by Mike Callaghan

Moi University, Kenya

Image 1: “Holding HAART,” photography by author.

Sometimes exclusion doesn’t work the way we expect.

In 2008, I moved to the coast of Namibia to begin fieldwork for my PhD in Anthropology. The country had achieved near-universal access to highly active antiretroviral therapy (HAART), the medication that treats HIV. While many countries in sub-Saharan Africa scrambled to manage HIV outbreaks in crisis mode, Namibia had a fairly stable, mature program that had overcome most of its logistical challenges. For this reason, Namibia seemed like a perfect place to ask which patients benefit most from a public-sector rollout of HAART.

In the early days of HAART, the evidence – and common sense – suggested that women would fare worse than men. This is generally the case in North America and Europe. Further, in many parts of sub-Saharan Africa, patriarchal cultures disproportionately expose women to violence, economic marginalization, and socio-political disempowerment. Surely, the assumption went, lifelong treatment would be one more challenge on top of the rest, and women would find themselves struggling with its demands.

What I found was the opposite.

Despite the myriad ways in which they were marginalized in daily life, women consistently outnumbered men in HIV testing and care, were more likely to stick to their treatment and return for follow-up, and were less likely than men to die before and after starting HAART.

Why should men fare so badly?

As time went on, it became clear that many of them were bound up in a form of masculinity that was basically incompatible with the demands of HIV treatment. Women who moved to the city often indicated that they felt liberated to either delay marriage and become entrepreneurs, or to stick to the more traditional rural female roles by marrying and bearing children. Both the confident, assertive role and the obsequious, conservative one were well suited to the demands of HAART.

Clinic staff reported that they appreciated that women were generally either ‘compliant’ or ‘earnest,’ but in either case made for ‘good patients.’ Men, on the other hand, were still constrained by rigid notions of masculinity.  In rural areas a man might acquire more land, cattle, or wives to assert his masculine status; in the city the a ‘real man’ was one who is stayed late carousing and womanizing at the bar or spent conspicuously on cars or natty clothes.

Masculine identity in the shantytown also seemed to involve embracing risk and eschewing help. Men would smoke cigarettes while filling their cars at the gas station, or blithely disregard the advice of their doctor.  The choice between being a good patient and a good man, it seemed, was an easy one for many to make, though the consequences were deadly.

Some men opted out the version of masculinity, but there was no esteemed alternative in its place. One of my informants dreamed of simply leaving town and moving to the country, where he would no longer be caught up with the demands of urban life.  Another, whose treatment was going well, called his wife his lone source of support and said he had no real male friendships in the shantytown.

It was a strange thing, to be a young male anthropologist in the midst of this situation.  As a resident of the shantytown where most of the clinic’s patients lived, I was relatively wealthy, and drove an old truck that locals esteemed as appropriately ‘serious’ to mark me, as one friend remarked, as ‘a real man.’

On the other hand, as a fair-haired white man I stood out like sore thumb.  I had learned to speak Afrikaans, useful as a lingua franca in such a polyglot environment, but also stigmatized as the language of apartheid. In the feminized spaces of the clinic, where the majority of patients and staff were women, I was an outsider too.   My lack of social capital in all of these situations hamstrung me.

Image 2: “Clinic,” photography by author.

In the end, I wrote my PhD thesis on the experiences I had in Walvis Bay, and the things I learned there about gender and HIV treatment. This tension between insider and outsider, between the costs of fitting in and the costs of being excluded, loomed large in my work. I developed a theory of a sort of ‘toxic’ masculine identity in the shantytown, and grappled with the fact that, even in a patriarchy, men may be marginalized.

In some sense the lessons here may lie less in the findings than in the methods.  Anthropologists have a long history of working on the margins, ‘studying up,’ and keeping ourselves honest through critical reflexivity. In Walvis Bay, I learned that the very question of what constitutes the margins, and where they’re found, is far from straightforward.  Exclusion, it seems, takes many forms.