Pathologies of Patriarchy: Death, Suffering, Care and Coping in the Gendered Gaps of HIV/AIDS Interventions in Nigeria

Thesis (Ph.D.)--University of Washington, 2016-08

In many sub-Saharan African countries, HIV seropositive women intentionally shun life-saving medical technologies like antiretroviral drugs or only engage inconsistently with treatment regimens. These self-destructive patterns of behavior continue in many contexts despite the free provision of drugs and institutional policies that claim to be inclusive of the needs of HIV positive women. Such paradoxical patterns demand urgent attention and this dissertation contributes to research explaining how and why these patterns persist. It does so based on close ethnographic investigation of the social contexts and associated social constraints and inequalities delimiting the ways women access and experience biomedical treatment regimes. This dissertation argues on the basis that orthodox biomedical analyses of interventions fall short insofar as they elide the social realities of vulnerable women with methods that assume too much about these women’s experiences of treatment. Using an intersectional framework, the alternative analyses offered here seek to situate women’s uptake and adherence to HIV treatment and care across multiple contextual scales from the personal and local up to the global. Across all these scales, the persistence of patriarchal social relations is shown to be a dominant social influence on health outcomes and as such a primary cause of pathology and premature death. The intersectional approach helps explain how pathology becomes embodied at the intersection of patriarchal social relations and experienced on a very personal level as well as the organizational practices of global and local HIV/AIDS institutions that systematically inhibit and curtail sustainable treatment among HIV positive women in Nigeria. Unsustained HIV treatment access and care among HIV positive women thus occur at the juncture of two seemingly contradictory scales, the individual and institutional. A major disconnect exists between HIV subjects and intervening HIV/AIDS institutions with the result that women shun treatment when social gaps in treatment are perceived to threaten their physical access to available biomedical resources. Germane to this disconnect is the construction of ‘needs’ in development discourses and practices mostly articulated as the provision of material or tangible goods and infrastructure, a departure from women’s experiences of needs situated at the intersection of self-care and economic empowerment. Women’s caring and social responsibilities are practiced in such a hierarchical way that self-care which circumscribes their HIV care is usually subordinated to care for others. In this sense, a simple valorization of care by care ethicists as simply what individuals are wired to do might not necessarily conform to how marginalized HIV positive women experience or practice care in male dominated societies. Such misperceptions of care obscure the social realities that constrain women’s access to treatment thereby, taking such bottlenecks off the radar of interventions. Within a social relations framework and an institutionalized cultural system that reproduce women’s over dependencies on oppressive intimate heterosexual relations for social and economic security, this study problematizes the normative constructions of care in patriarchal cultural systems as a relational activity that is neutral or autonomously performed. Conventional construction and practices of ‘empowerment’ deployed through a needs based development paradigm are also challenged, complicated and reconstructed to include forms of empowerment that enable the practice of women’s self-care and by implication, secure their sustained access and adherence to treatment. These research findings contribute to the critical genre of HIV/AIDS scholarship through this study’s emphasis on the often neglected social dimensions of treatment interventions on multiple scales. It does so by addressing the role of global-local policy transfer in development practice at the intersection of traditional cultural systems and the political economy as they shape HIV seropositive women’s treatment access and adherence within a place specific context.