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By Tanja R. Müller
In her article Anke Niehof eloquently criticises the shortcomings of two social science approaches for analysing home care for AIDS patients in the geographical context of rural sub-Saharan Africa and proposes as an alternative the ‘micro-ecological approach to health’ (MEAH). The MEAH allows for the inclusion of important aspects of care giving neglected by both of the other approaches. But it also raises some questions.
The most important of those, in particular when looking at care issues in relation to AIDS, centres on the household as unit of analysis and main building block of the micro-ecological context.
Within the broader HIV/AIDS impact literature the prevailing emphasis on the individual household has been called into question (Topouzis 2000) and ‘cluster analysis’ – for want of a better term – has been proposed to better understand the social dynamics unleashed by the epidemic (Drinkwater 2003). A ‘cluster’ is defined as a group of producers between whom multiple resource exchanges, usually based on kinship, labour, and possibly common access to resources, are taking place (Drinkwater 1994). Referring to livelihood analyses conducted in Zambia and Zimbabwe, Drinkwater (2003) argues that ‘cluster analysis’ techniques allow to consider the intimate interconnections between urban residents and rural households, something that household based analysis often overlooks. In addition, such techniques show HIV/AIDS impact being experienced in terms of the deterioration of household economies as well as in the unravelling of the wider social fabric of the lives of those affected or afflicted by AIDS (Drinkwater 2003, Waller 1997).
When we look at the case study presented by Anke Niehof, the need to move beyond or redefine the household becomes obvious, for the following reasons: Firstly, when applying her definition of household as a “co-residential unit”, Sam is, strictly speaking, not a member of the household. He works in the town of Bulawayo, where he also seems to live (we learn that as he falls ill Liza has to go to visit him there). From what we know about such (semi-migratory) relationships in the wider context of sub-Saharan Africa, there is near certainty that Sam has other sexual partners in Bulawayo, either on an occasional basis or as a ‘permanent’ girlfriend (in all likelihood he contracted the HIV virus in such sexual encounters and in due course infected Liza). This leads to the second problem with the definition of household advanced here: the extent to which Sam takes care of “resource management and primary needs” of the rural household (and its members), whose de-facto head is Liza, is open to question. Instead of focusing on the household, it is thus suggested to consider Liza as the “primary producer” (Waller 1997) within a ‘cluster’. The rationale for a ‘cluster’ based analysis becomes even more pronounced when AIDS induced illness hits Sam. Upon falling ill, he is entitled to return to the family household within the rural homestead and to receive care from Liza. As AIDS induced illness and death further progress within Liza and Sam’s family, other specific relationships between individuals and households based on gender, wealth and generational status which can be captured by the concept of ‘cluster’ (Waller 1997) come to the fore: Liza has a claim to her mother’s help who joins Liza’s household temporarily. Liza is also affected by the claims of her parents-in-law. They take away savings she might be entitled to by law, and retain custody of some of her children, undermining her capabilities as primary producer and provider of care. In fact, the analysis provided by Anke Niehof centres exactly on this inability of Liza (and not that of her household) to cope, an inability embedded into multiple social relationships within and outside the household.
The case presented here thus provides, in my opinion, a strong argument in favour of looking for alternatives to the focus on the household as unit of analysis, and the ‘cluster’ seems a promising way forwards. It has to be said, though, that to date, cluster based analysis has only been used in very few studies. Its wider usefulness and practicality thus needs to be tested more thoroughly (Müller 2004).
Moving beyond the household also sheds new light on the debate around ‘coping’. While households that dissolve do not ‘cope’ as households, their members might still be ‘coping’ (or adapting or responding), and arguably be better off than they would be without the dissolution of the household. In the case presented here we do not know much about what happens to surviving family members, in particular those of Liza’s children who stay behind at their deceased father’s homestead. We learn from the text that the eldest son is at school in Bulawayo, presumably in boarding arrangements or staying with extended family. AIDS induced morbidity and eventual mortality within his family might, apart from the psychological effect of having lost his father, not have any further negative consequences for him. Liza herself could evidently not ‘cope’, a fact to a large extent related to herself having fallen ill. But dissolving her household (we do not know whether due to pressure from her diseased husband’s family or by choice) and returning to her parental home might give her the opportunity to ‘cope’ with her own illness in terms of being taken care off – however inadequately – by her mother and be able to die with some dignity. One of Liza’s daughters has to leave school to assume a productive role within the new household arrangements, making her the only person in this case scenario with a potentially destructive ‘coping’ strategy. Taken together, the dissolution of Liza’s household and the integration into other social units allows some of its members to ‘cope’. Such tendencies are confirmed by a number of studies on AIDS orphans in which it is argued that while households might dissolve or disintegrate, surviving orphans not necessarily face destitution but are often not worse off than before in terms of nutritional status and school attainment (Ainsworth & Filmer 2002, Monasch & Boerma 2004). Viable ‘coping’ strategies seem to depend on ‘cluster’ relationships rather than on ‘coping’ strategies exercised by individual households.
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Previously published on medanthrotheory.org and is republished here under a Creative Commons license.
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