Review of Collective Care: Indigenous Motherhood, Family, and HIV/AIDS By Pamela J. Downe, Toronto: University of Toronto Press. 2021. pp. 157.

Reviewed Book

Collective Care: Indigenous Motherhood, Family, and HIV/AIDS By Pamela J. Downe, Toronto: University of Toronto Press. 2021. pp. 157.

Heather Howard-Bobiwash

Michigan State University

It might surprise some readers to learn that Canada has one of the highest rates of HIV transmission in the world. Although Saskatchewan is one of the less-populated provinces, it is the epicenter of HIV transmission, with rates three times the national average. There, Indigenous People constitute 16% of the population but 70% of all new HIV diagnoses, 90% of which are in women (4). These hard quantitative facts attest to the persistence of the stark structural violence of the colonial state in its unrelenting assault on Indigenous Peoples’ lives. Pamela J. Downe presents a carefully researched and powerfully written ethnography carried out with the staff and people who access services through AIDS Saskatoon and The 601 drop-in center. Downe compellingly conveys the layered cruelties of suffering for Indigenous People inflicted by the syndemic conditions of HIV/AIDS, hepatitis-C virus (HCV), addiction and injection drug use, all “driven by poverty, intergenerational trauma, and the legacy of colonialism” (9).

Significantly, Downe centers Indigenous epistemic praxis and methodologies. While characteristically ethnographic—using interviews, photovoice, and deeply immersed participant observation—the research was designed collaboratively to privilege the conceptualization of the people experiencing these conditions and their community survivance strategies summed up as collective care. Mescinewin, a Cree concept translated as the “loss of an entire family to disease,” shared by one of Downe’s participants, captures the totalizing demise illness brings with the long arm of colonial reach. The concept recalls historical waves of smallpox, followed by the removal of family members to distant tuberculosis wards never to be seen again—experiences remembered as instruments of genocide that decimated Indigenous communities (82). Mescinewin can be extended conceptually to the effects of policies such as compulsory boarding school, child welfare and social work practices, unconsented sterilizations, missing and murdered Indigenous women and girls, and the criminalization and medicalization of addiction in ways that separate individuals from the embrace of Indigenous community collective care.

This cultural logic, Downe explains, defines “conditions and treatments in far-reaching and integrated ways [and] is considerably different from the reductionist and biomedical logic employed by most health care providers” and others encountered by people who access services, such as social workers, law enforcement, and school authorities (72). Mothers are on the front lines of this devastation with dehumanization as its main mechanism, for whom the effects are syndemically multiplicative when one also has HIV/HCV diagnoses and/or an active or historical record of illicit drug use. Mothers receive harsh criticism and are characterized as irresponsible or lacking in the capacity to provide maternal love. Blinded by persistent stereotypes of Indigenous People, social and healthcare providers and others do not take into consideration how the mothers’ conditions require creative childcare solutions to attend multiple appointments, adhere to treatments, and manage sickness while facing racist discrimination in housing, employment, and care. Ninety percent of children taken into care in Saskatchewan are Indigenous, and so child apprehension is a real, crushing, and cold threat. Indigenous mothering is “dangerous” while Western settler-colonial “model mothering” is expected, imposed, and completely unattainable. Combined with the dehumanization of persons living with HIV/AIDS and addiction, as Downe aptly shows, this treatment of Indigenous women is consistent with the long history of state micro-surveillance of Indigenous People’s lives, and the denigration of Indigenous women especially.

Indigenous mothers are individualized and often cut off from the very community support with which they can be successful—a network of natural and chosen kin who are resilient, responsible, and proud. This “mom team” provides circles of care and trust epitomized in another Cree concept, kikosewin, which centers mothers, children, and grandmothers in a matrifocal matrix. Concentrically extended circles of care and trust fold in first, second, and third lines of defense: aunties and fathers, friends who are like family (“heart family”), and elders, grandfathers, and community leaders. Kikosewin, “being with family,” represents an ethos of social interconnectedness and provides a sense of belonging. It constitutes collective care, healthful revitalization, and harm reduction and is by necessity decolonizing (49, 118, 120).

This kind of model of care is far more cross-culturally and globally common than individualistic models of care, making Downe’s book an excellent choice for diverse medical anthropology courses, where it will provide coverage of many key concepts and approaches of the field. Collective Care contributes to decentering colonial production of authoritative knowledge about Indigenous Peoples and illustrates how Indigenous epistemological framings of social life and structures offer insights for current critiques of expertise and can and should be positioned as academic canon. It is also appropriate for more general courses in the social sciences and public health and for professional trainees in social and other public services. This is a brief and highly readable book that nonetheless is replete with many key critical medical anthropology concepts and approaches, making it very appealing for teaching undergraduate and graduate students alike.

I recently used the book in my graduate-level medical anthropology course, which admits senior undergraduate students, and I share some of their reactions that may be useful for readers considering it for course adoption. In addition to the explicitly stated themes of the book, students were moved by the deeply emotional narratives that underpin the book’s central arguments. They compared the impact of the approach with cold quantitative evidence such as the statistics cited at the top of this review. They appreciated the critical lens on expertise and the anthropological (re)valuing of kin relations at the center of human relations. They linked coloniality with white supremacist, patriarchal, neoliberal, and capitalist systems of oppression and therefore gained insights into the value of an anticolonial understanding of health and social care experience. They welcomed Downe’s explanation of her own positionality and the sensitivity with which she communicates difficult knowledge and experiences belonging to others. Many reflected on learning for the first time about the depth of the colonial impact on Indigenous People in North America and were challenged by the way the book revealed their own biases. Several premedical school students appreciated learning about the complexities of stigma in care, the role and knock-on consequences of their chosen profession in perpetuating stigma, and how they might apply this understanding in their future careers. Collective Care is a small book with great impact. It is a very accessible read, a model for community-engaged research, and packed with transformative potential for teaching, researching, and applying medical anthropology.