THE POLITICAL ECONOMY of HIV in URBAN UGANDA by MEGAN M

Home , Bobi Wine, Economy of Uganda, Kabalagala, Kibuli, Posala, P Money

MEN MANAGING UNCERTAINTY:

THE POLITICAL ECONOMY OF HIV IN URBAN UGANDA

MEGAN M. SCHMIDT-SANE

Submitted in partial fulfillment of the requirements

For the degree of Doctor of Philosophy

Department of Anthropology

CASE WESTERN RESERVE UNIVERSITY

May 2020

CASE WESTERN RESERVE UNIVERSITY

SCHOOL OF GRADUATE STUDIES

We hereby approve the dissertation of

Megan M. Schmidt-Sane

Candidate for the degree of Doctor of Philosophy.

Committee Chair

Janet W. McGrath, Ph.D.

Committee Member

Lee Hoffer, Ph.D.

Committee Member

Jill Korbin, Ph.D.

Committee Member

Aloen Townsend, Ph.D.

Date of Defense

February 19, 2020

*We also certify that written approval has been obtained for any proprietary material

contained therein.

Table of Contents LIST OF TABLES ...... 6 LIST OF FIGURES...... 7 ACKNOWLEDGEMENTS...... 8 LIST OF ABBREVIATIONS ...... 10 GLOSSARY ...... 11 ABSTRACT ...... 14 CHAPTER 1 INTRODUCTION...... 16

1.1. RESEARCH OVERVIEW ...... 16 1.2. RESEARCH OBJECTIVES ...... 17 1.3. SIGNIFICANCE ...... 18 1.4. ORGANIZATION OF THE DISSERTATION ...... 19 CHAPTER 2 BACKGROUND ...... 21

2.1. OVERVIEW ...... 21 2.2. POLITICAL ECONOMY OF HEALTH ...... 22 2.2.1. Neoliberalism ...... 28 2.2.2. Power and Prestige ...... 29 2.2.3. Inequality...... 30 2.3. THE RISK ENVIRONMENT ...... 33 2.4. STRUCTURAL AND SYNERGISTIC VULNERABILITIES ...... 35 2.5. SOCIAL RESILIENCE ...... 38 CHAPTER 3 UGANDA CONTEXT ...... 40

3.1. OVERVIEW ...... 40 3.2. URBANIZATION, INEQUALITY, AND JOB LOSS: A BY-PRODUCT OF NEOLIBERALISM AND COLONIALISM ...... 41 3.2.1. Colonial Rooted Processes of Urbanization and Stratification ...... 41 3.2.2. Winters of Discontent: Precursors to Independence ...... 44 3.2.3. Post-Independence, Neoliberal Policies, and the Makings of Inequality ...... 45 3.2.4. Rural to Urban Migration ...... 49 3.2.5. The Impact of Urbanization on Social Relations ...... 51 3.2.6. The Informal Settlement ...... 53 3.2.7. The Informal Economy ...... 54 3.2.8. The Policing of Urban Social Space ...... 56 3.3. NEW OPPOSITION AND RISING TENSIONS: MP ROBERT KYAGULANYI (BOBI WINE) ...... 59 3.4. UGANDA’S HISTORY WITH THE HIV EPIDEMIC ...... 61 3.4.1. Overview of HIV in Uganda ...... 61 3.4.2. Navigating Uncertainty ...... 63 3.4.3. Literature on HIV among Ugandan Men ...... 65 3.5. STUDY SETTING ...... 67 CHAPTER 4 PILOT FINDINGS ...... 76 Overview ...... 76 Sampling ...... 76 Semi-structured interviews ...... 76 Analysis ...... 77 Findings ...... 77 CHAPTER 5 METHODS ...... 79 5.1. OVERVIEW ...... 79

5.2. SURVEY DESIGN ...... 81 5.3. COMMUNITY CENSUS ...... 81 5.4. SURVEY ...... 83 Sampling ...... 83 Sampling Frame...... 84 Randomization ...... 84 Data management ...... 88 5.5. QUANTITATIVE DATA ANALYSIS ...... 89 Preliminary Data Screening ...... 91 Hierarchical OLS Multiple Regression ...... 92 Cluster Data Analysis ...... 93 Least Square Dummy Variable (LSDV) Fixed Effects Model ...... 94 5.6. SERVICE PROVIDER INTERVIEWS...... 95 5.7. IN-DEPTH INTERVIEWS ...... 95 5.8. PARTICIPANT OBSERVATION ...... 97 5.9. QUALITATIVE DATA ANALYSIS ...... 99 5.10. INTEGRATION OF QUANTITATIVE AND QUALITATIVE METHODS ...... 100 5.11. ETHICS PROCEDURES ...... 102 CHAPTER 6 HIV IN CONTEXT ...... 104

6.1. SAMPLE CHARACTERISTICS ...... 104 6.2. HIV KNOWLEDGE, ATTITUDES, AND PRACTICES ...... 107 6.3. RISKY SEXUAL BEHAVIOR ...... 110 6.3.1. Multiple Regression Analysis: Predictors of Risky Sexual Behavior ...... 112 Hierarchical Regression ...... 112 LSDV Fixed Effects Model...... 116 6.3.2. Additional Findings on Risky Sexual Behavior (Survey and Interview Data) ...... 118 6.4. ACCESS TO HEALTH SERVICES ...... 122 6.5. THE HIV CARE CONTINUUM: TESTING ...... 124 6.6. THE HIV CARE CONTINUUM: LINKAGE TO CARE AND ART ADHERENCE ...... 135 6.6.1. Starting on treatment: A life decision ...... 136 6.6.2. Social determinants and the care continuum ...... 138 6.6.3. HIV stigma and peer influence ...... 139 6.7. FORESHADOWING THE RISK ENVIRONMENT ...... 142 CHAPTER 7 THE RISK ENVIRONMENT ...... 143 7.1. PHYSICAL RISKS ...... 144 7.1.1. Population Density in an Entertainment District...... 144 7.1.2. When the Bar is Your Home: The High Concentration of Bars in Kabalagala ...... 145 7.2. SOCIAL RISKS ...... 146 7.2.1. Sex Work as a Risky Business ...... 146 7.2.2. Changing Gender Norms and New Forms of Marriage in the City ...... 148 7.2.3. When Your Social Life is Centered on the Bar: Bar Norms and Dynamics with Implication for Risk ...... 150 7.3. ECONOMIC RISKS ...... 152 7.3.1. “Business by Chance”: Informal Economy, Economic Opportunity, and Working Conditions.. 152 7.4. POLITICAL RISKS ...... 154 7.4.1. Regulatory Regimes: Vagrancy Laws, Drug Laws, and Other Forms of Control ...... 154 7.4.2. Upgrading the “Slum”: KCCA Policies and the Making of the Urban Space ...... 157 CHAPTER 8 VULNERABILITIES ...... 159 8.1. STRUCTURAL VULNERABILITIES ...... 160 8.1.1. Urban Migration ...... 160 8.1.2. Governments and the Role of Corruption at the National and Local Levels ...... 164

8.1.3. Economic Pressure: Job Instability, Low-Wage Labor, and the High Cost of Living ...... 168 8.1.4. Police Surveillance and Crackdowns ...... 174 8.1.5. Exposure to Violence ...... 183 8.1.6. Generational Status ...... 188 8.2. SYNERGISTIC VULNERABILITIES ...... 191 8.2.1. Dislocation from Social Support ...... 191 8.2.2. Surviving and Precarity in the Informal Settlement ...... 193 8.2.3. Housing and Food Instability ...... 195 8.2.4. Alcohol and Drug Use ...... 199 8.2.5. “Luzira is not a home”: Incarceration and the Cycle of Arrest ...... 202 8.2.6. Ability to Fulfill Gender Norms ...... 205 CHAPTER 9 SOCIAL RESILIENCE-BUILDING STRATEGIES ...... 210

9.1. INFORMAL ECONOMY ...... 211 9.1.1. Music and Celebrity Life ...... 212 9.1.2. Working in the Lodge ...... 214 9.1.3. Drug Sales ...... 214 9.1.4. Hustling ...... 216 9.2. SOCIAL RESOURCES ...... 218 9.2.1. Aligning with People in Power ...... 219 9.2.2. Bar Group Participation, Other Social Organizations, and Reciprocity ...... 222 9.2.3. Sex Worker Partner ...... 229 A True Love Ideal ...... 229 “The Materiality of Sex”: Bayaye and Survival in the Informal Settlement ...... 231 “Nduye naye” (I have been with her for long): Implications for men’s HIV vulnerability ...... 233 CHAPTER 10 DISCUSSION ...... 238

10.1. SUMMARY FINDINGS ...... 238 10.2. SOCIAL AND STRUCTURAL DRIVERS OF VULNERABILITY ...... 243 10.3. THE INFORMAL ECONOMY: UNCERTAINTY AND PRECARITY ...... 245 10.4. MANAGING UNCERTAINTY: SOCIAL RESILIENCE-BUILDING RESPONSES AND PERVERSE IMPLICATIONS ...... 247 10.5. THE POLITICAL ECONOMY OF HIV ...... 250 10.6. THEORETICAL CONTRIBUTIONS ...... 255 10.7. FUTURE DIRECTIONS ...... 258 APPENDIX ...... 259 REFERENCES ...... 277

List of Tables

Table 3.1. Kampala population and growth (Nyakaana, Sengendo, & 42 Lwasa, 2007) Table 5.1. Final Sample Sizes 81 Table 5.2. Survey Measures 86 Table 5.3. Bar-Level Characteristics 88 Table 5.4. Quantitative data analysis overview 90 Table 5.5. Regression assumptions and relevant statistical tests 92 Table 5.6. Data Analysis Procedures 101 Table 6.1. Participant demographics (survey N=292) 106 Table 6.2. Mean values and standard deviations for risky sexual behavior and predictor variables 114 Table 6.3. Intercorrelations for risky sexual behavior and predictor 115 variables Table 6.4. Summary of hierarchical regression results predicting risky 116 sexual behavior Table 6.5. LSDV Fixed Effects Model results predicting risky sexual 118 behavior Table 6.6. Men’s HIV concern 122 Table 6.7. HIV prevention method 123 Table 6.8. Transportation to HIV testing 124 Table 6.9. Where men seek treatment 125 Table 6.10. Affordability of health services 125 Table 6.11. Men who have tested for HIV by age group 129 Table 6.12. Recent HIV test 130 Table 6.13. Location of recent HIV test 130 Table 6.14. Reasons why men did not test for HIV 132

List of Figures

Figure 2.1. Overview of Conceptual Frameworks in this Research 21 Figure 2.2. Factors in the Ugandan political economy in this research 27 Figure 3.1. Map of Uganda's largest ethnic groups 42 Figure 3.2. Regional differences in HIV prevalence (PEPFAR, 2019) 61 Figure 3.3. Map of Kabalagala and Kampala Divisions (KCCA, 2014) 68 Figure 3.4. A typical sewage trench (left) and a resident trying to avoid the 72 trench (right) Figure 3.5. When it rains, the trenches turn into rivers 73 Figure 5.1. Explanatory sequential mixed methods study design 79 Figure 6.1. Men’s HIV knowledge, attitudes, and practices (KAP) scale 107 Figure 6.2. Men's risky sexual behavior scale scores 112 Figure 6.3. HIV testing poster sponsored by USAID, along Kibuli Road adjacent to the study community 127 Figure 6.4. HIV testing poster sponsored by USAID, along Kibuli Road 128 Figure 7.1. Factors in the risk environment 144 Figure 7.2. View of the study community 145 Figure 8.1. Police round-up of Kabalagala men 179 Figure 8.2. Street art from the study community 180 Figure 8.3. Small sachet of gin 201 Figure 8.4. The Ghetto Soldier community 204 Figure 9.1. Organization of job types and social status 219 Figure 10.1. Final conceptual model 239 Figure 10.2. The political economy of HIV risk 250

Acknowledgements

This dissertation is the product of many years of support from countless individuals. I am eternally grateful to all of those individuals whose invaluable guidance and encouragement has brought me to this point today. This research was made possible due to generous funding from the National Science Foundation (Award

#1755673), the Social Justice Institute Fellowship, and the Eva L. Pancoast Fellowship. I would also like to give thanks for the support of the CWRU Department of Anthropology.

I am deeply grateful to all of the residents of Kabalagala, who welcomed me into a space that is richly textured by their social lives. I am so grateful that the men in this study shared their lives with me, entrusting me with their stories, their worries, and their hopes. For their generosity of time, trust, and camaraderie, I am forever indebted and appreciative. I am also incredibly grateful to my research assistant, Mr. Fred Kizito.

Without him, this research would have been much more difficult. He was my support system in the field, and provided not only logistical and research support, but also countless hours to discuss and debrief after data collection. His insights were invaluable.

I am grateful to all of my friends in Uganda who over the past seven years have helped me to build a second home of sorts there.

I am grateful to Makerere University, especially Dr. David Kaawa-Mafigiri at the

Center for Social Science Research on AIDS. He was a valuable site supervisor who guided me through various challenges while in the field. I am also thankful to the

Uganda-CWRU Research Collaboration, and the CWRU Center for AIDS Research, both of which provided varying kinds of support while in the field. Having this existing research collaboration made many of my logistical challenges easier to manage.

To my mentors who have guided me through this process, from year one – thank you. I am particularly grateful to my committee chair, Dr. Janet McGrath, for the

countless (really, countless) hours of feedback, guidance, and investment in my work over five years. I am also deeply grateful for my committee members who have reviewed this dissertation and provided guidance over the years: Dr. Jill Korbin, Dr. Lee Hoffer, and Dr. Aloen Townsend. Thank you for all of your time and support.

My fellow graduate students at CWRU have been a source of inspiration, guidance, and encouragement over the last five years. Sonya Petrakovitz has been a wonderful source of support. I am particularly grateful to Heather Baily and Kelley

Kampman. Our dissertation writing group kept me on track and provided me with invaluable support and feedback. Thank you for listening and reading and discussing.

Lastly, I am so grateful for my family – the Schmidts, the Sanes, and one

Nicholas. In particular, I am forever grateful for my parents who have provided me with a strong foundation and guidance over the last many years.

List of Abbreviations

AIDS Acquired Immunodeficiency Syndrome AIS AIDS Indicator Survey ART Anti-retroviral Therapy COP PEPFAR Country Operating Plan HIV Human Immunodeficiency Virus IMF International Monetary Fund IPV Intimate-Partner Violence NGO Non-Governmental Organizations PEH Political Economy of Health PEPFAR President’s Emergency Plan for AIDS Relief SAP Structural Adjustment Program STI Sexually Transmitted Infection UDHS Uganda Demographic and Health Survey UNAIDS Joint United Nations Programme on HIV/AIDS VCT Voluntary Counselling and Testing WHO World Health Organisation

Glossary

This dissertation is situated in an informal settlement, meaning an area where housing is not in compliance with current regulations. Another common meaning is that an informal settlement is an area where housing units have been constructed on land that the occupants have no legal claim to. However, this latter definition does not capture the situation in the study community. The land is legally owned by an owner, who rents it out to residents. Throughout the dissertation, I refer to the study community as an informal settlement.

Men refer to the study community as a ghetto, both in their everyday speech and in their street art. A ghetto has specific connotations in much of the world, and so I more frequently use “informal settlement” rather than “ghetto.”

Local leadership in Kampala follows a system that developed in the rural areas.

Each “village” or zone contains roughly 500-1,000 people and is governed by a Local

Council I (LCI) overseen by a chairman. A council has various positions, including a

Chairman, a Vice Chair, a Defense, and others as needed. The zones are agglomerated into a Parish (LCII level) with its own Local Council II. In Kampala, the Local Council

III level is the division. This study is situated in a community that crosses 9 zones in

Kabalagala Parish, in Makindye Division, Kampala.

The National Resistance Movement (NRM) is the party of President Museveni, derived from his time in the Bush War, when he was leading a resistance movement.

People Power is not a political party per se, but is the name of the movement led by

Member of Parliament Robert Kyagulanyi (aka Bobi Wine), the current opposition leader in Uganda.

A lodge is what locals would call a guest house or a motel. Guests frequently stay for a night, or sometimes shorter periods of time (1-2 hours). More recently in the study community, lodge managers have been renting rooms to sex workers on a longer- term basis, from a week to even years. This shift might indicate that lodges are becoming more like what some call a “brothel.” In the study community, all lodges have active sex workers working.

A brothel describes an establishment solely for the purposes of sex work. Sex workers usually stay for longer periods of time. Rooms are not available to travelers

(unlike in a lodge).

Both lodges and brothels are managed by a manager, usually a man who takes care of the day-to-day work. This might include security, collecting payments, cleaning the lodges, or stocking condoms.

A sex worker is (typically) a woman who is employed in sexual commerce, exchanging sex for money, goods, or other services. The term “sex worker” is much preferred by sex worker activists, over more derogatory terms like prostitute. In this study community, the vast majority of sex workers are women. I know of a few male sex workers, and only one trans sex worker. Sex work is both lodge-based and street-based.

Most sex workers live in the community, but others come for just a night and stand on the street outside popular bars and lodges.

A client is a man (typically) who pays for sex worker services.

Most of the men in this study are, or have been, a non-paying partner of sex workers. This means that they are referred to as boyfriends or husbands, differentiating between paying clients and non-paying partners. I refer to these men as sex worker partners, or boyfriends/husbands, depending on the case.

A popular mode of transportation is a motorcycle taxi, called a boda boda. Boda drivers are men who drive passengers to and from destinations, for negotiated rates.

They usually park at a stage, and stages are organized by drivers, with an elected chairman, a treasurer, and so on.

Ganda refers to the people who belong to the ethnic Baganda, of the kingdom of

Buganda. An individual man or woman would be called a muganda (plural: Baganda).

In other words, in Luganda (the language of the Ganda), the prefixes are important (mu- for a single person, ba- for multiple people). The Ganda people are historically from central Uganda, and Kampala is historically their kingdom’s center.

Another ethnicity mentioned in this dissertation are the Banyankole, from

Western Uganda, which is the region that President Museveni is from.

Muyaye (plural: bayaye) is a derogatory term for a man who lives in the ghetto.

When most Kampalans use this term, they are calling the man a thief or a liar. When men in the study community use this term, usually re-claiming it and indicating that the person is innovative or clever, able to survive in the ghetto.

Masajja is the Luganda word for a man.

Men Managing Uncertainty:

The Political Economy of HIV in Urban Uganda

Abstract

MEGAN M. SCHMIDT-SANE

This research investigates political and economic issues of inequality and unemployment in Uganda, as manifested in one informal settlement in Kabalagala, and the effect of these issues on HIV. Uganda is one important site to study the intersections of inequality, formal sector unemployment, urbanization, and HIV/AIDS. Contemporary inequality and formal sector unemployment are driven by colonial policies that shaped urban stratification, and postcolonial policies that privileged economic growth over job creation. A central goal was to understand men’s risk of HIV in the context of these and other structural and social drivers of risk.

This research used an explanatory sequential mixed methods study design, including a pilot study (2016), survey pre-test (2017), and 12 months of fieldwork that began with survey data collection (N = 292) and ended with in-depth interviews (n = 54, a subset of the survey sample). Survey data were analyzed using multiple linear regression, and interview data and field notes were analyzed through thematic analysis.

Quantitative data described the patterning of risky sexual behavior (e.g. HIV risk), while qualitative data expanded on these relationships and helped to clarify areas of contention.

Men in this study have lower rates of HIV testing, compared to national averages.

Men also frequently report defaulting on ART, once they do receive a positive diagnosis and begin treatment. Inequality and unemployment impact their daily lives through experiences of uncertainty that must be managed. Economic instability is important, and

when men cannot access resources, they are likely to engage in a variety of strategies to improve their economic status. Men also face myriad vulnerabilities driven by the political-economic context, from housing instability to incarceration.

This work contributes to the anthropological literature on the political economy of health, HIV, vulnerability, and social resilience. Men’s experiences of HIV and uncertainty in Kampala are shaped by global processes, local politics, social norms, and sexual relationships.

Chapter 1 Introduction

1.1. Research Overview

Men in Uganda, especially in disadvantaged communities, have disproportionately worse outcomes for HIV testing, starting on treatment, and suppressing the virus (Ministry of Health, 2019). This research explored the roots of that patterning, focusing on how broader global processes locally pattern HIV risk. This dissertation engages with existing anthropological literature on political economy to detail how Uganda’s context frames HIV risk among men in the informal settlement.

Kabalagala is an informal settlement in Kampala, Uganda that lies at society’s fault lines where adverse social conditions are acutely experienced (Singer, 1994). It could be many informal settlements in Uganda, a country that faces rapid urbanization, poor urban infrastructure and planning, economic marginalization, low formal sector employment, and high inequality. Men in Kabalagala face uncertainty driven by joblessness, economic instability, and multiple environmental risks in the informal settlement. This research explores the ways in which men manage uncertainty by engaging in a variety of strategies in the informal economy to buffer these hazards. Both the economic instability and the strategies shape HIV risk, albeit through various pathways. This research untangles those pathways between the broader political and economic context and HIV risk.

By studying HIV in urban Kampala, this research engages with anthropological literature on political economy of health, using the concept of uncertainty to describe how men experience vulnerability and seek to manage it. This research builds on the political economy literature by incorporating discussion of the informal economy and how it structures vulnerability, and therefore situates HIV risk within a larger context.

1.2. Research Objectives

A central goal of this research is to understand men’s HIV risk in the context of inequality and unemployment in one informal settlement in Kampala, Uganda. By focusing on the informal settlement context, I also examine the informal economy. Key to understanding the experiences of the men in Kabalagala is to consider how work in the informal economy shape experiences of vulnerability, given the inherent precarity in informal work. This additionally raises the issue of how men buffer inequality, unemployment, and vulnerability. This research, therefore, explores the pathways between the risk environment, vulnerability and HIV risk. While HIV risk is assessed in terms of individual risk behaviors, I examine the factors that shape and structure risk.

The study had three overarching research objectives to:

(1) Examine how men’s risky sexual behavior is shaped by intersecting factors such

as alcohol use, knowledge, attitudes, practices, perceptions of access to

resources, job stability, frequency of arrest, bar group membership, and

economic dependence on female sex workers (FSW).

(2) Investigate the social configurations that men employ to bolster resiliency against

political-economic pressures, and understand whether these social

configurations impact men’s HIV vulnerability.

(3) Understand the pathways between social, political, economic, and legal

structures and men’s risk, resilience and vulnerability in this context.

This research uses theoretical concepts such as the risk environment, vulnerability, and social resilience to demonstrate the pathways between political economy of health and

HIV risk. A comprehensive review of these bodies of literature is included in Chapter 2.

The study was conducted in an informal settlement in Kabalagala. The study population is predominantly Baganda, mirroring the makeup of Kampala, a historically

Ganda city. Kabalagala is a low-income community, well known for sex work, a driving economic activity and one aspect of the risk environment. Sex work drives both the economic activities and social relations in the informal settlement, organizing many aspects of life there. However, as this research will highlight, Kabalagala encompasses a heterogeneous array of job types, income levels, and other factors which combine to shape the lives of its residents.

1.3. Significance

This research contributes to the anthropological literature on political economy of health, the risk environment, vulnerability, and social resilience. Political economy of health literature is at times imprecise in describing how broad global processes like neoliberalism affect local disadvantage. By describing national and local policies, and the social context of Kabalagala, this research makes these linkages clearer. The risk environment framework has primarily been used in public health. I integrate this framework into the study to describe the aspects of the community environment that contribute to HIV risk. Additionally, similar to other work on vulnerability and resilience

(Panter-Brick, 2014) this dissertation conceptualizes these processes as part of a continuum, whereby men can be both vulnerable and resilient at the same time. This dissertation draws on the concept of uncertainty (Whyte, 1997) to capture the reality of men’s lives in Kabalagala. By doing so, it describes why political-economic analyses are vital. It is imperative that we understand the implication of global processes such as neoliberalism and how, when paired with colonial legacies, this produces significant disadvantage.

This research also contributes to anthropological literature on the political economy of risk. By employing a social resilience and political economy of health framework, this study moves beyond reductive and individual-level understandings of

risk constructed as a probabilistic social category. Instead it emphasizes the patterning of risk within so-called “high-risk communities,” thus recognizing the synergy of risk with other factors in men’s lives. Through in-depth investigation of pathways that shape individual risk, this study identifies social systems that may be robust and resilient, even while simultaneously contributing to vulnerability to ill-health in what is termed “perverse resilience.” As such, this research advances our understanding of mechanisms of resilience that form in “high-risk” communities in response to constrained circumstances.

1.4. Organization of the Dissertation

In Chapter 2, I present the primary literature that underpins this dissertation, political economy of health with special attention to concepts such as neoliberalism, power and prestige, and health inequalities. Then related key concepts such as the risk environment, vulnerability, and social resilience are defined and operationalized.

Chapter 3 grounds these bodies of literature in the Ugandan context, focusing on urban

Uganda. An overview of the colonial and post-colonial drivers of inequality, urbanization, and unemployment in the formal sector is given. Implications of urbanization are reviewed, including changing social relations, the building of the informal economy, and the policing of urban space. Next, the HIV epidemic is described. Chapter 4 provides a brief summary of the findings from pilot research conducted in 2016 and 2017 before the findings from the main study are presented in Chapters 6-9. Chapter 5 details the methods used to design study instruments and to collect and analyze data. Chapter 6 details findings related to HIV knowledge, attitudes, and practices, risky sexual behavior, and data collected from HIV positive members of this study. Chapter 7 discusses the risk environment, which is hypothesized as the intersecting structural and social factors that engender HIV risk for Kabalagala’s men. Chapter 8 carefully describes these structural and social factors, which not only shape HIV risk but facilitate men’s precarity in the

informal settlement. Chapter 9 focuses on strengths and capabilities, arguing that men also engage in social-resilience building strategies as a bulwark against structural disadvantage. In the discussion in Chapter 10, I situate men’s experiences of

Kabalagala within the literature on vulnerability, social resilience, and political economy of HIV. It ends with application of this research for HIV programming. Chapter 11 summarizes and concludes this dissertation.

Chapter 2 Background

2.1. Overview

This chapter describes the theoretical underpinnings of this dissertation: the political economy of health. Specific aspects that relate to political economy are described, including neoliberalism, power and prestige, and inequality. In order to describe the pathways between broader political economy and individual HIV outcomes,

I engage with three specific conceptual frameworks: risk environment, vulnerability, and social resilience. The concept of a “risk environment” is a useful means to describe how political economy becomes localized in communities like Kabalagala. The literature on vulnerabilities provides additional conceptual tools to explain how the risk environment shapes individual outcomes, while literature on social resilience allows for consideration of how men engage in social resilience-building strategies to rebuff uncertainties produced by adverse life circumstances. These frameworks are juxtaposed in Figure

2.1. As represented in the figure, political economy of health is posited as the overarching frame driving dynamics at a community level. As such, Figure 2.1 represents the theoretical basis of this study.

Figure 2.1. Overview of conceptual frameworks in this research

In Uganda, the interplay of vulnerabilities and social resilience are experienced on an individual level by men, but set in a context of broader historical, political, and economic processes, which produced social, economic, and health inequalities.

2.2. Political Economy of Health

Political economy of health considers the historical, political, social, cultural, and economic contexts (e.g., colonialism, neoliberalism) that shape illness and disease, and the ways in which societal structures (e.g., political and economic policies or practices) interact with local conditions that lead to illness and disease) (Birn, Pillay, & Holtz, 2017).

In other words, health is a product of interacting determinants that work on multiple levels of society. Contemporary work in PEH considers both the proximal and distal causes of disease, moving beyond individualistic paradigms of health and disease to examine the social, structural, and economic context of ill-health (Minkler, Wallace, &

McDonald, 1995) and how social structures produce ill-health. As Birn et al. (2017, p.

134) frame the approach:

According to the political economy approach to health, your health is a result of social, political, and economic structures and relations that constrain your control over stressful situations and work environments, and limit your access to health care, recreation, housing, education, and good nutrition.

In other words, health problems can only be addressed by ameliorating social and economic policies and other aspects of the social and physical environment. A PEH framework does not argue that wealth leads to health (Steckel & Floud, 1997), but rather that economic, social, and political conditions intersect to produce differential outcomes.

Anthropological work examining the historical drivers of political and economic factors in health has flourished in the last few decades. Political economy of health

(PEH) further developed in the 1980s and 1990s to underscore the economic, political, social, and cultural forces that contribute to the unequal distribution of health, illness,

and disease (Minkler et al., 1995; Morsy, 1996) and the clustering of disease (Singer &

Clair, 2003) along a social gradient (Marmot, Stansfeld, Patel, et al., 1991). It places these dynamics in the context of class differences rooted in neoliberal capitalism (Baer,

1982).

Political economy of health fits within a rich tradition of anthropological research and writing critiquing the hegemonic world system. Critical Medical Anthropology provided some of the foundation for PEH, by describing the social origins of disease in a global economic system (Singer, 1989). A PEH framework matured as political and economic systems began to shift in the 1980s, as health system funding reduced with the advent of neoliberal policies (Marmot et al., 1991). Critiques of these policies are frequent in PEH scholarship. PEH has been applied to a variety of international and global health contexts as a means to assess the impact of neoliberal policy on contemporary health inequalities. Other aspects of the political economy that is frequently researched as related to health include working conditions (Packard, 1989), gender inequalities (Doyal, 1995), racial inequalities (Goodman, 2016), colonialism and its legacies (Benton & Dionne, 2015; Hunter, 2010), state welfare systems, austerity measures and structural adjustment policies that reduced state investment in social services (SAPs; Pfeiffer & Chapman, 2010), income inequality (Kalofonos, 2010), and gender inequality (Parikh, 2007; Hunter; 2007).

Political Economy of Health and the Informal Economy

Economic inequality can be viewed through the lens of the informal economy, defined as the sector of the economy that exists outside of formal state control or management (Bonnet & Venkatesh, 2016). However, PEH has not fully theorized the role of the informal economy. Past research demonstrates the impact of managing daily life and economic activity outside of state control (Anderson, 2000; Contreras, 2013;

Valentine, 1980). Anderson (2000) described a behavioral code that both produces and

hinders street violence in inner-city Philadelphia, challenging the prevailing paradigm that such spaces are “lawless” and arguing the critical role of “respect” or social capital in such spaces. Bourgois (1995) demonstrated similar management of precarious circumstances in New York City. In the informal economy, social relations become more important in the absence of a conventional economy, when individuals must rely on family and community networks to survive (Gaughan & Ferman, 1987). In cash-scarce locations such as Chicago’s south side, daily business activity is driven by the interconnectedness of individuals, allowing for barter and other forms of exchange

(Venkatesh, 2009). A PEH framework not only lends well to analyzing the informal economy, but can guide interpretation of the ways that individuals and communities manage in uncertain circumstances.

Political Economy of Risk

Anthropological work in PEH has challenged prevailing notions of risk (Panter-

Brick, 2014), critiquing biomedical and epidemiological approaches that focus on individual risk factors rather than the context framing that risk. Individual risk is a deterministic category that identifies whether an individual is likely to suffer from a disease outcome (Gravlee, 2009). Risk assumes individuals to be rational agents who act in a beneficial manner on information regarding the transmission of HIV (Kippax,

Stephenson, Parker, & Aggleton, 2013). In response to the focus on individual risk, contemporary work in anthropology and PEH places risk in a social, political, and economic context, focusing on structural and social drivers of HIV (Hunter, 2015; Singer,

1998). In doing so, the lens of political economy “adds meat to the descriptive bones of risk epidemiology” (Panter-Brick, 2014, p. 437).

Nancy Krieger’s critique (1994) of the “web of causation” focused on the problem with creating a web of statistical correlations in a proverbial vacuum. Krieger (1994) questions why these risk factors interrelate, arguing that we should instead focus on the

“spider” responsible for weaving the web of risks that traps an individual. Other key literature in anthropology mirrors this critique, including work on how and why risks occur

(Panter-Brick & Fuentes, 2010; Parker & Harper, 2006). Dressler’s work (2000; 2005) on cultural consonance used measures of cultural dissonance, meaning, the inability of individuals to fulfill shared cultural goals that shape behavior. Dressler (2000) tested whether cultural consonance mapped onto elevated physiological stress among African-

Americans. Through this research, Dressler (2000) spoke to the mechanisms through which stress becomes biology, in the form of negative health outcomes.

Political Economy of HIV

Anthropological scholarship includes a plethora of rich studies on the political economy of HIV. Because HIV is spread via sexual contact and injection drug use, it presents a unique opportunity to study other social factors such as stigma, public health policies, marriage and sexuality, and more. From the early days of HIV, anthropologists have argued that it is a social disease, “shaped by local, political, and biomedical cultures, political economy, and structural inequality in both local and global contexts”

(Moyer, 2015, p. 263). Singer et al. (1991) demonstrated the intersecting inequalities such as urban poverty, sexism, racism, and political public health policies drove HIV infection among marginalized populations. Altman (1999) linked global processes to HIV by arguing that its spread and impact was intertwined with globalization. Singer (1998) edited a volume on the political economy of AIDS, analyzing the impact of political and economic policy in shaping experiences of marginalization and HIV in diverse contexts.

Other work in PEH links the political economy to mediating social processes like labor migration or gender norms. Parikh (2007) investigated the role of labor migration, masculine sexual privilege, and domestic violence in exacerbating women’s HIV risk in

Uganda. Phinney (2008) places marital HIV risk in the context of Vietnam’s Doi Moi economic policy.

Pfeiffer and Chapman (2010) reviewed the role of structural adjustment policies, policies that were tied to International Monetary Fund (IMF) and World Bank loans in the

1980s and 1990s. These loans had conditionalities attached, whereby recipient governments were encouraged to institute neoliberal reforms such as scaling back government investment in social and health services. Set against a backdrop of neoliberal reform, Smith (2012) looks at the NGOs that fill the vacuum left by a receding state, and how inequality and corruption shapes how NGOs provide HIV care. Hunter

(2010) challenges the prevailing scholarship about high HIV prevalence in sub-Saharan

Africa as a result of number of concurrent sexual partners. Hunter (2010, p. 365) argues instead that political and economic factors drive unequal material relations between men and women, through “transactional” sex.

This research draws on these existing framings of the political economy of HIV, especially the work of Mark Hunter (2010;2015) in South Africa’s informal settlements. In other words, this research employs a political economy of health framework (Figure 2.2) that specifically considers the broader structural factors (macro level), community context (meso-level), and the individual.

Figure 2.2. Factors in the Ugandan political economy in this research

2.2.1. Neoliberalism

A core component of scholarship in PEH scrutinizes the impact of neoliberal economy policies on health systems. Neoliberalism is the approach to capitalism that emphasizes the free market and the role of the individual (Ganti, 2014). It has multiple meanings, with anthropologists framing neoliberalism as both a global process that affects individual life-chances, and as an ideology that shapes individual subjectivities

(Ganti, 2014). Neoliberalism can be described as a process that “moves the market” out of the economic sphere and into the social (Ganti, 2014; Sandel, 2012; Wilk & Cliggett,

2007). In this dissertation, neoliberalism refers to the resurgence of 19th century economic liberalism in the 20th century, when a laissez-faire, or a hands-off, approach is taken to governance and the economy and all aspects of social life, including health

(Ganti, 2014).

In a neoliberal economic approach, market competition is the basis of everything

– from economic exchange and coordination, to the distribution of social outcomes.

According to Ganti (2014), there are four main descriptions of neoliberalism as: 1) the set of economic reform policies that seek to deregulate the economy and liberalize trade

(Steger & Roy, 2010) a development model that defines roles for labor, capital, and the state (Boas & Gans-Morse, 2009); 3) an ideology that views market exchange as more than economic activity (Steger & Roy, 2010); and, 4) a governance system that relies on an idea of the market as self-regulating and efficient (Steger & Roy, 2010).

Each of these dimensions form the basis for critiques in contemporary political economy of health. Neoliberalism is one aspect of the political economy that has demonstrably contributed to negative health outcomes (Janes & Corbett, 2009; Pfeiffer &

Chapman, 2010; Richland, 2009). A goal of economic reform, often critiqued by PEH scholars, is to bolster economic growth, which is seen as a means to lift individuals out of poverty. However, research has revealed that neoliberal reforms often result in

increased inequality. When neoliberal reforms are unaccompanied by job-creation strategies, there is a dual erosion of employment opportunities and a receding social safety net (Young, 2019). This results in increased precarity for those who are both job unstable and no longer able to access social protections from the state, such as free health care (Han, 2018).

Anthropologists have described these processes of neoliberalism using a PEH frame, with emphasis on how local historical contexts and colonial practices produce varieties of neoliberalism (Gledhill, 2018). However, most work engages with neoliberalism on a local level, examining its impact on participants (an anthropology with neoliberalism) rather than examining the actual process itself (an anthropology of neoliberalism) (Ganti, 2014). This dissertation relies on the foundation of rich anthropological work that describes neoliberalism as a structural force with repercussion for participants’ lives. Past work has described how neoliberal policies shape experiences of marginalization and disenfranchisement (Bourgois, 2011; Comaroff &

Comaroff, 2000), urban stratification and inadequate planning measures (Guano, 2004), and how social welfare programs have been scaled back (Kingfisher & Maskovsky,

2008; Morgen & Gonzales, 2008). Finally, a body of work examines how the urban poor are unevenly incorporated into formal market economies (Han, 2011; Thomas, 2013).

2.2.2. Power and Prestige

Nested within studies of political economy of health is an implicit understanding of how power and prestige shape access to resources. A conceptualization of power was best articulated by Max Weber (1922), who demonstrated that “classes” are not equivalent to communities and therefore may not act as a cohesive interest group. Class is just one dimension of the broader social structure. Power was equated with various forms of economic, social, legal, or political power. Hanna & Kleinman (2013) cite

Weber’s rational-legal authority as a central category of power that shapes modern

society. Rational-legal authority emerges when the state is socially sanctioned and implementing policies that are legally sound.

Prestige, on the other hand, is linked to power and is nested within the social hierarchy of a local context. Prestige indicates reputation, esteem, or good-standing associated with an individual’s position in society (Weber, 1922). Prestige can either be acquired at birth, or built through occupation, social standing, social relationships, and other modalities that would increase social position depending on the context. The concept of prestige also relates to social stratification theories, differing in how prestige is attained – through achievement, esteem, honor, or charisma (Wegener, 1992). In other words, prestige is more than just social status, but it also includes some measure of esteem and respect. Wealth, power, and prestige represent three dimensions of

Weber’s definitions of social stratification (Weber, 1922).

Prestige, along with power, knowledge, and money, are highlighted as social conditions that are fundamental causes of health inequalities (Phelan, Link, & Tehranifar,

2010). Namely, having power, knowledge, and money can be protective against ill-health when an individual has the resources to avoid risk or minimize the impact of disease post-infection (Phelan et al., 2010). Steckel and Floud (1997)’s work suggests that this is not universally true. Rather, power, knowledge, and money must intersect with other social conditions to shape disease outcomes. This dissertation elucidates multiple pathways between political economy, social conditions, and HIV outcomes.

2.2.3. Inequality

Anthropological literature on inequality provides a rich foundation for examining health outcomes. The literature builds on work in epidemiology that demonstrates linkages between inequality and health outcomes. Wilkinson and Pickett (2011) argued that there are diminishing returns to economic growth, evidenced in poorer health outcomes from violence to obesity to addiction. Related to health, there is a growing

body of epidemiological evidence that indicates how social inequality shapes disease outcomes, independently of an individual’s income level (Kawachi & Kennedy, 1999).

This provides evidence that hierarchy acts across large populations and not just within strata (Nguyen & Peschard, 2003). Described as a “gradient effect,” individuals within the same economic strata but living in a more equal society would be healthier that those living in a more unequal society, regardless of individual income level (Kawachi et al., 1999). More unequal societies tend to invest less in infrastructure or social services, meaning that ill-health is more likely and less possible to control (Nguyen & Peschard,

2003).

Contemporary anthropological literature addresses health inequalities in a number of ways. First, by examining the impact of neoliberal economic reforms on local health care systems, PEH approaches have been foundational in tying global processes to local inequalities (Gudeman, 2016). Janes (2009) presents two key flaws that characterize most recent neoliberal economic reforms globally, focusing on inequality in

Mongolia in the wake of reform. Specifically, when core health services are not available at a community level, then the privileged and wealthy can bypass primary care and go straight to a specialized hospital (Janes, 2009). The underprivileged are limited to using the locally and freely available primary care system (Janes, 2009). This results in health system apartheid, where the privileged have access to one level of care and the rest are limited in their options – a clear example of health inequalities (Janes, 2009). In China, a transition to a market economy that began in the 1980s led to a similar fragmentation of health care and stratified access to health services (Gao et al., 2002).

Other work in contemporary medical anthropology and PEH focuses on local formations of inequality, with work in the United States focused on race and ethnicity.

Coburn (2004) presents an alternative model of class that focuses on the causes of inequality. Coburn (2004) argues that neoliberal policies led to increased inequality and

poverty, through unequal access to other health resources. Dressler’s (1993) work in the

United States looks at how health inequalities are formed along racial lines, similar to a conceptualization of health disparities.

Further, research in HIV has previously used inequality to frame disease outcomes (Heimer, 2007; Moyer, 2015). While the literature causally linking poverty to

HIV is diverse and context-specific (Fox, 2010; Fox, 2012; Magadi, 2013; Mishra et al.,

2007), structural inequalities continue to fuel the epidemic “in all societies” (Parker,

2001). The global distribution of HIV is unequal (Parker, 2001), with structural factors such as racism, gender inequality, sexual oppression, criminal laws, and stigma, shaping the contours of the epidemic (Parker, 2001). It is also clear that once an individual becomes HIV-positive, their socioeconomic status strongly influences their experience in controlling (or not controlling) the virus (Heimer, 2007). Heimer (2007) demonstrates that while HIV presents with similar biology and virology in most patients, it is the social embeddedness of the virus that matters and produces differential infection, treatment, and viral suppression outcomes.

Anthropological work has contributed to an understanding of the ways in which inequalities shape the global HIV epidemic. Neoliberal policies such as capital account liberalization, which removes restrictions on the movement of capital across geographic borders, and austerity, which erodes the role of the government as a provider of key social and health services, have particularly contributed to economic inequalities

(International Monetary Fund, 2015). Excessive inequality erodes social cohesion and ultimately lowers economic growth (IMF Fiscal Monitor, 2017). Income inequality correlates with health inequality, especially in places where health care is not free of cost

(Bleich et al., 2012; Krieger, 1999). Juxtaposed with local factors such as apartheid

(Hunter, 2010), the absence of a welfare state (Kalofonos, 2010), migration and job scarcity (Susser, 2011), income and health inequalities are drivers of opportunistic

epidemics such as HIV/AIDS. As Moyer (2015, p. 259) aptly argues, HIV/AIDS often serves as a metaphor for the “ills of modern society, laying bare inequalities in economic status and political power, and strengthening discourses of blame, classism, and racism.” In other words, to examine the HIV epidemic, one must consider political and economic factors such as inequality.

Hunter’s (2015) work in South Africa relies on a political economy of intimacy to examine the shift from self-sufficient rural homesteads to low-wage labor and the impact of inequality on HIV. Changing intimacies are produced by job scarcity, poor housing conditions, and a broader patriarchal structure. Apartheid led to growing class inequalities, along racial lines. Hunter (2015) argues that the rise of HIV/AIDS cannot be detached from the historical context shaping work and marriage. It underscores the role of neoliberal global policies that have produced vulnerabilities, especially among lower socioeconomic status women. Focusing on women, Hunter (2015) widens previous analyses of the epidemic in South Africa as simply due to “male migration.” Susser

(2011), working in KwaZulu-Natal, South Africa, looks at how neoliberal policies exacerbated gender inequalities through the economic oppression of the most vulnerable. Susser (2011) describes resilience amidst economic scarcity and provides a textured analysis of the political economy of gender inequality and HIV risk.

