LIVING WITH HIV/AIDS

222 Pages·2010·2.25 MB·English

LIVING WITH HIV/AIDS: AN ETHNOGRAPY OF CARE IN
WESTERN KENYA

A thesis submitted to The University of Manchester for the degree of PhD in the Faculty of
Humanities.

2010

HANNAH BROWN

Social Sciences/Social Anthropology
Contents Page
List of Figures and Tables 7
Abstract 8
Declaration 9
Copyright Statement 10
Acknowledgements 11
Map of Kenya 13
Map of Nyanza Province 14
Introductions 15
Practices of care 16
Theorising care 19
Care as methodology 22
Locations 22
Chapter 1.
Contextualising the Epidemic 28
The Moi government and the Kenyan state: 1978-1989 29
A note on ethnicity in Kenya 32
Health care in the first Nyayo decade: unequal distribution of resources 34
Kenya under Moi in the 1990’s: Structural adjustment, multiparty politics 36
AIDS policy under Moi (1985-99): Accusations and denial 38
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AIDS as a ‘national disaster’ (1999-2002): NACC, PACCs, DACCs and CACCs 41
ARVS come to Kenya 43
‘Total war on AIDS’: the Kibaki government from 2002 44
Oranges and bananas: The NARC falls apart 46
Care in Kenyan AIDS policy from 2003: The arrival of the ‘big three’ 47
Chapter 2.
Home and Hospital as Domains of Care 51
‘Culture problems’: Discourses on HIV prevalence in Western Kenya 51
Defining care 60
Home 65
Home, growth and prosperity 67
Hospital 71
Inequalities within 72
Inequalities without 73
Conclusion 77
Chapter Three.
Home-Based Care: Policy as practice 78
Introduction 78
Part One: Introducing Home-Based Care 80
Home-based care 80
Kagot development group 81
Community health workers 83
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Part Two: Embedded Enactments 87
Policy as practice 87
Home visits 89
Embedded care 93
Guests and visits; care and gifts 96
Nyamreche and Luo medicine 100
Part Three: Professionalising enactments 104
Professionalising model 104
Uniforms 108
Hellen and her uniform 110
Record-keeping and legibility: “embedded” and “professionalising”
in conflict 112
The limits of professionalization: ‘Attachment’ at the hospital 114
Embedded and professionalising make a policy 115
Chapter 4.
“Home-Based Care is not a new thing” 120
Introduction: Government and home 121
Home-based care as neo-liberal? 123
A meeting at Kagot development group 124
Home-based care as ‘engaged universal’ 128
The tangle of ideas 129
Women’s groups and health care in historical context 131
Community 133
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Women’s groups, patron-client politics and the distribution
of resources 135
Feminine distinction 140
Conclusion 141
Chapter 5.
The Patient Support Centre: Relations of care
in HIV treatment. 144
Introduction 144
Being brave: Becoming a client 145
Biological citizenship and relations of care 150
The Patient support centre 153
Becoming jokinda 157
Counselling 159
Defaulters 161
Conclusion 165
Chapter 6.
Fear/respect and medical care 167
Introduction 167
Care in the labour room 168
Harsh and cruel 170
Hierarchy and care: Luoro relationships in hospital and at home 172
Care, abuse and the proper management of pain 175
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Other kinds of care 177
Conclusion 179
Chapter 7.
Hospital Domestics: Care work on the wards 181
Introduction 181
Into the wards 182
On hospital spaces 183
Spatial practice on the wards: Making medical spaces 186
Being admitted 190
Caregivers and patients: Making domestic spaces 191
Mobile domesticity 195
How, then, to understand space in this hospital? 196
Conclusion: Towards an anthropology of care 200
In praise of shallow ontologies 201
Towards an anthropology of care 203

Word Count: 80,217

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List of figures and tables Page
Figure 1. Map of Kenya 13
Figure 2. Map of Nyanza Province 14
Figure 3. Coffins for sale on Kagot's main street, outside Pona (Swa. Heal)
Chemist 24
Figure 4. Map detailing the locations of the main ethnic groups in Kenya 32
Figure 5. Language Map of Kenya 33
Figure 6. Poster for the “Crush AIDS” campaign 39
Figure 7. Antenatal HIV prevalence in sentinel surveillance sites in
Western Kenya 1990-2000 41
Figure 8. Annual amounts dispersed by ‘the big three’, 2001-5 48
Figure 9. HIV prevalence in Kenya by province, Kenya AIDS Incidence
Survey 2007 52
Figure 10. Signboards outside Kagot District Hospital 75
Figure 11. “A Possible Home Care System” 81
Figure 12. A Wall in Kagot Development Group Office 104
Figure 13. The Community Health Workers visit the District Hospital
dressed in their uniforms 110

Table 1. Provincial shares of development expenditure for
rural health 1987-8 36
Table 2. Essential elements of CHBC 127
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Abstract
This thesis, ‘Living with HIV/AIDS: An ethnography of care in Western Kenya’, is based upon
18 months of ethnographic fieldwork carried out in Central Nyanza, Kenya, between 2005-
2007. It studies practices of care against the backdrop of the HIV/AIDS epidemic, which has
impacted the region severely. The thesis explores how home and hospital are established as
domains of care through practice. It draws upon ethnographic material collected from within
a District Hospital, a Community-Based Organisation and people’s homes.
The thesis follows practices of care across divergent domains of social life to consider how
practices of care within Luo networks of kinship and relatedness intersect with governmental
interventions to manage HIV/AIDS. The thesis describes two governmental projects
introduced to administer HIV/AIDS care in this region. It considers Home-Based Care, an
HIV/AIDS response in which Community Health Workers are trained to support particular
aspects of care at home, focusing on the practices of care employed by Community Health
Workers as they visit sick people at home and attend organisational meetings. The thesis
also describes the landscape of HIV care in the District Hospital, including the delivery of anti-
retroviral therapy. The focus here is on the relationships between caring practices in the
hospital and at home, and the divergent responsibilities to care experienced by hospital staff
and family members.
The main argument of the thesis is that care is a particularly useful analytical tool for
anthropology because practices of care take place across many different domains of social
life, cutting across the boundaries that have formed the traditional focus of anthropological
study. Studying practices of care illuminates the production of bounded domains of social
life whilst simultaneously drawing attention to similarities of practice across different
domains. Care provides a way of understanding the complex social landscape that has
developed as people in Western Kenya endeavour to live with HIV/AIDS.
Submitted by Hannah Brown to the University of Manchester for the degree of PhD in Social
Anthropology, in the faculty of Humanities, 2010.
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Declaration

I declare that no portion of the work referred to in the thesis has been
submitted in support of an application for another degree or qualification of
this or any other university or other institute of learning

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