In Mistreated, Nora Kenworthy examines how HIV program scale-up altered relationships between global health institutions and the Lesotho government and its citizens. Due to the exponential increase of external assistance earmarked for HIV programs since 2006, the government of Lesotho became increasingly accountable to donors and international priorities, and unaccountable to its citizens for basic services. As a result, citizens started looking to various NGOs in their attempts for survival, which created what Kenworthy terms a “politics of recipiency”: a hierarchical type of political engagement whereby donors set priorities and citizens are placed in a supplicant position. Based on fieldwork carried out between 2006 and 2014, Kenworthy demonstrates with compelling ethnographic detail how such a politics of recipiency had undesirable effects on democratic processes, community solidarity, and citizen subjectivities.
Mistreated takes a multi-scalar ethnographic approach to trace connections and frictions in the politics of global health at multiple scales. Early in the book, a comprehensive yet succinct discourse analysis of key policy shifts reveals how HIV policies were crafted in response to donors’ expectations of good governance, accountability, and “country ownership.” A key virtue promoted by these policies was the production of HIV-“competent” citizens and communities who would be able to “control their own vulnerabilities” without relying on external assistance (p. 68). Competency ideologies informed decentralization initiatives, which made local-level councils responsible for coordinating the HIV response. But without having the expertise to do so, these councils were ineffective and merely elicited distrust and accusations of corruption from citizens. By promoting self-reliance among citizens and communities, Kenworthy argues, the competency discourses relieved the government of its responsibility to address structural conditions such as poverty, food insecurity, and the absence of a social safety net, all of which created and exacerbated HIV vulnerability. HIV scale-up policies were thus creating a form of “anti-politics,” which obscured political and historical origins of the disease.
While Kenworthy suggests that her book may be read both as an ethnography of policy and an ethnography of citizenship, the ethnographic fieldwork concentrates on the latter. Focused on a semi-urban community, her long-term engagement with a community-based support group reveals how HIV scale-up eroded the solidarity between the volunteer caregivers and the community. During HIV scale-up, the support group members, who had been providing basic care and material support in the form of food and transport costs to fellow community members regardless of their HIV status, became enrolled as foot soldiers for NGOs, assisting with triaging material resources to people living with HIV. Because NGOs and donors often did not deliver the resources or did not deliver them in sufficient quantities for all those in need, community care givers were suspected of hoarding these “gifts.” A few years after HIV scale-up had begun, the support group dissolved. The group’s informal leader, once a well-respected traditional healer, had emerged from scale-up “poorer than she had begun,” not only financially but also “in terms of her social position, her group’s sense of solidarity, her relations with patients and community members, and her own self-regard” (p. 125).
Passive and apolitical. This is how the Basotho were often described to Kenworthy by NGO and donor agency staff. The chapter entitled the “The Privileged and the Damned” sheds light on how Lesotho’s citizens are condemned as passive while simultaneously being excluded from politics. By highlighting the dynamics of therapeutic clientship encountered in a community health clinic, the author shows how the hierarchical bonds with health providers to whom people living with HIV relied on for accessing life-saving drugs and food assistance made patients hesitant to openly voice concerns. Even if they dared to speak up, about drug shortages, for example, the projectified landscape of HIV service provision made it difficult to know to whom they should voice their concerns.
To answer one of the book’s fundamental questions: “How are new regimes of care, humanitarianism, and charity altering citizen subjectivities?” Kenworthy explored the therapeutic trajectories of people living with HIV working in a garment factory where a public–private partnership offered HIV services. Part of the country’s most powerful domestic industry, the garment factory was a highly contested space that made it risky for people to speak with the author. Rather than discussing HIV, the workers wanted to talk about things that were of much greater concern to them: low wages, the dangerous and stressful conditions of factory work, and the stress of meeting daily production quotas. Kenworthy’s insightful argument shows how these social and political conditions of work were rendered less visible because of the prominence of the factory’s HIV treatment program. As the HIV treatment program became the symbol for ethical branding and corporate social responsibility, it contributed to a greater silencing of workplace rights violations, illustrating the toxic effects HIV scale-up has had on democratic processes.
By highlighting people living with HIV’s experiences of invisibility, abandonment, and marginality in different localities during the period of HIV program scale-up, Kenworthy develops a situated understanding of the mechanisms (and limits) of governmentality and biopower. Mistreated contributes to the critical anthropology of global health and development by offering innovative insights about citizens’ everyday encounters with power in unstable political spaces. A limitation of the book is that it pays somewhat less attention to politics on a national scale and the power relations between the Ministry of Health and global health initiatives. However, as Kenworthy explains, to be granted permission to conduct her research by the ethical approval board from the Lesotho Ministry of Health, she agreed not to interview high- level government officials.
The book does not seem to have generating theory as its core purpose; rather, Kenworthy’s aim is to change the narrative of how stories of global health are told and how its recipients and their desires are represented. The author’s compelling yet concise writing style make it a powerful ethnography, suitable not only for teaching at undergraduate and graduate levels in medical anthropology, global health, and international development studies, but also for non-academics engaged in global health.