This research is situated within studies of inequality and HIV, locating the disproportionate prevalence of HIV among low-income men in Uganda within a broader political and economic context that structures inequality and produces differential strategies to manage HIV risk. In other words, this dissertation speaks to what Moyer

(2015) wrote, that HIV can be used as a lens to “lay bare inequalities” in a society.

2.3. The Risk Environment

The concept of a risk environment moves beyond an individual conceptualization of risk by pointing to the environment in which that individual is nested as an influencer of health outcomes. Individual risk is a quantitative measure of “the probability of an event during a specified period of time” (Rothman, Greenland, & Lash, 2008, p. 10). An event can be defined as a health outcome, such as HIV. Mary Douglas (2003) has been instrumental in defining the cultural and political influence on discourses of risk. In an article on the individual as a risk taker, Douglas and Calvez (1990) demonstrate that social control mechanisms can be used to ensure individuals adhere to acceptable behavior, while punishing those who engage in risky behavior.

Discourses of risk can also be problematic when individuals are categorized to be at “low-risk” or “high-risk” of a disease outcome. The “high-risk” label often leads to social labeling, marginalization, and poorly articulated policy (Lupton, 2006; Panter-Brick

& Fuentes, 2010; Parker, 2006). A more comprehensive framing is needed to understand the social context of the “web of causation” (Krieger, 1994), while anthropological approaches are well-placed to shift the discourse away from a causal measurement of risk factors (Douglas, 2003; Panter-Brick & Fuentes, 2010).

A risk environment framework, on the other hand, emphasizes more than individual behavior by accounting for aspects of an individual’s environment that influence individual-level risk (Rhodes, 2002). A risk environment is the space where factors that are exogenous to the individual interact to increase the chances of adverse health outcomes (Rhodes, 2002; Rhodes & Simic, 2005). Environmental determinants may also include structural factors, such as political responses, economic policies, social structures, and inequalities (Rhodes, 2002). There are two dimensions of the risk environment: types of environment (social, physical, economic, policy) and level of environmental influence (micro or macro) (Rhodes, 2002). The risk environment framework that includes the social, political, and economic context is conceptually linked

to political economy of health approaches of Bourgois et al. (1997), Singer (1998), and others. These broader structures influence “social relations” of risk and individual practices within the risk environment (Bourgois, 1998). However, a conceptualization of the risk environment shifts the unit of analysis from individuals to environments, especially when pointing to sources of responsibility for risky outcomes like risky sexual behavior (Rhodes, 2002).

Rhodes (2002) grounds this framework in the example of an HIV outbreak among injecting drug users in Vancouver in 1997 (Strathdee, Patrick & Currie, 1997). A set of environmental conditions laid the groundwork for an epidemic. These conditions included a shift in the availability of drugs to cocaine which was more frequently injected, a concentration of drug use in a geographic area, and limited harm reduction services

(O’Shaughnessy, Montaner, Strathdee & Schechter, 1998). A physical environment, such as a densely populated community, may sustain the social relations of risk

(Rhodes, 2002). For example, in Ukraine, the immediate physical environment provides a meeting point for drug dealers and drug users to conduct business (Rhodes & Fitch,

1997). In their 2010 study, Strathdee and Hallett identify micro and macroenvironmental risk factors for injecting drug users. In the microenvironment, factors such as drug injecting locations, homelessness, exposure to trauma, social norms, relationship and network dynamics, policing practices, and economic costs influence HIV risk. In the macroenvironment, drug trafficking routes, geographic population shifts, gender inequalities, stigma, and policies and laws on drug use and treatment all influence HIV risk.

2.4. Structural and Synergistic Vulnerabilities

Perspectives in political economy draw attention to how social conditions shape marginalized populations’ vulnerability to harm. Vulnerability is a useful frame to

understand how risk is structured. Chambers (2006) defines vulnerability as having two sides, “the external side of exposure to shocks, stress and risk; and the internal side of defenselessness, meaning a lack of means to cope without damaging loss” (Chambers,

2006, p. vii). In other words, structural factors shape individual abilities to cope with those structural pressures (Ribera & Hausmann-Muela, 2011). Chapman (2006) used a vulnerability framework to describe how social inequalities link to risk of poor outcomes in pregnancy. Vulnerability serves to explicate how individuals life chances come to be restricted and result in increased social suffering (Chapman, 2006).

Vulnerability is typically portrayed as a barrier to individual action, operating through economic scarcity and a broader structural environment (Kippax et al., 2013). It is an indicator of inequity and a marker of a more deep-seated position within a social hierarchy, which engenders certain risks (Rhodes et al., 2012). However, Chambers

(2006) warns against the trap of conflating vulnerability with poverty. To do so would sustain stereotypes of “the amorphous and undifferentiated mass of the poor”

(Chambers, 2006).

This research draws on the extensive body of literature framing HIV from a vulnerability lens (Bates, Fenton, Gruber, et al., 2004; Higgins, Hoffman, & Dworkin,

2010; Panter-Brick, 2014) and examining HIV vulnerability among sex workers (Infante,

Sosa-Rubi, & Cuadra, 2009; Onyango et al., 2019; Swendeman, Basu, Das, et al.,

2009). Onyango et al. (2019) use vulnerability to study HIV among female sex workers and their male partners. The authors describe how these partnerships are vulnerable to

HIV transmission because love and trust between partners influences low condom use.

Simíc and Rhodes (2009) describe HIV vulnerability among street sex workers in Serbia, arguing that violence and social and material inequality pattern HIV risk. In this study, structural and synergistic vulnerability frameworks will be used to frame HIV risk in a social-structural context.

Bourgois and colleagues (2017) define structural vulnerability as the condition of being at risk for negative health outcomes, such as HIV, through pathways to socioeconomic, political, and cultural hierarchies. Individuals face structural vulnerability when they are marginalized within society due to mutually reinforcing power hierarchies and institutional structures (Bourgois, Holmes, Seth, et al., 2017). Structural vulnerability describes the pathways between factors such as inequality or economic instability and individual health outcomes. Structural vulnerability is shaped by an individual’s location in a hierarchical social order shaped by an interplay of power relationships and effects

(Bourgois et al., 2017). Similar to discourse in the risk environment literature, studies of structural vulnerability point to broader structures as the source of harm, rather than individual behavior.

Structural vulnerability is shaped by a position within a hierarchical structure, which is determined by local variables and context (Holmes, 2011). In Holmes’ (2011) study of structural vulnerability among farm workers in Washington State, hierarchy is structured by immigration status and race. While everyone on the farm may be structurally vulnerable, those undocumented Mexican workers experience greater vulnerability due to a lower position on the social ladder (Holmes, 2011). Quesada et al.

(2011) similarly apply the framework to migrant laborers, who are an “economically exploited and politically subordinated” group in the United States. Quesada et al. (2011) highlight how lower social status is embodied where everyday oppression, scarcity, and insecurity is understood to be natural or deserved. Ill-health and disease follow as outcomes of these conditions. Finally, structural vulnerability includes a critique of agency, and therefore, risk-based models that emphasize individual choice. In other words, the broader political-economic forces in society constrain decision making and limit life options (Bourgois & Hart, 2010; Leatherman, 2005).

Synergistic vulnerability examines the way that different vulnerabilities combine to make individuals more at risk (Winchester, 2015). Winchester (2015) defined this concept based on research on women’s compounding vulnerability to antiretroviral treatment failure due to intimate-partner violence, poverty, and related factors. There are a multitude of factors that affect access and adherence and a synergy of vulnerabilities

(Winchester, 2015) that impact the experience beyond solely swallowing pills. The concept describes how different kinds of vulnerability intersect, creating a synergistic potential for negative outcomes and overall stress (Winchester, 2015, p. 883). Related to

Singer’s concept of syndemics, Winchester examines how the social dimensions of

HIV/AIDS are intersecting and mutually reinforcing.

2.5. Social Resilience

This dissertation relies on Obrist and colleague’s (2010, p. 327) definition of social resilience, meaning:

The capacity of actors to access capitals in order to not only cope with and adjust to adverse conditions (i.e. reactive capacity) but search for and create options (i.e. proactive capacity), and thus develop increased competence (i.e. positive outcomes) in dealing with a threat.

A social resilience approach shifts focus from difficulties in coping with a stress and what individuals lack, to how individuals build assets, capitals, or capacities to overcome a threat. Rather than examine how resilience shifts outcomes after an event occurs (e.g., a disaster), this research looks at resilience-building strategies in response to an ongoing crisis of economic inequality and formal sector unemployment. This research focuses on how social actors mobilize to build resilience to economic pressure.

Keck and Sakdapolrak’s (2013) review of work on social resilience draws attention to the significance of examining how cultural and social systems respond to conditions of stress. Social resilience is a useful heuristic to understand social entities

(individuals, organizations, or communities) and an ability to manage, cope with, and

mitigate environmental or social threats (Keck & Sakdapolrak, 2013). Social resilience not only includes social actors’ capacities to respond to threats, but it implies that stress or disaster may be an opportunity for innovation and development in response to constraint (Bohle et al., 2009). Further, social resilience accounts for the interplay between social structure and agency (Keck & Sakdapolrak, 2013). It can be rooted in political economy theory when stress is conceptualized as economic inequality rooted in systems of power and entrenched in social hierarchy.

Previous research on social resilience focuses on resilience to an environmental disaster, a future threat that is not necessarily predictable (Braun & Abheuer, 2011;

Howe, 2011; Rockstrom, 2004). Other papers examine longer-term stress related to natural resource management or resource scarcity (Adger, 2000; Marshall et al., 2009;

Scheffran et al., 2012). Finally, additional studies examine crises stemming from social change and development, such as migration (Adger et al., 2002) or health risk (Leipert &

Rutter, 2005; Obrist et al., 2010). This research contributes to the sparser body of literature on economic crisis and uncertainty (Schwarz et al., 2011; Zingel et al., 2011).

Resilience-based approaches are broadly predicated on strengths rather than vulnerabilities, signaling what Panter-Brick (2014) sees as a welcome paradigm shift. A resilience framework emphasizes well-being, strength, and capability and emerged as a counter-narrative to emphases on vulnerability and suffering (Almedom et al. 2010). In the context of health, resilience research underscores the ability of individuals and social systems to adapt to constrained circumstances (Wexler et al. 2009). In combining political economy of health with a social resilience framework, this dissertation contributes to studies of how communities rebuff structural pressure, signaling potential future interventions that are predicated on reinforcing existing strengths.

Chapter 3 Uganda Context

3.1. Overview

Uganda is a former British colony in East Africa that achieved independence in

1962. Despite decades of economic growth at the national level, the country has had high levels of inequality and joblessness. Combined with rapid urbanization, this makes

Uganda one important site to study the intersections of inequality, formal sector unemployment, urbanization, and HIV/AIDS. The underpinnings of these phenomena are rooted in the history of British indirect rule that privileged the Ganda over others and stratified Kampala into an African and a European area, paired with neoliberal economic policies post-Independence. Section 3.2 lays out several key aspects of Ugandan political history that are relevant for this research. First, I discuss the legacy of colonialism as seen in the rapidly urbanizing and increasingly stratified city of Kampala.

The section also explores the impact of weak formal sector job creation that results in increasing reliance by the poor on the informal economy, with its drastic uncertainty.

Finally, I illustrate how current political tensions are mirrored in the rumbling and rhetoric of the 1940s independence movement. Section 3.3 describes these current political tensions. Section 3.4 describes how HIV has come to be nested within this complex political economy, and can therefore can be conceptualized as a product of urbanization and urban stratification, joblessness, and uncertainty in Uganda.

3.2. Urbanization, Inequality, and Job Loss: A By-Product of Neoliberalism and Colonialism

3.2.1. Colonial Rooted Processes of Urbanization and Stratification

Urban growth in Uganda has been extremely high in recent decades (Bryceson,

2009; Fox & Pimhidzai, 2013). Kampala shifted from the center of the Buganda Kingdom

(Southall & Gutkind, 1957), to become a bifurcated African and European city under

British colonialism (Gartrell, 1983), and then to be the center of Ugandan economic and political power post-Independence. Kampala’s population doubles during the daytime, morphing from a city of 2.4 million to roughly twice that when individuals come from neighboring areas. The city was historically stratified, with one section dominated by the

African population (Mengo in the southwest quadrant of the map below), one section with Europeans, and one with Asian residents and traders (Nyakaana, Segenda, &

Lwasa, 2007).

The city has grown from a small township of 0.7 km2 to a city of 839 km2 after yearly growth averaging 6% from 1902 to 2018 (Table 3.1). While urban expansion and planning has been historically problematic because of this segregation, the pace of recent growth presents an even more urgent need for improved strategies to manage scarce and strained natural resources.

Table 3.1. Kampala population and growth (Nyakaana, Sengendo, & Lwasa, 2007)

Year 1969 1980 1991 2002 2010 2015 Kampala 330,700 458,503 724,241 1,208,544 1,811,794 2,400,000 Population Yearly -- 3.20 4.76 5.61 5.60 5.60 growth rate (%)

The features of this expansion can be traced to roots in Uganda’s history. During the pre-colonial era, the kibuga (city) was the center of the Buganda Kingdom, and the apex

of their military and political administration (Southall & Gutkind, 1957). It was of such cultural significance that for a long time non-Baganda were not allowed to enter without permission (Southall & Gutkind, 1957). Under the traditional Baganda system of land tenure, Baganda were given full control of land and were not allowed to sell land to non-

Africans unless special permission was obtained (Mukwaya, 1953; Southall & Gutkind,

1957, p. 8). Land was the property of the clan and subdivisions were given to families who would bury their dead on that land. Most did not live on this clan land, living on the

King’s land instead, which was freely given or rented to tenants who would cultivate and farm the land (Mair, 1933).

British colonialism radically shifted

these systems, with implications for the

planning of the country. The Uganda

Agreement of 1900 governed the system of

colonial rule and marked the beginning of

official British tenure in the country that

privileged the ethnic Ganda over others

(Figure 3.1). The agreement created two

categories of land: mailo, or land allotments

Figure 3.1. Map of Uganda's largest to the Buganda King and his chiefs, and ethnic groups Crown land, run by the colonial officials

(Nkurunziza, 2007). This division created a bifurcated Kampala with two different land tenure systems. The Crown land created a system of individual land rights while the mailo system changed the older Baganda way of managing land (Gutkind, 1963, p. 21).

The Crown system of land tenure established individual land ownership, right of purchase, and right of sale, with wide sweeping repercussions in and around urban areas (Nkurunziza, 2007). Under mailo, land was no longer communal clan property, but

could be bought and sold by individuals (Nkurunziza, 2007). Workers on the land were new tenants of the newly created landowning Baganda class. This impacted access to wealth and economic stability, particularly for those who could not afford to purchase land, and exacerbated wealth inequalities in a city that was already divided in other ways

(Richmond, Myers, & Namuli, 2018).

British colonial policies resulted in both a spatially and ethnically stratified colony.

Historians and social scientists have documented how the British used a hierarchy of appointed local officials during years of colonial rule in Uganda (Apter, 1961; Burke,

1964; Gartrell, 1983). Uganda is historically multiethnic (Figure 3.1), with the Buganda

Kingdom at the center of the country, geographically and in terms of power. The British began a privileging of Baganda within the protectorate established in 1894, in what has been termed a “Gandacentric” view of other tribes in Uganda (Gartrell, 1983). British colonial officials were few, and Baganda rulers maintained a degree of self-government.

Over time, as the British expanded their rule in colonial Uganda, Baganda officials were placed in positions of power over newly conquered peoples.

By the 1920s, senior Ganda chiefs were emerging as a highly privileged class

(Gutkind, 1963). Higher level chiefs built networks of influence, control, and patronage – a manner of ruling which persists to this day (Mamdani, 1996). Through their position of privilege, chiefs could influence access to education or other job opportunities, channeling these benefits to their own children or followers. These systems of patronage and inclusion began to create tensions among the excluded. As will be noted in later parts of this dissertation, the patronage system still shapes Ugandan society to this day with contemporary manifestations. Today, local leaders and the police perpetuate historically-rooted patron-client relationships, exacerbating social stratification and inequality when these relationships are rooted in financial exchange (Godfrey & Yu,

2014).

3.2.2. Winters of Discontent: Precursors to Independence

With the end of World War II, European empires in Africa faced both mounting internal and external pressures (Babou, 2010, p. 41). While escalating independence movements were gaining traction in the colonies, it was also a liberal colonial office in

London that paved the way for independence on the African continent (Babou, 2010, p.

42). Finally, shifting international priorities began to see colonialism and empire as traits of a bygone era. The new United Nations emphasized human rights and self- determination, undermining the policies of imperial rule (Gifford & Louis, 1988).

Writing during this time, Robert Kakembo (1944) produced an English language pamphlet, “An African Soldier Speaks,” that described soldiers who came to the army from poverty and with a low education status. Through the army, Ugandan soldiers were given a salary, clothes, and an education. This “newly educated man” would “never submit to the neglect that the uneducated masses back home in the villages” suffers from (Kakembo, 1944, p. 2). Kakembo further argued for harnessing skill, hope, and discontent, to produce change, development, and progress in Uganda. He critiqued elderly chiefs who “must give room to the young generation” (Kakembo, 1944, p. 17). In

Kakembo’s view, World War II changed Uganda not through violence but by remaking individuals and potential achievements. Kakembo was a member of the younger generation, one that desired to change the status quo and challenged older Baganda ruling elites. It was the older generation that had negotiated the Uganda Agreement of

1900 and continued to administer the country under patchwork laws and practices

(Burton, Burton, & Charton-Bigot, 2010).

Generation is a key theme in Africanist scholarship, as patriarchy and gerontocracy mark systems of order, particularly in male society where no social category governing relations is more important than generation (Burton et al., 2010;

Summers, 2005; Summers, 2015). From the 1920s through the 1940s, both the

Baganda and British officials saw youth and generational transition as disruptive to public order (Summers, 2005, p. 109). The British response to this threat was to nurture youth leadership as an essential aspect of governance (Summers, 2005). Baganda youth critiqued the kingdom and Ugandan protectorate, condemning the older generation’s complacency, hierarchy, and undemocratic rule (Summers, 2005, p. 109).

Youth politics played a critical role in this interwar period, and in the years following

World War II. It took until 1958 for Uganda to have a more structured internal self- government, and in 1962, full independence was attained.

3.2.3. Post-Independence, Neoliberal Policies, and the Makings of Inequality

Post-colonial policies, especially after the end of the Bush War (1980-1986), shape contemporary economic inequality in Uganda. This inequality is framed by a state that increasingly relied on foreign aid to develop the nation, using a model that promotes economic growth. Decades of indirect rule had weakened state capacity to govern in the post-colonial era. The next few decades were marked by intense rivalry and conflict between political actors, culminating in a 1971 coup (Gershenberg, 1972), conflict (1979

Liberation War; Kasozi, 1994), and additional conflict (1980-1986 Bush War; Kasozi,

1994) that ousted President Obote and instated President Museveni in 1986. The postwar period beginning in 1986 saw efforts by President Museveni to stabilize and industrialize the country (Wedig & Wiegratz, 2018). Industrialization, in part, was financed by a government strategy to increase control over export revenues gained from agricultural production, especially coffee (Wedig & Wiegratz, 2018).

Policies instituted in the 1980s in Uganda have important legacies for today’s economy, which many individuals are unable to fully participate in. Beginning in the

1980s, Uganda adopted neoliberal reforms to liberalize its economy (Young, 2019). Free market neoliberal policies were instituted to promote economic growth, stabilize out-of- control inflation, and maintain a sustainable balance of payments (Bigsten & Kayizzi-

Mugerwa, 1992; Bigsten, Kayizzi-Mugerwa, & Organisation for Economic Co-operation and Development, 2001). While the economy subsequently improved with improved economic growth, this growth has been concentrated in the upper echelons of society; the Gini coefficient increased from 0.39 in 1996 to 0.43 in 2016 (World Bank, 2019). This economic liberalization has not translated into adequate formal job creation in the country (Young, 2019), evidenced in part by the high rate of participation in the informal economy. In other words, neoliberal reforms have had a negative impact on available job opportunities in the formal economy.

There is healthy debate surrounding the positive and negative impacts of these policies and structural adjustment in Uganda (Dijkstra & Van Donge, 2001; Himbara &

Sultan, 1995; Mamdani, 1990). On the positive side, Uganda is considered “successful” in terms of both economic stabilization and growth, transforming from a subsistence economy to one with rapid economic growth (Dijkstra & Van Donge, 2001). On the negative side, the quality of that economic growth has been challenged with critics pointing to weaknesses in the Ugandan economy in terms of a negative balance of trade, dependence on foreign aid, and a large external debt (Belshaw, Lawrence, and

Hubbard, 1999). Additional criticism points to a negative impact on Ugandan citizens, with falling income, increasing cost of living, and reduced spending on social services

(Harrison, 2001). An increasing debt burden meant that much of Uganda’s budget was redirected to loan repayments, leaving less room to pay for national social services including health care. Simultaneously, structural adjustment significantly reshaped

Uganda’s economy, resulting in high unemployment (Dollar & Svensson, 2000).

While Uganda is lauded for its strong economic growth and progress, “no substantial improvement in social welfare” accompanied this “progress” (Okuonzi, 2004, p. 1632). Okuonzi (2004) points to the way economic growth was achieved as being incompatible with social welfare. Namely, Uganda’s economic policy had privileged

private-sector investment. To create conditions to attract investment, the country chose to vastly restrict public expenditure (Brownbridge, 2004). With these policies, while

Uganda’s economy looks strong at first glance (high economic growth, moderate inflation), this masks inequalities in poverty and wealth (Okuonzi, 2004). The $2/day measure for poverty excludes those who are barely surviving, but make just more than that threshold (Okuonzi, 2004). Further, income inequality has increased (0.43 in 2016;

World Bank, 2019), Uganda has a high debt burden (US$4.3 billion), and key health indicators have not improved enough (Okuonzi, 2004).

Uganda has instituted development plans in five-year increments since 1962.

The first five-year plan sought to control urban development by providing social services and gainful employment already in towns, and limit rural-to-urban migration (Mukwaya,

Sengendo, & Lwasa, 2010; Obbo, 1980, p. 24). In successive development plans it is assumed that unemployment is due to the imbalance between a rapidly swelling urban labor force, driven by rural-to-urban migration, and the slower growth of job opportunities. Obbo (1980) cites macronational forces such as the U.N. Development

Decade in the 1960s, which contributed to growing inequality as elites were able to access more and more opportunities, and the urban poor were defined as wage laborers.

The current development plan has its roots in 1980s neoliberal policies.

Uganda’s current National Development Plan (2015-2020) expected to increase economic growth and per capita income in the country. It emphasized the commercialization of agriculture as a path to industrialization. Investments in mineral, oil, and gas would be made, with an emphasis on processing in-country to maximize value.

Overall, the policies support economic growth, with few mentions of job creation or improving livelihood in the country. This is evident in Uganda’s Human Development

Index (HDI) value, ranking it at “low human development” at 159th out of 189 countries.

Without accounting for inequality, Uganda’s HDI is 0.528 (low; United Nations

Development Program, 2019). Inequality-adjusted HDI brings that value down to 0.387

(United Nations Development Program, 2019), a marked decline.

Uganda’s legacy of focusing on economic growth in the post-Independence era has had implications for income inequality. Evidence demonstrates that the benefits of

Uganda’s economic growth was not distributed equally (Ssewanyama, Okidi, Angemi, &

Barungi, 2004). Income growth has not been experienced in rural areas, and in urban areas there is growing inequality between the top and bottom income quintiles (Appleton

& Ssewanyana, 2003). Further, ineffective tax regimes in Uganda drive the low rates of wealth redistribution (Ssewanyama et al., 2004). Education, agricultural production, and community infrastructure are additional key drivers of inequality in Uganda, with implication for health care utilization (Ssewanyana & Kasirye, 2012).

With the advent of neoliberal policies, health system financing shifted from being freely provided by the government to a system based on market principles. Beginning in

1994 and driven by neoliberal policies, health system reforms were based on four principles: (1) individuals, charities, and private organizations should be responsible for health care, (2) public funding of health care should be restricted, and (3) the government should solely be responsible for policy and technical guidance (Okuonzi,

2004). Underlying these reforms was a key notion that through economic growth, individuals would be better placed to refund their own health care (Okuonzi, 2004).

Okuonzi (2004, p. 1174) provides a scathing critique of the impact of inequality on access to health care:

Ministry staff and expatriate technical advisers have cited the reduced prevalence of HIV and AIDS (from 30% in 1990s to 4.1% 2004) and the increased use of outpatient services as evidence for the effectiveness of health sector reforms. Yet the reduction in HIV and AIDS was due to a political strategy of openness and massive public education; it had little to do with health sector reforms. The doubling of outpatient attendance was due to the abolition of user fees not their inception.

As noted above, Uganda’s celebrated success often masks the reality of how uneven this success was experienced in the country. Ideas of improved incomes did not materialize with Uganda’s economic growth because that growth came at the expense of paid wages. Meanwhile, because wages remained low, Ugandans were also unable to afford their health care in this new system (Canagarajah & Diesen, 2006; Kappel et al.,

2005).

In contemporary Uganda, health care is once again free through the country’s extensive health care system. In the 2000s, foreign aid recipient nations began to challenge health system financing predicated on the use of user fees (Xu et al., 2006).

Uganda first revoked all fees from its first level government health facilities in March

2001. Xu et al. (2006) study the impact on health service utilization, noting that utilization increased for the non-poor, and utilization among the poor increased rapidly. However, importantly, payments for catastrophic health expenditures and other out-of-pocket expenditures among the poor did not reduce and pose a significant challenge to financial stability (Nabyonga Orem, Mugisha, Kirunga, Macq, & Criel, 2011; Xu et al., 2006).

3.2.4. Rural to Urban Migration

A migrant labor system emerged in British colonial tenure that shapes migration to this day. The labor system that emerged during British rule privileged Ganda elites over other groups. Class divisions reflected ethnic divisions as Baganda landowners employed migrant tenants from other ethnic groups. In the first half of the 20th century, a great deal of economic development was accomplished in Uganda through the expansion of agriculture, particularly through the addition of cash crops like cotton

(Byerlee, 1974, p. 552; Elkan, 1967). Rural-to-urban migration was encouraged as a way to work Baganda-owned cash crop farms (Obbo, 1980). Migrants were typically incorporated into the Baganda tribe, albeit in a lower social status. This system would lay

the groundwork for a steady stream of individuals migrating from rural to urban Uganda.

Landless urbanites were transitory and typically living in precarious circumstances

(Southall & Gutkind, 1957).

Historically, urban migration was circular, with short periods of time spent in the city and frequent visits home (Southall & Gutkind, 1957). Only a few individuals remained as urban-dwellers for their entire lives. In Kampala, those who remained in urban employment tended to be Baganda or Basoga who had small land holdings within cycling distance of the towns (Southall & Gutkind, 1957). These individuals were able to combine farming with wage employment. Elkan (1967) argued that circular migration was based on tax, whereby individuals would come to the urban area to earn money for tax payments, and then they would go back home. Younger men might work in the city for a short time, to save capital to set up as a farmer, which was important in the 1950s when cash crops were important sources of income especially in Uganda (Elkan, 1967;

Mabogunje, 1990).

Income from cash crops pushed rural wages to high levels, higher than what could be earned for the average urban resident in the 1950s (Elkan, 1970). From the late

1950s onward, urban wages rose, while rural incomes fell as export crops decreased in price (Elkan, 1970). During this period, urban migration became less of a temporary opportunity and more of a permanent solution as fewer opportunities were available in the rural area (Elkan, 1970). Young individuals, typically better educated, chose to stay in town where they might be better off working for wages than staying in the rural area

(Elkan, 1970).

Contemporary urban migration is marked by a range of related factors. Urban migration paused during the unstable 1970s under Idi Amin’s regime, and rapidly took off with the political stability of the 1980s (Nkurunziza, 2007). Urban migration is now more permanent, with longer periods of time spent in Kampala and shorter visits home

(Nkurunziza, 2007). More current factors driving migration include searching for economic opportunity, educational opportunity, or a range of personal factors based on the household situation (Awumbila, 2017). Once arriving in urban Uganda, many find ways of managing in the informal settlement where they are able to find housing.

3.2.5. The Impact of Urbanization on Social Relations

Urbanization was marked by social change, whereby “traditional” social relations dominant in the rural area no longer applied as different ethnic groups mixed in the city

(Southall & Gutkind, 1957), new forms of relationships were created (Obbo, 1988), and typologies of marriage shifted (Hunter, 2015). The kinds of work in the city, especially in the informal sector, also shaped the way that men and women relate with one another, with sexual relationships often complicating or overlapping with social ones (Hunter,

2015).

Trips to towns and cities like Kampala were traditionally associated with symbols of boys becoming men (Elkan, 1967, p. 584; Byerlee, 1974, p. 545). Young men moved to urban areas to seek employment opportunities, and later might return to rural areas where they had a greater degree of social support. Southall & Gutkind’s (1957) work in

Kisenyi is an important case study of urban disadvantage. At the time, urban life was regarded as having a negative effect on the traditional ways of life (Southall & Gutkind,

1957, p. 44). Specifically, urban life was thought to negatively impact the upholding of

Baganda traditions. Historically, the Baganda were known to integrate members of other tribes, as long as the new members took a Baganda name and adhered to Ganda customs (Southall & Gutkind, 1957). In the new, mixed city, Baganda and other ethnicities alike reshaped and shifted these traditional social and cultural patterns.

Urban Uganda was shaped by a unique and reconfigured pattern of social relations, that supplant social relations previously held in the rural areas (Obbo, 1988).

Every urban inhabitant tends to be involved in a complex network of social relations,

comprised of neighbors, workmates, friends, and acquaintances. At the core of this network are those who might fit into makeshift categories of kinship and those who are fellow tribesmen (Epstein, 1961). Studies carried out in Kampala, underscored the close relationship between membership in various associations – tribal and otherwise – residence in different urban neighborhoods, socioeconomic status and class (Epstein,

1967). Urban social relations are also dominated by a nexus of the cash economy and the labor market, and relationships are increasingly commodified (Obbo, 1988; Wirth,

1938).

Weisner, Bradley, & Kilbride (1997) declared that the African family was in crisis.

Although the focus of this edited volume is on Western Kenya and Eastern Uganda, we can note some similarities with other literature situated in Kampala. The patterns of family change are not in decline per se, but rather represent an increasing diversity in family structure due to changing patterns of migration and fertility. The authors also note, similar to work by Comaroff & Comaroff (1992), that colonial legacies shaped all aspects of the social environment (Weisner et al., 1997, p. xxvi). Kilbride & Kilbride’s chapter

(1997, pp. 208-226) on East Africa uses the concept of delocalization, referring to the ways in which men and women travel back and forth from urban to rural areas encouraged by colonial economic policy (see also Kilbride & Kilbride, 1990).

Urbanization created new patterns of relationships and marriage. In Kampala, some gender relation patterns shifted as men started to bring their wives and children to town. This was not the case in earlier waves of movement to urban Kampala, when young men were the primary migrants, leaving families behind in rural areas. Southall &

Gutkind (1957, p. 153) identify temporary sexual unions (prostitution, lover relationships, free marriage where no bride price has been paid) and two recognized marriage categories (tribal and Christian) that emerged in urban Uganda. These new and additional categories present the additional types of relationships formed in urban

spaces, where residency is often temporary and where new social rules apply in terms of inter-tribal marriage. Southall & Gutkind (1957, p. 167) note that in any social system which is undergoing change, traditional patterns of sexual relationships may be eschewed as new patterns emerge which provide satisfaction for all involved parties.

Southall and Gutkind (1957, p. 67) critically conclude that the problem is not marital instability, but rather the instability of male authority in the family. This is similar to Kilbride & Kilbride’s (1990) concept of delocalization, which also marks East African sexual knowledge, society, and moral responsibility. In Baganda culture, the father is revered and obeyed as the head of the family. A man’s social status is determined by those with whom he has established relationships of patron-client. Within this carefully constructed social network, men manage their future by choosing friends and patrons carefully.

3.2.6. The Informal Settlement

Uganda’s history and political economy have implications for Kampala’s development as a city, and for the creation of neglected spaces or “informal settlements.” Colonial and post-Independence government investment in urban infrastructure, housing, and economic diversification was not at all sufficient to meet the needs of a burgeoning urban population (Fox & Pimhidzai, 2013). Towns and cities were designed to manage the extraction of minerals and other commodities and to protect the interests of the European minority (Fox & Pimhidzai, 2013). Under President Museveni’s rule, urban development has been rooted in national legislation like the Kampala Capital

City Act (KCCA) of 2010 (Goodfellow, 2013). This act created the KCCA and decentralized management of the city into five divisions. However, the act also facilitated the creation of several city-wide development plans, which were poorly managed and implemented (Goodfellow, 2013). Some argue that these plans were hindered by the complicated land tenure system in Kampala (Goodfellow, 2013).

The history of land management in Kampala is further complicated by more contemporary developments, particularly in neoliberal policy. Fox and Pimhidzai (2013, p. 192) argue that the continuance of the status quo interests “coincided with the rise of an anti-urbanization bias in international development discourse at a time when countries in Africa were experiencing historically unprecedented rates of urban population growth.” Meaning, there was a neoliberal approach to national policy and a neoliberal or laissez-faire approach to urban development. This approach favored reactive, rather than proactive urban development.

In response to unclear policies that were unevenly implemented, ad hoc spaces ballooned to house the many urban migrants. Informal settlements act as a byproduct of economic change, becoming a staging area for the new migrants who work to integrate into the city (Fox & Pimhidzai, 2013). Informal settlements are also marked by lack of land tenure, poor housing conditions, and inadequate access to basic services and amenities, engendering high levels of vulnerability (Richmond, Myers, & Namuli, 2018).

The original theorization of the “slum,” described these spaces as temporary, to house city migrants, as a place that plays a necessary role in development, and one that allows migrants to earn enough to buy formal housing (Turner, 1969). The flaw in this theory is that informal settlements are not temporary, and wealth does not trickle down to those living in informal settlements, meaning they are rarely able to move to more stable housing (Fox, 2013).

3.2.7. The Informal Economy

The informal economy exists outside the specter of state regulation and control.

Its rise is strongly rooted in two political-economic factors: colonial urban planning policies that bifurcated the city into African and European areas, and postcolonial neoliberal policies in the 1980s that promoted economic growth at the expense of job and wealth creation (Young, 2019). These conditions, and the role of the state, played a

crucial role in producing and perpetuating the informal economy, through historical roots and contemporary poor governance and instability, tax policy, and state corruption

(Young, 2019).

In contemporary Kampala, the informal economy is rooted in colonial urban planning and stratification, post-independence poor governance and instability, and recent neoliberal reforms (Young, 2019). These factors lay the groundwork for contemporary informal economic activity, which fills the gap left by low formal sector employment. Kampala’s informal economy is most visible in its street vendors, who populate the city center and every major trading center (Young, 2019). However, recent regulations have cleared many vendors from these more visible spaces.

Definitions of the informal economy are wide ranging, from illegal activities to street vending, to untaxed labor and production of goods and services. The informal economy is a critical component of informal settlements. In fact, the informal economy manifests itself in different forms across and within nations, shaped by historical, social, and cultural processes. The concept originated with Keith Hart’s work in economic anthropology in Accra, which highlighted observations on entrepreneurship at the margins (Bonnet & Ventakesh, 2016, p. 3; Portes & Haller, 2010, p. 404). Here, Hart identified specific practices of income generation among individuals living in impoverished circumstances (Bonnet & Ventakesh, 2016, p. 3). In other words, Hart described practices of survival in a context of economic scarcity and a lack of opportunities. Yet, to paint the informal economy with this broad brush of language that is similar to rhetoric of structural violence, denies individuals agency and capacity to choose to resist participation in the formal economy.

To talk about the informal economy, across contexts, consideration of the role of social support is often critical (Richmond et al., 2018). In the absence of the state, issues around negotiation, exchange, and contractual obligations often arise. Social support is

a critical mode of buffering in this liminal space (Richmond et al., 2018). Social support may lead to reduced instances of violence or arrest. Bonnet & Venkatesh (2016, pp. 12-

13) point to the self-organizing tendencies of society in the informal economy. The authors describe De Soto’s (1989) work which detailed spontaneously arising regulations in the absence of the state. Here, this may not be the result of the informal economy per se, as much as the result of a diminished state.

3.2.8. The Policing of Urban Social Space

In this dissertation, policing is conceptualized as a form of social control, to impose “order” in a seemingly disordered informal settlement space. Baker (2006) notes that there have been efforts to establish Western models of policing in urban Africa, including Uganda, for the past half-century. The inability of the police to provide security within a country has created a power vacuum, where informal policing agencies have arisen to fill the gaps. Urban citizens rely on a wide social network of actors, who settle disputes in various circumstances – from a friend who might break up a fight in a bar, to a local councilman who might settle a debt dispute, to a union that mediates a case of minor theft (Baker, 2005; Baker, 2006, p. 57). In urban Uganda, formations of policing mirror the patchwork nature of changing social relations that characterize other aspects of urban life. There are different ways in which the state influences policing agencies, to maintain its sovereignty. With the end of Uganda’s war in 1986, Local Councils were introduced to fill the gap of old discredited appointed local chiefs (Oloka-Onyango,

1989). Local Councils are well-respected for their contribution to social ordering in urban

(and rural) Uganda (Loader, 2000; Wunsch & Ottemoeller, 2004). Although initiated and regulated by the state, they are regarded by many as locally controlled (Baker, 2006, p.

64).

In urban Uganda, a community policing program has emphasized education in the law and crime prevention (Baker, 2006, p. 62). Crime Prevention Panels consist of

local residents who are trained in crime prevention; these individuals played a noted role in the recent 2015 elections. In Katwe, the Crime Prevention Panel trained 30,000 individuals as ‘crime preventers’ (Baker, 2006, p. 62). In Kawempe, crime prevention has focused on the leveraging of local associations including boda boda (motorcycle taxi) drivers, teachers, bars and brothels, and religious leaders. Patterns of crime that affected these groups were identified and complaints were made as the associations acted as mediators between the police and local communities (Baker, 2005, p. 23).

Moreover, these local associations often fine anti-social behavior such as smoking marijuana, spitting, and some cases of fighting and debt – serve as mediators in these social disputes (Baker, 2005; Baker, 2006). This is one way in which a top-down initiative has been co-opted by local communities, and reformed to work in each local context. Of course, there are exceptions to this, especially when the Local Council or association takes advantage of their situation of power to extract patronage. Finally, these local associations and Crime Prevention Panels provide opportunities for youth to advance in an otherwise rather rigid social structure (Baker, 2006).

Further, the city is a site of social encounter and social division. The military coup of 1971 was bolstered by public support for sentiments of wealthy elites who speak of socialism, while they grow richer and others grow poorer (Obbo, 1980, p. 25). In this regard, to speak of urban renewal is to examine it as a lens on wider issues of inequality in urban Uganda. Crack-downs on the informal sector are nothing new, having begun in

1974 with the government rounding up informal traders in a well-publicized example of a growing totalitarian regime (Obbo, 1980). These crack-downs have continued in the

Museveni era, whereby failed urban planning policies might well be leading to increasing marginalization of urban residents (Mukwaya et al., 2010). If, as Tonkiss (2005) writes, the city is as much a social category as a spatial one, then cities in Uganda constitute

spaces where broader socioeconomic tensions are renegotiated and contested – where elites cling to power and use police and policy to create an idealized urban space.

3.3. New Opposition and Rising Tensions: MP Robert Kyagulanyi (Bobi Wine)

Since 2017, Ugandan politics have become increasingly tense with the rise of a successful and popular opposition leader standing against President Yoweri Museveni.

Uganda has seen other opposition leaders since President Museveni’s ascension, but none have resonated with such a large swath of society (Malingha & Ojambo, 2019).

These political tensions will likely continue until at least the 2021 elections, which will pit the opposition leader against President Museveni (Nyeko, 2020).

Member of Parliament (MP) Robert Kyagulanyi is better known by his stage name, Bobi Wine and also as the “Ghetto President” because of how his politics resonate with the “ordinary citizen” (“Ugandan pop star Bobi Wine to run against Yoweri

Museveni,” 2019). Bobi Wine is a popular reggae, dancehall, and afrobeat musician in

Uganda. In 2017, he won a seat in Parliament from the Kyaddondo East Constituency in

2017. After his election, Bobi (as many local residents call him) began gaining political support as he supported other candidates in their election. Most of these candidates won their seats. He gained even more traction when he spoke out against a 2017

Constitutional amendment bill that allowed President Museveni to extend his time in office and removed an upper age limit on the presidency (“Ugandan police shut down protests over presidential age limit bill,” 2017). During the debates in Parliament, Bobi was seen on the floor wearing a red beret, a symbol of resistance that would come to represent his People Power movement (“Bobi Wine denounces Uganda’s red beret ban as ‘sham’”). The Age Limit Bill was passed in 2017, after lengthy debate and controversy in both Parliament and the Constitutional Court. The Bill paved the way for President

Museveni to stand for the 2021 elections (Goitom, 2017).

The more recent and acute rise in tensions came in August 2018, early in my fieldwork year. Bobi was campaigning for Kassiano Wadri in Arua, Northwestern Uganda

in an MP election race (Ojwee, 2019). On August 14th, supporters of now-MP Wadri allegedly blocked President Museveni’s convoy and threw stones at his vehicle. This incident resulted in clashes between the president’s security forces and protesters.

During the melee, security forces fired at Bobi Wine’s vehicle, killing his driver. Bobi was arrested at his hotel that night, and charged with the unlawful possession of firearms and inciting violence. He was brought to a military court, where he appeared beaten with visible injuries to his head, face, and leg and he was unable to walk (“Bobi Wine protests: Uganda army sorry over beating journalists - BBC News,” 2018). After this incident, protests grew in urban centers across Uganda, as protesters demanded his release. The August 20th protests in Kampala paralyzed the city for a day and resulted in violence and pandemonium (“Uganda’s Bobi Wine crisis: Court frees pop star MP - BBC

News,” 2018). Bobi was eventually released, but has been arrested several more times since, accompanied by cycles of additional protests and instability.

This background is significant because it speaks to rising political instability in the country, an issue that has been noted by conflict researchers (Cheeseman, 2019; Khisa,

2019; Omach, 2017). President Museveni’s growing authoritarianism and the country’s weak institutions are cause for concern, evidenced later in study participants’ rhetoric.

These issues have been noted by political scientists for multiplying the country’s challenges (“Uganda | Crisis Group,” 2019). Researchers note rising conflict at the local level due to unclear political succession, economic stagnation, and a youth bulge (Khisa,

2019). The state is also becoming increasingly repressive of political opposition, while relying on the security apparatus to target areas that are politically and economically marginalized (“Uganda | Crisis Group,” 2019). These issues resonate in the daily lives of men in my study community.

3.4. Uganda’s History with the HIV Epidemic

3.4.1. Overview of HIV in Uganda

One goal of this research is to examine how inequality explains patterns of HIV risk, which may result in increased HIV prevalence in the study community. Nationally, it is not surprising that a country with high inequality and low human development also faces higher rates of HIV (UNAIDS, 2019). However, Uganda has made great progress since the beginning of the epidemic, reducing prevalence from a high of 30% to 6% in

2016 (UAC, 2018). There are regional differences in HIV prevalence, with Kampala experiencing one of the higher prevalence rates (6.9% in Figure 3.2).

Figure 3.2. Regional differences in HIV prevalence (PEPFAR, 2019)

Overall, the epidemic continues to be “severe, mature, generalized and heterogeneous” with 1.3 million Ugandans infected (UAC, 2016). Further, HIV is differentially experienced, with higher infections, lower uptake of ART, and higher AIDS- related mortality among men (UNAIDS, 2019). More recent estimates demonstrate that

85% of female sex workers are HIV infected (UNAIDS, 2019), and 18% of their male non-paying partners have HIV (Crane Survey, 2010). However, this latter prevalence estimate is based on a smaller sample size and is outdated. This research argues that

HIV is shaped by inequalities experienced in the informal settlement, which place men at higher risk of HIV.

