AIDS the Islamic Way: Treatment, Masculinity, and Ethics of Care in Northern Nigeria

AIDS the Islamic Way: Treatment, Masculinity, and Ethics of Care in Northern Nigeria by Jack Leonard Tocco A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Anthropology) in The University of Michigan 2013 Doctoral Committee: Professor Elisha P. Renne, Chair Associate Professor Kelly M. Askew Associate Professor Mark B. Padilla, Florida International University Associate Professor Gayle S. Rubin © Jack Leonard Tocco 2013 DEDICATION To Harold Gatewood, who has seen me through from beginning to end. ii ACKNOWLEDGEMENTS No scholarly pursuit comes to fruition without the support of others. I wish to thank my parents, Kim Tocco and Vito Tocco, and my sister Maria Tocco, for their unwavering love and commitment to me. Patrick Enweonwu has been a source of encouragement and insight during research and write-up on both sides of the Atlantic. Regina Chopp has been a constant friend and guide through life generally and through pursuit of our respective PhDs. I wish to thank my dissertation committee. Elisha Renne has been an excellent, dedicated advisor throughout my graduate career and is a paragon of committed, long-term fieldwork. Mark Padilla has been a friend and mentor, guiding me through both my PhD and my MPH. Gayle Rubin has given insightful feedback and great encouragement on my work. Kelly Askew has been equally kind and rigorous in her intellectual support of me. Three other scholars deserve particular recognition for their commitment to my development as a scholar. David Halperin has been a tireless friend, mentor, and source of awe since my undergraduate years; I can hardly overstate my gratitude for all he has done on my behalf. Rudi Gaudio’s friendship over the last ten years, and his insights into Northern Nigeria, have been overwhelming and indispensible. Gillian Feeley-Harnik has provided the most probing and charitable feedback on my writing. My dissertation improved immeasurably because of her. I wish to thank several other scholars for their feedback on parts of this dissertation: Murray Last, Sue O’Brien, Serena Osuwa Dankwa, Hansjöerg Dilger, Marian Burchardt, Rijk van Dijk, and Nadine Beckmann. Colleagues in the 2012-13 iii Ethnolab writer’s group at the University of Michigan also provided many useful suggestions on my work. Trevor Hoppe and Aston Gonzalez were supportive writing partners and made the writing process less tedious. Usman Aliyu was a joy to work with and during the period of my research in Kano. A more capable, experienced, dedicated, and professional research assistant could scarcely be imagined. At Bayero University Kano, the Department of Sociology provided administrative support and encouragement. I particularly wish to thank the department head, Sani Malumfashi, for his efforts on my behalf. Dr. Ashiru Rajab, Deputy Director of the Kano State Ministry of Health's AIDS Control Programme, was enormously kind to grant me so many interviews, share his insights into the AIDS epidemic in Northern Nigeria, and throw his considerable weight behind my research. Carmen McCain’s companionship and assistance navigating Kano made my research process less frustrating than it would have been otherwise. For reasons of confidentiality I cannot thank by name the many individuals and organizations in Nigeria that granted me the opportunity to conduct participant-observation, interviews, surveys, and collect documents. Without the trust—and in many cases, friendship—of these people, I would never have been able to produce this dissertation. In short: thank you. Harold Gatewood, to whom this dissertation is dedicated, saw me through all the joys and frustrations of my doctoral program. More than anyone, he has supported me emotionally and intellectually for the duration of my studies. I doubt I would have finished without his support. iv My research was funded by a grant from the Fulbright IIE, and at the University of Michigan by the Center for Afroamerican and African Studies, the International Institute, and the Global Health Research and Training Initiative. I also benefitted from a writing grant from the Sweetland Writing Center. I thank these institutions for making this research possible. v Table of Contents Dedication ..................................................................................................................................................... ii Acknowledgements .................................................................................................................................. iii List of Figures ............................................................................................................................................ vii Abstract ...................................................................................................................................................... viii Chapter 1: Introduction ........................................................................................................................... 1 Chapter 2: The Curative Word: Prophetic Therapies for a Modern-Day Pandemic . 54 Chapter 3: The New Orthodoxy: PEPFAR and the Islamification of Antiretroviral Therapy ....................................................................................................................................................... 92 Chapter 4: HIV, Polygyny and Ethics of Care Among Muslim Men ................................. 135 Chapter 5: The Mode of Transmission That Dare Not Speak Its Name: Islam and the Public Secret of Male Homosexuality ........................................................................................... 176 Chapter 6: Ethics of Intervention .................................................................................................. 216 Appendix 1 ............................................................................................................................................... 245 Bibliography ............................................................................................................................................ 246 vi List of Figures Figure 1: Map of Nigeria with the 12 Northern Shari`a states……………………………….25 Figure 2: Trend in HIV prevalence over time in Nigeria, 1991-2010……………………..30 Figure 3: HIV prevalence in Nigeria by state, 2012………………………………………………33 vii Abstract AIDS the Islamic Way: Treatment, Masculinity, and Ethics of Care in Northern Nigeria by Jack Leonard Tocco Chair: Elisha P. Renne This dissertation is an ethnographic account of the AIDS epidemic among Muslims in Northern Nigeria. Based on research among HIV-positive people in clinical and support group settings and with different types of healing practitioners who treat them, I examine how the transmission, treatment, and care of HIV/AIDS are imagined and enacted in the region. My research demonstrates how Northern Nigerians draw upon the moral authority of Islam to make assertions about where HIV/AIDS comes from, what obligations arise from the disease, and how it should be prevented and treated. The research further reveals that despite recent efforts to assert a unified Islamic response to AIDS, substantive disagreements persist over how to intervene in the epidemic, which treatments are most efficacious, and how those living with disease should be morally evaluated. This dissertation makes four main scholarly contributions. First, it advances the critical medical anthropology of infectious disease and global health programs by demonstrating the interaction of micro- and macro-level forces that affect the AIDS epidemic in a specific cultural context. I do this by analyzing local responses to the United States President’s Emergency Plan for AIDS Relief, a program that has viii significantly improved the life prospects of HIV-positive people. Second, I examine how patients negotiate different healing systems this era of expanding therapeutic options with an account of the expansion of Islamic prophetic medicine in the region. I show how this is linked to the broader Islamic reorientation of Northern Nigerian society since 2000. Third, I contribute to studies of masculinity and health with in-depth accounts of the lives of HIV-positive Muslim men, demonstrating how HIV infection paradoxically brings about heightened obligations and opportunities to achieve ideal masculinity. I demonstrate, however, how these same masculine expectations have foreclosed upon addressing the epidemic among men who have sex with men, and argue that this has broad social and epidemiological implications in a society where heterosexual marriage is compulsory. Fourth, I conclude the dissertation by proposing several culturally appropriate interventions that would lessen the burden of the epidemic in Northern Nigeria. ix Chapter 1: Introduction The title and subject of this dissertation, 'AIDS the Islamic way', arose from a conversation I had in 2007 during my first research trip to Kano, Northern Nigeria's largest and oldest city. Interested in meeting people living with the human immunodeficiency virus (HIV), I visited the office of an HIV support group about which I had learned from the local office of a national Nigerian AIDS organization. Arriving unannounced at the support group's office on a Wednesday afternoon, I happened to meet Fahad, the group's vice president, a man in his mid-thirties wearing the customary Hausa long men's kaftan [dogon riga] and matching cap [hula]. I explained that I had come to Nigeria to study the AIDS epidemic and he agreed to talk

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