Infected Kin: Orphan Care and AIDS in Lesotho

Theodore Powers

University of Iowa

Infected Kin: Orphan Care and AIDS in Lesotho. Ellen Block and Will McGrath, New Brunswick, NJ: Rutgers University Press, 2019, 246 pp.

With Infected Kin, Ellen Block and Will McGrath have crafted an insightful contribution to the anthropological analysis of the southern African HIV/AIDS epidemic. Based on eight years of research, the authors analyze the shifting dynamics of kinship and care, focusing on HIV/AIDS orphans in Lesotho, where HIV is estimated to infect nearly one in four adults. Situating their research in the rural Mokhotlong district, they employ a kinship-first approach to explore Basotho sociality, highlighting that HIV/AIDS is not simply a biocultural phenomenon, but a kinship disease. Written in a clear, accessible style, Infected Kin is divided into descriptive and analytical sections. Each chapter opens with a vignette by McGrath, followed by in-depth analyses by Block. Combining insights from the new kinship studies with anthropological debates on global health, the authors have created an ethnographically nuanced account that foretells of a looming crisis at the epicenter of the global HIV/AIDS pandemic.

The starting point for this book lies with the authors’ frustration with the design and limited impact of global health interventions. In response to the vertical, disease-specific programs that have defined transnational health interventions since the early 20th century, the authors approach the HIV/AIDS epidemic in Lesotho from a different conceptual starting point: that HIV/AIDS and kinship have a mutually reinforcing relationship. For the authors, an understanding of the epidemic—and the care needs that it produces—must begin with this insight. This account is also informed by contributions from critical medical anthropologists. The authors deploy the concept of structural violence to analyze the socio–economic undercurrents that produce an uneven distribution of global HIV/AIDS infections in regions where the epidemic is concentrated, such as southern Africa.

While this ethnography is based entirely in the land-locked southern African society of Lesotho, the authors situate their analysis of HIV/AIDS utilizing a regional lens. This enables them to construct a historically informed account that situates Basotho health and illness within a broader set of dynamics and to contextualize the social determinants of health as a key driver of HIV infection. Block and McGrath set out to understand the epidemic at multiple levels, and they succeed in bringing broader socio–economic factors into conversation with the intimate lifeworlds of care that they observe in rural Basotho households.

For example, they link the historical impact of regional migrant labor systems on family life and marriage, the subsequent decline of the mining sector, and the effects of persistent resource shortages on Basotho families to frame the context within which the epidemic has spread. Block’s historical analysis is woven into the text of the book, as are critical analyses of the HIV/AIDS response. Tracing the contours of the national, regional, and local response to the epidemic throughout the text, Block clearly outlines how continued limits on access to health services in rural areas have been decisive for life trajectories in communities infected and affected by the epidemic.

These thematic concerns are interspersed with ethnographic vignettes that underscore how HIV/AIDS is reconfiguring kinship and the dynamics of care in Lesotho. An important insight that derives from framing HIV/AIDS as a kinship disease is that kinship and relatedness are shifting in response to the impact of the epidemic. Building on practice theory, Block analyzes how idealized conceptions of patrilineal kinship are being creatively reworked as people and communities adapt to provide care for HIV/AIDS orphans. While extensive fostering systems have been commonplace in Lesotho and build on long-standing cultural practices, the ravages wrought by the HIV/AIDS epidemic have placed further strain on already stretched systems of kin care, leading to increased flexibility in the application of patrilineal norms.

Block contends that rigid kinship norms, and patrilocal residence particularly, have been rendered increasingly flexible due to the impact of the epidemic. The shift toward matrilocal residence patterns has been driven by care for HIV/AIDS orphans provided by maternal grandmothers. In part, the change to matrifocal residence has been enabled by a decreasing capacity for men to pay bride wealth (likhomo). Traditionally paid in cows, likhomo concretized patrilineal claims on grandchildren. In practice, the decline of likhomo has meant that maternal kin can increasingly lay claim to their grandchildren. In what is the book’s strongest element, Block intersperses ethnographic descriptions of family life and the labor of care alongside an extended discussion of kinship and relatedness. In doing so, she identifies the Basotho house, the rondavel, as both the locus of care and a site that has become increasingly significant for understanding relatedness and care arrangements.

Another area of strength is Block’s analysis of how Basotho people navigate the quest for treatment, often accessing traditional and biomedical practitioners in the process. Here, Block emphasizes how structural barriers to care produced by history, geography, and rampant rural poverty limit access to treatment for people living with HIV/AIDS. An uneven and insufficient response also leads to unclear and inconsistent education relative to the epidemic. While the authors were primarily based at an NGO that provided treatment and care to HIV/AIDS orphans, home visits across the rural stretches of Lesotho underscore that rumor, misunderstanding, and a lack of coordination undermine attempts to limit the spread of the epidemic.

While the book focuses on the changing dynamics of kinship, Block also highlights a looming crisis relative to HIV/AIDS orphans and in the social organization of care across Lesotho. Grandmothers have played an outsized role in caring for people living with HIV/AIDS over the last three decades. Block underscores that the imminent mortality of this generational cohort stands as a direct threat to the reconfigured notions of kinship and care that she describes throughout the book. In short, those whose work has remained invisible to the vertical, disease-specific programs that typify global health (and vital to the success of such programs) will soon no longer be able to provide life sustaining labor.

While this insight provides a harrowing conclusion to the book, it is also a missed opportunity. This point is significant for understanding the regional HIV/AIDS epidemic and ongoing debates on global health. Similar dynamics of fostering via extended kin networks have long been practiced across southern Africa. Thus, it would have been interesting to see the authors extend this insight to the region as a whole. The invisibility of women’s care work in global health programs also affirms what a growing body of scholarship has claimed: that global health programs largely depend on unpaid labor and may actively produce inequality. Further development of this line of analysis would have strengthened the book’s contributions to the discipline and to debates on global health.

With Infected Kin, Block and McGrath have crafted a clear and concise contribution to the anthropological literature on the southern African HIV/AIDS epidemic. The book’s conceptual focus should be of particular interest to scholars and graduate students studying the interplay between kinship and care in varied cultural contexts. The book is ideally suited for intermediate and upper-level undergraduate courses that focus on kinship, care, infectious disease, and global health. Reflecting this audience, the authors have provided a series of discussion questions and exercises for each chapter, enabling easy adoption of the monograph for undergraduate courses.

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