Globally, there has been increasing attention to improving HIV outcomes among men (MenStar Coalition, 2019). The data demonstrate that while men in Uganda are at higher risk of HIV, they do have worse outcomes across the care continuum, from testing (85.2% of men have tested for HIV, compared to 94.4% of women), to currently being on ART (52.4% of HIV positive men compared to 61.9% of HIV positive women), to viral suppression (53.6% of men, compared to 62.9% of women) (Ministry of Health,

2019). Indeed, PEPFAR’s Country Operating Plan (COP)1 2019 is concerned with these disparities, highlighting that through their policies and oversight of in-country programming they will “find the missing individuals and populations, enroll them on treatment and ensure they are virally suppressed.”

An analysis of HIV risk in Uganda demonstrates that risk is higher when men have had more than two sexual partners in the last year, report an STI, and inconsistently use condoms (Mermin et al., 2008). Most literature about HIV in Uganda fails to acknowledge the broader context of these risk behaviors. Some contemporary research based in Uganda focuses on gender norms and how they structure risk among men (Mathur et al., 2015; Siu et al., 2012; Wyrod, 2016). This dissertation builds on this literature by expanding the consideration of the political and economic context by

1 The yearly COP presents PEPFAR’s policy and programming priorities for the year. As the biggest funder of HIV services in Uganda, this has a significant impact on where programs focus their efforts, especially for those programs directly funded by PEPFAR.

examining how inequality and unstable employment, paired with a risky environment, structures HIV vulnerability.

3.4.2. Navigating Uncertainty

Previous literature speaks to the dynamics of managing risk in an environment marked by economic and other uncertainty. Several findings in this dissertation speak to an environment of uncertainty, with unstable employment, frequent police arrest, and violence. Susan Reynolds Whyte’s (1997) monograph Questioning Misfortune: The

Pragmatics of Uncertainty in Eastern Uganda details the ways in which individuals managed constrained and uncertain circumstances in Tororo District. Here, Whyte uses

Dewey’s theories to describe how the Nyole people are searching for security rather than certainty. Problems that arise in life are always representative of broader social meaning. Further, life is characterized by uncertainty, ambiguity, and planning; this insecurity shapes individual abilities to plan and control (Whyte, 1997, p. 18). Further, humans are not simply helpless, agency-less individuals in a risky world – they engage in decisions that attempt to produce some measure of security. Whyte describes this as pragmatic action in the face of uncertainty, an uncertainty that is an aspect of specific experience and life circumstance.

The Nyole experience of uncertainty is tied to changing political and economic circumstances – to years of living through political conflict, and HIV/AIDS as a new source of uncertainty. In this context, ritual and religion is often used to manage these uncertain circumstances and restore some measure of control. Whyte (2014, pp. 226-

227) describes a modern shift where risks from the natural-environmental world are fewer, and risk is now “socially created and dangers are socially mediated.” Further, a

“natural” disease like HIV/AIDS is socially managed and socially constructed as risk.

Wallman’s (1996) work, Kampala Women Getting By: Wellbeing in the Time of AIDS,

similarly details life in an urban neighborhood and how women’s health-care decisions are socially mediated and shaped by constrained circumstances.

Other literature relies on a framing of uncertainty to explain implications for managing HIV risk (Brashers et al., 1998) and HIV treatment (Brashers et al., 2000;

Brashers et al., 2004). Uncertainty is framed as a “chronic and pervasive source of distress” for people living with HIV, who are told to maintain careful, regular treatment regimens with dire consequences if not maintained (Brashers et al., 1998). Research on uncertainty has grown to consider experiences over time, and over the course of an illness using a biopsychosocial model (Brashers et al., 1998; Mast et al., 1995). Whyte

(1995) extends these concepts to also consider uncertainty created by the social- economic context, with negative implications for health. Lastly, Moyer and Hardon

(2014) aptly employ a concept of “continuous uncertainty” to describe how HIV positive individuals are unable to find meaning in their lives that have been “saved.”

The more recent monograph edited by Whyte (2014) sheds light on this range of issues related to uncertainty, focusing on this “first generation” to access ART in

Uganda. Prior to the introduction of ART in Uganda, HIV/AIDS was a death sentence. It is still a death sentence today for those who cannot consistently access medication, treatment services, and do not have the support (social, nutritional, economic, familial, etc.) needed to facilitate this. The medicine gave individuals diagnosed with HIV/AIDS a

“second chance” at life, but one that was full of uncertainty: uncertainty over livelihood, medication stock-outs, dependency on clinics funded by foreign aid, a life still full of

“problems and pain and the specter of death” (Whyte, 2014, p. 278). In other words, the problem of HIV does not exist in a vacuum (Whyte, 2014, p. 282).

Uncertainty at the treatment level was matched by a similar ambiguity in the negotiation of daily life (Whyte, 2014), challenging the chronic disease paradigm

(McGrath et al., 2014). In the post-ART era, HIV has been re-framed as a manageable

chronic disease with relatively normal life expectancy (McGrath et al., 2014). This paradigm is rooted in assumptions about stable livelihoods, food access (Kalofonos,

2010), and familial and partner relationships. Whyte (2014) challenges this notion, arguing that all aspects of HIV care have a high level of uncertainty attached. Both

McGrath et al. (2014) and Whyte (2014) demonstrate that long-term management of HIV is affected by these uncertainties and that HIV should be understood in its social, political, and economic context.

3.4.3. Literature on HIV among Ugandan Men

Antiretroviral therapy (ART) does provide a second chance at life for those who are HIV positive. However, it does not erase the multitude of uncertainties that exist, especially for those living at the margins. HIV is typically a marker of social disadvantage. Providing ART moves individuals “from certain death to uncertain survival” (Whyte, 2014, p. 278). It does not eradicate the uncertainties around food access, housing, and all the other markers of economic scarcity. Livelihood presents a means to attain social participation and to gain social status within a community (Whyte,

2014, p. 282). When status is intertwined with masculinity, and men are unable to fulfill their economic provider role, it certainly has implications for other aspects of life.

Wyrod’s (2016) ethnographic study in Bwaise is an important example of contemporary anthropological research in Uganda on HIV/AIDS. The author argues against caricatures of masculinity as a driver of the epidemic; rather it is the opposite as the epidemic has been a social force that shapes masculinity. Ugandan men in Bwaise face numerous risks, which synergize to shape the choices that they can make with implications for adhering to masculine expectations. HIV risk shapes the way men practice hegemonic masculine ideals of being a provider, exercising authority and sexual privilege. Rural-to-urban migration shaped new gendered tensions for men due to experiences of socioeconomic stratification and unemployment, where men were no

longer able to provide (Wyrod, 2016, p. 64). In this environment of uncertainty, men are also navigating new terrain where they are no longer able to fulfill their hegemonic role – unemployment is de-masculinizing, and female earners are seen as a threat to male authority. In these precarious and uncertain circumstances, men’s pragmatic choices may present as constraints.

Other work on men in diverse contexts in Uganda underscores the way in which the HIV epidemic, changing sociocultural landscapes, and gender, intersect to shape urban men’s risk. Nyanzi et al. (2008) looked at how male hegemonic norms of multiple sexual partners is at odds with prevailing discourses on “safer sex” and “reduced risk.”

Mathur et al. (2015) discussed how young rural men possess child-bearing aspirations that lowers condom use and increases HIV risk. Siu et al. (2014) showed that men’s treatment seeking behavior is associated with different masculine ideologies. Seeley’s

(2015) work sheds light on thirty years of the HIV epidemic in Uganda. Seeley argues that the epidemic was emboldened, in a sense, by political, economic, and social changes that have taken place in recent Ugandan history.

Parikh’s (2016) recent ethnographic work examined the intersection of desire, morality, aspiration, and uncertainty set against a backdrop of the HIV/AIDS epidemic.

The first part of her book described the historical changes that have taken place over a century in Uganda, shaping a high level of uncertainty and anxiety in Iganga. Moral responses to the epidemic are often in opposition to sexuality and desire among youth.

Similar to findings in work by Tamale (2009), these moral responses attempt to regulate sexuality in a changing world. These moral responses are also rooted in colonial notions of what constitutes morally sanctioned sex (Tamale, 2009). As certain subjects become taboo or illicit, illicit practices of sex are forced underground.

3.5. Study Setting

This research took place in a densely populated low-income area known as

Kabalagala, situated in Makindye Division, Kampala, Uganda (Figure 3.3). The name

Kabalagala, means “pancake,” chosen because of the famous pancake street vendors who used this area as their base of business. Kampala, similar to other districts, is sub- divided into divisions, and then further into parishes and zones.

The actual name and location of the study community is masked to protect the identity of participants. Kabalagala is a parish, headed by a local council II (LCII) and made up of smaller units (zones). Each zone in Kabalagala contains roughly 500-1,000 people and is headed by a local council at the first level (LCI), consisting of a Chair, a Vice-Chair, a

Defense, and other members.

Figure 3.3. Map of Kabalagala and Kampala Divisions (KCCA, 2014)

Driving on Kabalagala’s main road, it would take only a moment to pass the study community. It is easy to miss the community and the microworld contained in the deceptively small side road, with myriad homes haphazardly stacked above and below the road. The study community is adjacent to the main road through the heart of

Kabalagala, where numerous bars, clubs, and sports betting businesses make up the core of this well-known, or by some accounts, notorious, entertainment district. In the words of Kabalagala policemen, the study community is infamous in Kampala, and indeed in much of Uganda. It is known as a place where all types of dubious activities take place. It is called a “ghetto” by local, resident men. A term that has taken on a social meaning with a set of rules determined by the residents.

The main economic activity that drives the local economy in Kabalagala is sex work. Female sex workers live in the community and spend their earnings in local restaurants, bars, hair salons, shops, and video halls. Sex work has been established for

20 years in Kabalagala, with numbers of sex workers ballooning in the last 5-10 years.

Kabalagala first started attracting sex workers in the late 1990s-early 2000s, when bars were first established on the main road. Sex workers created their base in the community, due to the availability of cheaper housing. The first person to build a lodge specifically for sex worker needs was a man known as Uncle Paul. He built a lodge with a number of rooms that could be rented out nightly or hourly, based on sex worker needs. Other entrepreneurial men and women soon built additional lodges to take advantage of the burgeoning sex business. The lodges are managed by either the lodge owner, who reports healthy profit margins, or a lodge manager. Lodge managers have their own networks of casual workers, both men and women, who supply the lodge with water, wash laundry, provide security, manage the bar, and undertake other odd jobs that might be needed.

Sex work is illegal in Uganda. Sections 136-139 of the Penal Code (1950) criminalizes living off the earnings of prostitution, keeping rooms for prostitution, and regularly exchanging sex for money. Nonetheless, in many places in Uganda sex work is not regularly policed and laws are not regularly enforced. Therefore, sex work occurs rather openly, although sex workers still face stigma and discrimination in the country

(Tamale, 2009), which limits access to health services, thereby contributing to adverse health outcomes, including a high prevalence of HIV (37% of FSW) (Vandepitte et al.,

2011). In this particular area, sex work is functionally decriminalized. The police do not conduct sweeps of the area, to arrest sex workers, nor do the local leaders attempt to stop sex work. There have been attempts to regulate the sex work industry, with established codes of conduct put into place in Kabalagala. In the early 2010s, local leaders created one such code that stipulated that FSW could not wear mini-skirts before 7 pm, and could not stand on the road in the open. At one point, sex workers were asked to register with local leaders and purchase an identity card, although this was later revealed to be a scam for local leaders to collect money. Now, one community liaison to the police registers new women at every lodge, taking their names, next of kin, and contact information.

Sex workers start gathering for work around dark (typically 7 pm). They start preparing themselves in the afternoon, going to the salon, drinking alcohol, changing clothes, and so on. At 7 pm, the roads start to fill with women standing just outside of lodges or bars, standing along the street. Women gather, typically in the shadows, and stand, patiently waiting for men to come through. Visitors start coming into the community around 7 pm, with a peak at 11 pm – 12 am. Men can approach sex workers standing on the road, or they can ask a lodge manager or any other male in the community to help link them up with a sex worker. Some sex workers call to and pull passing men, asking them to buy a “short” (five minutes of sex). Some wealthier visitors

can afford to pay for an entire night of entertainment, taking a sex worker of choice to a nearby bar, and buying beers for her and friends. Sex workers are a highly mobile population, and go where the money is. This is seasonal, and depends on which towns, divisions, or cities have the most money at any given time. The peak season is during

Christmas, when scores of rural men visit Kampala with their agricultural earnings, to purchase items for the holiday season.

Alongside the typically transient female sex workers, there is a population of young men who are residents of Kabalagala. Young men come to Kabalagala looking for work, and stay because of the low cost of living, the round-the-clock entertainment, and networks of friends who provide company and social support. Men come to Kabalagala from all over Uganda and Kampala. As an urban informal settlement, housing is relatively cheap (5,000-10,000 Uganda Shillings per night, which is equivalent to

US$1.35-$2.70 per night), although notably this is still unaffordable for many youths.

Meals are likewise affordable, with a basic meal of chapati and beans costing 1,000-

2,000 Shillings (US$0.27-$0.54). Many of these men enter into longer-term partnerships with the sex workers as a way to survive economically.

This study focused on the resident men – not men who come only at night or only come to Kabalagala once in a while. The resident men are part of the social fabric of

Kabalagala and are involved in the local businesses of Kabalagala – sex work, laundering (a “dobbi”), bars, clubs, restaurants, and lodges. They are also at high risk of

HIV due to low condom use in their intimate relationships. Male partners of sex workers

(non-paying boyfriends) have a disproportionately high prevalence of HIV at 18% (Crane

Survey, 2010).

Despite this thriving informal, or illicit, economy, the community in Kabalagala remains an area with challenges in the physical environment. The community consists of small brick or cement houses, with a few wooden structures in between. Many

restaurants and businesses are open air, with tin roofs to shield customers and staff from the rain. Houses and buildings are built very close together, with small passage ways traversing the neighborhood. An intricate network of sewage trenches run through the community. To walk through the community, you have to pass next to or over trenches and through very narrow passages. It is both easy to get lost, and difficult to walk, especially at night when you have to be careful not to fall into a trench. Residents and passers-by throw (primarily plastic) trash on the ground or in the trenches. In many zones, the trenches are not cleaned or maintained. During the rainy season, the trenches flood and rainwater flows freely through the communities, exposing residents to the risk of water-borne illness (Figure 3.4).

Figure 3.4. A typical sewage trench (left) and a resident trying to avoid the trench (right)

There are no flush toilets, and few

buildings have water piped onto their premises.

Most residents rely on shared toilets, either

public or in the few lodges that have them.

Some use buckets and then throw waste into

the trenches (Figure 3.5). Showers are taken

from a bucket, either in residents’ rooms or in

the shared toilets. Residents rely on shared

taps, which cost 200 UGX (US$0.05) to fill up a

7-liter jerry can with unfiltered and unpurified

Figure 3.5. When it rains, the trenches water. Drinking water (1,000 UGX for 0.5L) has turn into rivers to be purchased, but waragi (cheap local gin) is cheaper (500 UGX for 100 ml) for a smaller but potent packet. Electricity is usually stable, but almost all residents tap illegally into the electric grid. Some lodge owners pay off Umeme (the electric company) electricians, and install faulty meter readers that do not cap electricity use based on payments. In other words, they might pay a minimal fee, but they get to use as much electricity as they want. Those who do pay for electricity, pay by the unit. The complicated mess of wires are extremely hazardous. Residents are at risk of being killed by a wayward wire, or houses are set on fire.

The Kampala Capital City Authority (KCCA) is responsible for the oversight and development of Kampala. The KCCA has driven efforts to redevelop key informal settlements. However, these plans have been accompanied by implementation challenges. In its Strategic Plan 2014/15-2018/19, the KCCA outlines its “Slum

Upgrading Project.” This aspirational plan includes plans to upgrade 62 “informal settlements”, including the study communities, which face challenges with access to

water, shelter, and sanitation. Plans are mentioned to provide housing, create land banks, develop and implement a relocation program for residents, and identify areas where urban low-cost housing can be constructed. The latter did not come to fruition, at the time of writing in December 2019. As experienced by the residents, the implementation of this plan has been one of the factors influencing their economic fragility.

A major landmark moment in the community’s history was in 2015, when KCCA owned bulldozers plowed through the community’s main road. The city razed informal

“kiosks,” or small businesses, sending business owners into financial ruin. Small wooden structures were systematically torn down, and replaced with brick-and-mortar and cement buildings. While on the one hand, this has improved the structural soundness and safety of buildings, on the other hand many of these buildings are unaffordable and rent has sky-rocketed. Only those who could afford the price of the buildings were able to stay. Since then, many others are either housing unstable or homeless. The KCCA has also mandated that all business owners must register and obtain a license, while street vendors are no longer allowed to sell their wares. In fact, whenever the KCCA enforcement vehicles come through the community, pandemonium ensues. They have been known to arrest street vendors selling fruit or other small items. They have also been known to arrest goats or other animals that are not allowed to openly graze. To bail goats out of the KCCA jail is too expensive for most residents, and many choose to lose their items rather than pay for them.

Petty theft is common in Kabalagala, with stolen cell phones and other electronic equipment constantly traded on the black market there. However, in addition to this day- to-day burden of crime, lodge managers described collaborating with sex workers in an organized effort to steal from clients during the period of 2010-2015. The sex worker would take client’s pants, and throw them near the door. While the client is “conducting

his business,” the manager would reach under the door and take the wallet or money from the client’s pants. Other acts of theft were more overt, but rarely was violence ever used. Some clients reacted negatively, and would threaten the manager with a gun, or in more extreme cases, beat or kill the thief. Theft became so common that clients stopped coming to the Kabalagala lodges. In response to this, lodge owners banded together in

2015 and banned several managers from the entire community (see Chapter 4 Pilot

Findings), refusing to even let them cross into the community from the main road. After these managers left, crime quickly decreased.

The study community, therefore, might be characterized as a risky location to conduct research. I ensured my safety using two primary strategies. First, because I had previously spent time in Kabalagala, I was well-known in the area and I made concerted efforts to maintain relationships with residents of the community to gain their trust. In this way, my outsider status was mitigated. As most victims of crimes were unknown outsiders, being “known” gave me a degree of protection against petty crime. Second, although I recruited participants in the evenings (3-8 pm), I did not do interviews at night.

For the purposes of this study, it was easier to identify the resident men during the day time, rather than at night, when Kabalagala is filled with outsiders who are there to drink and buy sex.

Chapter 4 Pilot Findings

Overview. An ethnographic pilot study was conducted in July 2016 to examine themes of risk and vulnerability among men in sex worker communities, and in 2017 to pre-test a survey tool. The pilot research built on previous work in Uganda with sex work communities and generated a description of men in a low-income sex work community in

Kabalagala. It refined key theoretical frameworks and variables and examined men’s identities and role(s) in the community, thereby guiding the rest of this study design.

While initial questions during the interviews (n = 24) focused on HIV, the interviews quickly turned to broader contextual issues in the community.

Sampling. Participants were selected purposively based on age, job status and type, and zone of residence within Kabalagala. The specific communities within this parish are not named to protect participants’ identity. Participants included unemployed men, men who worked or owned lodges, local leaders, men who worked in other small local businesses (e.g., chapati making, mechanics, restaurants, bars), and boda boda

(motorcycle taxi) driver, thereby representing the range of income-generating activities in the community. An NGO worker from an NGO that serves female sex workers and their male partners was also interviewed to gain a perspective from the service provision side.

Semi-structured interviews were conducted in Kabalagala or nearby in quiet and private locations of the participants’ choice. Interview domains included demographic information (age, sex, gender, occupation, ethnic group); length of time in present occupation(s); formal or informal role(s) in the community; and relationships with the wider community and social structures. Interviews also included questions on HIV/AIDS, health services, individual beliefs, gender norms, social networks, community resources, and migration within and to/from Kampala. Participant observation was conducted in

bars and other leisure locations in the community to observe context, social norms, conversations, and other goings-on in Kabalagala.

Analysis. Thematic analysis (Braun & Clarke, 2006) of interview transcriptions and field notes included an iterative approach to coding. The codes were synthesized into 21 categories covering migration, education, employment status, perceptions of sex work, gender roles, social network, and HIV knowledge and service uptake. Four broad themes were created based on these categories, including the “study community profile,”

“gender roles,” “social networks,” and “HIV/AIDS and health.” These findings serve to inform the survey design. The variables identified as important in the study were included in the survey. Existing validated scales were chosen if available. Other survey questions were generated based on the pilot study.

Findings. Recent city-wide regulation of the informal economy has led to a large number of unemployed men who previously found steady work in informal jobs. Job instability characterized life for men (n = 24) in Kabalagala. These participants described how Kabalagala is home to a large number of completely unemployed individuals, who are typically, younger and well-educated men. Findings in Kabalagala demonstrated the importance of participant (n = 14) experiences of city regulations related to boda boda

(motorcycle) taxi driving, street vendors, lodges, and building codes. These regulations hampered men’s abilities to engage in informal employment, which was now subject to new regulations and control.

In Kabalagala, each bar had a group of men who congregate daily. Participants

(n = 15) describe the purpose of bar groups to share resources and information, suggesting these are sources of social resilience. Gambling solidifies social relationships within bar groups as men place individual bets based on group advice. Preliminary data suggest that bar groups represent a system that is both vulnerable and resilient. In

Kabalagala, it was observed that members of bars where mobile clinics were held rarely

utilized the mobile clinic services. Informal conversations revealed that these men preferred to go outside the community to local government and private clinics for testing services. This suggests that although bar groups serve as social safety nets to buffer against economic hardship, they may also facilitate unhealthy behaviors (e.g., gambling and alcohol use) and discourage uptake of mobile clinic services. Additionally, because the community is frequently targeted by mobile health providers and other educational outreach programs, it would be helpful to understand the level of HIV knowledge, attitudes and practices, and how this intersects with risky sexual behavior.

Interviews (n = 13) revealed that economic constraints juxtaposed with limited job opportunities often led to men’s economic dependence on FSW partners. Most men in

Kabalagala, nearly 100% according to one participant, are or have been intimate partners of FSW, who often have a more stable source of income than the men do.

Although many unemployed men benefit from social safety nets such as bar groups, they are unable to fulfill their societally-ascribed gender role of provider. The implication of this loss of status in terms of risky sexual behavior merits further study to determine if it interacts with other factors to increase risk.

Finally, men are frequently subjected to arrest under laws such as “idle and disorderly” or “rogue and vagabond,” meaning “poor laws” that disproportionately target the poor. Men cycle in and out of jail, often paying bribes to be released. Police conduct frequent surveillance of the community, targeting specific areas where men gather.

Based on the findings of the pilot study, it became clear that a data on job stability, HIV

KAP, alcohol use, frequency of arrest, and related variables were critical to understanding the context of HIV risk for these men. As such, the pilot study pointed to a need to expand the theoretical lens to include the political economy of health as a framework.

Chapter 5 Methods

5.1. Overview

This research investigates the impact of political and economic issues of inequality and unemployment on men’s HIV outcomes. This research was conducted over a three-year period using an explanatory sequential design (Creswell & Clark,

2018). An explanatory sequential design is a mixed-method design that uses qualitative methods to explain initial quantitative results. The design involved sequential stages, beginning with an exploratory qualitative data collection phase (e.g., the pilot study) that assisted with development of a survey tool grounded in the views of participants

(Creswell & Clark, 2018, p. 67). In turn, the survey analysis provided questions to be asked in the final interviews, specifically to address unclear or contradictory results.

Figure 5.1 depicts the study design and each phase of the research, beginning with the pilot study in July 2016 and ending with completion of ethnographic data collection in

June 2019. Data collection consisted of semi-structured interviews, a community census, close-ended surveys, in-depth interviews, and observation. Purposive sampling was used for all methods except for the survey, which relied on time-location sampling (TLS).

Figure 5.1. Explanatory sequential mixed methods study design

Interviews, surveys, and daily conversations were conducted in English or

Luganda, the local language most commonly spoken in Kampala. The interview language depended on each participant’s choice. In Kabalagala, as in most informal settlements in Kampala, daily speech contains a lot of slang. This was culturally informative as well as practically helpful to understand. I entered the field proficient in

Luganda and learned the local slang through daily immersion in the community. One community resident, Mr. Kizito Fred, assisted with data collection – conducting surveys and providing specific translation when needed during in-depth interviews. His status as a trusted community member also provided entrée to many venues and he provided assistance in times of potential security issues.

Data collection took place in one community in Kabalagala, Makindye Division, in

Kampala, Uganda. Table 5.1 summarizes the sampling strategy and size for each phase of data collection. Community participants were men, at least 18 years old, who had completed at least Primary 7 in school2 and who had resided or worked in the community for 6 months or longer. Other participants, such as health care workers and local leaders, who were over the age of 18 years, were included based on their professional role in the community. The sampling strategies, data collection procedures, and analysis for each phase of research are described in more detail in the remainder of this chapter.

2 Uganda’s school system is divided into the following: primary school (P1 through P7), secondary school (S1 through S4), and advanced level study (S5 through S6). Men who have completed Primary 7 (P7) have completed primary education, while those who have completed S4 have completed secondary education.

Table 5.1. Final Sample Sizes

Research phase Sample size Sampling Strategy 1. Pilot study 24 men + 1 NGO worker Purposive 2. Survey pre-test 40 men Purposive 3. Community census 3 local leaders Purposive 3. Service provider 5 health clinic/center workers Purposive interviews 3. Survey 292 men Time-location sampling 4. In-depth interviews 54 men* Purposive *A nested sub-sample of the survey sample (N = 292).

5.2. Survey Design

The variables identified as important in the pilot study were included in the survey designed for the next stage of the study. Existing validated scales were chosen if available and appropriate. The final survey included 7 sections and 112 questions, albeit with skip patterns. Two versions of the survey were pre-tested in Kabalagala in July

2017 to identify issues with language, length, format, and question order. Participants were purposively sampled based on age, job status and type, and zone within

Kabalagala. The pre-test sample included 10 participants for a shorter version (10 questions) of the survey and 40 participants for a longer version (112 questions). At first, the full longer instrument was tested, and then the sub-section on HIV testing was tested with the smaller number. Participants were consented according to approved procedures, but they were not aware the survey was a pre-test so as to simulate realistic conditions to taking the actual survey and so that respondents would appropriately respond to questions.

At the end of the survey, participants were asked to flag unclear items.

Commonly rejected items were removed from the survey. Instances of unclear language were clarified. The survey was then refined and edited based on these issues. The final survey is described later in this chapter.

5.3. Community Census

The community census was undertaken to provide a detailed assessment of community assets such as any available NGO services, health provider services, and any other types of service available to community members. It is helpful to know whether there are services, where they are, and how they related to people’s use. The community census included 1) physical mapping and survey sample design, 2) community tour with key informants, and 3) interviews with local leaders and health service providers. This provided me with a better understanding of the local context and to identify whether there were major gaps in health service availability.

A physical map of the bars and other places where men gather aided in the design of the survey sample, which relied on location as a primary sampling unit. I identified establishments, such as lodges, gambling joints, bars, where men congregate.

Some of these areas, such as gambling businesses and lodges were deemed unsuitable for sampling because the men are far too engrossed in what they are doing to conduct an interview. Additionally, interviews were conducted with local leaders as part of the census to get a sense of the community history and context.

Defining the survey sample frame. The community census honed the sampling strategy for the later survey data collection that took place in Kabalagala Parish. The community was toured with two key participants who had lived in the community for 17 and 33 years, respectively, and who were key informants through all phases of research.

Through these tours, I was able to document the community’s topography, its major landmarks, its social institutions, and any other key features. It was during these tours that various socially meaningful locations were identified. Bars were settled upon as the most frequented and the most reasonable place to sample young men from. The bars are a social gathering place, whether or not a man is drinking. Each bar was listed and then numbered from 1 to N. On each day of the survey, the described procedures were followed. As part of the census, interviews were conducted with local leaders and health

providers to gain a better understanding of the community’s history, local governance, social services, social challenges, and issues related to HIV services and prevention.

Local leader interviews. Interviews were sought with a number of local leaders from the Local Council I (Zone Level) and the Local Council II (Parish Level). Few leaders accepted to be interviewed, while some accepted and then were too busy and it was difficult to coordinate schedules. Local leaders (n=3) were interviewed about a range of topics – from the history of Kabalagala, to current politics, and challenges and successes in the community. Local leaders included two Local Council I members, and one Local Council II member. They provided invaluable insights into local politics, and community context. Interview analysis is described later in the Qualitative Data Analysis section.

5.4. Survey

Sampling. The survey used a time-location sampling (TLS) technique (Karon &

Wejnert, 2014). TLS is designed to sample hard-to-reach populations that can be found at identifiable locations. It allows sampling around these locations, which are hypothesized to have some influence on HIV vulnerability. It approximates random cluster sampling whereby every person at the location has an equal chance of inclusion, but importantly TLS accounts for time as well as the location of the sample (Raymond et al., 2007). Men in this study cluster in specific locations, primarily bars, and therefore

TLS is appropriate. It was learned in the pilot study and the community census that men frequent one bar, while infrequently going to other bars only if a friend calls them there, or for similar reasons. Their “home” bar, therefore, is the primary sampling unit (PSU) or cluster (also called the Level 2 measure in later analysis). This is where they are known, where they have a social group, and where they can be found especially during the

afternoon and evening times. Each individual man represents the secondary sampling unit (SSU).

Sampling Frame. Locations were chosen during the community census, and numbered (1-33), following the description above. All locations at which potential participants might be found on any day during a specified time (3-9 pm) were included.

As going to your home bar is a daily event for men, it was possible to sample any day of the week. Sampling occurred during peak attendance time (3-9 pm), and each bar was sampled on at least two consecutive days to catch any individuals who might have been gone on a particular day. My research assistant, who was very familiar with the various venues, also assisted with identifying peak times for each bar, which overlapped with the sampling frame and was generally the same for all bars. This was helpful to determine whether all potential participants might be reached. The venues were roughly comparable in size and number of attendees (average bar size = 46.67 men).

Randomization. At the beginning of each day, a bar was randomly chosen for recruitment, using a random number generator phone app that was set at an upper limit of 33 (33 total bars were listed during the census). The number selected corresponded to a bar that was then visited to recruit men for the survey. The number of men in the bar who appeared to be eligible (>18 years) was counted to get a baseline understanding of the bar’s attendance. This number was used to determine that bars were roughly equal in size and population. We stopped sampling when we reached Bar 19 (our last bar). At that point, we had reached our target sample size (~N = 300) based on power calculations (95% power) and so we could stop the survey data collection.

Overall, my research assistant and I moved together in the field, separating when we conducted surveys. Men at the bar were approached with a recruitment script and invited to participate. The overwhelmingly majority of the men chose to participate

immediately. A private location of their choosing was selected, typically somewhere private where chairs could be taken, and then the survey was completed.

The survey (see Appendix) was conducted one time with each participant between August to December 2019. Each survey interview lasted approximately one hour. The survey content was based on the pilot interviews, which shaped the topics that would be asked and what measures to include. The survey contained 79 questions covering demographics, economic stability and housing, alcohol use, experiences with police arrest, HIV knowledge, attitudes, and services, partner status, and health behavior. Six questions were open ended, and the rest were closed. Participants could skip over any questions that they did not want to answer, although this rarely happened.

Skip patterns were programmed into the survey tool, so that if they answered yes or no to certain questions (e.g. Do you drink alcohol?), then certain following questions would not be asked. The survey utilized previously validated scales where possible, and several newly-created items based on the pilot study (see Table 5.2 below).

Table 5.2. Survey Measures

Survey Domain Operationalization (Survey Measures) Demographics • Participant age • Ethnicity • Place of birth • Current residence • Years in neighborhood • Education level • Religion Economic • Regular employment Stability & • Irregular (or casual) job Housing • Formal employment (legal, taxed) and number of current formal jobs • Informal employment (untaxed, unregulated) and number of informal jobs • Job satisfaction • Number of hours worked per week • Number of months unemployed in the last year • MacArthur Scale of Subjective Social Status (Adler et al., 2000) • Measures of household wealth • Number and ages of children • Perceived costliness of a basket of goods (sugar, fuel, housing), housing stability (rent, own) • Frequency of going to bed hungry Alcohol Use • Number of beers in the last day • Number and unit of spirits in the last day • Alcohol use (summated alcohol measure, see description below) • Location of drinking • Bar groups (e.g. do the same men come to this bar every week?) • Whether men help each other at the bar and expectations of help Police Arrest • Number of times arrested in the past one year • Life history of imprisonment Health • Self-rate health Knowledge, • HIV knowledge scale (AIDS Indicator Survey, 2011) Attitudes, • HIV stigma scale (AIDS Indicator Survey, 2011) Practices • HIV testing knowledge and behavior (World Health Organisation, 2009) Partner Status • Current girlfriend or wife • Number of current girlfriends/wives • Current partner occupation • Primary income earner (which partner contributes more to household expenses) Health Behavior • Risky sexual behavior self-reported items (Cleland, Ingham, & Stone, 2001)

The survey included a validated measure of social status, the MacArthur Scale of

Subjective Social Status (Adler et al., 2000). This measure has demonstrated test-retest reliability (Ostrove, Adler, Kuppermann, & Washington, 2000), construct and criterion validity as evidenced with different racial groups and geographic locations (Adler &

Adler, 2006; Adler, Epel, Castellazzo, & Ickovics, 2000).

The survey contained two validated scales (Vu et al., 2017) adapted from the

AIDS Indicator Survey (2011): one measures knowledge, attitudes, and practices (HIV

KAP), and one measures risky sexual behavior. The 10-item HIV knowledge, attitudes, and practices scale was tailored to reflect popular HIV myths. For this, two myths were selected based on prior knowledge of the community: that HIV can be spread by witchcraft, and that it can be transmitted via mosquitoes. Other items covered HIV behavior (e.g., ‘does condom use reduce the chance of getting HIV?’), and HIV attitudes

(e.g., is it possible for a healthy-looking person to have HIV?’). Relevant items were reverse scored, so that each item was coded 0 = incorrect response, 1 = correct response. The 10-item scale was summated, so that 0 indicates poor HIV KAP, and 10 indicates high HIV KAP.

The survey contained one scale from the World Health Organisation: a risky sexual behavior scale (Cleland, Ingham, and Stone, 2001). Risky sexual behavior (8 items) is the outcome measure of interest in this study, used as a proxy for HIV risk. The scale includes questions on being able to reduce the risk of HIV or STI infection, alcohol use at last sex, condom use, and so on. Relevant items were reverse scored, so that each item was coded 0 = incorrect response, 1 = correct response. The 8-item scale was summated, so that 0 indicates no risky sexual behavior, and 8 indicates extremely risky sexual behavior.

Finally, in order to precisely measure alcohol intake, questions were asked about type and number of beer and spirits in the last day and in an average day. For example,

the amount of beer was noted (typically a 500 mL bottle), the number of beers, and the alcohol content (6% by volume). Additionally, the amount of spirit was noted (100 mL sachet), the number of sachets, and the alcohol content (40% by volume). By calculating the pure alcohol intake (0.40 x 100 mL = 40 mL), it was possible to create a combined measure that accounts for both beer and spirit intake. Amount of pure alcohol intake was calculated for the last day and for an average day. The amounts for an average day were then categorized based on definitions of “moderate drinking” for men using pure alcohol as a measure (CDC, 2019). These amounts of pure alcohol intake on an average day were categorized from no alcohol to low, moderate, heavy, and very heavy drinking. The ‘average day’ responses were used because the ‘last day’ responses were artificially low because we sampled during the afternoons, before peak drinking hours.

In addition to these level one (individual) measures, Mr. Kizito and I noted characteristics of the bar (Table 5.3), through our observation, familiarity with the locations, and questions asked to the manager during informal discussions through participant observation. These data included the time of the observation, the size of the bar, whether the location is primarily a bar or primarily a lodge, the gender of the clientele, and drug use. These measures, which account for the primary sampling unit

(meaning, the bar) are listed below.

Table 5.3. Bar-Level Characteristics

Bar • Bar size (number of clients) Characteristics • Bar rooms (is the location primarily a bar, mixed with lodges, or primarily a lodge?) • Bar gender (are clients primarily men, mixed, or primarily women?) • Bar drug use (is there no drug use at the bar, some drug use, or heavy drug use?)

Data management. Survey data were collected and managed using REDCap electronic data capture tools (Harris et al., 2009) hosted at Case Western Reserve

University. The survey tool was transferred to RedCAP, and mobile apps were downloaded on a tablet and a smart phone so that the online version of the survey could be accessed. REDCap (Research Electronic Data Capture) (Harris et al., 2009) is a secure, web-based software platform that provides 1) an interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; and 3) automated export procedures for data downloads to SPSS (Harris et al., 2009). REDCap allowed us to ask the interview questions and store data offline on the tablet or phone.

Each day, I connected the tablet and phone to the internet and data were pushed to the secure RedCAP server for storage and thereby removed from local storage on the devices.

5.5. Quantitative Data Analysis

Quantitative data analysis took place in several stages (Table 5.4), with the primary aim of answering Research Objective 1. Two hypotheses were tested under this research objective:

H1: More regular employment predicts lower risky sexual behavior, controlling for

age, education level, alcohol use, HIV KAP, frequency of arrest, and primary

income earner.

H2: Higher HIV KAP scores predicts lower risky sexual behavior, controlling for

age, education level, alcohol use, regular employment, frequency of arrest, and

primary income earner.

To test these hypotheses, I screened all variables to look for any violations of assumptions which would impact a regression analysis, and to look at the descriptive data to identify potential missing data. This step was also useful to gather descriptive statistics to inform the later write-up of findings. Second, I conducted bivariate analysis

between key variables of interest to flag any correlations close to zero and identify instances of multicollinearity.

Table 5.4. Quantitative data analysis overview

Quantitative Data Staging (see Fig. Tests Key Variables Analysis 4.1) Preliminary Post survey data Descriptive statistics All screening collection, pre- Histograms interview data collection Bivariate tests Post survey data Pearson’s r • Age collection, pre- correlation • Ethnicity interview data Scatterplots • School completed collection Boxplots • Regular employment • Number of times arrested in the last year • Primary income earner in the household • Alcohol use scale • Risky sexual behavior • HIV KAP • Self-rated health • HIV concern • Recent HIV test (<12 months) Multiple regression I Post survey data Hierarchical OLS • Age collection, pre- multiple regression • Ethnicity interview data • School completed collection • Regular employment • Number of times arrested in the last year • Household primary income earner • Alcohol use scale • HIV KAP Multiple regression II Post data collection Least Square • HIV KAP Dummy Variable • Regular employment (LSDV) Fixed • Dummy variables for Effects Model each bar

Next, multiple regression was conducted to test initial hypotheses (H1, H2) in this study regarding predictors of risky sexual behavior. Specifically, hierarchical OLS multiple regression was used to examine the relationship between risky sexual behavior and age,

ethnicity, school completed, regular employment, number of times arrested, primary household income earner, alcohol use, and HIV KAP. The focal predictors for this analysis were HIV KAP and regular employment.

Preliminary Data Screening. All analyses were conducted in SPSS statistical software.

At the univariate level, I ran frequencies on all variables, including descriptive statistics

(mean, standard deviation, median, mode, skewness, kurtosis, minimum & maximum) and histograms (with a normal curve). Using these data, I could check the shape, distribution and range of scores on each variable and flag any violations of assumptions.

At the univariate level, I checked for non-normality and outliers. In order to check for normality, histograms and skewness and kurtosis values were examined and compared to Curran et al.’s (1996) threshold of concern after skew > 2 and kurtosis > 7.

Histograms were examined and compared to their normal curve lines to detect any deviations.

Regression assumptions (see Table 5.5) include 1) a linearity of relations between risky sexual behavior and predictor variables, 2) homoscedasticity of residuals

(i.e. equal error variances), 3) independence of observations (i.e. independence of residuals), 4) the residuals should be approximately normally distributed, 5) no multicollinearity (two or more independent variables too highly correlated), and 6) no significant outliers (Allison, 1999, p. 122-123).

At the bivariate level, I examined the relationship between each of the variables to flag any correlations close to zero and any instances of multicollinearity. Extreme multicollinearity was diagnosed using Allison’s (1999, p. 64) criterion of a Pearson’s r correlation greater than 0.80. It was also crucial to look for concerning tolerance

(tolerance < 0.40) and anywhere variance inflation factors went above 2.50 (Allison,

1999, p. 141). I examined the scatterplots and boxplots for potential outliers (greater than or less than two standard deviations) to flag for further diagnostic testing.

Table 5.5. Regression assumptions and relevant statistical tests (Allison, 1999 unless otherwise noted)

Assumption Tests of Assumption Linearity of outcome and predictors Scatterplots of the outcome and each predictor Homoscedasticity of residuals Scatterplots of the residuals versus each predictor and predicted outcome Independence of observations Difficult to assess with one wave of data. Not applicable for this dissertation. Normality of residuals Normal Q-Q plot of residuals No significant multicollinearity Correlation coefficients and tolerance/VIF values No significant outliers Mahalanobis distance (Aguinis et al., 2013)

The linearity of relations was assessed by examining scatterplots of the outcome and predictors (Allison, 1999, p. 123-124). Homoscedasticity was assessed by examining scatterplots of the residuals versus each predictor and the predicted outcome (Allison,

1999, p. 125-126). Finally, normality was assessed by examining a normal Q-Q plot of residuals (Allison, 1999, p. 130-131). Additional diagnoses at the multivariate level included examining plots of Mahalanobis distance versus each predictor to identify outliers (Aguinis et al., 2013, p. 277).

Hierarchical OLS Multiple Regression. Hierarchical OLS multiple regression was performed in three steps, with variables added as follows: Step 1, demographic variables

(age and school completed); Step 2, Alcohol Use and HIV KAP were added to the previous variables; Step 3, regular employment, frequency of arrest, and household primary income earner were added in the last step. I chose to first examine the additional variance explained by demographic variables, then alcohol use and HIV KAP separately, followed by the final variables. I wanted to separate out the additional

variance explained by each group, by selecting two traditional drivers of risky sexual behavior (HIV knowledge, and alcohol use).

Finally, the ultimate hierarchical OLS multiple regression equation (i.e. after Step

3) is as follows:

I Risky Sexual Behavior = B0 + B1 * Age + B2 * Schooling Completed + B3 * Alcohol

Use + B4 * HIV KAP + B5 * Regular Employment + B6 *

Frequency of Arrest + B7 * Household Primary Income

Earner (Male Primary Earner = 1) + e

In other words, the model examines the relationship between predicted risky sexual behavior scale scores and age, education level, alcohol use, HIV KAP, regular employment, frequency of arrest, primary household income. Each B above represents the variable coefficient. The model also includes an intercept (B0) and error term (e).

Cluster Data Analysis. Typically, the 30/30 rule (Hox, 2002) guides the number of clusters and number of individuals per cluster to conduct multilevel modeling. For this dissertation, 19 bars were sampled with a range of individuals per bar (6-32) and an average cluster size of 15.73. With clustered data, the intra-class correlation (ICC) can be used to determine the amount of dependence on group membership, and therefore guides the type of analysis to be used (Hox, 2002).

To calculate the ICC, I first ran a null model (an intercept-only model) without any predictors using Maximum Likelihood Estimation:

Yij = !0j + "ij

The intercept only model does not explain any variance in Y (risky sexual behavior), but includes the intercept (ß) and the lowest level error term (e). From this model, I

* * calculated estimates for between group variance ('() ) and within group variance ( ', ), used in the ICC formula.

* '() - = * * '()+ ',

The ICC was calculated to equal 0.09, which signifies that multilevel modeling is not necessary using Hayes’ (2006, p. 394) criterion. From the ICC, I calculated the design effect to calculate the adjustment needed to analyze clustered survey data.

Design effect = 1 + ICC * (average cluster-1)

Using the ICC of 0.09 and the average cluster size (15.74), the design effect equaled

2.35. Multilevel modeling (MLM) is not needed if the ICC and the design effect are sufficiently close to zero, indicating that observations are statistically independent.

