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ABSTRACT
Much has been written about how structural (e.g. colonialism) and social (e.g. gender) determinants shape embodied health outcomes. However, little attention has been paid to the ways that marginalized populations become complicit in their own oppression. Ethnographic data collected over two years at a rural public hospital in Malawi show that the tobacco political economy produces significant intra-rural inequalities that result in the exclusion of migrant farm workers, called “tenants,” from HIV care. Using an analytical framework informed by Bourdieu’s concepts of social field and habitus, I illustrate how social inequalities persist unchallenged, even by the most disadvantaged people.
Acknowledgments
First, I dedicate this article to my research participants, half of whom have passed away since 2011. Mwasowa Chomene Mose. A heartfelt thank you to Holly Wardlow, Amy Kaler, Hollis Moore and the anonymous reviewers for their helpful comments on previous drafts.
Notes
1. A quarter of all children presenting with malnutrition are also HIV positive, making routine screening for HIV at these “entry points” essential (Thurstans et al. Citation2008).
2. “Universal access” refers to a set of evolving clinical criteria used to determine treatment eligibility.
3. Embodied inequalities is an interdisciplinary concept emphasizing how our material and social worlds result in uneven population patterns of health and disease (Krieger Citation2012:672). However, most researchers have not agreed on the mechanisms behind differential health outcomes, or on what to call them. Ssee Quesada et al. (Citation2011) for a summary.
4. The tenants I surveyed represented nearly every ethnicity in Malawi including: Lomwe, Mang’anja, Chewa, Nyanja, Yao, Tumbuka, Nkhonde, Lambya, Sukwa, Nyika and Sena. Tenants from Northern Malawi generally spoke chiTumbuka and chiChewa while tenants from Central/Southern regions usually only spoke chiChewa (the official national language). A few were also from Mozambique, Zambia and Burundi.
5. For example, important theoretical contributions by Quesada et al. (Citation2011) and Willen (Citation2012) do not adequately address how these frameworks would apply to internal migration.
6. This gap is surprising because village chiefs kept detailed records of every single “visitor” in their village area, including date of arrival, home district, and current residence. The erasure of internal migrants at the hospital, district and global policy making levels is an extension of symbolic violence experienced by tenants in Temwa at a global scale.
7. See Bonilla (Citation2017) for a discussion on unsettling anthropological theory in relation to western modes of understanding power and authority.
8. Currently, all infants and children are eligible for ART as soon as they test positive (MOH2016).
9. Although beyond the scope of this paper, debates about ethnic favoritism linger.
10. In theory, the right to land among the Tumbuka is inherited from father to son, but is more flexible in practice. However, the quality of land distributed to female kin was often inferior.
11. The gendered dimensions of land ownership are also at play here. Southern Malawi is matrilocal; male tenants often stated that they migrated to avoid living with in-laws.
12. Tenants were able to borrow from landowners against their yearly cash payment.
13. Demographic data indicate that internal migrants were 18% of Rumphi District’s population (NSO Citation2008). Two possibilities for the higher rate (36%) I found: 1) Temwa was the tobacco hub for Rumphi; and/or 2) Tenants use the hospital more than local landowners.
14. Bourdieu would characterize the deference cultivated by tenants a “strategy without strategic calculation” since necessities are reimagined as virtues (Richardson Citation1990:214).
15. According to Mpatso’s health passport, she weighed 8.5 kg and was eligible for 16 pots, but was prescribed only eight.
16. The Tumbuka have an informal clan system. Thus, in this context “clan” is an idea used to juxtapose with “ulendo”.
17. The exceptions are stillbirths or neonatal deaths.
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Laura Sikstrom
Laura Sikstrom is a CIHR Health System Impact Fellow at the Krembil Center for Neuroinfomatics and the Office of Education at the Center for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada. She is also a lecturer in the Department of Anthropology at the University of Toronto. Address correspondence to: Laura Sikstrom, Krembil Center for Neuroinfomatics (CAMH), 250 College Street, M5T 1R8, Toronto, Ontario, Canada. E-Mail: [email protected]