan context, is mitigated by local and global processes, politics and service provision that actively shape people’s interpersonal relationships.
Department of Anthropology
University of Manchester
Semi-structured interviews, close-ended surveys, open-ended ethnographic interviews and observation in two field sites in Uganda: urban Kampala and peri-urban Mbarara, Uganda
Government policy documents and newspapers
Case Western Reserve University. 2011. 328 pp. Primary Advisor: Janet McGrath.
Image: Scanning electron micrograph of HIV-1 budding (in green) from cultured lymphocyte. Wikimedia Commons.