Therefore, an ICC of 0.09 and a design effect of 2.35 do not warrant MLM analysis.

However, McNeish and Kelley (2018) advise accounting for the nested structure of data through analysis.

Least Square Dummy Variable (LSDV) Fixed Effects Model. This dissertation used McNeish and Kelley’s (2018) recommended method for handling nested data. The authors define “fixed effects” as an entire modeling framework (Allison, 2009) to model the clustered structure of data using cluster affiliation dummy variables. The dummy variables are incorporated directly into the model as predictors (from 1-19 for each bar)

(McNeish & Kelley, 2018). Each coefficient produced by this method represents cluster- specific estimates that account for all Level 2 (bar level) variation. To accomplish this, I used “absolute coding,” whereby a different cluster affiliation dummy variable was created for each of the 19 bars, while also removing the intercept to avoid overparameterization of the model (McNeish & Kelley, 2018). By doing so, each cluster represents a cluster-specific intercept representing the average risky sexual behavior at that bar. A specific assumption of this model is that the model needs to be correctly specified with Level 1 (individual level) predictors. These Level 1 predictors must have

variability within clusters because an FEM would only account for within-group variation

(McNeish & Kelley, 2018). The following equation guided this analysis:

I Risky Sexual Behavior = B1 * HIV KAP + B2 * Regular Employment + α1 * Bar

Group 1 + α2 * Bar Group 2 … α19 * Bar Group 19

In the equation, B1 denotes the relationship between HIV KAP and risky sexual behavior,

B2 captures the relationship between regular employment and risky sexual behavior, and the alpha parameters represent the bar-specific intercepts. Note that no intercept was included.

5.6. Service Provider Interviews

Sampling. Service providers were sampled if they were employees of any of the clinics or health centers surrounding Kabalagala, which included one private clinic, one

NGO clinic, and one government health center at level three. Providers were purposively sampled, based on the type of work (HIV services) and their availability to be interviewed. At the private clinic, there was only one nurse who was on staff during the daytime, and one at night. Both were interviewed. At the NGO, where all doctors specialized in HIV, the doctor in charge of the staff was interviewed. At the government health clinic, two staff members working in the HIV unit were interviewed.

Interviews with service providers were ongoing throughout data collection.

These interviews included questions about community demographics, health services, and challenges they encounter in providing services to men. Analysis is described below in the section on qualitative data analysis.

5.7. In-Depth Interviews

Sampling. Every survey participant was asked at the end of the survey whether they would be willing to be contacted at a later time if chosen to participate in an

interview. Nearly all (98.6%) participants agreed to be contacted, and of those actually contacted all (100%) agreed to be interviewed.

In-depth interview participants were purposively chosen to represent a range of ages and experiences with HIV (HIV+, HIV- and high-risk or low-risk, no knowledge of status). Because of sparse data regarding HIV prevalence, exact numbers for these categories were not set. Men were selected based on employment status as well: unemployed; underemployed, which included doing small, odd jobs; and fully employed.

Most men were underemployed, very few were fully employed. A few participants were selected specifically because of their female sex worker partnerships, lodge management work, or drug use – what represent some of the more challenging life experiences in Kabalagala. Again, because of the sparse data on men in sex work communities, specific percentages were not set for the aforementioned categories.

Finally, some of the participants turned into ‘key informants,’ or individuals with a depth of knowledge and experience in Kabalagala (Bernard, 2017). Not all of the key informants (n = 5) were selected a priori, but some emerged (n = 3) throughout the course of the interviews. Mr. Kizito and I gathered lists of potential interviewees while conducting the surveys. We met before sampling for the interview and chose individuals who represented these ranges of experiences. Rapport with participants was also important, and some were chosen because I had a higher level of rapport with them.

The target sample size of 60 men was set to represent 20% of the survey sample. The final sample size was 54 participants (18% of survey participants) with data saturation reached at this point.

Interviews were primarily conducted in English, the national language used in education in Uganda. Sometimes the conversation switched to Luganda. Men were interviewed at a place of their choosing. All chose to be interviewed in the community,

and chose either a semi-private corner of the community (behind a bar or business), or a quiet corner of a bar or restaurant.

Interviews guides (see Appendix) were designed based on the survey results and addressed contextual factors that pattern men’s risk and vulnerability. Further, as participants were recruited from specific community locations, interviews assessed the meaning of social mechanisms associated with these bars, including “bar membership” or reciprocity groups. This information elucidates the patterning of men’s sexual health risk in this context, and men’s social resilience and vulnerability more broadly.

Interviews were not specifically designed to last multiple sessions. Some participants finished the interview in one sitting, while others required additional follow up. Sometimes the conversation expanded on a specific topic or aspect of their life experience. Most (n = 48) participants were interviewed more than once, with a few (n =

3) participants interviewed 3-4 times. These few participants were interviewed multiple times because they were not only key informants, but their life experience required multiple sessions to cover – and they were very willing to share these experiences related to HIV vulnerability and social resilience. Others, n = 16, were interviewed only once and were not interviewed again for a variety of reasons. These reasons included that some participants who moved away, went to their familial home in the village, or left for some other reason. Others were interviewed only once because of their lack of willingness to respond to the interview questions, or because they were too taciturn.

5.8. Participant Observation

Participant observation continued throughout the study, in key venues such as bars, restaurants, lodge reception areas, shops, or on the street. Participant observation included periods of time in these areas to build rapport with community members and

cross-check information from the interviews. It also served to provide context, including local developments, political issues, interpersonal gossip, and so on.

Observation was conducted throughout the community, in public spaces with meaning for the men as identified in the pilot study and the community census. These included bars, spaces with ludo (a game similar to Parcheesi that people play for money), small shops, video halls, and other informal gathering spaces typically outdoors.

These observations served to build rapport with the men, as they got used to my presence and folded me into their daily conversations. They would offer food or drinks

(e.g., water, soda) as my reputation for refusing beer or alcohol was soon learned.

Occasionally, I would take part in local community meetings led by local leaders or police. These meetings allowed community members to air their grievances to local leaders and to review goings-on in the community. Police would often frequent the community to educate on various issues – e.g., change in opening hours for the bars, or education on what sex workers should do with their kids when they were with clients, for example, leaving them with a neighbor to supervise their safety. These education sessions were part of a “Community Policing” initiative rolled out nationwide as an effort to improve relationships between the police and the community.

Too often, there were also times of crisis that were important to observe, for example, the aftermath of the murder of one sex worker, the murder of a local phone repairman, and other such cases. Fights and violence were all too common, resulting from interpersonal issues between couples to fighting between rival lodge managers.

Arrests were also quite common, with police sometimes rounding up more than 25 men at a go. I was also in the community during times of political crisis, such as one day when the entire city shut down due to massive protests in support of a musician-turned

Member of Parliament, Bobi Wine, who leads an opposition party.

Often during observation in the field, a notebook was taken out to jot down observations. If this was not feasible or appropriate, I would sometimes take notes on my phone or use voice memo. At the end of each day, field notes were written up to capture these observations and any events that had taken place. Taken together, these observations informed understanding of the local context – from political goings-on to crisis events, to understanding the ways in which men struggled to survive on a daily basis.

5.9. Qualitative Data Analysis

Service provider interviews, local leader interviews, men’s in-depth interviews, and field notes were analyzed using thematic analysis (Braun & Clarke, 2006) as described here. Thematic analysis is useful to understand how people attribute meaning to particular phenomena “in interaction with those around them in context-specific settings” and it is useful to develop culturally anchored methods (Jason & Glenwick,

2016, p. 33). The focus is the interpretive, inductive process of identifying themes in interview text.

As an initial step, a codebook was created based on iterative readings of the transcript or field note and selection of emergent codes. Additional codes were added to represent key variables of interest based on theoretical frameworks guiding this research. This codebook was then tested on three transcripts to check for feasibility and identify any issues with implementation. The codebook was then appropriately revised.

Finally, all remaining materials were iteratively coded. During the coding process, I added annotations and notes throughout each transcript.

As a next step (Bernard, 2017; Braun & Clarke, 2006), the coded transcripts and field notes were reviewed to identify an initial list of semantic and latent themes. Codes were grouped together into themes based on how they relate to one another (see

Appendix). At this stage, a table was created that included themes and associated codes. Most codes were associated with one theme, but some associated with more than one theme.

In the next phase of analysis, I reviewed, modified, and developed the preliminary themes identified to date (Bernard, 2017). Example quotes were provided for each theme. The themes were examined in relation to one another, while areas of overlap and gaps were identified. Themes were examined from a single interview as well as across interviews. Two steps were involved in this process (Jason & Glenwick, 2016, p. 35): 1) evaluation of whether the coded extracts under each theme are coherent, and

2) assessment of whether the themes capture the entire data set.

Finally, I conducted final refinement of the themes to identify the essence of each theme (Braun & Clarke, 2006, p. 92). Next, themes were defined and named, and the central idea in each theme was described (Jason & Glenwick, 2016). Subthemes were useful to identify further categorization of the coding. I drafted language for potential inclusion in the results, to explain how each theme related to the overall findings of the dissertation. As part of this, a thematic map was created to interrelate the themes (see

Appendix).

5.10. Integration of Quantitative and Qualitative Methods

Mixed method analysis involved several procedures (Table 5.6) following recommendations by Creswell and Clark (2018). For ease of comprehension, a table format modified from Creswell and Clark (2018, pp. 210-211) is used below (Table 5.6).

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Table 5.6. Data Analysis Procedures

Phases in Data Step 1: QUANT Data Analysis Step 2: QUAL Data Analysis Analysis • Assign a numeric value to • Listen to interview survey responses in an Excel recordings database • Transcribe the data • Clean the database (check for • Check transcripts for Data analysis errors) accuracy preparation • Recode items and compute new • Organize the data by variables participant • Establish a codebook with the • Import data to NVivo name and definition of each variable • Conduct preliminary analysis by • Read through the data and checking for normal distribution write memos to identify Explore the data • Conduct descriptive analysis for initial themes each major variable • Develop initial codes and a • Identify any missing data priori codebook • Calculate the intra-cluster • Select the analysis correlation to identify potential approach based on the between-group variation research questions • Select appropriate statistical • Use NVivo to analyze the tests data by implementing a Analyze the data • Analyze the data using SPSS to coding process, including: answer quantitative research 1) code with initial codes, questions and test hypotheses 2) include axial codes as described above • Conduct thematic analysis as described above

There are two main areas where the integration occurs in an explanatory sequential design (Creswell & Clark, 2018, p. 80). The first is between the quantitative data analysis and the qualitative data collection. Integration in this explanatory sequential study involved connecting the results from the initial quantitative phase to help plan the follow-up qualitative data collection. For example, to integrate these stages, I first analyzed the qualitative data collected in the survey phase. The analysis included preliminary screening of variables (univariate frequencies and distributions) and bivariate Pearson’s r correlations. I also ran one hierarchical logistic regression to examine predictors of recent HIV testing. The integration plan included what questions need to be further probed and what individuals can be sampled to best help explain the

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quantitative results. By identifying unclear relationships between survey variables, it was then possible to outline areas of follow up for the qualitative data collection. It was the quantitative analysis that informed the interview guide for the qualitative portion, thereby integrating the quantitative and qualitative data.

Secondly, once the qualitative phase is complete, I was able to integrate the two sets of connected results and draw integrated conclusions about how the qualitative results explain, interrogate, contradict, and extend specific quantitative results.

5.11. Ethics Procedures

Ethics review was obtained from three institutions, from my home institution Case

Western Reserve University’s Institutional Review Board (IRB-2016-1440), from the local ethics review at Makerere University’s School of Social Science Research Ethics

Committee (MAKSS REC 12.17.107), and from the Uganda National Council of Science and Technology (SS199ES).

All participants were initially approached using an IRB-approved recruitment script that reviewed the study procedures and purpose. For the survey, men were allowed to be interviewed at a place of their choosing. Almost all chose to be interviewed at the time of recruitment, and we often found a quiet and semi-private location – either in a corner of a bar, or outside on a bench, or other suitable alternatives. Participants were first consented and then the survey began. At the end of the survey, participants were asked whether they would be willing to be contacted in the future for additional interviews. If so, their first name and mobile number were stored in a separate notebook.

This information was transferred each night to a participant log, on a password-protected laptop. Interview participants were approached with a similar recruitment script, and were re-consented using a different consent form for the in-depth interviews. Permission

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was obtained to audio record, and notes were taken if audio recording was refused. All interview audio was transferred to a password-protected laptop at the end of each day.

As this population has a very high rate of alcohol use, we encountered many men who were too drunk to be consented. Men were asked a series of simple, introductory questions (e.g., how much have you had to drink today?) for comprehension and to determine their level of soberness. Men who were drunk or near-drunk were asked to schedule an interview on another day, earlier in the day – before they would start drinking. This was also a reason for conducting interviews early in the day – usually between 12-3 pm, before most men start drinking.

Frequently during or at the end of interviews, men would express a desire for HIV services – from testing to re-starting their antiretroviral therapy. Relationships were established with two nearby clinics, both of which had free or near-free health services to offer. We would provide referrals to these locations, and in some cases when asked, escort the men to the clinic and sit with them during their visit. Additional services for post-violence or post-arrest were requested, and handled ad hoc using a network of organizations for appropriate referral – including a legal aid organization, a sex worker organization, and an intimate-partner and community violence organization. On many occasions when participants were arrested, I linked them to the legal aid organization to assist with their case.

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Chapter 6 HIV in Context

A central aim of this dissertation is to understand the political economy of HIV, specifically to understand the linkage between inequality and unemployment and poor

HIV outcomes among men. To better understand the disproportionately high prevalence of HIV among male partners and clients of sex workers (18%; Crane Survey, 2010), baseline data were gathered on HIV knowledge, attitudes and practices, risk behaviors, access to health services, and care along the continuum (HIV testing to treatment).

A number of paradoxes emerged from these findings. While men had a high knowledge of HIV knowledge, attitudes, and practices, this was accompanied by high rates of risky sexual behavior. In terms of health services, men are able to access services, but HIV testing rates are below the goal of 90% set by international programs such as the United States’s PEPFAR program (PEPFAR, 2019). Further, HIV treatment is often interrupted and these interruptions are driven by social conditions such as housing instability. The chapter ends by posing apparent paradoxes in men’s response to HIV: for example, why do men engage in risky sexual behavior despite having a high knowledge of HIV transmission? What are the upstream barriers to HIV medication adherence? These paradoxes are best addressed by employing the frameworks of the risk environment (Chapter 7) and vulnerabilities (Chapter 8) both of which derive from a political economy of health framework (Chapter 2).

6.1. Sample Characteristics

Table 6.1 below shows the characteristics of the men in this sample. The average age of the sample was 29.6 years old, ranging from 18 to 52 years old. This group is younger than the population sampled in UDHS (UBOS & ICF, 2016), where

29% were 25-24 years old. Of the sample, 31.3% were born in Kampala, while 68.7% migrated from outside the city. On average, men had spent 3.3 years in the study

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community in Kabalagala. The majority (51.2%) of the sample are Baganda, and the second largest ethnicity represented was the Banyankole (15.1%). The sample was mostly Catholic (35.7%) and Muslim (29.9%). The sample education level was roughly comparable to the UDHS sample, with 21.7% of the sample having finished high school compared to 26% of the UDHS sample. Notably, 9% of my sample completed post- graduate education, while 12% of the UDHS sample had completed more than secondary school.

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Table 6.1. Participant demographics (survey N=292) Variables N (Survey) Percent (%) Age 18-24 69 23.9 25-34 156 54.0 35-44 56 19.4 45-54 8 2.8 Mean ± SD 29.6 ± 6.6 -- Birthplace Kampala 92 31.3 Masaka 23 7.8 Mbarara 16 5.4 Wakiso 7 2.4 Mukono 7 2.4 Other 147 50.7 Ethnicity Baganda 149 51.2 Banyankole 44 15.1 Acholi 9 3.1 Other 89 30.6 Residence Zones 1-4 184 62.6 Zones 5-9 82 27.9 Other 26 9.5 Years in neighborhood 0.5-4 47 18.2 5-9 67 26.0 10-14 43 16.7 15-19 43 16.7 20-24 23 8.9 25-29 15 5.8 30-34 11 4.3 35-39 5 1.9 40-44 4 1.6 Mean ± SD 3.3 ± 1.9 -- Education level Primary 7 110 37.9 Senior 1 19 6.6 Senior 2 28 9.8 Senior 3 15 5.2 Senior 4 63 21.7 Senior 5 6 2.1 Senior 6 20 6.9 Institute certificate 8 2.8 University or higher 21 7.2 Religion None 9 3.1 Anglican 70 24.1 Catholic 104 35.7 Muslim 87 29.9 Born-Again 17 5.8 Traditional 2 0.7 Other 2 0.7 Note: N, number of non-missing values; SD, standard deviation

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6.2. HIV Knowledge, Attitudes, and Practices

A pillar of Uganda’s HIV policy is prevention (Uganda AIDS Commission, 2015).

The Uganda AIDS Commission, responsible for much of the coordination of HIV programs and policy in the country, described priorities in their National HIV and AIDS

Strategic Plan, 2015/16-2019/20. Scaled up HIV prevention interventions were identified as key to reduce new HIV infections. A particular focus was combination HIV prevention, focusing on biomedical, behavioral, and structural interventions. Their prevention strategy contains three objectives, 1) to increase the adoption of safer sexual behaviors and reduction in risky behaviors, 2) to scale-up coverage and utilization of biomedical

HIV prevention interventions delivered as part of integrated health care services, and 3) to mitigate underlying socio-cultural, gender, and other factors that drive the epidemic

(Uganda AIDS Commission, 2015). One key measure of HIV prevention mentioned in

Figure 6.1. Men’s HIV knowledge, attitudes, and practices (KAP) scale

The scale (AIS, 2011; see Appendix) aggregates responses to 10 items. Items were scored with 0 = Incorrect response, 1 = Correct response. All relevant items were re-coded so that 0 indicates no knowledge of HIV, and 10 indicates complete knowledge. Any score above 7 would indicate positive KAP.

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the strategic plan is knowledge, attitudes, and practices related to HIV. This section goes into detail on this key aspect of HIV prevention. In order to better understand HIV transmission among Kabalagala’s men, I collected baseline data on the level of HIV knowledge, attitudes, and practices (Figure 6.1). Fifty-one percent of men in the sample correctly answered all questions related to HIV knowledge, attitudes, and practices. A subset of five questions from this scale can be aggregated to measure “comprehensive knowledge of HIV” (AIDS Indicator Survey, 2011). In this study, 65% of men have comprehensive knowledge of HIV, compared to 58% of all urban men in Uganda in 2011

(AIDS Indicator Survey, 2011). A mean score of 9.03 was observed on the 10-item scale, indicating a high level of HIV knowledge, attitudes, and practices.

No participant received a score lower than four. Participants had the most trouble correctly answering the question on whether HIV/AIDS can be transmitted via mosquito.

Of the 292 participants, 66.4% correctly answered the question. In 2011, the AIDS

Indicator Survey (2011) reported that 59% of men understood that HIV is not transmitted by mosquito. An additional question, “if a member of your family got infected with HIV, would you want it to remain a secret?” generated debate, with men interpreting the question differently. Some interpreted it as keeping it a secret within the family, others understood it to mean that the HIV+ individual would tell no one. Ninety-seven percent of men knew that condoms prevent sexually transmitted illnesses (STIs), while 96% percent knew that it prevents HIV. Nearly 100% (99.3%) agreed that they would care for an HIV positive member of their family. Finally, 96% of men know that HIV is not transmitted via witchcraft, while only 84% of men nationally understood the same in

2011 (AIDS Indicator Survey, 2011).

Kabalagala is frequently targeted by HIV service providers because it is considered a “high-risk” location because of the prevalence of sex work. Because of this, residents are likely more aware of HIV than the average person. During the interview, I

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would ask men from where they receive HIV information. Men generally reported that they do not speak about HIV with their friends or family members. Their information is received mainly through health workers who come to the community, or who they interact with at the health center. Only one man reported that he talks about HIV with his friends “very much,” especially that:

I tell them to get tested and when they are positive to get drugs or go to the counsellor if they don’t want to go to the hospital. - Hamim

A lodge manager, Muhammad, reported that he is concerned about HIV, particularly among his sex worker staff:

We talk about it [HIV] because the work I do, I personally work on issues concerning sex so when someone visits me the first things I say are “you have come to this place but it’s not easy”, because there are many children that I have brought up they say “ahh, if not for that man we wouldn’t be here because we came to this area with high expectations of having fun but he talked to us and gave us direction”. They thank me until now so I do a lot on health. I talk about it even now because people love this area, they love Kabalagala. Even the new girls who come here that I work with, I call them and tell them “you have come to look for money, right”? Right. “But the ways of life here are not easy, there are a lot of men and they love new girls so when they see you, they will all want you but be careful because you came to look for money and not love so if you find a man who has money, use a condom, and don’t fall in love with them because when you use a condom three or four times he will tell you, “my dear, let’s stop using a condom because I am safe.” Go with him twice but not the third time because they always have a mission. - Muhammad

Muhammad presents an unusual approach to HIV prevention in the workplace. He certainly demonstrated more concern for his staff than other lodge managers interviewed. It is possible that he was trying to make it look like he is concerned, but this response is not out of character. He has an established reputation in the community for being a hard-working businessman who cares about the people who work for him. It also demonstrates his savvy after years of working in the community in the lodge business.

Moreover, this approach to using condoms with clients is coherent with what other men said about sex workers. It is not the client-sex worker relationship that presents the highest risk of HIV transmission, because condoms are frequently used.

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Further, Kabalagala is frequently targeted by HIV outreach workers. It is not uncommon to see health workers in Kabalagala; they come at differing times, during the early morning or daytime, but never at night. They arrive with a few health workers, HIV testing kits, questionnaires, and establish their outreach at one of two bars centrally located in the community. Both bars are visible from the road, and it is easy to see who is testing or receiving counseling. I observed these outreaches on many occasions, with various organizations cycling through the community. Despite these attempts to reach people “where they are,” men (n = 19 out of the 54 interviewed) lament that they have no one who they can speak to about HIV, in case of any questions or concerns. Throughout the course of interviews, men would often ask questions that they have, as indicated:

“you are now the people who can advise me on what to do and what not to but there is nobody else that I can ask, nobody can advise me.” To handle these questions, we would answer the questions as appropriate, and refer participants for services at a nearby clinic.

6.3. Risky Sexual Behavior

In this community, HIV is typically spread via unprotected sex, as injection drug use is very rare. Therefore, risky sexual behavior is used as a proxy for overall HIV risk, because it accounts for the overwhelming majority of HIV infections in Kabalagala. All men in this study are current or former partners and/or clients of sex workers.

Unprotected sex between both casual and longer-term partners is common, shaped by complicated dynamics of love, fertility desires, trust, a desire to differentiate client and non-client relationships, and alcohol use that accompanies low condom use (Argento et al., 2015; Barrington et al., 2009; Deering et al., 2011; Godin et al., 2008; Syvertsen et al., 2015). Unprotected sex between sex workers and their male partners is a cause for concern in public health, because of the high prevalence rate in FSW. As a result, male

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partners are deemed a “priority population” in HIV prevention due to the high-risk sex with sex workers. Men are also considered a “bridge population” between the higher prevalence sex workers and the general population. However, as this section details, not all intimate partnerships between men and their sex worker partners are uniformly characterized by risky sex. The dimensions of risky sex, including multiple sex partners, condom use, and alcohol use, and the social meaning of risky sexual behavior, are both explored here.

Risky sex is defined generally as having multiple sexual partners, low or no use of condoms, and alcohol use before sexual intercourse (CDC, 2019). In the context of this study, it is operationalized using an 8-item scale that covers condom use, other forms of contraception use, numbers of current sexual partners, and alcohol use before last sex. The aggregated results of the scale are reported in Figure 6.2.

Figure 6.2. Men's risky sexual behavior scale scores

Note: Risky sexual behavior among men (n = 292), as measured through an 8-item scale. The summated scale contained questions on condom use, and HIV and STI concern and avoidance strategies. Items were rescored so that 0 indicates a self-reported risk behavior, and 1 indicates no self-reported risk behavior. Individuals scoring 6 and higher would indicate “high risky sexual behavior,” 4-5 “medium risk,” and 1-3 “low risk.”

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Only three of the men in this study reported no risky sexual behavior, while a majority reported four or more risky behaviors. UPHIA (2016-2017) reports results on condom use with the most recent sexual partner (Ministry of Health, 2019). Of all men (15-64 years old, note my sample was 18+) who reported a recent sexual relationship, 45.2% used a condom (UHPIA, 2019). To investigate possible predictors of risky sexual behavior, two types of regression analyses were conducted.

6.3.1. Multiple Regression Analysis: Predictors of Risky Sexual Behavior

Hierarchical Regression. A multiple linear regression model was conducted to determine if risky sexual behavior could be predicted by age, schooling completed, alcohol use, HIV KAP score, regular employment, number of times arrested in the last year, and household primary income earner. The null hypotheses tested were that the multiple R2 was equal to 0 and that the regression coefficients were equal to 0. The data were screened for missing data and violations of assumptions prior to the analysis.

“Household primary income earner,” a categorical variable with three categories (Male

Primary Earner, Wife Primary Earner, Equal Earners) was dichotomized to account for the low number of responses under “Equal Earners.” The final variable included Male

Primary Earner (= 1) and Wife Primary Earner (= 0). Equal Earner responses were included under the Wife Primary Earner category. Overall, there were some missing data across the participant responses. After listwise deletion, a final N of 258 was included in this regression.

A review of the partial scatterplot of the predictor variables and the outcome

(risky sexual behavior) indicates that linearity is a reasonable assumption. Preliminary data screening found no skewness (skew > 2) and no kurtosis (kurtosis > 7) on any individual variables (Curran et al., 1996). Means and standard deviations (Table 6.2) were within expected ranges for each variable. All variables looked relatively normal,

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after examining histograms, and were within the normal range based on Curran et al.’s

(1996) criteria.

Table 6.2. Mean values and standard deviations for risky sexual behavior and predictor variables Measure Mean Standard Deviation Risky Sexual Behavior (Outcome) (0 = No 4.05 1.83 Risky Behavior, 10 = Highly Risky Behaviors) Age 29.18 6.64 Schooling Completed (1 = Primary 7, 9 = 3.57 2.57 University or Higher) Alcohol Use (1 = None, 5 = Very Heavy) 2.81 1.83 HIV KAP Scale (0 = None, 10 = Perfect) 9.01 1.30 Regular Employment (0 = No, 1 = Yes) 0.52 0.50 Number of Times Arrested in the Last Year 0.80 1.23 Household Primary Income Earner (Male 0.51 0.50 Primary Earner =1) Note: n = 258 for all variables. No excess kurtosis (> 7) or skewness (> 2) was detected and so values are not reported here (Curran et al., 1996). Note that a 3.57 mean on schooling completed indicates an average schooling level between Senior 2 and 3. A mean of 2.81 on the alcohol use scale indicates moderate drinking. A mean of 9.01 indicates a high level of HIV KAP.

In addition to the sample being young, mean risky sexual behavior was moderate (4 out of 10). Men were frequently unstably employed (52% report not being stably employed), and most of the participants had a record of arrest in the last year. About 51% of men reported that they were the primary income earner in their household, compared to 49% of women as the primary earner or equal earner.

At the bivariate level (Table 6.3), the following correlations were close to zero: age and risky sexual behavior, and alcohol use and risky sexual behavior. Only schooling completed, HIV KAP score, regular employment, and number of times arrested were significantly correlated to the outcome. No multicollinearity (correlation >

0.80) was found, using Allison’s (1999, p. 64) criterion to diagnose multicollinearity. The strongest correlation was -0.28, with higher levels of schooling associated with lower levels of risky sexual behavior.

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Table 6.3. Intercorrelations for risky sexual behavior and predictor variables Measure 1 2 3 4 5 6 7 8

1. Risky Sexual ---- Behavior (Outcome)

2. Age -0.03 ----

3. Schooling -0.28** 0.11* ---- Completed

4. Alcohol Use -0.02 -0.05 0.01 ----

5. HIV KAP -0.13* 0.09 0.26*** -0.07 ---- Score

6. Regular -0.17** 0.18** 0.10 -0.04 0.19** ---- Employment (Yes = 1)

7. Number of 0.11* -0.23*** -0.13* 0.07 -0.16** -0.22*** ---- Times Arrested in the Last Year

8. Household -0.09 0.14* 0.15** -0.01 0.07 0.16** -0.21*** ---- Primary Income Earner (Male Primary Earner = 1) Note: *p < .05 **p < .01 ***p < .001

The lowest tolerance value (0.88) and highest variance inflation factor (1.14) both for the variable “number of times arrested in the last year” were not concerning based on Hair et al.’s (2014) criteria for flagging multicollinearity. The boxplots suggested a relatively normal distributional shape with no outliers of the residuals. The Q-Q plot and histogram suggested normality was reasonable, as did the Mahalanobis distance (Aguinis et al.,

2013, p. 277). A relatively random distribution of points in the scatterplots demonstrated that the spread of residuals is relatively constant across the predictor variables.

A hierarchical multiple regression (Table 6.4) was run to determine if the addition of age and schooling completed, then of alcohol use and HIV KAP score, and finally regular employment, number of times arrested, and household primary income earner,

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improved the prediction of risky sexual behavior. To assess the contributions of each block of predictors, the F statistics for individual blocks were examined. In Model 1, schooling completed was statistically significant, and the overall model was significant as well, with F(2, 255) = 10.82, p < .001. In Model 2, neither added predictor was significant, but the overall model was significant F(4, 253) = 5.68, p < .001. Model 2 explained an additional 0.4% variance in risky sexual behavior compared to Model 1, with a change in R2 = 0.004. The full model of age, schooling completed, alcohol use,

HIV KAP score, household primary income earner, regular employment, and number of times arrested in the last year to predict risky sexual behavior (Model 3) was statistically significant, R2 = 0.11, F(7, 250) = 3.10, p < .001, adjusted R2 = 0.08. The null hypotheses were rejected at p < .001.

Table 6.4. Summary of hierarchical regression results predicting risky sexual behavior B SE B b CI Model 1 Intercept 4.74*** 0.51 -- [3.74, 5.74] Age 0.01 0.02 0.03 [-0.03, 0.03] Schooling Completed -0.20*** 0.04 -0.28*** [-0.29, -0.12] Model 2 Intercept 5.56*** 0.92 -- [3.76, 7.37] Alcohol Use -0.02 0.06 -0.02 [-0.14, 0.10] HIV KAP Score -0.09 0.09 -0.06 [-0.27, 0.08] Model 3 Intercept 5.13 0.96 -- [3.24, 7.01] Regular Employment -0.48* 0.23 -0.13* [-0.94, -0.03] (Yes = 1) 0.08 0.10 0.05 [-0.11, 0.27] Number of Times Arrested in the Last -0.08 0.23 -0.02 [-0.53, 0.37] Year Household Primary Earner (Men Primary = 1) Note: Each additional model included variables from the previous model. *p < .05 ** p < .01 *** p < .001

To assess the contributions of individual predictor variables, the t ratios for the individual regression slopes were examined for each variable (Warner, 2013). In Step 1, schooling completed was statistically significant t(255) = -4.63, p < .001. The relationship

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between schooling completed and risky sexual behavior was as expected; it indicates that higher levels of schooling predict lower risky sexual behavior. For each additional year of schooling completed, predicted risky sexual behavior would be 0.19 points lower on average, controlling for other predictor variables. In Step 2, no predictors were significant. In Step 3, regular employment was statistically significant t(250) = -2.09, p <

0.05.

The relationship between regular employment and risky sexual behavior was as hypothesized; with more regular employment predicting lower risky sexual behavior.

These regression results demonstrate that hypothesis 1 correctly predicted relationships between key variables. More regular employment does seem to predict lower risky sexual behavior, controlling for other variables. Not all of the variables were significant, indicating that other variables may better explain variance in risky sexual behavior.

Additionally, hypothesis 2 was not proven as the HIV KAP score was not a significant predictor of risky sexual behavior.

LSDV Fixed Effects Model. To account for the nested structure of the data, a

LSDV fixed effects model was run, including cluster affiliation dummy variables that describe the average risky sexual behavior at each bar (e.g., the intercept). Only the two focal predictors, HIV KAP score and regular employment, were included in this model. I ran the model as a hierarchical regression with no intercept, entering only the focal predictors in Step 1, and all cluster affiliation dummy variables in Step 2. The null hypotheses tested were that the multiple R2 was equal to 0 and that the regression coefficients were equal to 0. This regression had a final N of 275, after listwise deletion.

In Model 1, both focal predictors, HIV KAP score and regular employment, were statistically significant, and the overall model was significant as well, with F(2, 273) =

582.90, p < .001. This differs from the results presented in the single-level regression above. In Model 2, all cluster affiliation dummy variables were significant. The full model

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of HIV KAP, regular employment, and all cluster affiliation variables to predict risky sexual behavior (Model 2) was statistically significant, R2 = 0.86, F(21, 254) = 75.72, p <

.001, adjusted R2 = 0.85. Model 2 (all bar level effects) explained an additional 5% variance in risky sexual behavior compared to Model 1, with a change in R2 = 0.05.

Table 6.5. LSDV Fixed Effects Model results predicting risky sexual behavior

B SE B b CI Model 1 HIV KAP Score 0.48*** 0.02 0.97*** [0.44, 0.52] Regular Employment -0.65** 0.24 -0.10** [-1.12, -0.17] Model 2 Bar Group 1 4.16*** 0.94 0.17*** [2.30, 6.01] Bar Group 2 6.52*** 0.98 0.30*** [4.59, 8.45] Bar Group 3 5.86*** 0.87 0.39*** [4.14, 7.58] Bar Group 4 6.17*** 0.86 0.46*** [4.48, 7.86] Bar Group 5 5.65*** 0.96 0.20*** [3.75, 7.54] Bar Group 6 6.28*** 0.96 0.36*** [4.39, 8.17] Bar Group 7 6.05*** 0.96 0.28*** [4.16, 7.94] Bar Group 8 5.12*** 1.08 0.18*** [3.00, 7.25] Bar Group 9 5.49*** 1.11 0.18*** [3.31, 7.67] Bar Group 10 5.76*** 0.83 0.39*** [4.12, 7.40] Bar Group 11 5.25*** 0.94 0.25*** [3.40, 7.10] Bar Group 12 5.58*** 0.93 0.28*** [3.75, 7.41] Bar Group 13 7.12*** 0.95 0.38*** [5.26, 8.99] Bar Group 14 6.50*** 0.85 0.46*** [4.82, 8.17] Bar Group 15 5.99*** 1.10 0.20*** [3.87, 8.10] Bar Group 16 7.00*** 0.83 0.43*** [5.38, 8.63] Bar Group 17 6.74*** 1.13 0.22*** [4.50, 8.97] Bar Group 18 5.42*** 0.89 0.25*** [3.66, 7.18] Bar Group 19 6.22*** 0.96 0.24*** [4.32, 8.12] Note: Each additional model included variables from the previous model. *p < .05 ** p < .01 *** p < .001

In Table 6.5 (above), the results from the LSDV fixed effects model are presented. In Step 1, HIV KAP score was statistically significant t (273) = 25.18, p <

.001. The relationship between HIV KAP score and risky sexual behavior is not as expected; it indicates that higher levels of HIV KAP score predict higher risky sexual behavior. Regular employment was also statistically significant, t (273) = -2.68, p < .001.

The relationship between regular employment and risky sexual behavior is as expected; it indicates that lower individual regular employment predicts higher risky sexual

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behavior. These results also demonstrate the influence of the bar on individual men’s risky sexual behavior. The individual risky sexual behavior score varies from a low of

4.16 (Bar Group 1) to a high of 7.12 (Bar Group 13). However, we can see wide confidence intervals, as demonstrated in Bar Group 1, where the individual risky sexual behavior score could range from 2.30-6.01.

Taken together, the results of these regression analyses demonstrate key findings. First, regular employment was statistically significant across both models, indicating the importance of regular employment in predicting risky sexual behavior, and by proxy, HIV risk. This was predicted in the pilot study. A second key finding is the importance of the bar modeled in the LSDV Model, whereby individual and average risky sexual behavior scale scores varied across bars. While these quantitative analyses are helpful, we can turn to the qualitative results to provide additional clarity and context.

6.3.2. Additional Findings on Risky Sexual Behavior (Survey and Interview Data)

Several key findings emerged from both the survey and the interviews. When men in this study were asked, “when you first had sexual intercourse with your partner, did you or your partner do anything to avoid pregnancy?”, 44.6% did use contraception, while 55.4% did not. Of the men who did use contraception, 35.7% used condoms.

When asked what men used with their partner more generally (apart from the first time),

43.8% had ever used condoms to avoid pregnancy. Men reported differences based on the length of their relationship and the amount of trust they in their partner. As one man described, there is a difference between having sex with his wife and his girlfriend:

With my girlfriend I can use because I cannot trust her, I can give like 60% because I am not sure, I can know that you have gone to sleep but I don’t know how but with my woman I know, I trust her so for a condom I can use with a certain somebody but for my wife its different. – Ruhakana

Ruhakana’s response is not unusual. Kabalagala men report using a condom at first with their partner, but then stopping after about a month or so. Condom use was also

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deemed unpleasant, and condoms were often avoided for that reason. Condom usage was also shaped by desires for children, with some men expressing that they wanted more children and others reporting that they did not want any.

Men reported discussing contraception with their partners, with 24.9% discussing contraception before the first time they had sex with a current partner, and 43.6% discussed contraception after. An additional 31.5% have never discussed contraception with their current partner. Overall, men in this study discussed desires for more children, tying it to a masculine ideal and what society expects of them. Muhammad’s view is typical of many Kabalagala men, who express desires for more children:

Yes, I won’t say much about family planning but we talk about sex, because as a man I cannot talk about family planning. I still want to give birth because I have two kids so when I talk about it even the person that I will be telling will laugh at me because they would say “you still want kids but why are you stopping us from having kids.” So I don’t talk about it [family planning] because I still want kids. - Muhammad

As described by Muhammad, even the idea that a man would discuss family planning is laughable. Many respondents described not knowing whether their partner was on contraception, giving reasons like “it’s not something we discuss,” or “I assume she is on the pill, but I am not sure.” Overall, 187 men in this study had children, and 105 did not have children. Of those with children, men had a mean number of 2-3 children, ranging from 1 to 8 total. Of those men without children, some were young (18-19 years old), while others were unable to have children.

Another man, Benedict, is 29 years old and does not yet have children, a rather uncommon situation in Kabalagala. I asked him whether he had children, and he told me about his girlfriend who had an abortion:

I: Do you have any kids? P: No, I don’t have. Eah, I used to get a kid, but the lady who passed here, she aborted my baby at seven months. That lady, she aborted my baby at seven months. I: You can abort a baby at seven months?

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P: Yeah, they do here, here it is very common, and it’s common. That time I was not around, I was in Kenya. I had gone to Kenya to see my Aunt in Kenya. I spent there one week, and I came back when she has aborted the baby. I: How did it make you feel? P: I was very annoyed, I was going to Dubai on that day, somebody sent me a visa, I was going to Dubai to work in a super market as a manager but I said before I go, I first will stay here so that when this lady has produced a baby then I go, the guy sent me a visa I had a passport but I said, just give me two months because I thought it will find when she has given birth and the time she gives birth I go to Dubai but all my things failed. All of them, I didn’t go to Dubai. I started being like a mad person by the way. I was very annoyed, that day I was going to kill her, but I just feared to go to prison I just leave her I let it go. I: Do you still talk to her these days? P: Yeah, we are like friends, I just keep it in my heart. I just leave it there. I: So have you forgiven her? P: Okay you know, one day when I drink small, small beer that thing comes back but I just keep it in my heart I don’t bring it out. - Benedict

Benedict was visibly upset when he recounted this story to me, even though it had happened years ago and he was now friends with the woman who had an abortion. As

Benedict recounted, he was not consulted when his mama abaana (mother of his child) had an abortion. Benedict went on to detail how this affected his family’s opinion of him.

My sister is in Saudi Arabia, so she tells me you have to be a man, get a wife; you have to be a man. You know in my family, if you don’t have a kid and a wife, they don’t take you as a man. Unless you have a wife and a kid and a house you are not a man you are just a boy. - Benedict

As will be discussed in later sections, Benedict’s family is not uncommon. Men are expected to have a house, a wife, and children. Men in this study who were unable to produce children or who had not yet had children were concerned. Another participant,

Kibirige, discussed how he had been happy with his wife. However, after years together, they were unable to conceive. Kibirige’s grandmother encouraged him to get another girlfriend, so that he could have children. Two more girlfriends later, Kibirige still did not have children and asked me what he could do.

Multiple sex partners are common in Kabalagala, with most men reporting concurrent sexual partners, including a typically more stable partner and other “side dishes.” Men differentiated between the longer- and shorter-term partners:

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There is a difference, the one that you stay with becomes part of your life that whatever happens to them is also your concern like, eating. When she falls sick you take care of them that’s the difference. But the one-night girl can even call you and you refuse to go. She doesn’t put you on pressure like the one you love. -Benedict

Out of the men interviewed (N = 54), only two reported being in monogamous relationships. Others had either multiple longer-term partners or a mix of longer- and short-term partners. Sex was described as the main business in the community, so it is not a stretch to report that multiple sex partners are common.

Questions were asked pertaining to men’s concern that they might catch HIV

(Table 6.6) or other STIs from their sexual partners. Of all men who answered the question, there was a nearly even distribution from “not concerned” to “somewhat concerned” to “very concerned.”

Table 6.6. Men’s HIV concern Men (n = 273) reporting concern that they might catch HIV from their partner N Percent (%) Not concerned 73 26.7% Somewhat concerned 98 35.9% Very concerned 101 37.0% Don’t know 1 0.4% Total 273 100% Note: Men’s responses to a question of whether they are concerned that they might become HIV infected because of their current sexual partner(s). A majority reported being somewhat (35.9%) or very (37.0%) concerned. This question excluded those men who are not currently in a sexual partnership.

Men were asked whether they were able to do anything to reduce the risk of HIV infection, and 47.0% said yes, while 53.0% said no. Men were also asked what they were able to do (Table 6.7). The most common response was “testing” for HIV, although it is not technically an HIV prevention measure. There was some association between knowing one’s status, testing with a partner, and therefore being able to prevent the spread of the disease. However, it is highly unlikely that men test with each and every sexual partner, especially the casual partners.

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Table 6.7. HIV prevention method Method of HIV prevention used by men (N = 292) N Percent (%) Testing 167 57.19 Condom use 82 28.08 Reducing number of sexual partners 27 0.09 Abstinence and condom 7 0.02 Abstinence 6 0.02 “Some kind of medicine” to avoid getting infected 1 0.00 Stay busy chewing mira [khat] 1 0.00 Being careful and not over using drugs 1 0.00 Note: Responses to an open-ended question on what kind of HIV prevention they had used in the past or currently use to avoid HIV infection.

These responses can be compared to preventing STI transmission. Men were asked whether they were able to do anything to reduce the risk of STI infection, and 34.2% said yes, while 65.8% said no.

In addition, risky sex is linked to high rates of alcohol use in the community (see

Chapter 7). Alcohol use related to sex is reported as a single item, aggregated in the larger risky sexual behavior scale previously discussed. Men were asked whether they had alcohol before the last time they had sex, and 39.7% said yes, while 60.3% said no.

This is likely under-reported and open to interpretation, based solely on the observation that many, many men drink every day in Kabalagala. UPHIA (2016-2017) does not report their data on alcohol use at last sex (Ministry of Health, 2019). The AIDS Indicator

Survey (2011) however, reported an even lower figure, with 25.1% of men ages 15-59 who reported drinking alcohol before having sex.

6.4. Access to Health Services

When men were asked the cost of transportation to the clinic where they had most recently tested for HIV (Table 6.8), 79.92% reported that it was free or up to 1,999

UGX (US$0.54). This is a seemingly marginal cost, but it is too expensive for those with fragile incomes, who may struggle to afford the cost of food.

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Table 6.8. Transportation to HIV testing Cost of transportation to the facility where men (n = 259) were most recently tested for HIV N Percent (%) 0-1,999 UGX 207 79.92% 2,000-3,999 UGX 0 0.00% 4,000-5,999 UGX 7 2.70% 6,000-7,999 UGX 0 0.00% 8,000-9,999 UGX 1 0.39% >10,000 UGX 44 16.99% Total 259 100% Note: Reported cost of transportation to the clinic or hospital where men had most recently tested for HIV, excluding those who have never tested for HIV. The lowest range (0 UGX) included those who walked to the clinic or received services from mobile outreach providers in the community.

Men sometimes find creative ways of getting to the clinic. The nearest clinic is private, with a community wing that charges 10,000 UGX for an ART refill, plus extra charges for tests. This clinic is walkable. The next nearest clinics are not exactly walkable, but are a

1,500 UGX boda boda ride away. These clinics serve clients for free, although the wait times are often lengthy and a clinic visit is at least a half-day affair. Some men in this study reported high costs for clinic visits, above 10,000 UGX (US$2.70). Based on follow-up questions, this was because they visited clinics far outside the community, in

Mengo or Wandegeya, both of which are far across town where men are unlikely to be recognized. If transportation was not affordable, some boda boda drivers from the community would take men for free.

Men were also asked about their general health-seeking behavior, beyond HIV

(Table 6.9). Men responded that they prefer government health centers (54.1%) compared to private hospitals (42.1%). Some differences between centers were noted, as government health centers are free, but they have long wait times and cannot always handle complex cases. Men also expressed frustration with the referral system, where one government center will refer to another place for specialized care, and men can end up visiting three to four centers to resolve one issue. Private health centers worked expeditiously, but the cost of care is too high for many. Overall, most men can afford

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care wherever they go (92.8%) but a small number (7.2%) (Table 6.10) cannot afford care at all.

Table 6.9. Where men seek treatment

Where men (n = 292) will go for their general health issues, not just HIV-related issues N Percent (%) Private hospital or clinic 123 42.1% Government hospital or clinic 158 54.1% Other 1 0.3% Nowhere 10 3.4% Total 292 100% Note: Men were asked where they might go in case of a health issue. Participants were provided with the above response options.

Table 6.10. Affordability of health services Whether men (n = 292) can afford the services at their clinic or hospital of choice No N Percent (%) Yes 21 7.2% Total 271 92.8% 292 100% Note: Men’s responses to whether they can afford the services at their clinic or hospital where they seek health care for any kind of issue, not necessarily only HIV. 6.5. The HIV Care Continuum: Testing

A key programmatic question is how to improve men’s HIV testing participation and linkage to treatment. While HIV outreach workers do frequent Kabalagala, men’s uptake of those services is low. This section will unpack how and when men seek HIV services, with a focus on knowing one’s status via HIV testing. While HIV testing was a major focus of PEPFAR programs in 2017 and 2018 (PEPFAR, 2017; PEPFAR, 2018), new guidance focuses not on testing everyone but rather testing those suspected to be at high-risk of HIV (PEPFAR, 2019). This is a subtle but important difference. PEPFAR staff also lamented the lower than desired rates of testing among urban-dwelling men,

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during a recent COP 20193 stakeholder review meeting. This concern is mirrored in

USAID-funded HIV testing messages pictured below (Figures 6.3, 6.4). The messaging seems to speak to poor health-seeking behavior norms among some men, with commonly cited excuses like “not having time” or “feeling strong.”

3 PEPFAR’s Country Operating Plan (COP) process, which guides their programming and policy for that year.

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Figure 6.3. HIV testing poster sponsored by USAID, along Kibuli Road adjacent to the study community

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Figure 6.4. HIV Testing poster sponsored by USAID, along Kibuli Road

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To better understand the broader dynamics (beyond health-seeking behavior) of

HIV testing, this study included questions on HIV testing in the in-depth interviews. The survey instrument did not include questions on HIV status, and therefore, did not ask about current HIV treatment or treatment adherence. These questions were not included to protect the privacy of participants. However, during the interviews, some men chose to disclose their HIV positive status to me. Those results are also presented, although in

Section 6.6.

Of all men surveyed, 89.4% had ever tested for HIV, compared to 10.6% who have never tested for HIV. This is compared to UPHIA (2016-2017) data, where 80.8% of Kampala’s men (ages 15-64) and 68.9% of all men (15-64 years old) report having ever tested for HIV (Ministry of Health, 2019). Kabalagala’s men have a slightly higher than average testing rate.

Further, these results are broken down by age group (Table 6.11), with men ages

18-24 reporting the highest percentage (20.29%) of never testing, compared to none of the men ages 45-54. This table below demonstrates important differences by age group. UPHIA (2016-2017) reports similar differences, with 54.4% of men ages 15-24 having ever tested for HIV, compared to 95.2% of men ages 25-34, 91.2% of men ages

35-44, and 82% of men ages 45-54 (Ministry of Health, 2019). In this sample, the oldest men have a higher rate of HIV testing, but there is also a much smaller sample size compared to UPHIA data.

Table 6.11. Men who have tested for HIV by age group

Age Group No (% of age group) Yes (% of age group) % (Age Group) 18-24 14 (20.29%) 55 (79.71%) 23.9% 25-34 14 (8.97%) 142 (91.03%) 54.0% 35-44 2 (3.57%) 54 (96.43%) 19.4% 45-54 0 (0.0%) 8 (100.00%) 2.8% Totals 30 259 Note: Three men did not report their age and were not included in these calculations.

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To further unpack the characteristics of men’s HIV testing, men were asked how recently they had tested for HIV (in months). These responses were dichotomized, to differentiate between a recent HIV test (12 months or more recent) and an older HIV test

(more than one year). This is important to distinguish programmatically, because it is important to know how recently they have tested (PEPFAR, 2019). As demonstrated in

Table 6.12, 58.9% tested for HIV recently, while 30.1% tested more than one year ago.

This latter category includes those who tested, but tested positive, and are on ART, therefore not requiring repeated HIV tests.

Table 6.12. Recent HIV test

Men (n = 292) who have recently tested for HIV (<12 months) N Percent (%) HIV test was <12 months ago 172 58.9% HIV test was >12 months ago 88 30.1% Never tested 30 10.3% No response 2 0.7% Totals 292 100% Note: Men were asked when their most recent HIV test had occurred. These responses were dichotomized into recent (<12 months) and not recent (12+ months) tests.

Men also expressed a clear preference for testing (Table 6.13) in government hospitals or clinics, which are free and located nearby. Intriguingly, only 29.3% of men had recently tested with a mobile provider in their community. This paired with the qualitative data below indicates a low preference for mobile providers, despite the convenience of the service.

Table 6.13. Location of recent HIV test

Where men (n = 259) had their most recent test for HIV N Percent (%) Private hospital or clinic 74 28.6% Government hospital or clinic 108 41.7% Mobile clinic 76 29.3% Other 1 0.4% Totals 259 100% Note: Total (259 men) excludes those who have never tested for HIV. Men were asked where their most recent HIV test was conducted, and given the above response options.

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One participant elaborated that there is a general perception in Kabalagala that the mobile providers are not trustworthy. The following was described in the survey responses, when asked why men chose a particular facility. Men (n = 22 in the survey sample) reported not using mobile providers because of a lack of trust in them. Reasons for this varied, but repeated stories (n = 14 in the interview sample) about incorrect results are commonly retold through interviews and conversations.

I: When you look at [the community] here, do men test? P: I see that the problem that we have is that these organizations [mobile service providers] are difficult. Some organizations test people but they fear to tell them the truth, ask me how. I: How? P: There is a youth who is on ART and he knows it, he came and went to test [with the mobile providers] but when he got the results, he was told that he was negative so he said ‘have you seen our people, I am HIV positive, I tested twice and I am now on ART, this is now a paper telling me that I am negative but what really is this?’ Everybody was shocked so I don’t understand what trick there was, do they fear to scare people so the boy told them that he was positive and on ART, so was the virus hiding or the people who tested him first made a mistake when they told him that he was positive? They didn’t tell him that the viral load has suppressed, they told him that he is negative so he said ‘no stop deceiving people, I am positive.’ Another thing is we have been seeing a lot of things because there is a friend of mine who told me ‘boss, my wife took me to get tested but when we got there, she was already a member (positive) she was already getting drugs from there. When they called him, the results said that he was negative so these days’ people no longer want to go into such things [to mobile providers] to waste their time, they go to big hospitals. – Muhammad

As the participant described above, there are common perceptions that the mobile service providers are not to be trusted. Men describe different stories of individuals who have gone to the mobile providers, and received results which were not possible.

Someone may have tested negative, when they were already on ART, while others received mixed results – positive one time, negative another. This broadly contributed to a distrust in the mobile providers.

Other men described reasons for not testing for HIV more broadly (Table 6.14).

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Table 6.14. Reasons why men did not test for HIV

Reported reasons for not ever testing for HIV (N = 30 in survey sample) • Doesn’t want to know (n = 7) • Because he knows he is not sick or doesn’t see any signs of infection (n = 6) • Fears to test for HIV and doesn’t want to know his status (n = 4) • Because he only has one partner (n = 2) • He is scared (n = 2) • It’s not good to live a life of fear, and if he tests he might get bad news (n = 1) • Doesn’t know why (n = 1) • Doesn’t have money (n = 1) • He’s a virgin (n = 1) • He doesn’t care about it (n = 1) • He never thought about it (n = 1) • Never wanted to (n = 1) • Not yet ready to test (n = 1) • He doesn’t know where to go (n = 1)

While it is useful to visualize the range of responses, and how they relate to the messaging in the photographs at the beginning of this section, it is important to note some broader themes. Men described not feeling sick or seeing any symptoms of HIV, and therefore not needing to go and test. Reasons for this will be explored further.

Rhetoric such as “fear” or being afraid of the results might mean that a man thinks he is

HIV positive:

When someone tells me, because it’s not easy to disclose and most of the time it’s what makes people fear [meaning, being afraid of something] to test because they think that when people know that they are sick, how will they survive, friends will leave them, their girlfriends will leave them so they refuse to go there and they’d rather be with the sickness until they die. Others say that they are being bewitched yet they just fear to get tested because of fear of being laughed at. Even those who laugh at the positive are not right because not everyone with the virus gets it when they want. Like sex without a condom, some get it from accidents and others by use of sharp instruments, others are born positive so those who laugh at the positives are wrong, and it’s not a good thing. They should make it normal that it’s a disease that anyone else can get like malaria or flu because it’s very hard to prevent HIV if you are sexually active but these people who laugh at those who are positive prevent others from testing. – Muhammad

It [HIV testing] is scary and you don’t want to get it, and when you get it you don’t want to know that you have it. So when you test me and you tell me to start taking drugs it will be as if you have given me another sickness. I get worried about HIV and I also get worried that I may die so they [other men] believe that

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when they don’t get tested, they are sure that they don’t have the virus…. Many times when health workers come to test, you can tell someone to test but they tell you that they don’t need to test because it will worry them. So they decide to stay without testing so that they don’t have to worry about having the virus and taking the medicine. – Mugisha

Muhammad articulately indexes the fear experienced by men in Kabalagala. Mugisha elaborates, noting that HIV testing is scary. He describes how men in the community do not want to test, because then they would know for sure that they have HIV. Knowing for sure comes with its own burden, such as taking daily medicine, keeping medical appointments, changing alcohol use, and so on. Yet, it is unclear why men prefer to not know. Everyone in Kabalagala is aware of the high prevalence of HIV in the community, everyone sees the young men and women who die at a young age from illnesses, often related to HIV. Meanwhile, treatment is available and free.

Some individuals described feeling fatalistic about HIV, and therefore argued that there is no need to test for it since getting HIV was nearly inevitable. Fatalism describes an attitude or belief that the outcome of events, such as HIV infection, is uncontrollable and unchangeable by an individual (Benghiac, 2012). In other words, it is perceived to be a near-sure outcome, one that cannot be controlled by individual action, with implication for HIV prevention and testing behavior. While most men in this study (n =

31) described being hopeful about the future, they also paradoxically describe a feeling of fatalism that pervades men’s attitudes toward HIV prevention in Kabalagala.

Most men are tired and are frustrated of the world, they get to a point when they don’t want to put on a condom. That’s why it’s very difficult for people to survive the virus here because sometimes they give women 20,000 so that they don’t use a condom, when she is drunk and she needs money to pay for her house she agrees. –Rahim

Because HIV is common in Kabalagala, some men feel it is inevitable that they will also get HIV at some point. The participant above alludes to this notion, that men are “tired and frustrated” and these sentiments underlie low desires to use a condom. An alternative explanation is that HIV may not be the most important concern in their lives,

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when they face more urgent issues such as where to sleep at night or where to find money for food.

We can also understand reasons why men might not want to test for HIV using a concept of uncertainty (Reynolds-Whyte, 1997). Susan Reynolds-Whyte (1997) described ‘uncertainty’ as related to adversity, which includes illness and other issues in

Eastern Uganda. The Nyole prefer to take medication over testing for HIV, which would inform someone of their fate. Uncertainty, in a sense, is preferable to knowing for sure.

Knowing for sure ends any modicum of hope that remains, and would make life more stressful. Additionally, pragmatic responses are grounded in the adversity that men face.

In this case, men decide how to handle problems based on potential outcomes of their efforts (Reynolds-Whyte, 1997). In other words, pragmatism describes a way of dealing with uncertainty and the potential consequences of doing so. Applied here, we can understand why some men choose not to test for HIV, because it would not be the most pragmatic decision. If they do test, then they would know their status and this would add a great amount of stress to their already stressful lives. Many decisions are made with the goal of limiting stress – drinking alcohol, not going through the complicated rigmarole of starting on HIV treatment, and not testing for HIV.

Another explanation for why some men do not test for HIV is the rumor- mongering in the community. Despite a high prevalence, it is interesting to note to that

Kabalagala’s residents also tend to gossip a lot about individuals with HIV. HIV positive participants in this study described friends or girlfriends spreading lugambo (gossip) about their status. Others describe not wanting to tell anyone about their status, and taking great measures to hide their medication or visits to the clinic. It can reach such an extent that men, as described above, would rather not test for HIV than know their status, and have their friends or girlfriends find out. One day I asked Benedict, who recently had found out about his status, whether he had told any of his three girlfriends:

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She told me that “[NAME], they told me that you have HIV”? I asked who told her and she said ‘some guys’ then I told her “you show them to me”, she feared to show them to me. Now last time she talked to me and yesterday I was playing pool there so she came and looked at me but her sister doesn’t want me to talk to her, the sister of that lady doesn’t want to talk to me now, yet she was my best friend. -Benedict

Somehow, in the short time between Benedict testing for HIV and this follow-up interview

(a week later), not only had his girlfriend and her sister found out about his status, but his friends had also found out. Indeed, everyone knows everyone’s business in this community that feels more like a small village than a part of a large city. Rumors and news spread quickly, with implications for seeking HIV services.

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6.6. The HIV Care Continuum: Linkage to Care and ART Adherence

When men were asked what could be done to improve the HIV outcomes of

Kabalagala’s residents, the most frequent suggestion (n = 26) was to distribute ART in the community to those HIV positive clients, on a monthly basis, rather than having people come to the clinic. While there may be some obvious issues with this, it is an interesting suggestion that implies men might have trouble going to the clinic to refill their medication or even start on ART. Results reported earlier demonstrate that most men are able to visit a clinic. While survey data do not report on ART use or adherence, it was a topic that arose with HIV positive participants (n = 12; 22.22% of the sample). The number of HIV positive men in this study mirrors the Crane Survey (2010) estimate for

HIV prevalence among partners of sex workers, 18%. Out of the 6 men who described knowing exactly how they became HIV positive, 5 men became positive because of long-term relationships with female sex workers. Throughout the course of this study, 4 of the 12 participants found out that they were HIV positive. Others described disruptions in their HIV treatment during interviews, and at the end asked for referrals to re-start

ART. By the end of the research, all of the HIV positive men who disclosed their status were taking ART. It is not known whether they are continuing.

It is important to reiterate that at no point were questions asked about men’s HIV status. Therefore, other participants may have known that they were positive but did not disclose their status. This section reports on those who chose to disclose their status during the course of the interview and some of the challenges they face in following advice from doctors and HIV counselors to take their medication at the same time, every day, eat fruits and vegetables, and quit drinking. Men reported on some of the challenges that men in general face when deciding whether to start HIV treatment. Men

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also reported treatment challenges related to unstable housing, food, social stigma, and alcohol use, as reported here.

6.6.1. Starting on treatment: A life decision

My second interview with Orlando began when he showed me the medication he had recently started taking, after visiting the community wing of the nearby hospital. Men are given both ART pills (a combination pill taken once per day) and septrin (co- trimoxazole, a broad-spectrum antibiotic). This starting package is accompanied with extensive counseling, warning men that if they fail on these pills, that they would have to move to more complicated and severe second- and third-line treatment. In addition to treatment counseling, men are told to reduce drinking alcohol, stop taking drugs, eat fruit and vegetables, and live a healthier lifestyle. As Orlando recounted the more practical advice he received:

They asked me, ‘what time do you start to booze?’ and I told them eight, so they told me if every day I start to booze at eight, then I have to reduce because ‘if you start to swallow this medicine you have to rest for four hours.’ – Orlando

Orlando was excited about taking medication, and demonstrated a renewed sense of wanting to take care of his life and his health, emphatically declaring that he “loved his life more than Jesus.” He had even broken up with his girlfriend, because she was not supportive. He told us that he preferred to keep his medical papers somewhere else, because his girlfriend would find them and tear them up out of anger. Men are given cards when they start on treatment, and are told to keep those cards, and bring them to the clinic for each appointment. The cards are usually yellow or blue, have an ID number, and a list of appointments past and future. Men usually cannot get treatment at the clinic without those cards, and yet, some report (n = 6 out of 54 men) losing the cards and stopping treatment because of a lost card.

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Orlando describes the arguments that took place when he finally disclosed his

HIV status to his girlfriend. Orlando had known about his status for some time, because he had last tested for HIV a few weeks ago when he was drunk and he “did not really believe the results” because they came from a mobile clinic. He later wanted to re-test and asked that I go with him. His new positive result was not surprising to Orlando. Most of the challenges came later, when he tried to convince his girlfriend to also test for HIV.

Quarrelling ensued, resulting in Orlando leaving his sex worker girlfriend’s home. By our second interview, he had shifted to a smaller room that charged 10,000 UGX per day, of which Orlando had to pay 5,000 UGX and his friend matched that amount. He explained why his health was more important to him than staying with his girlfriend, and why he had to choose between the two:

“But the last day when I am going back, and I take this ka [Luganda, a small thing] whatever, this empty [bottle] to give them back because power is nothing without control. Fred you see, that woman hit me with a bottle but I didn’t do anything, she bit me, all of these are the marks of her teeth, all these scars are from her but I keep quiet. This is [community name]…every man is supposed to suffer like that, but me I am a survivor.” - Orlando

Orlando’s story illustrates a few points that were similarly experienced by the other HIV positive men. For one, HIV testing is not a one-time event. Men described not believing their first result, and taking quite a bit of time to accept that they were positive, and even longer to decide to start treatment. They contrasted their decision with other men in

Kabalagala who do not want to start treatment at all, until an individual begins to exhibit signs of HIV:

Some fear [to take medicine] because they feel that they will get ashamed, others fear that when they are taking it, they feel that the women will chuck them but me whether you chuck me, I feel that life is the best. – Orlando

It comes from the condition that they are in because for me to tell you, it’s because I didn’t have what to eat or where to sleep. There is a time that I didn’t care if I die because I didn’t have a child or any responsibility, so how can I go back to [my home village] and tell my parents that I am sick? And when this that made me weak, is that even when you think about killing yourself, you can’t die

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so I would say it but when I saw [a sick friend of his], I got scared, without a place to sleep or what to eat so I became strong and I told you [about my status]. – John

Fear was a word that often came up during interviews with men (n = 40). It doesn’t exactly mean the same thing in English and Ugandan English. In a sense, it means being afraid of something, but it also denotes a sense of dread, worry, and uncertainty regarding the future.

Some men fear to know the truth that they are positive because they will get worried and have stress afterward, so they don’t go. – Mugisha

Both John and Orlando mentioned fear and being scared, in relation to medication. The first is speaking about men in general in Kabalagala, where men worry that their sex worker partners will leave them. The second speaks about “the condition” or the situation that men are facing, whereby they do not have stable housing or food and these factors shape decision making around treatment. The second participant speaks of his own experience, where deciding to start on medication was contoured by his own life, without a home or regular meals. He saw a friend of his who was even sicker, and would never leave the house during the day because he was too weak. It was that illness that influenced his desire to start medication, and we referred him for services at a nearby free clinic.

6.6.2. Social determinants and the care continuum

Other social determinants influence both when someone starts on HIV treatment and whether they continue. Based on the interviews with the HIV positive men (n = 12), treatment interruption is a common experience among them, with men going on and off treatment frequently. Notably, services are available. Unlike rural areas, Kampala clinics rarely have stock-outs of medication, so treatment is available and there are numerous places to access it. There are some logistical challenges to obtaining treatment: men have to go to the clinic with their card (they often lose their card), men have to go early

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in the morning to receive services that day (yet, men wake up quite late after a night of drinking), men have to have a place to store their medication and food to take their medication with (sometimes they have neither).

We may have the same disease but our problems are not the same and the situations are not the same. One may get food in time but you may not so you see them and you know that they may be positive but they are better [because they have food]. The problem now is feeding, they tell us to eat fruits, eat fruits but we cannot afford. There are those who cannot afford to buy food and yet they are supposed to take the drugs, it’s a daily thing and a must, it’s a must unless you decide to stop taking drugs, but it’s a must. – Ssemujju

Ssemujju has been HIV positive for a while, but did not start on treatment until recently, after asking for service referrals after our first interview. He came back from the clinic, asking questions about how to follow the counselor’s advice, especially when he could not afford regular meals or fruit. Similarly, Abed described:

When I take the medication and get something to eat and then sleep, it doesn’t make me feel bad at all. – Abed

Abed is one participant who has frequently interrupted his treatment. In fact, his doctor complained to him that he was often lost to follow-up and often missed his medication refill appointments. Abed was homeless for much of the fieldwork time, and did not always have food to eat. These realities impacted his treatment decisions, with the unfortunate result of interrupting treatment during times of extended hunger or homelessness.

6.6.3. HIV stigma and peer influence

Kabalagala norms around HIV shape men’s treatment-seeking decisions, whether it is to avoid starting treatment because they are worried about their girlfriend kicking them out of the house, or whether someone starts treatment because they saw someone who looks much healthier after ART. One “miracle story” is that of Jude, who at the beginning of fieldwork was in his house every day, and every night, coming out only to use the bathroom. He was small, and could not have weighed more than 90

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pounds, despite his moderate height (roughly 5’6”). Jude has HIV and TB, which he discussed during our interviews. He had recently started TB treatment, after asking us for a referral for services. A few weeks later, we had a first interview, when he was on the mend. By the time I left, Jude was returning to an average weight, after weeks of taking nutritional supplements and his medications. This is not uncommon as has been documented since the early days of the HIV epidemic in a variety of settings (Moyer,

2015; Reynolds-Whyte, 2015). What is interesting is the way that this turnaround influenced other men. Other men in the community started to wonder about starting on treatment themselves, after seeing Jude’s resurrection.

These positive stories about peer influence were not uncommon, but are also not the norm. Other men described trying to influence their peers, by telling other men their treatment stories:

It would be good if he [a friend’s name] told his family, to comfort him and to support him so that he doesn’t miss out on taking his medication. Many times, when I have someone who is positive, to give him strength, I also tell him that I am positive so that he gets the courage, I can even tell him that I have had the virus for about 12 years but I take medicine. Sharing this can help give him peace of mind. – Rahim

Despite this one person’s desire to change other men’s perspective on taking treatment,

HIV status and taking drugs are not common topics of discussion in Kabalagala. The reasons for this are speculative, but some men describe their perspective:

It is helpful but as I told you, people have different hearts because I could call you to talk, but people mostly talk about finances and don’t give time to health issues and HIV, they do not. When you tell someone that HIV exists, they will just tell you ‘suffer alone.’ They will say ‘If you are sick, struggle alone.’ – Ssemujju

Another describes the impact that this has on treatment, where some men chose not to start or continue treatment because they worry that others will get to know their status.

Indeed, living in such close quarters, it is difficult to hide anything. Even a bottle of medication would likely be found, especially since most rooms are shared with partners or roommates, depending on the situation. This close proximity and desire to maintain

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relations with friends and partners can shape treatment decisions. Some men go to greater lengths to ensure their privacy:

You may stop taking the drugs, but when the sickness comes back, it may be worse and become a problem. Other people change the places that they get their refills from because of the stigma of how people will see them. – Ssemujju

Some of the results presented here relate to privacy issues and others highlight HIV stigma in Kabalagala. While interrelated, it is important to note the difference. A slight majority of men (n = 52.4% of the survey sample) prefer to keep their status to themselves to protect their privacy, while others do not acknowledge their status and do not start treatment because of a range of factors – housing instability, HIV stigma, or not wanting to take control of their health.

That medicine, the problem with it is you can’t swallow when my friends are seeing me, that’s the problem. But when you put me aside and sit and talk and tell them that “me, I am taking my medicine and the day you take, you can be okay but if you don’t take, it can just make you slow and when you are on bed and everybody comes, you can’t feel free.” I don’t know if the ladies here can understand ‘cause those ones who can understand, they can advise themselves. I know some of them like [person 1], this one who was my wife, that lady who has passed here, the husband who has been washing clothes because I have seen them in one place when they are advising themselves, they know their status, but they don’t tell others. – Benedict

Benedict describes how and when individuals talk about their HIV status, and how residents do not always give advice regarding health. In Benedict’s experience, he does not speak about his status with his friends, because they would not understand. He also did not feel like women of the area are open about their status, preferring to keep their status hidden.

The study findings highlight the ways in which social dynamics of treatment decision-making are shaped by complex factors such as desires to maintain personal privacy and fear of general stigma in the community. While some positive peer influencers were identified, including a few men in this study, generally the sense is that men do not speak about HIV with their friends, and there are few people who can pass

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on positive advice on how to navigate the complicated process of starting and maintaining treatment. The bureaucracy alone can be challenging. Overall this discussion of the care continuum demonstrates the social and structural factors that shape HIV testing, treatment, and treatment adherence. This section also points to the importance of understanding present social conditions and plans for the future. Both of these factors are important in how and when men decide to start on HIV treatment.

Taken together, these themes should inform the current HIV programming in place to reach men in places like Kabalagala.

6.7. Foreshadowing the risk environment

This chapter has described various social and contextual aspects of HIV in

Kabalagala, along the care continuum from HIV testing to treatment and treatment adherence. While men have lower than desired rates of HIV testing and treatment initiation, the reasons for this are predominantly socioeconomic, from unstable housing and food, to HIV stigma. Beyond individual behavior, it is clear that something else is going on. Kabalagala, as described, is frequently targeted with HIV outreach services. It is labeled a “high-risk” area because of the sex work that goes on. It is also nearby to several hospitals and clinics where individuals can start and stay on treatment for free, just covering the cost of transportation and lost wages on days when clinic visits are needed. If the services are there, what exactly explains the high prevalence of HIV and the lower rates of testing and treatment? The next section will use a framing of the risk environment to detail the juxtaposition of risky factors in the social environment with a high community viral load, shaping HIV prevalence in a community that faces risks on multiple levels. Starting with unequal HIV outcomes allows us to examine the broader underlying causes of these health inequalities: vulnerabilities embedded in a risky environment that structures differential risk of HIV.

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Chapter 7 The Risk Environment

A risk environment framework seeks to address the limits of public health approaches that focus on individual behavior by locating individual risk within a social context (Rhodes, 2002, p. 86). Rhodes (2002) and colleagues (Strathdee, 1997;

Drucker et al., 1998) argue that it is no longer enough to assume that the presence of behavioral interventions is sufficient to decrease HIV prevalence. That is precisely the situation in Kabalagala, despite the presence of free condoms, HIV testing and linkage to treatment, men are still not starting treatment, and experience frequent interruptions in their care.

A risk environment approach (Rhodes, 2002)

extends from a political economy framework to

highlight the role of uneven distribution of income and

social inequalities in unequal health outcomes. HIV is

viewed as an outcome of a complex system of

interacting components – within and between

individual men and their broader environment

(Rhodes et al., 2012). As Rhodes (2002, p. 90)

describes, distinguishing between the physical,

economic, social, and policy aspects of the risk

environment is a false distinction serving more as a

heuristic rather than a representation of the reality of

how risk influences disease outcomes. The following Figure 7.1. Factors in the Risk Environment sections acknowledge the fuzzy boundaries between each dimension of the risk environment, and the complicated way these dimensions

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intersect to affect men’s HIV outcomes. An outline of the following chapter is depicted in the adjacent figure (Figure 7.1).

7.1. Physical Risks

7.1.1. Population Density in an Entertainment District

One of the first

things a passerby notices

about Kabalagala is its high

population density (Figure

7.2). Homes, businesses,

shops, and lodges are built

alongside a slowly rising hill

like blocks of Tetris.

Weaving in between these

Figure 7.2. View of the study community myriad buildings are small passageways and trenches that are not easily navigable. Residents rent rooms barely larger than a twin-size bed, almost none of which have a separate bathroom. All water is fetched from a nearby pipe. It is these dense living conditions that shape the risks of

Kabalagala’s men.

Further, more people in an area that is known for sex work and alcohol increases the chances of interacting with others who use alcohol, drugs, or frequent the lodges. It is both the physical and the social aspects of population density that influence men’s risk. The population density contributes to men’s (n = 6) sense that they cannot change their behavior unless they leave the area totally:

The people and the community are all gone [e.g., wasted], they are living like it’s the years of Sodom. The people living here, they are like that. Yeah, because everyone is doing whatever he or she finds, drinking, doing what, so me what I feel like most, what I feel can save me is to first leave this place. Leaving the

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place because when you are somewhere and no one is disturbing you, you even get time to think about your medicine because you have them there when you are on your bed here and you say that it’s time to check on them and you take but here, a woman will take today and she will take a full week without making fire. My dear, what I am seeing here is a terrible story, it’s a terrible story. – Jude

In other words, it is both the large number of people in close quarters, and the types of activities that take place (sex work, going to the bars and clubs, drug use, gambling, etc.) that constitute a defining aspect of the risk environment. Quoted above, Jude describes this symbolically as similar to Sodom. Within this risk environment heuristic, the physical environment intersects with the social in many ways, with implications for men’s HIV outcomes.

7.1.2. When the Bar is Your Home: The High Concentration of Bars in Kabalagala

There are more bars than shops or restaurants in Kabalagala. It is the second most important business, in terms of income generation, after sex work. It is not just that the bars exist, but they are open twenty-four hours a day, every single day of the year. In fact, 34.6% of the survey sample are “very heavy” drinkers, defined as more than 150 mL of pure alcohol on an average day, and an additional 14.4% are moderate-to-heavy drinkers (35-100 mL of pure alcohol on an average day). Alcohol use has been shown to facilitate HIV risk in a variety of settings (Fisher et al., 2007; Kalichman et al., 2006; Stall et al., 2001). It facilitates risk by leading to reduced condom use and increased number of sexual partners. Additionally, it is the owners of these businesses who are evidently profiting from the freely available alcohol:

So, the lodge owners, the bar owners, the drug sellers, even the hoes [e.g., prostitutes] themselves, they benefit when someone has money and they enjoy it and they will support it, they will put everything in place to see that they supply it. It’s funny they don’t even drink themselves. – Josiah

In Kabalagala, alcohol is so easily available at any time of day, that it is easier to buy alcohol than to buy food which is limited to certain hours around breakfast, lunch,

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and dinner. Bars are not only places for leisure, but are also places of temporary shelter for Kabalagala’s many housing unstable men:

Most of them usually start at… we have our boda men who start in the morning, at the time when they should be working they take alcohol. Sometimes when I don’t have work to do I sit at a certain shop down there and I just look at them. Others go to Topi’s [bar name] and drink then after one just sleeps on a chair without eating or working, wakes up and drinks. I usually leave the garage at 2:00 am to go home but I find them fast asleep on the chairs. I always fail to go to sleep in the night but I get sleep in the morning so when I go to get my breakfast so that I can sleep, I find them sleeping on the chairs, dehydrated and drinking again so I think what can be done in that situation is to tell the bar owners so that when someone is drunk they be sent back home. -Salongo

What emerges from this description is how alcohol structures men’s lives, where many, not just the housing unstable, men center their social lives around the bar. Men meet their friends, conduct business, and meet female friends or sexual partners at the bars. It is the physical placement of the bars in close proximity to so many homes that poses a risk, but it is also the structural-social interaction centered on the bar that facilitates the micro-level HIV risk behaviors. In other words, it is not the physical bar that is the problem (other than its physical location), but it is what takes place within the bar that structures HIV risk for Kabalagala’s men.

7.2. Social Risks

7.2.1. Sex Work as a Risky Business

Norms and dynamics of sex work emerged as important aspects that shape both the risks that are present and the ability of men to develop practices to manage those risks. Sex work lodges are managed differently, with different housing standards. Some diligently clean their rooms and provide security and free condoms. Others do not provide condoms, do not provide quality housing, and security may be lax or non- existent. Besides presenting risks to the sex workers, resident men (n = 7 in the interview sample) are often involved in the sex work lodge business, either by directly working there or drinking in attached bars. The high frequency of sex, often risky sex,

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associated with sex work also has implications for men’s HIV risk, as perceived by many of the men:

What can save the lives of men in [community name] is still hard because some are rigid. Unless it is decided that all the prostitutes in [community name] are taken back to where they came from, women being chased [sent away] is the only thing that could work, but besides that the men here in [community name] cannot change. The ones here right now are not the first, some of those who came first died and every regime has its generation because the generation I found in [community name] is not what is not here now, we have a new generation. – Rahim

Rahim, who has lived in Kabalagala for a long time, describes having seen an entire generation of men die. I can second his observation, having heard of many young men

(and women) who died in Kabalagala during my fieldwork. Typically, the cause is unknown, but often the underlying cause of HIV/AIDS is suspected. Interestingly, Rahim is not alone in his opinion that it is the women who present HIV risk for men. Other men in this study similarly blamed sex workers for causing the high rate of HIV. Blame is not a helpful term, but it points to what men perceive as a harm, of which they are the recipients. This kind of perceived harm resurfaced (n = 9) in interviews with men, where sex workers, or ‘prostitutes,’ were thought to be putting men at risk. Women were often seen as part of this negative environment of risk, where other activities like alcohol, drugs, and gambling, make life enjoyable and entertaining, but are challenge other aspects of life like economic well-being and health. There was another subset of respondents (n = 4) who did not blame the sex workers, but rather saw the women as part of the social fabric, as partners and girlfriends.

Another aspect of sex work that constitutes part of the risk environment is the physical lodge where sex work is embedded. These venues, depending on the security, are often scenes of violence between sexual partners or between clients and sex workers. The presence or absence of safety measures within the lodge shapes both risk perception and men’s ability to manage it. Some lodges are very small, with dark

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passageways, no emergency exit, and plenty of areas where violence can happen unnoticed. Responding to an incident of a client killing a sex worker in his lodge, one owner actually closed off an entrance that opened to a passageway leading to the street.

Individuals were able to enter the lodge through that passage, without going past the security guard at the front. Other lodge owners do not take such measures to secure their lodges.

There are several pathways through which sex work structures men’s HIV risk.

Men in this study are both clients and long-term, non-paying partners (“boyfriends”) of sex worker women. Otherwise, sex work is part of the social fabric of the community.

Men are often associated with the venues where sex workers work, either through the location of their home bar (which is usually adjacent to at least one lodge), or through direct work in the lodge. Men in this study repeatedly described how women are “freely sexually available” in the area. It is primarily that lodges and the sex work provide a mechanism through which men can experience as many sexual partners as they want.

7.2.2. Changing Gender Norms and New Forms of Marriage in the City

In Robert Wyrod’s (2016) book AIDS and Masculinity in the African City, hegemonic masculinity is examined in the context of Bwaise, another Ugandan informal settlement that is very similar to this study community in Kabalagala. Rather than examine how masculinity affects HIV, Wyrod (2016) interrogates how HIV has altered the way that masculinity is lived, with implication for HIV prevention and programming on the continent. The author describes marriage in precolonial Buganda as based on mutual decision making and a woman’s consent to the marriage. Women were allowed to leave their husbands for most reasons – a man’s inability to provide, sexual incompetence, or leaving for another man (Doyle, 2013). After time, polygyny became more common and became a regarded male ideal, although few men could afford the

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multiple bride prices (Wyrod, 2016, p. 50). Wyrod argues that while men are unable to attain the marriage ideal in contemporary Bwaise, masculine sexual privilege continues as amaanyi (sexual strength) continues unabated.

Southall and Gutkind (1957) were perhaps the first to describe the new kinds of marriage in urban Uganda. The authors created typologies of new intimate relationships in “slum” communities, from sex work-client, to temporary lover (mukwano), to cohabitation without bride price. These new forms of marriage were rooted in tensions over shifting gender and sexual relations in urban Uganda, related to limited earning opportunities. These typologies are very much present in contemporary Kabalagala, where men are similarly challenged by limited economic opportunity, but are presented with new forms of relationships that are socially sanctioned in the informal settlement.

These new forms of sexual relations structure HIV risk:

The reason why HIV is mostly high among the young generation is because they don’t have the ability to marry. Secondly, one would be able to protect themselves from HIV but they get married to prostitutes, they buy prostitutes and use condoms but when they go for a shot, the woman marries the boy so they stop using condoms so the one who has been negative also gets the virus. Because the boy can’t afford to get a house to sleep in, or to marry a wife, we find that HIV is increasing every day it doesn’t go down. – Rahim

Rahim articulates the challenges presented to men in Kabalagala. He describes how men in Kabalagala cannot afford to get married. Then, because sex work is prevalent, most men “get married” to sex workers, which increases their risk of HIV. Describing new forms of marriage in urban Kampala is not new. Southall and Gutkind (1957) describe in the 1950s that new and less long-lasting forms of marriage arise in the city, where social relations are broadly redefined.

Further, Wyrod (2016) argues that urbanization was central to new ideas of masculine respectability and status. These ideas are linked to male sexual privilege, a core dimension of hegemonic masculinity in Kampala. Wyrod sees sex work as part of this, where men’s sexual privilege intersects with the growing number of women living in

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town, many of whom turn to sex work for income. Obbo (1980) similarly documents social change in urban Kampala, focusing on two informal settlements in the 1970s.

Obbo (1980) characterizes the social milieu as one conducive to changing gender and social relations. Obbo also documents urban unemployment as a facilitator of men’s dependence on women who had more innovative ways to generate income. Similarly, this study documents the continuation of these themes, albeit in a different informal settlement, almost 40 years later. Men describe it in 2019 Kabalagala as follows:

They [men] are with them for survival because they seem like they go to work with their bodies and prostitution and they come and they seem like they still love their man at home and they offer everything so the man so they don’t do their responsibility and the man will stay at home. The man will start caring for the kid and cleaning the clothes, taking responsibility of a woman instead, while the woman takes responsibility of a man and goes for work. – Wasswa

The following sections will go into greater depth about the “new” forms of marriage in

Kabalagala. Here, Wasswa links economic dependency to the reason why men engage in these forms of marriage, particularly with higher-earning sex workers. These relationships, these survival strategies, pose great risk to the men who are financially depend and less likely or able to leave.

7.2.3. When Your Social Life is Centered on the Bar: Bar Norms and Dynamics with Implication for Risk

As conceptualized in this research, the bar is a core constituent of the risk environment in Kabalagala. Described previously, there are a large number of bars (N =

33) in the community. However, it is the social fabric of the bar that structures risk. This was first observed during preliminary research, when I began to notice that men would not test for HIV during the frequent visits to bars by mobile clinic health workers. When men are seated with their friends at the bar, it becomes difficult to talk to them or call them away somewhere. They are, in their words, “busy.” While it might not be readily apparent how they are busy, after several years in the community, it is clear that men

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are building their social relationships and often try to influence opportunities that might come their way. Described as “peer groups” by men, or “bar groups” in this dissertation, men’s social groups are often seen by the men as deleterious. As one man describes:

When I was still a boy, I used to love the street and I used to love ghettos and I found myself like in peer groups, I joined groups and I was admiring them, taking these drugs and admiring their independency or their ways that looked independent that they are not disturbed by parents or siblings, that they are not followed, they are not tracked down and taken back home, they are not harshly treated and they have all the freedom. They pulled me to take the drugs and I took the drugs and I found that the drugs will really help me to survive on my independence which is street. On street, you are independent; you run everything by yourself so when you have the help of the drugs it helps you more. To be brief, I used to take drugs as my blanket as a savior from cold or from stress and like sorry but I am trying to mean like way out, you get worn out and you are tired but you don’t need to feel that pain or that so it used to help a lot. That’s I how I did start. -Wasswa

While Wasswa focuses on the drug use, what underlies that is the influence of his peers.

Often, men would speak about moments from their past and present, moments when decision making was, in their words, questionable. They would describe the influence of their peers as having structured their choices. Orlando spoke about his days of thieving, and how it was because of falling into “bad groups.” Abed also spoke about his group:

“It’s the groups because when I came here I wasn’t taking alcohol, I wasn’t eating mira or taking any drug, or smoking but it’s the groups that taught me.”

In fact, of the 54 men interviewed, 37 (68.5%) spoke about the influence of bar groups. It is clearly an important part of men’s lives, and as described above, a structuring influence in the risk environment. Men do not directly link peer influence to their HIV risk behaviors, although alcohol and substance use are both risk behaviors. It was rather observed and described that men do not want to test for HIV in front of their friends. It is not a subject that is openly discussed, and men with a positive status do not discuss it with hardly anyone. This environment tends to suppress healthier behavior, pushing forward constant alcohol use, substance use, and other risky behaviors.

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7.3. Economic Risks

7.3.1. “Business by Chance”: Informal Economy, Economic Opportunity, and Working Conditions

“Kabalagala, is a city for unskilled laborers. We do business by chance not by profession so today I may get good money, tomorrow I don’t get. The next day I get zero but what you should know, there are three business in Kabalagala. One, prostitution. Prostitution goes to lodges, goes to bars. Another business is alcohol and the other one is these chips, kikomando, but they don’t compete with these two. These two [prostitution and alcohol] are the leading business.” – Kintu

In Kabalagala, the informal economy extends beyond prostitution and alcohol, but these are the core driving components of the local economy. Precluded from participating in the formal economy, the community’s nearly 10,000 residents have formed a shadow economy of their own. As Kintu describes above, everything extends from sex work. Sex work props up the lodges, which support the bars. Occasionally, in between all these other activities, people do need to eat, and that’s where the local restaurants and snack shops come in. A major benefit of participation in the informal economy is that taxes are non-existent, except on goods which are purchased a market price. The informal economy is a core part of the risk environment, driving men’s precarity, not only in Kabalagala, but worldwide in other urban settings (Agbiboa, 2016;

Ference, 2016; Rogan, Roever, Chen, & Carré, 2017).

Kabalagala’s informal economy is an extension of decades of city policy and trends toward urbanization in the city. Policies focused on regulating the informal economy will be discussed in the next section. It is because of the increasing urbanization that can be traced to the colonial era (Southall and Gutkind, 1957), and the neglect of successive governments in creating coherent urbanization policies (see

Chapter 2), that residents were left to build cohesion on their own terms. This power vacuum left by the state in urban areas, particularly informal settlements, is conducive to other forms of local leadership. The local leaders dictate much of what happens, with an

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entrenched hold on power and the ability to shape the economy and society as they would like.

Here, I focus on the residents’ descriptions of how the informal economy evolved over the last few decades (since the late 1990s). A few men (n = 3) went into great detail about the community’s history and described Kabalagala as having first been a residential area. Most residents left the community for work in neighboring Muyenga, or directly in the town center which is an easy takisi ride away. As the bars began to thrive on the main road, sex work soon followed as women found money-making opportunities in the bars. Soon, the neighboring community became a haven for entrepreneurial individuals who opened the first lodges. Today, the sex work business is thriving in a precarious balance involving local leaders, the police, and residents. In other words, everyone is making money. Problems only develop when someone wants to increase their share of the income, or when the business is not making enough. It is because of this focus on money that many local leaders are not trusted:

The local leaders are not fulfilling their roles, because most of them love money so much that they forget to do their work. A person may be a criminal and the local leader covers for them because they have been given money so that’s the situation. I think that the local leaders are betrayers and they are not strong enough to make certain decisions so maybe there are higher people. -Edward

Other men (n = 13) affirmed the role of the local leader in the economy, as someone who creates rules and structures access to opportunities, business or otherwise. Local leaders are also notorious for taking over a business or land when it is deemed to be physically valuable:

The problem with the local leaders is that some of them are family members, family inheritance, bribery, obubbi [theft]… those MPs, those LC5 even a mere LC1 you find them disturbing people’s property, chasing people out of their land. Even my Dad before he passed away, we were staying the other side, when he passed away these LCs they connived with some people and they came and I had constructed my two, well-built not like this one, well built. After breaking it I went to the police with the Mum, that they are compensating us 10m [10 million UGX], they gave us 5 million first in installments and with the building which is not equivalent to the what, our construction. – Erias

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Beyond these more extreme cases where local leaders directly appropriate land or businesses, nearly every interaction with a leader involves some small amount of money. While local leaders run the informal economy, its participants have a stake in its success. The informal economy runs on exchanges, but also on relationships.

Individuals doing business do so with friends, or contacts of friends. A common “job” in this informal economy is a “broker.” A broker deals in different things, sometimes renting homes, sometimes selling used electronics or phones. A broker is someone who can solve a problem and connect people to what they need. It is quite easy to get whatever you need for a price, and brokers are incredibly creative at facilitating these exchanges.

Sometimes it is a type of cell phone, other times it is equipment like a refrigerator or laptop.

7.4. Political Risks

7.4.1. Regulatory Regimes: Vagrancy Laws, Drug Laws, and Other Forms of Control

In Kabalagala, Ugandan Penal Code [1950] and other more recent statutes are used to enforce state control in an area where state control does not always reach in other ways. It is through its vagrancy and drug laws that the state perpetually cycles men in and out of prison. In a scathing indictment of the prison system, Human Rights Watch

(2011) cites prisons as places where routine physical abuse takes place, with increased exposure to health problems like HIV or TB, and unclear paths to justice or adjudication.

The report (Human Rights Watch, 2011) states that 50,000 people pass through

Uganda’s prisons each year, with 56% of incarcerated individuals not having been convicted of a crime. Bail is nearly non-existent and inadequate legal representation is the norm (Human Rights Watch, 2011). Kabalagala’s men are acutely familiar with the prison system and its awful conditions, with tales of Luzira spread by returning men who

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vow never to return. Many men from Kabalagala describe that they were arrested not for a specific crime, but they were caught up in a police raid or were unable to pay a bribe.

Other than cases related to violence, theft, or murder, most of Kabalagala’s police pick up men on trumped up charges of vagrancy or drugs. They are often exaggerated, because proving vagrancy is difficult, and men describe how police planted drugs on non-drug users. Under the Ugandan Penal Code [1950], Section 167 deals with “idle and disorderly persons,” and Section 168 relates to “rogues and vagabonds.”

The laws on idleness criminalize begging, public gambling, disorderly conduct, and soliciting or loitering for immoral purposes. Not surprisingly, this law can be very widely interpreted. Kabalagala’s men are arrested under these very laws:

Idle and disorderly, they take me there because I don’t have a job, everyday idle, you know, taking waragi without a job that’s why I am trying my best to get a job. I have a certificate in metal and fabrication but I am still looking for a way. – Orlando

Men here, they used to arrest them because they don’t have work, they [the police] just move up and down they tell them that they are idle, they take them up to Luzira. -Mutebi

That’s [idle] not a case [meaning, that’s not a real criminal case] I know but they take us that we are idle, now that’s another problem. – Lutalo

Less commonly used are the Rogue and Vagabond laws, which pertain to 1) everyone previously convicted under Section 167, 2) anyone seen begging in a public space, 3) a suspected or reputed thief, 4) a person found wandering under dubious circumstances. These are equally vague and unclear statutes. In 2016, the Human

Rights and Awareness Promotion Forum (HRAPF) wrote a report on the enforcement of the vagrancy laws on the human rights of marginalized groups in Uganda. This preceded their more recent filing of a constitutional court case challenging the laws. The human rights legal association, which has been raided and targeted multiple times by the government for its work, argues that these vagrancy laws simply criminalize people who have no permanent home or employment, in other words, the poor. They are rooted in

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14th century English law, and were introduced in Uganda via British colonial rule

(HRAPF, 2016). HRAPF contends that these laws are used to arbitrarily arrest the poor and marginalized and extort money in order to be released. Indeed, it is also used as a tactic to clear out “undesirable” men from Kabalagala, those who are jobless or who may be routinely using alcohol and seen as disturbing the peace. This situation is not unique in Kabalagala. Over-policing or indeterminate arrest is described in other informal settlements in Kampala (HRAPF, 2016).

State control is also asserted through increasingly stringent drug laws. While drugs were already criminalized in the Uganda Penal Code [1950], increasingly draconian laws have been passed with increasing expediency since the 1990s. A recent

Narcotics Law (2014) was part of the quartet of morality laws passed on HIV, pornography, and anti-homosexuality. The law penalized possession of illicit drugs with

10 to 25 years in prison. Trafficking is punishable with a life sentence. In 2019, an additional Narcotics and Psychotropic Substance [control] Act was passed. Historically, the previously legal mira (khat) drug was criminalized, affecting the large numbers of people who grow, sell, or use the drug. Drug use and drug sales are strictly controlled.

Kabalagala police are notorious for arresting known sellers and users of marijuana, in specific areas known for the drug:

You can’t know [when they are coming], they can even come from this side, they can come from their up, everywhere for you when you’re just sitting there smoking your weed, they just grab you. – Brian

Brian is a self-professed purveyor of marijuana. He was describing more generally the operations that police make in the area, where they frequently target his group and his corner of the informal settlement because it is known for selling and using marijuana.

It is important to note these laws as part of the risk environment as a mechanism of state control that has several implications for HIV risk. A clear body of evidence documents the harms perpetrated by strict drug control laws, which end up pushing drug

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users further underground and out of the reach of health services (Goldenberg et al.,

2011; Rhodes & Simic, 2005; Strathdee et al., 2010).

7.4.2. Upgrading the “Slum”: KCCA Policies and the Making of the Urban Space

The Kampala Capital City Authority (KCCA) previously headed by Jennifer Musisi was frequently and near-universally vilified by the men in this study. KCCA policies are outlined in its Strategic Plan (2015-2019), which articulates a Slum Upgrading Project that has deeply affected Kabalagala’s residents in its implementation. The project is part of its larger strategy for a Planned and Green Urban Environment that envisions a beautiful, well-planned and developed city resilient to climate change. Unsurprisingly,

Kampala’s many informal settlements are a point of concern in achieving this goal.

According to the KCCA, Kampala’s 62 informal settlements with a population of roughly

560,000 would be affected. Rightly, the KCCA points to substandard water, sanitation, and housing standards in the settlements. In the KCCA’s plans to upgrade Kabalgala, a targeted community for the strategic planning period, substandard buildings would be removed, and squatters would be relocated.

In practice, the way this program was implemented was through the razing of all informal structures, including most wooden structures, in Kabalagala. Any illegal or unregulated small shops were also razed. This razing took place in 2015, and all small businessmen and women, and vendors were cleared out. Street vending was outlawed, and all businesses had to file for and obtain a KCCA license, to be renewed annually.

These policies adversely impacted Kabalagala’s residents:

Yeah, you know I had constructed a temporary structure, a work shop made of wood now when Jennifer Musisi (the Executive Director, Kampala Capital City Authority) came in, everything, temporary structures came down. Now I am just working at the road side, there in [location] we are just working by the road side because all our constructions were demolished, all the land was bought so you [the KCCA] can’t say that “this land is mine” only that there in [location1], we rent there and there in [location 2], we work there for free because just the President came there and said that we should work there as we look for land for our businesses. – Erias

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These policies were a turning point in the way that Kabalagala’s men describe their opportunities, with a marked downturn after the implemented regulations on the community’s space and businesses. Many residents find a workaround to sidestep these laws, but it still restricts what was possible. As part of the risk environment, KCCA policies and their implementation make it harder for men to earn an income, in turn affecting their ability to manage risk. Job instability is also linked to higher alcohol and drug use, which equally impacts HIV risk as described in other sections.

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Chapter 8 Vulnerabilities

Nested within a risk environment framework, vulnerability factors are ‘features of a social or economic entity that make it more or less likely that excess morbidity and mortality associated with disease will have deleterious impacts upon that unit’ (Barnett,

Whiteside, Khodakevich, Kruglov, & Steshenko, 2000, p. 1394). In the context of HIV, vulnerability constitutes the level to which structural factors have a negative impact on an individual’s ability to mitigate HIV risk. Further, a society, community, or group might be described as ‘susceptible to infection by a disease but vulnerable to its effects’

(Barnett et al., 2000, p. 1394). Vulnerabilities derive from the political-economic context, which in this dissertation includes poverty, inequality, and unemployment. The findings presented here describe both structural vulnerabilities and synergistic vulnerabilities.

Structural vulnerability is a useful frame to encompass political-economic and local sources of physical and social distress (Quesada et al., 2011). Individuals become structurally vulnerable after facing a pattern of structural disadvantage. Meanwhile, synergistic vulnerabilities describe how vulnerabilities coalesce at the individual level to produce differentially patterned levels of HIV risk. These data are organized thematically, discussing dislocation from social support, precarity in the informal settlement, housing and food instability, alcohol and drug use, incarceration and injury, and a mismatch with expected gender norms. Together, these sections describe both structural and more individual-level vulnerabilities to demonstrate that men’s risk of HIV is nested within a complicated patterning of that risk.

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8.1. Structural Vulnerabilities

8.1.1. Urban Migration

Most of the study participants (n = 200 of 292, or 68.5% of the survey sample) come from the rural areas to Kabalagala. Some came in search of work, following in the footsteps of the myriad young workers who have migrated to the promised land of

Kampala since the colonial era (Kilbride & Kilbride, 1997). Some of these individuals are responding to the pressures of village life, while others leave home as part of a tradition of young men leaving in search of better economic opportunity in the city (Kilbride &

Kilbride, 1990). Other men in this sample left home due to patterned abuse by a parent or caregiver in the home.

This journey has been historically temporary (Southall & Gutkind, 1957), with the expectation that young men will return to the village to settle down, farm, and start a family. As described here, this is not always the case in contemporary Kampala, where young men grow accustomed to town life. Now, we see a more permanent migration with lasting implications for social relations in Uganda. Migration to town is notable for several reasons. One, it marks a transition in a young man’s life from ‘youth’ to

‘independent’ status. It serves as a transitory time, where young men are expected to make their way in the world and return home successful and established. Second, urban migration is meant to provide additional financial support to family members residing in the village. Third, it removes the individual from the social and financial safety net of their home, and men are folded into the organized chaos of the city.

Participants (n = 18 of the interview sample) described migrating to Kabalagala because of an aunt, father, or brother who already worked there. Others came to join their friends. If Kampala is the promised land, then Kabalagala is its hedonistic center.

Men described Kabalagala as the kind of place that pulls you in and does not let go:

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I am most certain, they [men] are pulled by many women that come from many different places, for prostitution, they are pulled by the many sounds. Everywhere is entertainment, to be entertained. And the fact that they are not working, you know they are poor and yet they are pulled by many things in the community that bring them here, like games, like money machines and like groups, all of this. - Jacob

Men described ‘hearing about’ Kabalagala from friends or family members. It was described as a place where there was “a lot of fun and no sleeping” (Orlando). Some men who were sent to Kampala to obtain work would end up in Kabalagala, and would often stay there. Part of this was the described lifestyle in Kabalagala, where there is entertainment around the clock. This was juxtaposed with village life, where “in the village you must dig” (Mutebi). “Digging” was often cited as a reason not to return to the village and referred to the agricultural labor of digging, planting, and harvesting crops, as is common in rural areas. In the village, you have to grow whatever food you plan to eat.

In Kabalagala, food is available anytime, without needing to dig.

Men described coming to Kabalagala because of pressures at home, from financial pressure (n = 12) to experiences of abuse as a child (n = 6). One participant experienced frequent abuse in his grandmother’s home, where he was living because his parents had separated. This was the impetus for him leaving the village:

My mother left without us and when she left, my father took us to our grandmother’s house. The situation at home was not good, we got mistreated. – Abed

The participant went on to describe how the abuse became “too much” and he ran away from home one day when his grandmother was out shopping. He regretted his decision because he had to leave his younger brother at home, and he was not sure what would happen to the boy. He went back years later to find that his younger brother was doing alright. While abuse was one reason for leaving, other push factors are described by participants:

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I came to hustle, I came to look for a life because at home we were peasants, we didn’t have anything so I came to look for a good life, to support my family back home. -Frank

These aspirations rarely translated into reality, with most men unable to find stable work and unable to support themselves, let alone send money home to the village.

Meanwhile, men become accustomed to town life, and rarely want to go back to the village. One participant spoke about how they might want to go back to the village, but there is “nowhere to start” (Abed), indicating the lack of opportunities back home.

While migration was seen as an opportunity to supplement village income, it was also seen as a rite of passage for young men (Burton & Charton-Bigot, 2010). Reaching an economic status where a man can afford a home, a wife, and children, is the way to transition into adulthood and become a respected man in many Ugandan tribes

(Baganda, Teso, Banyakore). This may be difficult to attain in villages that lack economic opportunities for advancement. By moving to the city, a man would (theoretically) obtain a job that would fund these various markers of status.

Kiiza is one example of a young man who migrated from Mbarara to Kampala, after his mother first moved to Kabalagala and established a lodge business there.

Kiiza’s mother brought him from Mbarara, and expected him to work and make a living.

Over the years, Kiiza (now 21 years old) has grown to manage his mother’s lodge business. Kiiza and Mama F. were in constant tension, with Mama F. complaining about

Kiiza’s alcoholic tendencies. Kiiza managed Mama F.’s lodge, collecting fees for the large lodge, managing the cleanliness of the place, and taking care of security. Mama F. would often threaten to send Kiiza back to Mbarara, and in fact she did send him back for a few months in 2017. Mama F. expressed frustration that Kiiza remained dependent on her financially and was unable to make his own way in the world. Mama F. said that

Kiiza was struggling to “become a man.” This case demonstrates several things: that movement to the city is often a type of ‘chain migration,’ where relatives come to the city

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to join other relatives; that city life is meant to be full of economic opportunity; men are expected to establish themselves in the world; and that it often does not work out as planned.

Migrating to the city has several unintended consequences. While economic and social pressures encourage young men’s migration to the city, it has the effect of dislocating men from their familial and social safety networks. This crisis was described by Weisner, Bradley, Kilbride & Kilbride (1990) as two-fold: that elders in the village worried about who would support them as they were no longer receiving assistance from children, and youth lose family and community support systems after migrating. Some participants described this economic crisis as antecedent to their urban migration:

Yes, by that time my father also got sick, he couldn’t manage to support the family until he passed away. That is why we ended up in such a life, taking care of ourselves. (Daniel)

Others described the loss of family and social safety networks in the village, after their migration to Kabalagala and their failure to send remittances back home. One participant, Orlando, was unable to send remittances. He was frequently maligned as kitafeeri (useless), whenever he went back home.

Young men living in the city, outside of the gaze of their tribal elders, were vilified as rabble-rousers by colonial and Baganda elite during the British colonial era

(Summers, 2005). “Dangerous” young men have often “challenged” the status quo in

Uganda, characterized by the establishment as antisocial or anti-government, either way as a problem to be solved. Colonial officials and tribal elders in 1940s Uganda also worried about the effects of “detribalization” on the youth, a process by which youth were becoming disconnected from the moral guidance and supervision of family and elders in the village (Bruner, 2017). Similarly, older men in Kabalagala malign the laziness and immorality of younger Kabalagala men who “do not want to work” and have been

“spoiled” by town life. In colonial Uganda, the solution was to educate young men

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(Summers, 2005), so that rather than becoming dangerous they might become productive. In contemporary Uganda, and indeed in Kabalagala, the challenge is that many young men are educated, but there is a dearth of economic opportunity.

8.1.2. Governments and the Role of Corruption at the National and Local Levels

Study participants describe the national government as corrupt, with national leaders perceived to be acting in their own interest. Corruption is locally called “eating the money.” Young men describe seeing how government leaders and Members of

Parliament (MPs) travel around Kampala, with police escorts and bullet-proof cars. MPs are described as owning large homes in gated communities, traveling abroad for health care, and sending their children to expensive schools. This perceived wealth accumulation has implication for men in Kabalagala, who describe people in power as accumulating wealth which is evidence of corruption. Meanwhile, men perceive to be left out of the economy. In other words, men believe that because Uganda is a naturally resource-rich country and the average citizen should not be impoverished. The only explanation that makes sense to these men is that the government is “eating their money.” To the study participants, this corruption reduces opportunities for young men in

Kabalagala and presents a hopeless situation as portrayed by one participant, Kintu:

The only thing which can be better for Uganda to go further than this, we need to change everything. If they can accept federal governance for some parts, the Banyoro, Basoga, Baganda, that should be the start. I don’t know if it will happen because the government people, all of them are corrupt from the head. At least these other people, let’s give them a chance and see if they can change the situation but in that side of presidency, I see no future. Unless we bring Bobi Wine, the country will remain poor. We need a transparent government, we need a government which can respect people so whereby if you know that [NAME] is sick, we have medicine in the hospital. Now it’s like, those who cannot access medicine has maybe a friend to an MP, friends with a doctor and they get the medicine while we [with no friends] remain with no medicine. If not, let them say that with corruption, you pay 20,000 and you get what you want. If you go to finance you give them 50,000 and you get what you want, let them legalize bribe, maybe we can be fine but people are suffering because of corruption. But you will never, never stop it because Museveni is using it, he sees it is for his own good, doing this for himself; everything he does, he sees as a good business for himself. – Kintu

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Kintu is a well-established lodge manager in Kabalagala. To speak with him, I always had to make an appointment and give him advance notice. He would take our meetings seriously and would never allow others to interrupt our lengthy conversations. He is self- educated, having left the village at a young age after being orphaned. He does not always blame the government for his problems. When his parents died, Kintu was in secondary school. At the time, he needed to continue with school and so he spoke to the school’s principal to find a way to fund his education. After graduating, he began working odd jobs, mostly in Kabalagala where he had family. Despite being educated, he was unable to find any kind of stable work in the city, because (to paraphrase) “those jobs are only for Westerners [e.g. Banyankoled and other Western tribes].” This perception that opportunities are limited because of tribal status arose during our interviews, where he spoke about the disadvantage that Baganda men face in Uganda. This was positioned next to the corruption of the government, which only acted in its interest and the interest of the Banyankole.

Perceptions of corruption have become more pronounced. Public cases of corruption are often in the news, and Bobi Wine has contributed to critiques of government corruption. In line with the above individual, Kabalagala’s men describe the government as bankrupting the country. The government is described as instituting higher and higher taxes on fuel, food, and income. Yet, with no perceived benefit to the average citizen, as Erias describes.

Uganda would have been far far much better because right now we pay taxes, unreasonable taxes. You start paying taxes, you pay taxes starting at a toddler stage but those bigger men can’t show you what your money does and they are squeezing you, you are toiling hard, every other year KCCA are creating new taxes of which even the old ones are too hard for the people to handle so you find yourself at the end of the month like one hundred thousand left after all expenditure where you cannot even drive the family. Right now, for us the time we used to study, O level we use to pay something like 34,000 [US$9.19] but right now, I read the news its 1.2 million [US$324.32] for you to study. – Erias

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While Erias exaggerates at times, he describes a feeling of being “squeezed” by the government, while men are working hard to earn money. He critiques the new taxes, which take away from his earnings and leave little money left over for expenses.

Further, there is a perception that people in power are staying in power and not letting go to make room for the next generation. Men in Kabalagala describe those staying in power as “old men” who refuse to leave, thus reducing the chances for advancement in a society that was not only unequal, but has deeply entrenched power structures that are unlikely to change.

It has been the spell [long tenure] of this government, I am old like the age of this country. It started when this old man [President Museveni] inclined not to get out of power, everything now is political, everything is politicized even those guys who are working in those positions, every one doesn’t want to move from that position, you find an MP for 25 years you are an MP, you are in the seat for 28 years, they don’t want to get out of that position. He wants to move out of that position when his family is okay like I told you. – Erias

The idea that “everything is now political” was repeated during my time in Kabalagala. It came to denote the increasing polarization of NRM and People Power supporters, both at the national and local levels. In Kabalagala, local leaders similarly were divided along party lines (although, People Power is a movement and not technically a political party).

Kabalagala’s leaders at the parish level are predominantly NRM supporters, while younger zone level (Local Council I) leaders tend to support People Power. Kabalagala’s youth are overwhelmingly People Power supporters. These political tensions characterize many of the disputes taking place in the area, as described elsewhere.

Finally, the implementation of KCCA urban development policies is vastly unpopular in Kabalagala. Men often point to these policies, which came into effect in

2015 in Kabalagala, as responsible for the loss of jobs in the area.

P: I can’t say anything good about it [the KCCA demolishing businesses] because it hurt us a lot. We had shops, stalls of chapatti but it was all demolished saying that they were going to construct a road but they have not. It’s even

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around that time when poverty increased, they put in place some laws so income also changed. I: Has it done anything to help the youth? P: No, I have never seen it, I have not seen anything that it has done. I: So you have not seen any program from KCCA? R: No. – Saturday

These policies were cited as further constraining the opportunities that young men have in Kabalagala. After 2015, small businesses were increasingly regulated and were expected to purchase a license from the KCCA, otherwise their business would be shut down in one of the numerous raids that the KCCA would stage.

The KCCA treated us really badly in Kabalagala. What I have to say is that if you are going to demolish, first tell the people and give them time, explain to them the period and also compensate for where I will go after. Don’t just come and destroy my business with 15 million and dump it, we lost a lot of things, our spare parts, boxes were taken that is why it’s still difficult for us to build back up. Many people went back to the village. The job of KCCA would be good except that they are demolishing and destroying people’s houses. Let me tell you, we have sisters staying in these rooms but if someone gives you money and you send them out without warning them, it would hurt them. My request is for KCCA to change the way it works. When they are going to send people away, they should be given a time period to move their things, find where to put them instead of coming with a grader to destroy everything. Personally, I have not seen KCCA help any person besides destroying the community. I was given birth to in Nsambya hospital but I have not seen KCCA here I repeat 10 times, KCCA has not helped any youth here in Kabalagala, all it does is torture us. - Salongo

Salongo articulates the harms that the KCCA has perceived to have perpetrated in the community, from destroying shops to pushing residents back to the village. Further, these kinds of actions were not understood to have a purpose. Participants were frustrated that after having already too-few job opportunities, they were also unable to be self-sufficient through vending or selling items. These types of businesses require very little capital and no physical space, so overhead costs are low. Young men would buy clothes or shoes from Owino Market, and then walk around Kabalagala selling their wares to residents during the day time. Now, this kind of work is illegal under the

KCCA’s new regulations.

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8.1.3. Economic Pressure: Job Instability, Low-Wage Labor, and the High Cost of Living

Explanations for job instability range from barriers to employment, low access to financial capital, increasing government regulations, government corruption, or instability in the informal economy. Despite these different perceived causes, all study participants agree that joblessness is the biggest problem facing men in Kabalagala. The jobs that are available are in the informal economy, and are unstable and low paying. Meanwhile, increasing KCCA regulations present barriers to those who cannot comply with costly upgrades or requirements.

The jobs that are available to men are often casual and unstable. Businessmen or contractors will come to look for men to do casual work: construction, moving, or other odd jobs, often for wealthier families in neighboring Muyenga. Men spend most of their days sitting around, waiting for work opportunities to present themselves. These might come from outsiders, or they might come from the few Kabalagala business owners. The few Kabalagala businessmen and women (wealthier, typically older individuals who own land) will send young men to buy things, or to run errands. Some will send young men to park their cars, others will send men to pick something up from town. Men might be asked to clean a room or toilet, or fetch water. Men might be asked to wash clothes, buy cigarettes, wash dishes, clean trenches, or similar tasks. None of these odd jobs are stable, and none pay more than 5,000-10,000 shillings (US$1.50-2.50) per job (the latter would be considered high pay). This may not be a livable wage, but it is enough to buy food for the day. Some men prefer to spend the day waiting for these opportunities than to leave the community and search for work, which might also pay little. Other jobs would also have transportation costs associated with leaving Kabalagala, and often there is no net gain. These mental calculations are part and parcel of the ways that men negotiate precarity in the urban informal settlement.

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One income-generating option is to create a small business of your own. This is becoming increasingly difficult with limited access to capital and onerous KCCA business registration rules. To access capital in a bank, an individual would need multiple documents, including a current bank account, a completed loan application form, payment of loan processing fees, a financial card, collateral, security or movable assets, a guarantor, residency in the bank’s area of operation, and so on. For a man from Kabalagala to get any of these things, let alone a national ID or a bank account, would be extremely onerous. To access capital in Kabalagala, men instead turn to informal money lenders in the community who offer loans for cell phones, laptops, a land title, or anything else of value. To access these informal money lenders, men must have relationships with men in power and be viewed as a “responsible” member of the community.

Even if men are able to access capital to start a business, they are subject to

KCCA regulations, including industry-specific regulations and renewable business licensing. Boda boda drivers, for example, have to have a license, wear combat boots, leather jackets, and long pants, in addition to having two helmets. These are requirements that can cost upwards of 1 million shillings. Businesses have to renew their licenses, while street vendors are no longer allowed to sell their goods. These were once good opportunities for men to make money, but now they are no longer able to do that kind of work because of the regulations.

P: As we are seated here, I have seen some guys, they have been caught up by KCCA and do you know, someone is having a small business, the capital can be like sixty thousand but when you go to the courts of law, they are saying fine is six hundred thousand, it’s quite high. I: Do shop keepers and street venders fear the KCCA? P: Ahh, to the less extent, the shop keepers like when the year has started because of license they always shy away but for the vendors, it’s just pick and play [meaning, a gamble] on their side because it will never stop. Every time they see KCCA, at times they just drop their merchandise, they just run away because Luzira [prison] is not a home, there are no sausages. – Milton

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Milton differentiates between shop keepers and street vendors, both of which are subject to KCCA rules, but the latter is illegal. Another participant has been directly affected by these changes, as he describes:

I: Why did the KCCA take your things? P: I don’t have any money for tax, I don’t have any physical shop, so they took my things. I: Why did they take things from you? P: My capital it was very small. When I have at least a little capital, I can start again and I will move away. When I get money, I can get a shop but now there is no money. The KCCA will come and chuck me, anytime I am selling my things. – Charles

Many times, this kind of back-and-forth with the KCCA is no longer worth it, especially when an individual is subject to multiple fines and fees that they cannot afford. The legal cost of doing business is no longer affordable, and many men opt to look for less stable, less self-controlled forms of work. Kabalagala’s residents point to KCCA rules as a turning point in the local economy, after which time men started to sleep in the bars and stay in the bars 24/7. Street vending was no longer an option, and this significantly impacted the local economy. Additionally, as witnessed on numerous occasions, anytime the KCCA truck rolls into the community, a warning spreads from resident to resident and remaining street vendors quickly scatter or hide their wares. Small business owners similarly discussed the challenges they faced with the KCCA, as evident in the following:

Yeah, yeah, You know I had constructed a temporary structure, a work shop made of wood now when Jennifer Musisisi (the executive Director Kampala Capital City Authority) came in, everything, temporary structures came down now I am just working at the road side, there in Nsambya we are just working by the road side because all our constructions were demolished, all the land was bought so you can’t say that “ this land is mine” only that there in Kansanga, we rent there and there in Kansanga, we work there for free because just the president came there and said that we should work there as we look for land for our businesses. – Erias

Erias is a good example of someone who has tried different income-generating strategies, but has faced misfortune. His family was wealthy and owned land in

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Kabalagala. Sometime during his youth, Erias’s father was displaced from his land when local Kabalagala leaders (who are still in power today) appropriated his land and forced his father to sell at a low price. Erias and his family were forced to move, and became renters. Years later, after his father’s death, his mother had an established furniture business that she built up. Her furniture business (described above) was located in

Nsambya and eventually torn down by the KCCA. To Erias, it was a cycle of building up his life and his source of income, and then seeing it taken away by local government. He was understandably frustrated, and articulated his frustrations by maligning the perceived corruption at all levels in Uganda. Erias describes the various barriers to establishing his business, barriers that are just too high even though he tries hard to make his business work. One local leader, an LCI Vice Chairman, described these struggles:

So the youth decide to come to Kampala because the government no longer cares about them. The things they would have got money from like coffee, have no market [in the village], the land that they would call theirs, they sell it because of the struggles so after a year because of the taxes, they decide to buy a boda boda. Even after this attempt to make money, the KCCA is the one who benefits because of taxes. So end up selling the boda as well and remain with nothing so that’s why they end up sleeping on the street verandas.

Like the Local Leader, Erias linked his troubles to systemic issues. Erias voiced what many other young men said, that the system was just not fair:

My hope for the future is, we youth have to get involved in the politics and the problem is when we try to engage, they distance us from that, those old men, they distance us and they make us like we are destructors, like we are wrong doers. There is no kind of demonstration, if you demonstrate, they take you and put you behind bars. Now we have decided to resort to working but even though we work, the system is not fair. – Erias

Participants (n = 15 of 54 men) cite the government’s policies at the national and city levels as economically harmful. This was not the case when I first started fieldwork in

2016. At that time, men might have blamed the city government (the KCCA), but they were generally satisfied with the national government, and more specifically, President

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Museveni. In 2019, the political scene began to change with the ascension of Member of

Parliament Robert Kyagulanyi (Bobi Wine). His rhetoric strongly resonates with the young men of Kabalagala. Bobi Wine is able to articulate the frustrations of being poor in the ghetto, but links this situation to government corruption. This same rhetoric is now being appropriated by young men.

There are some jobs available in Kabalagala’s informal economy, but these jobs are scarce and unstable, with little profit. More than ever, sex work is the dominant economic activity in Kabalagala. As such, most jobs are associated with sexual commerce. For the men in Kabalagala, work is available in the form of a lodge manager or the smaller jobs associated with managing a lodge, including cleaning, washing sheets, or providing security at night. The lodge manager is the central focus of the lodge business, responsible for collecting fees from occupants, paying any bills

(electricity, trash collection), and tracking the occupants and their payments in a book.

The lodge manager also steps in during times of conflict, at times sending unruly occupants away from the lodge. It’s also a dangerous and often unprofitable business:

All problems, the customers they come, they just want to fight with us – saying that we have taken their money, the lady has taken their money so they tell you “bring the lady she has taken our money”… some of them [customers] bring the guns because their money was stolen. The lady steals their money and then disappears. So, the man comes and asks “are you the owner of this lodge?” Yes. “You bring the lady that has stolen my money.” It’s very dangerous. – Mutebi

Lodge work was often described as dangerous, and sometimes ultimately not financially worth the physical risk. No matter how much money they brought into the business, some men are paid a fixed amount each day. Others have a fixed amount that they pay to the lodge owner, and then retain a share of the profits. Either way, business is not always profitable.

There is a broad perception in Kabalagala that men, especially young men, are jobless in the community and that this joblessness translates to men sitting around in the

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bars all day, drinking waragi (local gin) and beer. Joblessness is perceived to be widespread, with few opportunities for educated or uneducated alike. This phenomenon is also perceived to be more recent, as participants compared the current economic situation to generations before. This is broadly called “the situation,” where men spoke about a number of challenges related to the situation that they found themselves in. It is because of this “situation” that men struggle to make ends meet, are unable to pay for their children’s school fees, and are living on the street.

Actually, I feel like so many other things are going on because that’s not how I wanted my life to be. Because of the situation, I’ve lived in the ghetto since I came to Kampala. I have been living in the ghetto. You might be in the ghetto when you have nothing to do, you don’t have where to stay, you understand, you just stay with your friends, you don’t have a job that you are working and get money from there. For everything you be hustling, that’s not the way we want our life to be, but the situation. The situation forces us to stay in the “ghetto”. Because here in the ghetto you can be when we are just sitting here like this and they come and arrest us, and take us to the police. -Jonathan

This rhetoric indexes a subtle shifting of responsibility, from the individual to the broader economic context, or to the government, depending who you speak with. Joblessness is no longer the fault of the individual man, but rather this man is disadvantaged by the lack of opportunity, or “the situation.” The situation also indexes aspiration, with some men holding to the notion that if the situation would just change, then their lives might turn around.

While jobs are increasingly unstable for Kabalagala’s men, the cost of living is increasing at a fast pace. When asked whether the price of key items is too high, 96.1% said the price of sugar was too high and 97.4% said the price of fuel is too high. The cost of living, although cheaper in Kabalagala compared to Kampala in general, was still too much for many men to afford. Base cost of living would be 2,000 Ugandan Shillings

(UGX, US$0.40) for breakfast, 3,000 UGX (US$0.80) for lunch, 5,000-10,000 UGX

(US$1.30-2.30) for a room, and then anything extra would go to drinks (water, alcohol).

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Compared to the cost of living, income is uncertain and unstable, whereby men survive from day-to-day:

My earning is not so good. I am a Dobbi [laundry man]. Not so good, I earn little but not daily. I earn little but a get money daily, I get everyday though it’s little. It’s not enough because I have to pay rent. The rent that I pay is bigger than my job. I pay 300,000 UGX (US$80) in rent every month. I pay daily, 10,000 (US$2.30) every day but it’s hard for me to get the 10,000 every day because I have to eat and also pay the person who helps me. – Apolo

They don’t have money to buy food at home, they cannot rent a house, and you find four men in one house. – Kintu

This section has demonstrated the economic pressures that men face in Kabalagala, and likely, in much of urban Uganda. The chronic job instability, entrapment in low-wage labor, perceived blockage by entrenched local leaders, and high cost of living are characteristic of life in the informal settlement. Some are able to break that cycle, but those that prosper are usually the multi-generational land owners, local leaders, bar owners, or money lenders, “Kabalagala’s businessmen.” Meanwhile, Kabalagala’s younger men face shrinking economic opportunities in a shrinking informal economy space increasingly subject to KCCA regulation.

8.1.4. Police Surveillance and Crackdowns

Kabalagala is frequented by the police. The police describe the study community as a place where every kind of crime is committed. Participants have different perceptions. Since August 2019 or so, President Museveni integrated military with police, so that all patrols are joint, led by a policeman, and composed of both military and policemen and women. While the police have longer-standing relationships with the community, the military does not. The reasons for integrating the two are unclear, although speculation relates to ongoing politics between the police and the President.

The most recent Inspector General of Police was fired, charged with treason, and imprisoned. Nonetheless, the police are significant to this narrative for several reasons:

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1) the police regularly conduct sweeps of the study community, during which time men are arbitrarily arrested, 2) police bribes and corruption is commonplace, as described by the study participants, and 3) men cycle in and out of jail with implications for their well- being and stability.

Fears of what was seen as unpredictable and arbitrary arrest was a clear and present theme in this research. Men describe being seated near their home, bar, or place of work, and being suddenly arrested by the police. Others, who admit to selling marijuana, are constantly on edge, ready to flee at any moment. Those who do not sell drugs or engage in any kind of criminal activity still are nervous around the police. This is because the police are well-known to arrest men without apparent reason in absence of any criminal act at the time.

P: The challenges are that we are oppressed, we are arrested even without committing crime, sometimes they find you seated and they arrest you, they leave the criminals and arrest the innocent ones not even knowing what crime you committed and then they torture you, which breaks the law, that is a big challenge here in Kabalagala. I: What do you thing brings about that? P: I don’t know what causes that because if we knew the root cause of why we are arrested, we would change, but they just find you and arrest you without any explanation, so it’s so oppressive in our area. – Mugisha

Many times they find you seated and they just arrest you, even when they ask for your identity card and you present it they still arrest you so that is where its bad. – Abed

Mugisha and Abed distinguish between arresting someone for a crime and arresting them for no clear reason. It was described thusly: police patrols would come at night, approach a bar or area in the community, and then ask for men to show their national IDs. Those that did not have their ID would be summarily marched off to the police station. Those that did have their IDs were not necessarily safe. Either way, men may have to negotiate a payment to the police.

The participants above are not complaining about routine police work, meaning, arresting someone who has committed a crime. The men above represent the many

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others (n = 26) in the study who describe routine police sweeps, whereby the police will come into the community and arrest groups of men. I witnessed this on one occasion.

One day in April, just before Easter, I was seated off the side road, in a small passageway between two cement buildings. I was seated with Lutalo, a participant who had been difficult to meet. Lutalo was homeless and slept in the bars at night. He is a builder, but he had been sick lately with suspected TB and was unable to work regularly.

Building work is also uncertain, with some jobs taking Lutalo to places like the Ssese

Islands for weeks at a time, and other jobs lasting only for a day or an afternoon. We were in the middle of an interview, when chaos broke out. We were just out of view of the main road, but we noticed people running up the side road, scattering in all directions, diving for an open room or other place where they could hide. Soon thereafter, we saw the police chasing people. I immediately took out whatever papers I had, handed some to Lutalo, and handed some to another man who was nearby and looking for a place to hide.

One notable police officer came marching up the small road. He looked like he was dressed for battle, with camouflage clothing, a military beret, sunglasses, an AK-47, and extra bullet pouches. It was unclear whether he was police or military. He looked over at me, Lutalo, and the other man, and said that we were fine and should just stay seated. I called my research assistant Mr. Kizito, and told him what was going on. He was on the other side of the community, seated with another man, and he also thought quickly and took out some research papers. He similarly saw people running in all directions, with police chasing men down. Whatever men were caught were beaten with batons, collected in the center of the community in an area where cars park (Figure 8.1), in between two large lodges. Men were told to remove their shirts and belts, and lie down in rows on the dusty ground. The 50+ men arrested from Kabalagala that day were taken to the police station. Thinking they were safe, men relaxed a bit after this round of

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arrests. A few hours later, the police came back and arrested another group, including

Isma, taking some of them to Kabalagala police station and the overflow to nearby

Kisugu police. Isma described what happened:

I: The time we were supposed to meet and talk, there was a situation, and you were one of the people who were arrested. What happened? P: Of course, I went to a restaurant to get something to eat, because I work a lot, I get tired so I was in a restaurant, it was about three of us, the person who works there and another was also a customer so they just entered and arrested me, they didn’t care to ask, they just arrested me. When they took me, there were other people, we were all arrested at the same time and they were still bringing others and we were taken to Kabalagala Police station. I: What were you told you got arrested for when you reached the station? P: When we got there, I was not told of any crime that I got arrested for but at last, they finally told me to make a statement. In my statement, I wrote that I was found in a restaurant eating my food and I got arrested, that’s the statement that I made but, in the end, I asked them, “why was I arrested?” “It’s a security matter”, that was the response I got. – Moses

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Figure 8.1. Police round-up of Kabalagala men

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Figure 8.2. Street art from the study community

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This narrative illustrates several points: one, that life in Kabalagala is unpredictable and often uncertain. Second, state control of men in the informal settlement manifests in cases like this, where the police will sweep the community.

Singh (2016) indexes policing practice in South Africa as one aspect of state control that derives from social, political, and economic agendas and neoliberal policy. The policing of Kabalagala can be viewed from this perspective (Figure 8.2), with implications for the vulnerability of the community’s resident men. In Kabalagala, bribing the police is endemic, expected, and experienced by everyone.

P: Personally, I have seen the police arrest but there are those culprits who use energy while resisting, others say they can beat them up because they are short tempered and they forget that it’s unlawful to fight the police so if the police comes to arrest you and you are peaceful, they will not treat you badly. For example, 10 days ago, my friend that I work with got into trouble. Someone whose father is a soldier, got a soldier and locked him [my friend] up down at the project, I think it was Friday last week, he was beaten and all swollen but they were all arrested and one who tried to resist was beaten. So I say that when you are being arrested by a police officer you don’t need to struggle because he can also get mad. The last time we were caught chewing mira [khat] where Mama A sells it. I was in a vest but I didn’t struggle, I just put my hands out and I was hand cuffed, I was arrested with [NAME] but we were very calm when they put us in a special [a taxi] up to the police, even the money that was used to sell mira was taken by the police, when we reached Kabalagala [police station], we were asked, “who is your boss?” We said Mama Agnes. They called Mama A and she was asked to pay 1.5 million [UGX], even her car was taken. So Mama A paid 1 million at the police and we were released. I: So the money she paid at the police, did she pay it rightly or it was a bribe? P: It was a bribe. I: So do people have to pay a bribe to be released? P: There was nothing to be done, it was a bribe. That’s what you do. -Salongo

Participants report a typical narrative: the police arrest a man, typically at night, he tries to pay a bribe immediately (around 10,000 UGX), and if that fails he spend the night in jail until someone can come and negotiate a bribe large enough to get him out of jail.

P: For me how I see, the police have a lot of loopholes in them like do you know this thing they call “kintu kidogo” (bribes) it has eaten them up, it has eaten up most of the police around Uganda. In fact, the army guys when they put them on

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operation [meaning, when the army officers were embedded in the police force] they think that the police officers are like that but even for them it’s going to eat them up because they walk hand in hand [they work together]. I: Still on that point, how do you get out of the cells if you are arrested? R: One thing that I know about the police of Uganda, our police, the moment they see that you have someone who is above them, they will always release you but the moment they see that you are an underdog, they want bribe and that’s how they can release you and if they stretch the hand and they see that you have lawyers, they always fall back because you will bring problems to them but it’s all about money. – Milton

In my time in Kabalagala, I have heard of or witnessed various police cases. The case progressively becomes worse, with increasing bribe amounts, if the individual cannot satisfy the first demands. If a man is in jail, it takes at least 50,000 UGX to get him out. If his case file has been stamped and sent to the State Attorney, then bribes will take upward of 1-3 million UGX. If he is in Luzira Prison, then it becomes even harder to get him out. Kabalagala Police Station was (allegedly) cited for being the second most corrupt in all of Uganda, as several men told me. All of this bribery is negotiated in secret, but it is an open secret. Men, feeling desperate and desperately wanting to get out of jail, will pay at any cost: “of course you have to pay money because you are a human being, you have to pay because you are behind bars” (Saturday). Men also describe how the police will pin cases on them, with drug possession being the most common:

They just find you at your work place and they take you. They don’t care about what you have to say, they don’t answer questions, they just take you up to the police and they put you in prison. They don’t charge you for anything but if someone comes to bail me out, they put on me a case that I have never done like smoking weed. There is a lot that they can put on you because they are the law, and they are free to put on you any case that they feel like. - Mugisha

Mugisha describes two key factors: one, that police arrest is perceived to arbitrary, and this feeling of powerlessness, that police are in charge and they are the law, while you are just an ordinary citizen.

Several other individuals, outside of the police, are involved in the security and defense of the area. The Local Council has its own “Defense” or security person,

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responsible for security of an area. The police also hire Crime Preventers, instituted around the 2016 election in Uganda. Crime Preventers are notoriously harsh. They are recruited from the communities where they work, and in the words of one Kabalagala man, “they are crime promoters, not preventers.” They typically receive these jobs through connections with the police or local leaders. Elevated to this position of status, they are notoriously difficult to deal with. One crime preventer in the community was involved in a murder, and fled the community. Others will arrest at will, arresting men over personal disagreements.

The following vignette illustrates the role of one local leader in petty crime, often with adverse consequences for community residents. My knowledge of Al-Shabab (a pseudonym for this individual; not the known terrorist organization) is derived from informal conversations with men, local council meetings when residents leveled public accusations against him, and during one curious incident where a young boy was temporarily detained for suspected theft at the bar where I was seated having lunch one day with Mr. Kizito. Somehow the boy was left at the restaurant, and told not to leave, while someone went to get the police. Another man nearby explained the situation. A notorious LCII member, the Youth Councillor, nicknamed himself Al-Shabab. Al-Shabab runs a group of homeless young boys (ages 10-14), encouraging them to commit petty crimes. They were housed at a rented home on the outskirts of the main community. The young boys would move around the community at night, and steal mobile phones or other items of value. These crimes were often reported, and the young men were often taken to the police. However, Al-Shabab would invariably get them out of jail, indicating some kind of collaboration between local leaders and the police.

Local residents were furious with Al-Shabab, publicly accusing him of these ill deeds during a community meeting. This incident climaxed when I was seated doing interviews in the community one day. I looked up, and saw a large group (20-30) of

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armed men marching down the road. They were armed mostly with sticks and batons. I happened to know the leader (Orlando) of the mob justice, and so I asked him what was going on. He said that they were going to find the house where the young thieves were staying and take those men to the police. After finding the boys, melee ensued. During the pandemonium, the landlord of the house gave the mob permission to break down the structure, because he was also tired of housing the young boys. The young boys were actually taken to the police, unharmed (to my knowledge), and Al-Shabab went on the run for several months.

8.1.5. Exposure to Violence

Various forms of violence were discussed as a challenge in Kabalagala by 48 of the 54 (89%) men in the interviews. The nurse at the local clinic in the community described violence as the main reason why individuals seek care. Violence is commonplace and is mostly a problem after dark, especially in the later hours of the night (12 am – 4 am) when drinking is at its peak. Violence has purportedly gone down in recent years, although it is endemic among partnered men and women. There are several manifestations of violence, from the everyday intimate-partner violence to the punctuating violent acts of beatings and/or murder.

Several participants described the fighting within their own relationships. These incidents were often fueled by alcohol and feelings of jealousy. One participant was frequently fighting with his girlfriend, whoever that happened to be that week. When I first heard about Orlando in 2016, it was because a sex worker was being kicked out of one of the lodges. Other sex workers had complained that she was constantly arguing with her boyfriend (Orlando), and that he threatened to hurt her with a knife. The lodge owner, Muzeyi, was considering what to do. Because the sex worker had refused to break up with Orlando, Muzeyi felt he had no choice but to send her away from his lodge. She was causing too much disruption and he worried that she might be harmed

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and he would be liable. Years later, when I began interviewing Orlando in 2019, I heard more of his side of the story. He was just 21 years old at the time of the interview. He presented himself as a victim (he had a visible bite mark on his cheek), rather than a perpetrator of violence, although undoubtedly some of these cases are murkier than a victim-perpetrator dichotomy.

No for her, I told her we go and test ourselves together at first, I told her ‘let us go to KCCA Namuwongo [nearby government clinic] for free, she refused. Now yesterday she saw this [points to his bottle of ART] she just started quarrelling with me, instead of fighting to find me inside in the jail I just decided to leave her. Now let me take my waragi and swallow my medicine, life is the best I like this. – Orlando

At the time of the interview, Orlando had recently found out that he was HIV positive and had started to take ART. When we met after that HIV+ diagnosis, he came to the interview with his ART bottle, to show me that he had started the medicine. He also had asked his girlfriend Harriet to go with him to test for HIV, but it led to an argument. He said he stopped arguing and walked away, rather than allowing it to escalate to violence.

He was frustrated with her unwillingness to test, and decided to leave her after that incident. Indeed, I saw that he had changed his residence and was no longer to be seen with Harriet. He framed this decision as one where violence would have prevented him from adhering to ART, and because of this, he made a choice to leave the relationship.

Alcohol use and fighting are interlinked, and alcohol is described as a driver of the everyday violence in the community, as described below:

P: Okay you know, of it [alcohol] can make them to fight. Like when I am walking and somebody comes and steps on me, some of them can fight because the booze can make me lose my temper but when somebody drinks and sits in one place, that is okay but these one who drink and walk are the ones who fight because the drink he has drank makes him to just want to fight. I: Do you see fights a lot, do people fight a lot? P: Eeeh, mama nyabo [literally, “dear mother,” an expression of shock] here fighting is like a game in [community name] here. It can’t take a week when people have not fight here and almost the drankos [drunkards] are the ones who fight here. I: Do you have like a good example of that? P: Yeah [laughing]. Shha [an expression meaning most literally, ‘duh’].

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I: Tell me one which you remember. P: Okay that one seated in front of us, that one with the red shoes, that one can drink and fight [laughter] almost the husband and those two even the other lady seated inside there, both of them can drink and fight almost like husband, okay boyfriend and girlfriend. I: So what do they fight about? P: I don’t know, maybe the booze can make them to fight [laughing] I don’t know. You know me sometimes when I drink, I just sit in one place and I just cool when the drink is gone then I stand up. You know fighting, last time I used to drink I was going to fight with somebody but I just cooled my temper because I didn’t have stamina that time somebody can just kick you and you die. So, I just sit down and I just cool [down]. – Benedict

What Benedict is describing is the regularity of fighting in Kabalagala, where cases are so common that people laugh about it. The fights that I have witnessed are fortunately not overly violent, meaning, no weapons are used. Guns are very tightly regulated in

Uganda, and allegedly no one has a gun in the informal settlement. Knives are also rarely used. Occasionally, people fight with broken bottles or electrical cables. Mostly, fighting seems performative and involves slapping and pushing one another. That’s not to say that it is not serious, or cause for concern. Cases of stabbings are rarer, but do take place. What is most concerning about violence in Kabalagala is the everyday, routinized characteristics. It is broadly accepted, with local leaders rarely getting involved, unless it is a serious case. Emily Mendenhall (2012) similarly talks about

‘everyday violence’ in her book about the VIDDA syndemic among Mexican immigrants in Chicago, Illinois. Violence becomes ‘everyday’ or ‘normalized’ when it happens regularly (Bourgois, 1998; Bourgois, 2009). These socially unacceptable acts are somewhat hidden and are not cause for concern among people who are used to it as a part of everyday life. While more often used to describe intimate-partner violence,

Kabalagala’s everyday violence is not just restricted to intimate partners. It is endemic in the wider population, more common among those who drink heavily.

Murder and aggravated rape cases are the more serious incidents of violence in

Kabalagala. During my one-year tenure in the community, I noted at least three cases of

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murder and one aggravated rape. The numbers fluctuate from year to year, with often very gruesome murders taking place. During a notable three-week spell in March 2019, there were three back-to-back murders in Kabalagala. In the first case, a sex worker was killed. Her husband hired a hit man to kill her, because she was HIV+ and allegedly had infected her husband. The hit man posed as a client, and when they were in the room together, he strangled her with her necklace. The community was outraged and managed to take the man to the police, where her husband was pinpointed as another suspect.

In the second case, a man was given a small Nokia mobile (valued roughly

60,000 UGX, or US$18) to fix. The man, a mobile phone repairman, somehow lost the mobile, or the mobile battery, depending on the version of the story. The repairman was a known alcoholic, and supposedly lost the phone while drinking one night. As retribution for this petty crime, three men from the community, including the owner of the phone, beat him while they were interrogating him. He was described as a very “weak” man, who was ill – HIV+ and not on treatment. After a few punches, the man collapsed. He died shortly after, at the police station, where people had taken him. It was unclear why he was taken to the police instead of a hospital. The three perpetrators of this act fled the community and haven’t been seen since. The third case involved two men – one a client of a bar, and the other a chicken roaster who works in the community with a small grill and food stand. Allegedly, the client stumbled out of the bar one night, and knocked over some pieces of chicken onto the ground. Angry, the chicken vendor beat the man so severely that he died.

These cases are not meant to portray Kabalagala as a scary or stereotypically violent place. Violence is routinized and commonplace, but the more extreme cases are unusual and leave an indelible mark on a community that is left reeling from the aftermath for weeks after a murder. I was never present in the community for any of the

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murders, but I did witness the pain it caused in the community. Walking into Kabalagala the morning after the mobile repairman murder, everyone who I passed and greeted stopped me to tell me their version of the story. They were greatly pained by it, and could not understand why three men had resorted to such a severe beating for such a small crime, involving a Nokia phone. In their words, it was not even a smart phone.

These cases are also notable because they mark the deteriorating security situation in the iinformal settlement, driven by local leader politics. Security is the responsibility of the local leadership and the police. The local leadership will get to know all of the goings-on in the community, and will conduct investigations into alleged crimes.

It is the Defense Councilor who oversees these investigations, and he will refer suspects to Kabalagala police. I interviewed the former Defense Councilor (LCII) who was tenured for several decades. He had recently been pushed out of his position because of corrupt interests as he described.

You see, the challenge we are having, it is in leadership because in Uganda our management starts from LCI, this is our first court but at the moment our LCs don’t know what is the law, they are just elected and they have no aim of leadership.

As me, I am not to earn, I am to save people. One time we arrested, [the new Defense Councilor] himself arrested somebody who had come with a lot of opium to sell within here… By the time they [police] were on the way, they agreed and [the Defense Councilor] was given 500,000 and he released that gentleman with the opium and he went away. So I said, “How can I deal with such people”.

In this description, we are given insight into the collaborations between leadership and the police. Sometimes, these collaborations end in arrest of the suspect. In other cases, like the one above, it ends with the negotiation of a bribe and a suspect’s release. The former Defense Councilor went on to describe:

So this is the challenge we are having in Uganda. When you have your money, you are free and when you are poor, you suffer unless you have a powerful person who can back you up.

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The Councilor succinctly summarizes how violence is managed, describing what seems to be a stratified justice system. His descriptions are also part of a broader issue, where police sweeps were conducted for no perceived reason. The Councilor disliked these sweeps, saying that rather than arresting arbitrarily, the police should “come on the ground” and find out who the real suspects are.

8.1.6. Generational Status

When paired with a lack of socioeconomic advancement, urban dislocation has historically driven generational discord (Burton et al. 2010; Kertzer, 1982; Summers

2005). In Kabalagala we can note a similar trend. Youth lack socioeconomic advancement in the study community. Combined with migration from rural areas and a dislocation from more traditional structures that do provide a pathway to advance to an elder status, being young and economically unstable is an intersection that strongly shapes structural vulnerability among Kabalagala’s men. Further, this economic fragility is perceived as long-term, with few opportunities for advancement in a society where older men have all the opportunities and do not afford many to their younger peers.

Generation was not an explicit focus of the dissertation research, but it emerged as men

(n = 19) began to talk about the differences between young and old men, with young men characterized as less economically stable, more intense alcohol drinkers, and more often drug users.

Generation as a concept has long been used to explain social change and social order (Alber et al., 2008; Cole & Durham, 2007; Eisenstadt, 2017). Wyrod (2016) observed social tension in Bwaise in Kampala, Uganda. This study similarly observed tensions, as described by Erias:

I: So what do you think will happen in the future?

P: Explosion. [Laughter]. An explosion, it’s like a time bomb that is what is going to happen, that is it, these young boys are the ones who do the hard work and these old men are stuck here and you find them fighting you not to grow, you

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understand. When you do something better they try to put you down because they have some good money on them. For me I’ve lived with this Mzee [old man] here for over twenty years, we have been here, we had our shop here, we used to rent back, they demolished the place now we are working on the roadside that is why I decided to leave this place and I go and rent the other side. – Erias

A large class of under- or unemployed young men is compared to an economically and politically secure older generation. Young men experience low economic mobility as they find it increasingly difficult to "move up" in the world, characterizing their lives as

"hopeless" and "without a future." Countless stories were told to me of cases where older leaders or businessmen colluded to ruin the business of a younger man. Some older leaders will collude with other leaders or the police, and find ways to appropriate businesses perceived to be successful or land that is of value. As the first participant describes above, old men are limiting the opportunities of the younger men. A dire prediction accompanies this analysis, that these tensions will lead to an “explosion.”

Meanwhile, the elder men broadly perceive the younger men to be lazy, alcoholic, and thieves.

P: They [young men] drink a lot because they don’t want to work, most of the men here they are lazy. I: But where do they get money for alcohol? P: They are beggars, they are thieves. Most of them are jobless.” – Edward

The difference is that the men who are a bit older booze but they can afford to rent their own houses something that the boys cannot do. They drink beer but in a controlled manner, they leave the bar by midnight, but the boys stay there till morning and others are even locked in the bars because they know that they don’t do anything during the day. That’s why the majority of them are thieves in the evening.” – Rahim

The men above speak about the differences in terms of generation. Many of the older men report the difference between their generation, which worked hard, and the youth, who are perceived to not be working but rather sitting around all day. Interestingly, some of the younger men would argue that yes, they are sitting around, but they are also

“working.”

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One example of these generational tensions is the tension between the older local leadership and the dominantly younger resident population. Almost all the local leaders of Kabalagala are older, above 60 years of age, with the exception of three LCI chairmen. One younger LCI chairman described the problems he faced in dealing with the older chairman, an LCII.

For example, like the LCII is the highly ranked, he is grown in age but he doesn’t understand. And he cannot serve the community, he only acts in his interest. Even when the police comes to help or any organization, he gives fake information. For example, if any of the lodges has a problem like what happened [e.g., the aggravated rape case], the owner of the lodge can give him a bribe so he [the LCII] assures the police that nothing happened.

These three younger leaders are constantly in tension with the older leaders, and they do not often come together on community issues. The younger LCI went on to share that he tries to act for the benefit of his constituents, but he cannot get anything positive done because the higher-ranked, elder chairman prevented it.

While the tensions usually cut across generational lines, not all older men are in power or economically stable. Some older men are just as housing unstable and job unstable as the younger men. One man in particular comes to mind – Salongo. Salongo has been in Kabalagala for a long time. He worked abroad for a while in Iraq, one of many security personnel sent from Uganda abroad to fight other nations’ wars. After returning, he worked as a truck driver for some time before losing his job. Whereas he used to spend time in Kabalagala during his leisure hours, he now found himself living there. In 2016, Salongo was on the outs with his latest sex worker girlfriend and sleeping in a bar. In 2019, he was still in Kabalagala, working odd jobs like washing plates and dishes, but still sleeping in a bar. While some of the younger men remarked about his age, and asked why he didn’t go back to the village, Salongo remained adamant about staying in Kabalagala, where life was more enjoyable. This vignette illustrates the rare

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older man who stays on the streets of Kabalagala and does not conform to the generalizations about younger versus older men.

8.2. Synergistic Vulnerabilities

8.2.1. Dislocation from Social Support

This section will focus on men’s dislocation from their life-long support systems.

This illustrates the following points: 1) that men’s migration to the urban areas notes changing social processes and a re-structuring of their support networks, and 2) while urban migration is a longstanding phenomenon, traceable to early 20th century Uganda, its configuration and implications are relatively new.

While some men left their homes in the rural areas because one or both parents had died, there were some who left due to economic pressures. However, by leaving, they were also leaving behind some level of social support that they were receiving from family members, extended kin, and the wider community. Kilbride and Kilbride (1990) describe new arrivals to Kampala, who have to negotiate a new social space and build up networks of support. Upon arrival in the city, men do not typically have the same level of social support that they had in the village. They may know one or a few people, but they do not have an extended network to rely on. Dislocated from these social support systems, men must rebuild their networks through makeshift affiliations.

I came to Kampala in 2004 [at the age of 7]. Ah then, because I started working in 2004. Then 2008, that is when I started to be on the street. Yeah, like looking for survival, life is not easy, no one I know here in Kampala and no contact cause at least when you have a contact, you can call someone to help you. Yeah so I had no numbers [no contact phone numbers]. I started to live on the street. It was just when someone calls me that “you come and I give you some money,” I would go ‘cause I wanted something to eat. – Rahim

Rahim describes not knowing anyone when he first came to Kampala. He also described the importance of knowing someone, to help you in times of need. He went on to talk about how he had friends and family in the village, a village near Tororo in Eastern

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Uganda. There, he could rely on extended kin. In Kabalagala, he had to re-make those support networks, relying on groups of younger men who spent time in the Ghetto

Soldiers community in the area. He described the Ghetto Soldiers as his makeshift family.

Other men, who come from abusive homes, are not leaving a positive social support system. Rather, coming to Kabalagala presents an opportunity for a new beginning.

When I remember that, I used to be with my step mum. During that time, she used to cane, beat me. I would bang my head on that veranda like this, this is the style, I remember that. When my father is not around, my step mum used to cane me a lot. “Where are you from? Playing football. “Have you finished to wash utensils?” One day, she met me when I was playing with my friends, she caned me, I just bang this [my head on the verandah], this head here like this. This is the scar [showing the scar on the head]. – Kintu

Orlando describes coming from a home where his step-mother beat him regularly. This pushed him to leave his home. Although his family still helps Orlando by paying for his daughter’s school fees and housing her, Orlando finds little support at home. On other occasions he described how his father greets him, calling him “useless.” In Kabalagala, men like Orlando can find a space to begin anew. Orlando soon fell in with a group of other young boys, and from that point began staying in Kabalagala.

As described previously, urban migration was typically temporary and men would return to their home villages (Southall & Gutkind, 1957). Out of the interview participants

(n = 18) who had migrated from a rural area, none had plans to return to the village.

Notably, one participant disappeared for a few days. When I asked what had happened to Ignatius, his friends told me that he had not returned to his village for several years.

His parents, worried, had come to Kabalagala to look for him and take him back to the village. I saw Ignatius after a few days, when had returned to the city. When I asked him why had returned, he replied that he “didn’t want to spend his life digging,” meaning the hard agricultural labor necessitated by life in the rural area.

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While these cases have long-standing roots, described by previous anthropologists in Uganda, urban migration has shifted since the mid-20th century when

Southall and Gutkind were writing. Now, urban migration is not a temporary solution, it is rather more permanent with men having to find more permanent social support systems in their new homes.

8.2.2. Surviving and Precarity in the Informal Settlement

Rising precarity in an age of neoliberalism has been documented across contexts

(Han, 2018). Precarity indexes a “bounded historical condition” that points to failures by the state to provide a basic standard of living for its citizens, paired with unstable wage labor in the informal economy (Han, 2018, p. 337). This juncture is what is significant, representing synergistic vulnerabilities. Precarity is deeply linked with vulnerability, describing how social and political disadvantage becomes embodied, or literally scripted in the differential disease outcomes produced in low-income populations (Butler, 2004;

Butler, 2016). Using language of precarity situates the individual in wider social, political, and economic institutions that shape individual life circumstances.

Examining how precarity is engendered and experienced in urban Uganda provides a means of better understanding marginality and how people find ways to survive in these circumstances. This section describes marginality as produced by unstable wage labor. This section ties (under)employment through low-wage, unstable labor in the informal economy to notions of precarity. In Kabalagala, precarity is conceptualized as the instability that accompanies low-wage, unstable labor. There is no ability to plan for the future for many of Kabalagala’s men in these circumstances, when some days might bring 50,000 UGX (US$15) and others might bring nothing. Men typically live day-to-day with little saved up to cater for expenses during times of illness or emergency. This precarity is embedded in men’s discourse on their lives, broadly conceptualized as “surviving.” This is not a term specific to Kabalagala’s men, but it is

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felt literally as economic opportunity is visibly constrained. One lodge manager, Kintu, elaborates:

Yes, but in actual sense you may have the figure [meaning, a source of income] but daily, the least I can get is maybe 60,000 (US$18) or 70, you deduct for the boss, you give him 40, you remain with 20 or 30, that money is very little yet at night I have to eat, my people have to eat so I have to save all that money which is not possible. And these ones selling alcohol, for a beer they are getting 500 UGX (US$0.25)…and now, to get even a little money you have to be selling too much. Our business in Uganda they are tangled, business is rough not because of you, you are very hard working, and you want to work and you are very creative because you have seen me how I do my things. But even when you work hard, they [the police or the government] grab you here, you change, if they block you there, again you change, that’s the way to survive. – Kintu

Two key themes emerge from Kintu’s polemic on surviving in the community. First, that even when someone has a stable source of income like managing a lodge, there are many people who benefit from that base income – the boss, family members, and then any friends that might ask for help that day. This speaks to a broader point that emerged from discussions with men, that when one person is working in Kabalagala, there are 5-6 people who depend on that income. This includes both family members and friends.

Second, this illustrates that the money really is not enough even with stable labor. It might be enough, but there are external forces that are perceived to be “blocking” opportunities, either the KCCA that stops businesses from operating because of a license issue, or the police who arrest men regularly. There is this perception inherent in

Kintu’s speech that even though he is creative and works hard, that this alone is not enough because circumstances prevent any kind of real advancement. His speech, in a sense, indexes precarity and vulnerability, yet he is a median-income earner in

Kabalagala. For those many more men who cannot even make 60,000 a day, but survive on 10,000 (if that), work and survival is even more precarious. Jonathan links joblessness to precarity, describing it as a “hard life in the ghetto”:

In my ghetto, actually in the ghetto we have many problems, like sometimes some of us we lack what to do, and sometimes the police comes, they grab us and take us up to Luzira and we go there, six month, 4 month, they leave you,

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you come back, sometimes it’s like a week after you have comeback, again they grab you and take you back without any reason so sometimes the ghetto, there is no many problems as long as you are working but for someone who is jobless and is staying there from morning to evening who is jobless, you can face a hard life in the ghetto. – Jonathan

There is a perception that taxes add insult to injury. After failing to provide a basic standard of living for its citizens, the government now expects to collect taxes, and no one is sure where the money is going because it does not manifest as improved social or health services. Although the second participant (Erias) exaggerates when he describes paying taxes at birth, it is this exaggeration that is important to understand how men experience precarity. It is perceived hardship, with an increasingly constrained ability to survive, and decreasing opportunity despite working “hard” and being creative.

Despite being already vulnerable in terms of job status, not being able to survive on the small amount of money they earn, men also perceive that both the police and the government are making life even worse, through the constant barrage of arrest and the perceived wealth and corruption of the government. The latter manifests in rising costs for basic goods and housing.

8.2.3. Housing and Food Instability

Adding to men’s precariousness, a depressed wage is complemented by a rising cost of living, particularly for food and housing. Rising food costs were traced through the last two decades or so, while rising housing costs are a more recent phenomenon.

The former is less clear, while the latter seems to be locally experienced, where the changing of housing from untenable wooden structures to cement was accompanied by increased rental costs. Many men in the study could not afford regular housing. A vast majority reported that their household income was not enough at the end of the month

(63.4% of the survey sample), 14.3% reported that they could just make do, and 21.9% reported that some money was left over. Meanwhile, 92.7% disagreed that housing was affordable. When asked whether they had enough money over the past year to pay for

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housing, 62.2% disagreed. An additional 6.6% said that they had no place to stay that night. Out of the survey sample, 61.5% were renters, just 5.6% owned their home, 10% were living at their family’s home, and 23% had some other arrangement (e.g. staying with friends or girlfriends). These data demonstrate that income is not enough to cover basic housing needs, housing is unaffordable, very few men own their home, and men are generally housing unstable with at least 23% requiring some kind of a connection to find a place to sleep.

Participants were often hungry. Out of the survey sample, 1.7% reported always going to bed hungry, 9.4% reported often going to bed hungry, and 73.1% reported sometimes going to bed hungry. I would typically ask interview participants if they had eaten that day, and/or if they wanted to conduct the interview over lunch. Many would accept this offer. Food and housing instability are emblematic of the economic instability that men experience in Kabalagala. They are markers of whether men are able to meet their most basic needs. Further, they have implication for men’s HIV status and ability to control HIV through adherence to ART. Without a place to store their medication and without regular access to healthy food, men often stop their ART and are much more likely to spread the virus due to their uncontrolled viral load. Finally, housing instability is sometimes exacerbated by Baganda cultural norms that men should have a separate established home that they pay for. Many participants had a family home where they could ostensibly sleep, but they often choose not to because as a man it was not deemed appropriate at that age (after 18 or so).

Food and housing instability are driven in part by rising costs. Food stability is a basic measure of well-being, and indexes vulnerability by measuring the most basic of human needs. Anthropological literature on famine often takes a vulnerability lens, highlighting food insecurity as a social, political, and economic process rather than a

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natural one (Baro and Deubel, 2006). As experienced in Kabalagala, food costs have risen steadily in the lifetimes of the younger men (<30 years old):

P: Totally, ten years ago people used to have lunch, breakfast supper but now, they cannot even afford to have a complete meal. A complete meal. I mean sauce, maybe with water or something but now for someone to seat and have a complete meal, it is a problem. So, being that you can’t get food, it is a problem, you cannot get rent, you cannot get maybe money for your health when you are sick, you cannot get money to take your kid to school, so everything is a problem now. People think that when you get kikomando,4 you know kikomando? I: Yeah! P: Then you have got a good meal, but it is actually not good to eat every day. That is men when surviving. – Kintu

It is noted as part of the general precarity of men, who are not only unable to get food, but are also housing unstable. Many of Kabalagala’s men rent on a daily, not even a monthly basis. Landlords are often patient, allowing people to overstay despite not keeping up with their payments. Others are harsher, and will evict tenants after a day or two of not paying. Housing and food instability are both part of a constellation of vulnerabilities, indexing a lower social position troubled with other livelihood challenges like affording health care and school fees.

Food and housing stability are important standalone problems in Kabalagala.

However, when we look at ART adherence, participants cite housing and food as important for staying on their medication. Namely, if participants are unable to maintain stable housing where they can store their medication, and if they cannot afford at least two meals daily, then medication becomes a less pressing issue compared to these necessities. This is described in the following excerpts:

I: So now, depending on how you feel, in your thoughts, and since you went back to pick the drugs, how do you feel? P: I feel good. I: What I mean is your thoughts, do you still think a lot and worry a lot? P: I no longer worry as long as I find somewhere to sleep, I will take my drugs. – Abed

4 Kikomando is a basic meal of chapati (fried flat bread, Indian style) and a bean stew. It is cheap, and filling, and tasty, but it does not provide a full range of nutrients, and could become problematic if that is all someone ate.

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The first participant (Abed) links ART adherence to housing stability. As he elaborated, he noted that he did not currently have a stable home and had nowhere to keep his ART safe during the day. His job required him to walk around the community all day, as he is one of the few nail salon businessmen, men who look for clients and offer nail cutting, filing, and painting. But ART adherence is also linked to food:

Some are in denial, they may not have got enough counselling, because if they had got adequate counselling and food because you can’t give them that tin of medicine when they don’t have food to eat. They may just throw the medicine, how do you expect them to take the medicine. - Hamim

Similarly, a large body of anthropological literature cites the importance of food stability to ART adherence (see Kalofonos, 2010). In this age of ART scale-up, medicine is available and free in Uganda. The doctors’ visits are also free and insurance is not required. Yet, the freely available medicine inadequately addresses the social conditions of men’s lives.

Lastly, it is important to note the importance of Baganda social norms. Many of the participants in this study have family in or around Kampala, with family homes. The men could go and stay at these homes, temporarily or for the longer term. Some who are in conflict with their families or who left home to escape an abusive situation would not, understandably, return home. Those who are on good terms with their families also do not want to go and stay at home, reporting that such an act would be inappropriate for an adult man. One participant said that he could not stay at home, because his father already does enough for him, paying for his child’s school fees. Another participant says that he is “old enough” and prefers the precarious, but independent life of the streets to his family home:

I: Okay, so you don’t rent a place for yourself? P: No. Okay, I have a room at my Aunt’s place but she put a composer [university student] because my cousins have to go to school. I’m old enough I can’t stay in a family house so sometimes when I am tired, I have to stay on the

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streets up to morning. Unless when my friend calls me and has a place to sleep. -Benedict

Food and housing stability are additional dimensions of men’s precarity in Kabalagala.

These instabilities are symptomatic of the broader economic insecurity that men face, all of which are not natural, but are socially, economically, and politically produced.

8.2.4. Alcohol and Drug Use

Alcohol and drug use are endemic in Kabalagala. It is one of the first things you notice, that most people in the community are drinking at any given time of the day, or can be seen chewing mira [khat]. Beginning with my pilot research, alcohol use has been a consistent theme throughout the project. It resurfaces again and again, with men talking about their own alcohol use, and the way that everyone drinks. In fact, it is so endemic that after sex, it is the second most important economic activity in Kabalagala, driving bar business and suppliers’ income. Alcohol and drug use are both individual characteristics, but more importantly, they are driven by social norms. Both facilitate social bonds in Kabalagala, with implications for men’s improved social connections and capital. This section highlights the heavy alcohol and drug use in Kabalagala, as symptomatic of men’s precariousness, but also as something that engenders social connectivity.

Participants link the high alcohol and drug use to the situation of unemployment that many of Kabalagala’s men are facing. Repeatedly, when asked why so many drink, participants turn the conversation to the joblessness of Kabalagala’s men, arguing that if the men just had jobs, they would no longer sit around in the bar all day. Others

(generally the older men) argue that men are lazy and drink a lot and do not actually want to work, that they are “spoiled.” One participant describes how this is symptomatic of depression driven by a lack of economic stability:

P: Of course, it is an addition or it is supportive of that because when someone doesn’t have a job, they need something to take away the depression or the fact

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stress that they don’t have a job. Nobody can be happy or smiling that they have no job, so when you have to kill your stress most of them use drugs, alcohol, women and so on and so on. I: So where do they get money for drinking? P: Money for drinking is not necessary, it’s not necessary really because it is affordable depending on what you buy. It depends on which type of alcohol do they use, or drugs, they mostly use cheap drugs which those drugs and alcohol fits in their prices. The alcohol budget is based on small, small wages from the small works they do. Not really necessarily a job but the small works they do, they get a wage and go back home and use their wages for survival but it’s not really satisfying for them so they use mostly their small wages to pay the alcohol they take. – Jacob

Erias is equally forgiving, capturing the desperate feelings of the unemployed youth:

Unemployment first of all, which leads to poverty and desperatism, and real desperatism, you find people here drinking, loud music, you think they are happy but they are killing the desparatism, the plastic life, this life is really plastic. -Erias

Both participants link alcohol and drug use to unemployment, mediated by issues of mental health. Erias clearly links unemployment to poverty to this mediator, a feeling of

“desperatism,” likely meaning hopelessness or feelings of desperation as if there is no future opportunity. It is this that people drink to forget, they drink to mitigate the situation that they live in. Erias also disparages the lifestyle, saying that the life is “plastic,” or fake.

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Throughout the day, large heavy trucks can be

seen traversing Kabalagala’s small dirt road. The

trucks are overloaded with beer crates, 20-feet

high, dropping deliveries at the numerous bars

throughout the community. Filled bottles are

dropped off and empty bottles are picked up, to be

taken back to the factory for re-filling. In fact, bottles

are one-for-one, if you take a filled bottle from a

shop, you have to return it or leave a bottle deposit. Figure 8.3. Small sachet of gin Beer bottles are expensive, running between 2,500

UGX (US$0.68) for Eagle and 4,000 (US$1.08) for the fuller-bodied Tusker or Guiness.

Men cannot always afford beer, and prefer to route their limited coin to the more reliable, and potent, waragi (Figure 8.3), a libation that is sure to intoxicate. A small sachet runs from 500 UGX (US$0.14) to 1,000 UGX (US$0.27), and nearly all are unregulated, very strong, alcohol. As Orlando always told me when I would see him drinking London, it was his “passport” because he always wanted to travel abroad. Although he was often flippant in his quick responses, once could dig deeper. Alcohol is, in a sense, a literal passport, or an invitation and means to forget life circumstances, if only for a little while.

Drug use is similarly present. The most prevalent drugs are, in order of most frequent usage, 1) mira/mairungi (commonly known as khat), 2) kabanga or kasadda

(marijuana mixed with tobacco) or plain marijuana/ganja, and 3) embooko/akacwiri

(heroin that is typically smoked, sometimes injected). Mira is by far the most common and the most open drug. Until very recently, it was not even considered an illegal drug

(Drug Law, 2017). The law is not usually enforced, as mira is openly bought and sold by saleswomen in the community. I got to know one such saleswoman, Mama A. Mama A had grown her mira business from the ground up, was well known for her consistent

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product, and was cited by many as perhaps the wealthiest person in Kabalagala. Mira is grown on the outskirts of Kampala, with the good, fresh, chewable leaves coming from

Kasenge in Wakiso District. Early in the morning, staff go and buy the leaves from farmers, who are also making a huge profit. The staff bring the fresh leaves to their boss, who packages it into 1,000 or 5,000 UGX packages (mira wrapped in banana leaves).

These packages are sold, and consumed by the many individuals buy from Mama A each day. Individuals choose to chew the leaves with bubble gum or g-nuts, anything that can turn the leaves into a kind of paste. The paste is chewed, and liquid is swallowed. But, the actual paste has to be thrown out after some time. The actual effects of mira are described as building energy, focus, and reducing appetite.

Drugs and alcohol are commonly used in Kabalagala. Both also solidify or build social relations, with men gathered in groups in bars or other locations. More than anything, the mira users are known to sit in the same locations and share their mira, chewing gum, or plastic bags to dispose of the paste. If someone is known to the group, they could easily sit and ask for mira from their friends. The ways that usage builds social relations is discussed further in Chapter 9. Marijuana and embooko are also used, but are much more hidden. Marijuana is supplied by many of Kabalagala’s young men, and specific locations in the community are known for marijuana use. Those who smoke marijuana and those who smoke embooko hang out in very different locations, and rarely mix. The marijuana users and dealers both are very frequent targets by

Kabalagala’s police.

8.2.5. “Luzira is not a home”: Incarceration and the Cycle of Arrest

Incarceration is a common theme in this research, a political and social tool that is used to control “deviant” individuals (Singh, 2016), a product of a surveillance state with increasing anxieties over its informal settlement youth (Owen, 2016), and a tool that cycles men in and out of jail and structures poverty through the frequent loss of income

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and payment of bribes. Owen (2016) links contemporary policing practices to colonial policing arrangements, with common traits, arguing for a more politically and economically engaged narrative of policing.

Section 8.1.4 describes the

characteristics of policing in the study

community. Here, I focus on men’s

experiences of incarceration and the impact

of arrest and incarceration on their lives. Out

of the survey sample, 42.4% of men had

been arrested in the last 1 year, and of those

who responded that they had not been

arrested that year (57.6%), 45.6% had been

arrested in the last 5 years. Nearly all

interview participants report having been Figure 8.4. The Ghetto Soldier community arrested once, but a subset is cycled in and out of jail, often for drug use or suspected theft. Jonathan, for example, is a former injection drug user who has been on the streets of Kabalagala since age 7 (he is now

21). Jonathan was quickly forced to “survive” in these circumstances, working for a salon owner and sleeping in the salon at night. He later got a job at a nearby factory, and would return to Kabalagala in the evenings. Once he started using drugs, he began to cycle in and out of jail as the police increasingly targeted men like him. When we talked in 2019, Jonathan said he had been arrested at least six times in his life, but honestly, he could not remember. He said that police often came over to the Ghetto Soldier

(Figure 8.4) side of Kabalagala, usually very late at night. In his words, they’ll come, grab you, and take you to the police station. Even if he tries to explain that he lives in the area, they will not listen. Instead, “they will just take you there sometimes when you

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reach there, they put on you a case that ‘we found him smoking ganja’ and you will not argue with them unless you have some money in your pocket, you give them, they release you” (Jonathan). It typically takes 50,000 UGX to get out of a case like that.

Jonathan has failed to raise this money on three occasions, because as he says, his relatives live far away in Iganga and cannot always send the emergency money for the bribe. In Jonathan’s words, life in Luzira is extremely hard. Many prisoners stay in one room, packed in tightly with barely enough room to sleep. Men are not given mattresses, but sleep on the hard floor. Men cook their own food, and subsist on a diet of yellow posho (disgusting, as Jonathan says) and beans. Water is not boiled, but men have

“nothing to do” (Ugandan English) and have to drink it.

Like Jonathan, other men report the difficulties of Luzira Prison. Those who return, come with stories of poor treatment by the guards, days of hunger, and for some unlucky ones who are taken to the farms, days of hard labor. Whenever police would come and arrest young men, Brian would always warn me that they were being taken to the farm to work. Some of the men returning from prison would describe their long days working on farms as free labor, when they would be taken in the morning to work in grueling conditions. If they tried to stop working, they would be beaten by guards. This coheres with a recent Human Rights Watch report (2011, p. 3) on the state of Uganda’s prison system, which reports that

A brutal compulsory labor system operates in rural prisons countrywide. Thousands of prisoners, convicts and remands, are forced to engage in hard labor – cultivating crops, clearing fields – day after day. Compulsory labor is often combined with extreme forms of punishment, such as beatings to punish slowness, and handcuffing, stoning, or burning prisoners who refuse to work… Prisoner productivity translates directly into profit for prison authorities, but prison authorities often do not account for the funds raised through prison labor.

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Men’s experiences with the police in Kabalagala are best captured by Bobi Wine’s more recent song, Afande.5 His rhetoric resonates with the youth of Kabalagala, who cite policing practices as a reason for losing a job (n = 3), losing their savings (n = 6), going into debt to pay associated costs (n = 4), and interrupting ART (n = 1). Whether taken to

Kabalagala Police Station, Luzira Prison, or the farms, the cycle of arrest and incarceration impoverishes those who are trapped.

In Kabalagala, men would go to great lengths to get the money to be released from the police station. Interestingly, when you visit the police station, there are clear posters saying that “police bond is free.” Indeed, if you are taken to the police and charged with a crime, then you are mandated to be released on a free bond within 48 hours. Yet, many men are released one or two weeks after being kept at the police station, which is really not equipped for long-term use. Participants not only lose their savings or go into debt to get out of jail, but they are not accessing their ART medicine when inside the cell. In fact, at least one known HIV+ participant was arrested recently and was not able to take his medicine. When he told the police officer that he needed it, the police officer laughed off his concern.

8.2.6. Ability to Fulfill Gender Norms

The last section of this chapter is concerned with men’s (in)ability to fulfill prescribed gender norms, norms that are passed through generations, from grandfathers and fathers to sons. These, dominantly Baganda norms, prescribe specific duties and meaning for men. Robert Wyrod’s (2016) ethnography is predominantly about hegemonic masculinity in urban Uganda, which he defines as (1) the ideal of men as economic providers, (2) men’s socially prescribed hierarchical authority over women and children, and (3) men’s sexual privilege. These masculine gender norms are shaped by

5 Why beat me, there is no difference between me and you! Why kick me yet I have no problem with you? – Bobi Wine, Afande (2019)

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other contemporary patterns, including rural-to-urban migration, economic inequality, and job instability, all of which constrain men’s ability to be men. This section argues that hegemonic gender norms are relevant in Kabalagala, and men are unable to fulfill these norms due to constraining political, economic, and social circumstances. At least one participant agreed with the hierarchy of gender:

Man, is an actually created human being and this man comes with like a whole package of superiority, or the responsibility of leading others. I understand a man like someone who is going to live as someone who is supposed to be heavily appointed or heavily experienced or highly understanding or fully responsible, that’s a man to my knowledge. A man is supposed to be responsible, that’s what I know and most of the men here are not responsible, they have no responsibility. - Jacob

Baganda gender norms are shaped by economic expectations of men, with

“being a man” rigidly intertwined with expectations that a man should have a job, own a house, own land, have a wife, and have children. In this hierarchy of expectations, men would first need land (passed down through generations), he would have a job which would allow him to build a house on that land, and then he would be able to afford a wife, with whom he would have multiple children. In Kabalagala, men are typically not able to have a steady job, and therefore there are cascading effects across this hierarchy and a general inability to fulfill gendered expectations. In this study, just 30.8% of the men are paying for their children’s school fees. The others rely on payments by the mama abaana (children’s mama) or other relatives. Yet, a man is expected to be a provider in the home:

What makes a man are the responsibilities how, a man with a wife, with a child, knowing how his child has eaten or how his wife is doing, how she slept, how the child is studying and come back home, that is who we call a man, someone who doesn’t forget his home. Even when poor, he takes care of his home. That is who we call a man. If you have a brain, you are able to differentiate between a hen and a duck so I also did my research and found out that not everybody who puts on a trouser is a man. It is possible in words yet in action he is not a man. – Rahim

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Beyond providing in the home, ancestral land has meaning in Baganda. In urban spaces, land tenure and access to land is a primary determinant of social class and stability. Set against this backdrop of land scarcity, most in urban Kampala are land or home renters. This has not changed much from the time of Southall and Gutkind’s

(1957) writing to today (Mabin, Butcher, & Bloch, 2013; Nkurunziza, 2007).

Additionally, as both Wyrod (2016) and Hunter (2010) write, changing economic circumstances change sexual relations in urban Africa. In Wyrod’s ethnography set in

Bwaise, this manifests as persistent masculine sexual privilege, which allows for multiple sexual partnerships. While Wyrod points to masculine gender norms, he also importantly highlights that there are “no fixed hierarchies of masculine types,” arguing that men cannot be pigeonholed into one category and identities are often conflicting. That is ever-present in Kabalagala, where men may be unable to fulfill traditional Baganda gender norms, but have remade themselves in the image of the informal settlement, where many different rules apply to behavior and social status. In Hunter’s (2010) ethnography, women engage in sexual relations as a survival strategy, adding new relationships to buffer their economic suffering. Sexual networks are increasingly important to migrant, young, men’s survival in Kabalagala, similar to what Hunter (2010) notes in informal settlements in South Africa. In Kabalagala, masculine sexual privilege that characterizes hegemonic masculinity is also used to buffer economic suffering, but marks a young man as a youth, rather than an adult.

When asked what constitutes a “man” in this setting, many respondents connected masculine expectations with “responsibility. Being a man is something that goes beyond just wearing pants, as several men (wearing shorts at the time) pointed out:

P: Older men have responsibility, they have things to do but the young men who wake up very early to sit don’t have responsibility, their thinking ends there so in

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short because they don’t have responsibility they are not self-drive to do certain things. I: What other difference do you see? P: The way they look, the younger men do not look smart like the older men who look like they have responsibility. I: How do you describe a man? P: A man, besides the trouser they wear, to me a man is someone who is responsible, with a family, they take care of them well and cares for them, takes them to school, that’s a person I consider a man. – Ibrahim

The term (in English) responsibility came up frequently when asked what it means to be a man in contemporary Kampala. The term is unclear, culturally- and historically-bound, and very different depending on who is using it. When asked what responsibility means,

Ruhakana elaborated, of course, using himself as a model example:

My responsibility is, what makes me responsible, somebody to come and say “that man is really responsible” it means first of all what makes me responsible is that you can’t find me drunk, do you know why? I: Why? P: I am the chairman of the boda boda stage, if you have responsibility and they find you when you are already drunk, it’s not good. After that, I have a family. Two kids. The way how I am producing, you are seeing the situation now, here in Uganda we have peace but there is lack of money, lack of jobs. You have seen the situation. It does not help me to produce 7, and some of them you find them they do not have responsibility. So arrogant, they are moving there but if you want responsibility because taking them to school is your responsibility, taking care of your woman is your responsibility. You want a woman to get school fees, that should not happen because that is my responsibility. I have to be responsible, it was in 2007, that’s when I got my woman and up to now she is my responsibility so we are going to make a jubilee, 10 years and I have two kids. – Ruhakana

Perhaps responsibility indexes or serves as a proxy for fulfilling culturally-expected gender norms. Responsibility does not sound that different from definitions of “being a man,” either from Kabalagala’s residents or Wyrod’s (2016) ethnography. Due to the economic situation, highlighted extensively in this chapter, many of Kabalagala’s men are unable to fulfill these norms. They are maligned by others in the community, who say that “they are not men,” or that “there are no men in this area.” Further, some participants provide the evidence that a traditional man would marry a woman, and not

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the other way around. Meaning, a man should have the decision-making power and should provide for his wife.

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Chapter 9 Social Resilience-Building Strategies

Current scholarship in social and community resilience focuses on building resilience to mitigate harm from future disasters, particularly climate change and natural disaster. This research deploys a social resilience framework (Keck & Sakdapolrak,

2013; Obrist, 2010), positing that it is a response to past and ongoing structural vulnerabilities such as economic inequality and unemployment. Framing social resilience as a response, rather than a proactive strategy, indicates a subtle shift in applying this conceptual frame. This research draws on literature that designates economic stress as a harm that puts negative pressure on communities (Schwarz et al., 2011; Zingel et al.,

2011), and pairs it with literature on social resilience (Keck & Sakdapolrak, 2013; Obrist,

2010). It also describes Kabalagala’s men as proactive, rather than passive, actors in this broader political-economic system that structurally disadvantages urban, informal settlement residents who are disproportionately harmed by economic inequality.

However, it is not always the case that these social resilience-building strategies unilaterally succeed. Rather, this chapter argues that men engage in strategies to buffer economic structural vulnerabilities, and build economic status, power, and prestige in

Kabalagala. While this may work to buffer economic pressure, some strategies have unintended effects for ill-health and HIV risk.

A concept of “layers of resilience” (Glavovic et al., 2003; Obrist et al., 2010) suggests that economic assets and access to loans or capital provide individuals with resilience. When individuals have fewer layers of resilience, they are more vulnerable to adversity and ill-health. This concept also highlights the complexity of social resilience, that not every individual within a socially resilient community will have the same level of resilience, but rather that resilience is based on dimensions of their social support systems. In this chapter, core concepts of economic status, power, and prestige are

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applied to my findings. I argue that men engage in social and economic activities to build economic status, power, and prestige within Kabalagala. These modalities and outcomes are locally defined, meaning that status, power, and prestige within

Kabalagala does not translate necessarily to increased status in Kampala writ large.

Similarly, the strategies to increase status, power, and prestige would ideally help to buffer against economic pressures such as inequality and unemployment. By increasing power and prestige, men are able to widen their social networks and open opportunities from business to capital to loans. Connections with powerful men also buffers against the quotidian pressures of life in Kabalagala, especially police arrest and incarceration.

In other words, economic status, power, and prestige are mediators of sorts affecting the relationship between political-economic pressure and social resilience.

The findings are divided into two sections: the informal economy and specific strategies within, then social relations and social support systems. Informal economy is positioned as a resilience-building strategy to increase economic status when men are excluded from the formal economy. Social relations and social support constitute a way of increasing power and prestige in the community, thereby buffering economic pressure by increasing the range of connections and options. The linkages to social resilience are demonstrated throughout.

9.1. Informal Economy

Men engage in the informal economy as a way to build economic status and buffer economic uncertainty. However, some of these income-generating activities present risks. Working in a lodge and selling drugs are both illegal, making men more subject to police arrest and violence, as discussed in Chapter 8. I report on several themes here, including: 1) engagement in the local music scene, 2) lodge work, 3) drug sales, and 4) hustling to make ends meet. In a city where many are unable to participate

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in the formal economy, the act of organizing social and economic space in the parallel informal economy is a reasonable response to these constraints.

9.1.1. Music and Celebrity Life

Kabalagala’s men engage in a variety of strategies in the informal sector to bolster economic status. Of these, being an aspiring musician, dancer, or a DJ at one of the many clubs and bars both increase men’s social standing in the community. Music shows are frequent, and men can be seen performing at the local bars and clubs at night. Karaoke is another area where men participate in music, where men lip sync and dance to a musical soundtrack. Some of these generate income, such as being a DJ at a local club or bar, but the majority are described as a future goal: to be popular in the music industry in Uganda. All of these actions bolster men’s popularity, with both women and other men. DJs, musicians, and other artists are well-respected in entertainment- driven Kabalagala. During interviews, men who DJ at local clubs (n = 4) would describe how easy it was to obtain sexual partners.

P: I have regrets. I used to sleep with all kinds of different women but since the time that I have been with [girlfriend’s name], I don’t even have the guts to go to other women. I: What do you mean, regrets? P: I don’t know how many women I used to sleep with. It was because the job that I was doing after school was not good. I was a DJ so I would get a woman in every area that we would go to. – Jude

Based on my time in Kabalagala’s bars and clubs, it was clear that the DJs and other musicians are the center of attention. Local musicians are very popular, and tend to band together in groups, with one bar (Swagga Bar) in particular being well-known for its musicians. Like other jobs in Kabalagala, music requires money and financial input to rent spaces to practice dancing, to hire transportation to shows, and to buy equipment.

P: So, as a DJ, I was working, but now I cannot look for a DJ job. I don’t have what is needed. To get a job here, you need to have what to use. You have to be with your own mixer, your own laptop. So now I am just here [not working]. I: So, you have to have money to get a job like that?

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P: Yeah I: So how did you learn how to DJ? P: Through the field, friends, I had DJ friends…There is a friend of mine I do music with, we don’t stay together. For him he is like a vocalist, I do rap. – Daniel

Both Jude and Daniel are former DJs struggling to get back into the business, but facing different economic challenges. Through the interviews, both described the work as a stable source of income. DJing increased economic status as well as prestige among peers in the community. One survey participant is a well-paid DJ at one of the bigger clubs in Kabalagala. He described making as much as 50,000 UGX per night, well above the average Kabalagala income.

Music and the celebrity life also represent the future goals of Kabalagala’s men.

In today’s celebrity-focused culture in Uganda (and much of the world), being a celebrity, or a “celeb” would mark a quick way to gain economic status and prestige. Similar to

Bobi Wine’s ascension out of Kamwokya and into music stardom, many of Kabalagala’s men see it as a way out of the informal settlement and into a more secure and stable financial future. Others, perhaps, focus on the gains that can be made in terms of accessing more sexual partners. One bar manager explains:

P: You see this is a bar; you can’t come and sit while you don’t buy a drink because you will be chased away. I: I see. That is different from other bars. In some places we see them there, just sitting. P: They are the “celebs” they go and sit at the pool and play pool table to see if girls will admire them, because they know the work of prostitutes and most of the prostitutes are women, and they will admire the men. – Frank

Whatever the reason, in a community like Kabalagala that is so driven by entertainment, it logically follows that its entertainers are valued by the community, remunerated well, and able to access sexual partners. By increasing their economic status and prestige in the community, Kabalagala’s entertainers are able to try to buffer against the economic pressure. However, as described by Jude and Daniel, participation in entertainment also takes some measure of investment in equipment.

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9.1.2. Working in the Lodge

Lodge managers (n = 8 in this study) also occupy a special status in Kabalagala, where sex work generates a majority of the income. Lodge managers work for some of

Kabalagala’s most esteemed men and women, the lodge owners, and through their day- to-day management of the lodge, control access to a valued social space in the community. When walking around Kabalagala, men who work in the lodges are greeted with the “manager” title, denoting respect. While lodge work is indeed dangerous, it has the potential to pay well, if it is managed properly. Having control over the lodge also gives managers power in this space, where they act as a mediator between police and sex workers, owners and occupants, and clients and sex workers. Managing a lodge does not always bolster economic status, power, and prestige. Major shifts in

Kabalagala’s sex work business model from 2015-2016 onward saw the decline of the lodge manager position. After that time, many of the lodge owners preferred to manage the operations of their lodges directly and maximize their own share of the profit, rather than hire a lodge manager. Those few lodge managers who are left manage the lodges that owners are not able to because of other commitments. Lodge management is one of the few money-making options for men in Kabalagala, but the job has become more and more precarious with threats of violence from clients and unstable income. It is another example of a strategy to build economic status, power, and prestige, that often ends up shaping precarity in the informal economy due to the realities of the job. Men wager that the trouble is worth it because of expected pay-off, but this is not always the case.

9.1.3. Drug Sales

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Another strategy to improve economic status in the informal economy is the sale of drugs, particularly mira and marijuana. Mira sales are openly conducted along the main road in the community, while marijuana sales are hidden in Kabalagala in small pockets of the community. Men describe both using and selling marijuana as a way to make a living. Mira business owners are almost all female, and so they were not interviewed for this study. However, the marijuana dealers are predominantly male, and several (n = 4) were included in the study. The marijuana dealers describe the potential profits that can be made from selling the drug:

R: Different places mean different prices. There you find they have their price like 1k, five thousand but us here. It depends on where you buy it, because us here we buy half of a bundle at two five (2,500 UGX), you come you sell five five (5,000 and 5,000 UGX), you get twelve thousand five hundred. Profits: ten thousand five hundred. But it’s difficult to sell it in one day, you find that if you sell like ten thousand you have to eat, if you sell, the landlord is knocking so there you sell but you are not getting from it, you only get money for a day. I: True, do you sell it openly or you sell it - R: Hiding. I: Hiding, of course. So, can I ask, do the police disturb you on that issue? R: They come, for sometimes they arrest us. When they find that you have something, you find those ones who don’t even want your pay, they just take you. If you reach there, they ask you for money, if you have they released you, if you are lucky they even release you for free. I: So, how often do they come to arrest? R: Those people to come here, they come if there is maybe habits like stealing people, if they hear that in this place they have started stealing people, the neighbors complain that those who are smoking here are the ones stealing people then they will start doing their operations so you find that other people they arrest us for nothing. They come from nowhere, you don’t know them, they just arrest everyone who is in the corridor, if you are lucky, you can escape. – Brian

Brian not only sells marijuana, but he also tattoos people by hand and does other odd jobs as the opportunity arises. Brian demonstrates the calculations that are made, comparing income to expenditure and finding ways to make profit. But, as was repeated by many other men in this study, the work is only “money for a day,” meaning that it is not something that you can save money with. The money only covers expenses for a day – daily rent, one or two meals, a few drinks. While this is enough to survive, it is not

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enough to save money. Additionally, selling marijuana comes with the risk that men will be increasingly targeted by the police. Brian describes how the police target the marijuana users and dealers during instances of reported crime.

Despite the challenges that present with selling marijuana, selling marijuana is a fairly reliable way of gaining income for a day, thereby buffering against the lack of economic opportunity in other sectors. Many of the marijuana dealers are also users, so the work overlaps with the leisure activity. However, selling marijuana is not a long-term strategy for most men, as the dealers report future dreams of “becoming a land owner”

(Brian) or “starting a business to sell clothes” (Ignatius).

9.1.4. Hustling

The term hustling was repeated quite a bit throughout interviews with men. To hustle means to struggle to earn money, but also denotes ingenuity and what has been called jugaad in India (meaning, innovation in the informal sector; Kumar & Bhaduri,

2014). Jugaad is a useful concept to understand the nuances of “hustling,” conceptualized here as innovation and “making do” despite scarce resources and major obstacles. It does not specifically include “hustling” someone, meaning taking advantage of someone or misrepresenting a situation for financial gain. It is the innovation in difficult circumstances that applies to Kabalagala’s version of the hustle. Men (n = 16) described having to hustle to get out of a problem, to deal with difficult circumstances, or to raise cash to solve some emergency such as a health problem or to get out of jail. It also indicates the fewer available options when cash resources are few, and access to capital is limited. Men, describing their hustling, also demonstrate that they are not passively accepting a financial challenge, but rather will go through social networks to borrow money or find work. Hustling straddles both the financial and social aspects of capital and demonstrates effort to regain control over a situation. One participant describes having to hustle once he was released from jail:

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When I came out [of jail], I wasn’t in a good situation because I didn’t have any money and we were going into festive days so I had to hustle to get what to eat but I was released on Saturday while Sunday was Easter. I didn’t have a penny and yet I was released in the night. – Ignatius Being arrested represents a major financial obstacle to men building savings, as described earlier in Chapter 8. It follows that innovative measures must be taken to financially recover after being arrested and having to pay money to be released. The participant above recounts being arrested around the Easter holiday, and not having enough money once he was released. He had to hustle to get something to eat, which he elaborated meant talking to his friends and asking for small amounts of money (500

UGX) to buy a plate of food. Similarly, another participant describes hustling as a way to

“survive” in difficult economic circumstances:

Because if you don’t have where to sleep that can force you to plan and find somewhere to sleep because we are all in the same situation. When we were chased from where we used to take drugs we had to hustle and find a place to sleep. – Salongo

Hustling is an active act, it is not a passive acceptance of the situation. Jonathan, above, describes being chased away from his rented room because of his drug use. It was this

“situation” that forced him to hustle, to reach out through his networks to find a place to sleep for that night. Because he had been in Kabalagala for many years by this time, he was able to stay at a friend’s business at night. His friend owns a salon, and Jonathan was allowed to sleep in the salon at night, when the business had closed for the day.

Hustling also implies working against obstacles, both economic and social. Men in Kabalagala describe relationships with their friends as sometimes tense. Apolo relates his hustling to the kinds of obstacles in the area, that many men do not want to see him succeed.

It’s all hustling because I didn’t study that much, my work needs a lot of energy because when I use my energy I can get whatever I need. The challenge that I have met here are not very many, but they are mostly from people who do not wish me well, whenever you get something, they want to put you down, they don’t want anything good for you because you are better than them, when you

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make a small mistake they want to turn it into something big to make you lose but the rest is good. - Apolo

Apolo also describes the work needed to maintain his dobbi (laundry) business. He makes very little profit from his business, yet he has to pay a room where he can store the clothes he is washing, he has to pay for water and soap, and an iron and electricity.

To gain profit, he has to “hustle” and maintain a steady client base. Apolo also underscores the individual energy needed to hustle, pointing to a sense of self-control over his life circumstances. This was at odds with other men who point to other external sources of blame for their economic situation.

Hustling is practiced to innovatively address a difficult economic situation. Men (n

= 13) describe hustling to regain some sense of control over their financial circumstance, but it also is used to buffer economic pressures. It is both an economic and a social act, relying on social networks to bolster economic gain. Men described their social contacts as sources of aid during times of need – for example, after being released from jail or losing a rented room. Hustling is one strategy to manage uncertainty in the informal settlement. While it is an important aspect of life and survival in Kabalagala, it is also part of men’s strategies to build social resilience against economic pressure that is not only one-off, but is a consistent part of life in poverty.

9.2. Social Resources

Brigit Obrist’s (2010) conceptualization of social resilience highlights a number of different capitals that individuals can draw on to buffer shocks and adversity: natural capital, physical capital, human capital, social capital, and financial capital. Social capital is described as the “social resources on which people draw in pursuit of their livelihood objectives” (Obrist, 2010, p. 331). Related to malaria treatment-seeking in Obrist’s

(2010) study, it is operationalized as forms of assistance provided through social contacts and networks. For example, participants were able to borrow transportation to

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go to the nearest clinic to treat a case of malaria. In this study, social resources are similarly operationalized and drawn upon in pursuit of economic stability. In Kabalagala, men rely on complex networks of friends, acquaintances, and other peers to build a buffer and improve economic capacity. Specifically, a range of social strategies will be discussed, from 1) aligning with powerful actors in the community, to 2) participating in a social bar group and reciprocity, and 3) engaging in longer-term non-paying relationships with sex workers. Not only are these strategies examined as a way of buffering economic adversity, but they are examined as sometimes having unintended negative consequences for health in what is termed perverse resilience.

9.2.1. Aligning with People in Power

While local leaders and the police are often characterized as problematic by study participants (see Chapter 8), they are also sources of assistance in times of need.

Relatedly, other men in power (wealthy business owners) are contacted to help with everything from starting a business, to resolving a legal or interpersonal dispute. Based on interviews, and observations, the social status of various residents can be roughly categorized as follows (Figure 9.1).

Figure 9.1. Organization of job types and social status

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Men’s “survival” and prosperity in Kabalagala depends on their ability to tap into the more powerful networks, as doing so would mean access to legal, financial, and social resources to help with business and other opportunities. Individuals with more power are also contacted in times of various need:

Yes, when you tell them anything about health, the chairman cannot fail to connect you to a person who can help. – Saturday

Local leaders (chairmen) provide access to connections to expand opportunities. They also can provide linkages to health and other services in times of need, as demonstrated above. Men often turn to their local leaders to ask for introductions to health service providers or for a referral to a nearby clinic. Overall social capital is demonstrably protective against economic pressure across different settings (Gronlie & Dageid, 2017;

Hassan & Birungi, 2011; Sen et al., 2010). Social capital helps to bolster connections to employment, social and health services, economic resources and financial capital (Boon

& Farnsworth, 2011). In Kabalagala, social connections structure access to financial and bureaucratic requirements to start a business. Here, connections are also needed before starting a job, as most jobs require an LCI letter.

While access to powerful networks would buffer economic pressure, this is not always attainable. Men also identified gaps in social capital, whereby they are not able to build connections with more powerful social actors, presenting challenges to their overall well-being. This was cited in the context of police-community relations, by the following participant:

The police do not give us chance to cooperate together, if we have space in the system we have space that we can speak loud and they hear. But they do not have a system connecter, a system mediator that we can cooperate with. It comes to them using us to explain or to give them answers to the sole questions that they have. Meaning they are not interested in our problems, but they just come to us when they need to arrest someone for a crime. – Jacob

Jacob describes the challenges in dealing with the police, that they are not willing to cooperate with community members. Other men described how police prefer to act

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through local leaders or crime preventers, much to the detriment of average men in the community. Rather than actually solving crimes, they will arrest people when it is convenient. This problem extends to other aspects of government and tribal unity, as

Kintu points out:

He [President Museveni] wants to break our region so that we cannot be powerful economically, socially and politically. We want to build our area, but time will come for him and it has already come. To me in my heart, it has already come, he cannot expand his years, he cannot prolong so we should just be waiting, be patient. – Kintu

This quote is excerpted from a longer polemic on government corruption and entrenched older leadership. Kintu views the government as actively seeking to hamper social and economic progress among the Baganda. He sees their entrenched positions as antithetical to Baganda prosperity. While an ideal would be that Kabalagala’s men can align with men in power, both at the community and national levels, the reality is that many of the community’s men are starting to see men in power not as allies, but as blockages to prosperity. This shift reflects broader trends at the national level.

Fieldwork happened to coincide with a major shift in political tensions.

Participants (n = 36) described these tensions in detail, often describing Bobi Wine as a source of hope and future change. For example, Randall was in the army, joining now

President Museveni’s Bush War at the age of 13. He joined Museveni’s army after witnessing atrocities committed by then President Obote’s army in his home village. He described joining the Bush War to fight for a country to be free from oppression and to challenge the impunity that army soldiers seemed to enjoy. Yet, decades later, he questions the current state of the nation:

I: So, is this the country that you wanted when you were 13? P: When I was fighting, I wanted to change everything. But some other things I am still not seeing any change. Corrupt politicians still take the money, for making roads, schools, maybe, you can see on TV. Yet the school is for government, ministry of education is there but the ministry, if you are the minister and me I am your assistant, if I get mine, you get yours, we don’t care about

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others. That’s why in Africa we suffer -because of our leaders. Because me, I know, in Africa we are rich in natural resources. So why are we men so poor?

His case was unusual in that he is one of two participants who fought for Museveni in the

Bush War. The other participant remains a staunch NRM supporter. Randall had also fought for the U.S. during the Iraq War in 2007-2008. He was able to take these life experiences in various armies, and describe how and why he wanted to see a better future for Uganda. Other men who did not have military experience echoed Randall’s sentiments.

So far for me, people need help. That’s why they are like Bobi Wine, this and this because they see hope in Bobi, this is what I am trying to put. These leaders, on the other hand they need to learn. You understand that we need to learn from others’ mistakes because we have got the same life, it’s not different, it’s only the difficulties and the challenges we face. To me, most men do not have hope, because of the poor leadership. We just need abled leaders, leaders who can lead and bring hope to these people. - Erias

This notion of hope was recurrent. As Erias describes, men do not now have hope, but they can hope for a better future with Bobi Wine. Bobi Wine speaks directly and vibrantly to the hopelessness of these study participants. Supporting Bobi Wine is likely an emergent strategy to manage hopelessness and uncertainty. By aligning with new potential sources of political power, men can develop additional strategies to manage opportunities and buffer uncertainty.

9.2.2. Bar Group Participation, Other Social Organizations, and Reciprocity

Reciprocity has been an embedded feature of society throughout human history.

It was first described by Richard Thurnwald and Malinowski to denote the exchange of goods or services between individuals. Generalized reciprocity occurs when there is no immediate expectation of payment, while balanced reciprocity indicates a time frame for repayment, and negative reciprocity indicates one party taking advantage of another.

Each form shapes social relations between men in Kabalagala, with generalized reciprocity indicating strong social ties and trust, and balanced reciprocity factoring into

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loans or other such temporary agreements. Negative reciprocity would have strong social repercussions. Reciprocity is a key feature of social groups that organize men in

Kabalagala, termed here “bar groups.” Kabalagala men (n = 12) describe networks of friends (bar groups) as a crucial form of support. Based on observation, men congregate daily in bars, typically relying on the same bars and bar groups every day. Some men will join the group at the start of their day, after waking up. Others, who might work within or outside the community, come after work hours, typically around 6-7 pm.

But if I get in [name of community], that’s my main – place, that’s where I kind of be all the time. People at least, I know there. People know me. Even if I have something, even if I want something, I can get it. – Kintu

Participants, such as the man above, described the draw of Kabalagala and their social networks. It is important to “be known” (an emic term) in case of any trouble, conflict, or need. Once someone is “known” – in other words, they are a part of

Kabalagala’s social fabric – the individual is a part of a bar group. Bar groups were described as being a two-way street. It is not strictly that someone must have money or resources to contribute to other “members,” but a member might be called upon to provide social support in times of need. Those members with more resources and money typically share their income with others – buying cigarettes, drinks, food, snacks, and occasionally sharing drugs such as mira:

You can give me 1,000, but we have five people who are a beneficiary on that 1,000. If I buy a cigarette, we are going to take – two people, three people. If I buy water, someone else also needs to take water. That’s why many people are going to be a beneficiary. That’s the only solution I can say – if you want to help people. – Randall

This alcohol, because I also drink. As long as you get starters [your first drink], you don’t even know where the people who buy for you come from. You just find yourself drunk and you are like “I had six thousand and I bought two bottles but at the end of the night I had taken 5 bottles?!” But, drunkards work together because they know their problem like the smokers. Those smokers, whether he knows you or not, as long as you ask for a smoke, they will give you so alcohol is also like that. A drunkard doesn’t need to have a lot of money leave alone the people who go and buy a crate [of beer] because they have their money. – Muhammad

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Bar groups also provide a way of getting extra help, especially on days when someone has not been able to work. This participant describes the way that friends can assist with food or other small amounts of money, which would be key to surviving during times of difficulty.

I: What do you do if you are not working, if someone is not working, how do they get 1,500 UGX? P: From doing these easy, easy jobs, like someone can say “help me with this and this” and he gives you some ka [e.g., little thing, said for emphasis] little thing, just like that. If a friend has, the little he has got, we share, it’s like a family. Everybody around here has their family, and it helps a lot to be friendly. I: What about people who are not friendly? P: If you are rude, you have to suffer. If you are rude, you can’t survive here in [community name], you have to be easy and understandable. – Daniel

In this sense, reciprocity and social capital are key to survival in Kabalagala, where life is often unpredictable and jobs are scarce. It is partly why men stay, because they are

“known” in this area, and can ask for help from social contacts. If they were to go elsewhere, they would have to rebuild their social networks. Because men have friends, particularly in their bar group, they are able to ask for help:

I: So how do those people survive? P: They just okay, oba [maybe] I can explain it like how. When we have a friend, when your friend has a job, you can just meet him and tell him ‘I don’t have money, can you just give me 1k and I get something to eat.’ When you see this area, when you don’t have a job, ‘your friend can come, have you got something to eat, have this, have this’ like that. – Benedict

Beyond the financial support provided, bar groups are a type of support network that serve as a de facto family and social unit that can make decisions in some circumstances. Bar groups aid in solidifying friendships, whereby reciprocity and sharing can help to build social relationships.

We make friends like it’s a relationship because when you go to a bar, you find a man using something that you also use, you sit together and you start sharing like beer or cigarettes, that’s so you end up being friends. – Mugisha

Bar groups are not homogenous, as there is heterogeneity both within the groups and between groups in terms of practices, norms, and socioeconomic status. One bar

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group headed by a local lodge owner consists of more stably employed men and leaders in the community – one local councilor, one security person, and so on. The lodge owner described the work of the bar group in terms of its security and development of

Kabalagala:

The ghetto was overcrowded, everyone had small wooden rooms. The strategy we [our group] came out with is to standardize prostitution. Better constructed rooms, standard lodges, clean, not wooden structures. – Kenneth

Average bar groups consist of men who are not typically community leaders. Men rely on their bar groups as a primary source of social support, to share problems or other issues that they face. One man describes the bar group as a space for sharing such issues. He proposes a group forum for HIV positive community members, to share problems and advice.

It’s a good thing to share because whenever you share with someone your heart becomes lighter, whenever you see others, you know that you are in the same category. We may have the same disease [HIV] but our problems are not the same and the situations…Whenever we go to hospital, we are told that when you have someone who is positive, you don’t need to give them space but to be around them and encourage them, things like that. – Ssemujju

Other men describe the kinds of social support provided by the bar group. It is a place where men can feel a sense of belonging and are able to substitute new social groups for family members who might be far away in the rural areas.

He was my first friend, I came here, and I worked in the salon and he was my first customer, we were next to each other that’s how we started. I had no place to stay; he is the one who took me in and we stayed together. Since then we are like brothers. The whole family, his family and mine, we are like brothers and all the people around, most of them think that we are brothers. – Daniel

In general, most men (n = 28) differentiate between bar group members who they can turn to for advice and support, and then others who they do not always speak about important issues with. More serious issues are typically reserved for closer friends. Men speak about the kinds of conversations that take place in the bar:

When we sit here with [NAME], we talk about music, and we talk about women and people who pass by like ‘I have had sex with her and her, I still want that

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woman.’ There is no conversation that is healthy here in [community name], we don’t think about any other thing we only think about what to eat and where to sleep, that’s all. – John

These conversations were described as superficial, with not every man being trustworthy or able to give good advice. Men will not always share their more personal problems

(e.g., relationships, family issues) with all colleagues, but will choose closer friends who may be able to provide advice. One man provides lengthy insight into the conversations at the bar:

R: We share issues and above all, when a juicy lady pass by, those ones with nice hips, good bums, we always look, as a man, you know. I can’t deny, I am not a father (priest) in the Catholic world, I am a real man. I: How important are friends as a source of information? R: They are very important, going back to the sexual world, me as a man who is very active, I always see ladies with juicy, nice nice curves, so at times I do and consult them “how do you see that madam?” some tell me you go, some tell me “that lady has HIV”, things like that. Or maybe that [NAME] passed there, or let me say [NAME 2] passed there so watch out. So that information keeps me going maybe it’s the one that has kept me when I am HIV negative, I don’t know, even true friends. – Mugisha

He continues, describing what a true friend is and differentiating based on the quality of the friendship. “Back biting” is raised, something that comes up in other interviews with men. Also called lugambo (rumors) or wolokoso (gossip), it is a main topic of discussion in the bar. Those at the center of the debate are not necessarily pleased that their personal happenings are discussed. This broadly contributes to a sense of distrust among some of the men.

I: How do you know a true friend? R: I can know a true friend one; when he doesn’t back bite [gossip about] me, a true friend will never look for beneficiaries when he is helping you, he may say let me help [NAME 3] because at their home they are rich, he will just bump in, you have a problem, anything, anything. I: Still on that point, do people back bite each other? R: Yes, they do more so in the African setting, they back bite each other. Back biting comes in when maybe a deal has gone down in the ghetto, you know when you enter a deal it’s like you have entered a contract, for us in the ghetto world it’s very dangerous, they will back bite you, you will find that even friends are shying away from you maybe when you go into some one’s wife, you are interfering with the relationship. – Muwenda

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Despite these nuances in social support, ranging from superficial support to deeper emotional support, men still rely on their bar groups for various needs. As described by the same participant, friends are necessary for survival.

I: Do you get help from friends in situations like that? R: Much, much, much, usually I get help from friends. Being a boda boda rider, if I get an accident, they always sit in for me, when maybe we have lost someone at home, when someone has died, they always come in, financially and socially they always come through into my life. I: We talked about discussing issues with your friends, which other issues do you discuss with your friends? R: Others are that in the ghetto guys, they always come to the ground, they always say “what should we do to get money,” you may find that, there are times when we discuss what we can do to get money, to get out of this situation we are in. We can see that I am employed but still, I am a boda boda rider at times. Even at times I go when I am just having money for the family, I put it down and say that what we can do. At times you discuss and you see that someone is reasoning, but when the drugs come in, you may even not talk about that shit. They call it shit. – Milton

Milton alludes to the kinds of relationships at the bar, and how necessary social support is for men’s survival. Beyond the quality of social support, men also describe the kinds of social norms that are reinforced and perpetuated in the bar space, from drinking alcohol to taking drugs. They describe the difficulty in choosing to be sober, especially when all their friends are drinking and sharing alcohol is so common. One participant,

Jude, was on both TB and HIV medication and had also stopped drinking. Rather than spend his days or nights in his usual bar, he choose to stay at home. However, his job as a DJ has made this increasingly difficult especially when he chose to go back to work.

He is still sober, but he struggles to maintain sobriety around his friends:

If you are in the bar, you can drink and your friends drink because you can’t be there, they are drinking when you are not drinking, they say that you drink all together cause your friends cannot drink when you are looking like this [laughter]… it’s not good. – Jude

Similarly, Abed points to his group as the reason why he started drinking and using drugs.

It’s the groups because when I came here I wasn’t taking alcohol, I wasn’t eating Mira or taking any drug, or smoking but it’s the groups that taught me.

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Men in Kabalagala reported on “learning from the group” (n = 16) and starting alcohol or drug use because it was common among their peers. While this points to a negative aspect of social support, it is also paired with something I observed during my many hours with bar groups. Whenever health workers would come to the bar to test residents for HIV, men from that bar would almost never test for HIV. I would ask those seated near me why they preferred not to test, and men would respond with “I’m busy” or “I already did.”

Bar groups are not the only form of social organization in Kabalagala. The group model extends to other professions, especially among boda boda drivers. A boda boda stage is more organized than the average bar group, with an elected leader, vice-chair, and treasurer. These men collect money on a monthly basis and use it for various needs, including motorcycles or other issues the group may face. One boda boda chairman explains his role:

P: We first decided that we should keep the money and put it in an account until 6 month, then we can start withdrawing and we buy boda boda because our members, they don’t have boda boda. We are like three or four who have a boda boda that’s mine but these ones, today he has this one, tomorrow he has this one. So when we collect our money, when someone gets a problem we can give them 10 or 20 like when they are taken to Luzira, in the prison. When I was making my statement before they elect me, I said chairing the stage doesn’t mean power, fighting, it means cooperation, if you connect, everything will move well. If you say on Sunday let us have a meeting, you come but if you say come to the meeting and some of them say “aah” and they ignore you, you end up feeling bad. I: How do you decide who becomes a member and who is not, you decide or the committee decides, like let’s say I come with my boda and I want to join the stage? R: You have to come, first of all you have to see me, after seeing me, I call my cabinet, I have my cabinet, me as the chairman, the vice chairman, the secretary and the treasurer, those are four then we have our meeting, “so and so wants to join our stage, what do we do?” according to me, I have been seeing him for several years, if they agree, we call for a general meeting then you share with everyone then you start becoming a member in that condition. You first come and consult me, I call the committee than we call a meeting. – Ruhakana

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Taken together, these local social organizations provide structure to men’s lives and social support. Nearly every profession and decision-making body in Kabalagala has its own organization and set of rules. In other words, residents have complex ways of managing the space and what kinds of social norms apply.

9.2.3. Sex Worker Partner

A major theme that emerged was the use of sex worker partners to maintain economic stability, especially for young men in times of economic trouble. These relationships are more complicated than material – with aspects of love, trust, fertility desires, and materiality structuring how the relationships are experienced and who benefits. This section describes the local conceptualization of love, differentiates it from

“true love,” and then places men’s relationships within this context.

A True Love Ideal

Love emerged as a frequent topic during interviews with men about their intimate, non-commercial relationships with female sex workers in Kabalagala. In this densely populated, entertainment- and commerce-focused community, relationships are complicated. Residents of Kabalagala have differing opinions on love and their relationships, as described here. “True love,” or what some would call “romantic love,” was intertwined with marriage, but was not only present in marriages. It was often cited as an unattainable ideal in Kabalagala where love has more transactional aspects. One man explained what true love means to him:

Love is a person that you be with and you feel the same to be, that’s love. When you get a problem, you can tell them and when they also get a problem, they can tell you and you move life forward together. Even when there is no food, no money, that’s what they call love. It’s not an easy thing. – Ssemujju

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As described, love is about companionship, being able to share problems and plan for a life together. Even when money is not available, true love would persist.

Similarly:

For me, true love is like someone you trust and she trusts you, you don’t keep fighting her, she understands you like in everything, and you don’t quarrel in front of people so you stay in good love not cheating so you stay in true love. – Brian

Here, an aspect of trust is mentioned – being able to trust someone relates in this context to monogamy. In other words, a “true love” relationship would mean staying with one partner.

Cheating, which was reported in interviews to be a common occurrence, should not occur in a “true love” relationship. Sex with male paying clients would not count as cheating, but having sex with a non-paying individual would count. For instance, one notorious incident involving two participants, Julius and Jude, demonstrates the complicated nature of relationships in Kabalagala. It emerged that Jude’s girlfriend had locked him in a room, and left to have sex with Julius (another nonpaying boyfriend). It was an often-discussed incident, as other residents saw them go to an isolated place together and quickly spread the gossip. Jude later told me:

Instead of quarrelling with her I just kept quiet. I can’t fight with a lady so instead I just go to my friends, I just booze. You know these ladies, we married them when they are sex workers, so we are supposed to keep quiet when they cheat on us.

Although conflict was frequent in Kabalagala, and observed on a near-daily basis, the men had a more cynical view of its potential to resolve any issues. Moreover, one man described his inability to fall in “true love” with a sex worker, because they have sex with clients, and the men also end up cheating:

Now quarrelling, why are you going to quarrel with your girlfriend? If you find any one quarreling, you may find he found someone having sex with his girlfriend… now that is not true love. Here [in Kabalagala] there is no true love, because you can know that you have also cheated on your woman, meanwhile your woman sells herself. You cannot fall in true love with her. – Brian

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Participants contrasted the ideal of true love with the realities of their current relationships. Love is present in these relationships, but it cannot be classified as “true love” – the kind of love where there’s trust, no quarrelling, monogamy, and companionship. As one participant stated, “we are in love, but it is not true love.” This was not classed as true love, because there was no mutual respect, they did not plan their future together, and cheating was often involved in their relationship. A different participant, one of the youngest in this study at 18 years of age, did believe he was in

“true love.” When asked whether he had “true love” with his girlfriend, he smiled and asserted “yes, definitely.”

What emerges is a complicated relationship between an ideal, “true love,” and a reality of complex relationships in difficult circumstances where so much is commodified.

Some men still aspire for a “true love” relationship in the future, one where they are the provider and they build a home with one woman.

“The Materiality of Sex”: Bayaye and Survival in the Informal Settlement

This contrasts with the reality, whereby men must act creatively in order to survive. A muyaye (plural: bayaye) was described by participants as someone who is sharp, innovative, and able to manage hard circumstances. More widely, in Kampala it is known as a term for someone who is perceived to be a thief, good-for-nothing, a drunk.

Although often hurled as an insult by outsiders, against low-income men, it was also owned by the young men of Kabalagala as an ironic term for themselves. In other words, they seemed to claim this apparent insult and turn it around as a badge of honor. In this research, the term emerged as a marker of how men engage in different management strategies to buffer uncertainty.

Young, innovative men engage in sexual strategies to buffer uncertainty, in what

Mark Hunter (2010) described as “the materiality of sex.” Female sex workers in

Kabalagala, an area well known for its nightlife, are able to earn a relatively steady

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stream of income. Men in Kabalagala, particularly younger men (<35 years old) enter non-paying relationships with sex workers and often depend on them for survival, as explained here:

Yeah, some guys stay with sex workers because they can’t manage to get where to sleep and you find that some of them don’t have where to get 5,000 (Ugandan Shillings, ~US$1.35) a day so they get sex workers who can pay for the house, buy for him food and you find the guy is managing. – Josiah

I think some of them [young men], they don’t want to work. You know some of them have a saying that “nze ndya ku mugongo gwange,” I eat on my back. - David

Relationships with women were discussed as a way to benefit economically. It was known, amongst men and women in Kabalagala, that men survive through these relationships. A commonly understood phrase in Kabalagala was often mentioned in interviews, that young men “eat on their backs.” It was explained that this means that young men use sex as a way to eat. In other words, men have sex (e.g., use their back) with their female partners, and receive economic support in return. This is used to facilitate their access to food. In other words, they “eat on their backs.” This was described as a “system,” Ugandan English for a common practice that is in place. As one man describes:

They are with them for survival because they go to work with their bodies through prostitution. Then they come [home] and they pretend like they still love their man at home and they offer everything so the man doesn’t have any responsibility. And the man will stay at home, will start caring for the kid and cleaning the clothes, taking responsibility of a woman, while the woman takes responsibility of a man. – Jacob

Women would pay for housing, provide men with small stipends for food, drinking, household items, and so on. As described above, the men often are left with responsibilities of the household – caring for children, cleaning, cooking, while the women go out and look for money. This seems to result in shifting gender roles, as

Mugisha reports:

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The relationship is so different. If I may tell you, some of these guys are the wife. When the women go to work, this time around he is the wife so the wife is like the husband, is supposed to pay for the room, to get food, she’s the bread winner and maybe the husband is just enjoying the fruits of god, sex. Our lives depend so much on the women. – Mugisha

Lastly, it is important to note that other men in the community had a broadly disdainful view of other men who depended on sex workers for survival, precisely because of this non-adherence to traditional gender norms. One participant described the difference between male sex worker partners and “a man” in the more traditional sense:

For someone to be a man is when he can dictate his life, he can buy food for himself, he can be in the society and accepted. For someone to be regarded as a man, those qualities must come out from him and above all, making sure that he has a goal in life. – Milton

Risking the censure of other men seemed worth the risk, as engaging in longer-term relationships with female sex workers is one way that men manage uncertainty.

“Nduye naye” (I have been with her for long): Implications for men’s HIV vulnerability

A main focus of the study is men’s HIV vulnerability, which is shaped by a variety of social factors. Here, men’s intimate relationships shape their HIV vulnerability. Men in this study reported low condom use with steady sexual partners, with one month as a marker for when couples typically stop using condoms. Participants (n = 23) frequently state that condoms were no longer necessary after a month or so, an indication of how relationship status plays into condom use. One man explains: “it depends on the time which I have spent with you. Let me say when I spend like a month with you, of course we are not using a condom daily. In the second month, you can say ndude naye (I have been with her for long), so let us do it live [without a condom].” This timeframe demonstrates condom use as a marker of how serious a relationship is. As the following examples show, condoms, love, and trust are intertwined in participants’ experiences, matching what has been demonstrated in much of the literature on condom use

(Syvertsen et al., 2013).

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In Kabalagala, condoms are the primary HIV prevention intervention, with free and frequent condom distributions in the many lodges where sex workers work. HIV testing is also present in the community, with weekly or bi-weekly visits from medical providers who set up a temporary site in the community to test local residents. Counseling is a part of this, and HIV negative individuals are counseled to use condoms and limit their partners. The former is often interpreted as using condoms with casual sex partners.

The latter is near-impossible in an area where sex is important for both men and women’s economic survival. Condoms, in a sense, represent trust. If you do not trust your sex partner, then use a condom. If you do, then couples will forgo the condom. One participant describes this: “With my girlfriend I can use [a condom] because I cannot trust her, I can give like 60% [trust] because I am not sure, I can know that you have gone to sleep but I don’t know how. With my woman [wife] I know, I trust her. So for a condom I can use with a certain somebody but for my wife its different.” The way that condoms, love, and trust are intertwined is also described below:

That time when we are in love now, condoms we started, one day she told me, ‘why do we use a condom, because we sleep on the same bed and we are in love’ that is the day we stopped using a condom. – Benedict

Beyond condoms, men’s relationships shape their access to HIV services. Men described having trouble going for couple HIV testing, something that is encouraged by health workers in Uganda. Orlando was tested during a mobile clinic in the community, and tested positive. At the time, he did not want to accept the results. A few weeks later, he wanted to repeat the test at a local hospital. He described what happened next with his girlfriend:

This, even I have already showed this [HIV positive result paper] to my girlfriend [name], I tell her to go [to test for HIV] together and she just quarreled. I took the paper to her, explained to her and I told her the paper is about our health, to know your status. She got annoyed with me. I was about to go to the health center but when I explained to her and told her that the services are free, use the chance when it’s there, just got mad at me and refused to go. – Orlando

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Even though Orlando is trying to encourage his girlfriend to test for HIV, she was unwilling. The participant thought that maybe, she already knew her HIV status and did not want to start treatment or disclose her status to him. The reasons why were not clear, as she was not interviewed for this study. Benedict had a similar experience when he asked his partner to go and test for HIV:

I said let me go and check [my HIV status] and I told her ‘you come and we go’ but she refused, I called her several times and she said ‘me I am dead’ and she started fighting and quarreling then she said ‘I checked the first time and I found I wasn’t okay’ [she had HIV]. And after one year, her friends they told me that she has. She was the one who infected me. - Benedict

HIV positive men in this study seemed to blame their partners for their status in a matter- of-fact manner, not in an angry or resentful way. This was a common reality for men, who describe an almost fatalistic attitude toward HIV. In a place where HIV is so highly prevalent, men are more surprised when they get an HIV negative result than when they get a positive one. I spoke to many men about their HIV test experience, although I did not ask about the actual result. Participants described being incredibly surprised and grateful if they turned out to be negative, while positive men “knew” their status already, without a lab-confirmed diagnosis.

Because the men are so financially dependent on their relationships, they often find it difficult to leave the relationship. This daily reality of needing to survive was more important than concerns about HIV, particularly in a climate of free antiretroviral therapy

(ART). As Benedict described:

Some, like last time I gave you an example, some guys here, they don’t have anything and they only need money, some don’t have a job so the women just go after him just like that because when they leave him, he doesn’t have where to sleep, or eat breakfast, lunch, and supper.

Similarly feeling “stuck,” one participant was previously diagnosed with both HIV and

Tuberculosis. It was the latter diagnosis that affected his health, his appetite, and his energy level. In fact, when we first met, he spent all day inside his house, in bed, unable

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and unwilling to come outside. He had to stop work because of his condition and entirely depended on his partner for food, housing, and other basic necessities. When asked about his partner, he derisively described her as “mad” and “a drunkard.” Yet, because of his lack of income, he could not move away and could not leave her. He saw her lifestyle as unhealthy, but he could not separate from her because he had nowhere to go. Another participant, a well-known partner to different female sex workers, had to separate from his girlfriend in order to take his ART daily. In his words, she was a negative influence and would not accept his desire to care for himself – that “she would throw my [ART] tablets in the dustbin if I stayed with her.” He saw his relationship as incompatible with a healthy lifestyle.

Not every man wanted to get tested for HIV, and not every participant described positive health-seeking behavior. However, those who do want to take measures to protect themselves described a limited ability to negotiate for HIV prevention, and an inability to “protect” themselves from HIV. If they were to ask for a condom, their partners would think they were cheating on them. If they insist on couple’s HIV testing, their partners might refuse. HIV disclosure was also uncommon, with men often finding out about their partners’ status through friends or neighborhood gossip. Taken together, this economic dependence on their partners limited their ability to negotiate for condom use and other forms of prevention.

I want to leave, but I cannot. I have nowhere to go. She [my wife] is very unhealthy, boozing all the time. I try to get her to go for an HIV test and antenatal care, but she refuses. Now how can I be healthy when I am stuck in this relationship?

This notion of “being stuck” – either in Kabalagala, or in their relationships was often referred to as a barrier to positive health-seeking behavior or a lifestyle change. Men see

“leaving” the community as the only way to remove social influences that negatively impact their health. Complicated relationships, often marked by conflict, high alcohol

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use, and economic dependence, shape the ways in which men can or cannot access

HIV prevention services or use condoms. This has very real implications for men’s HIV vulnerability.

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Chapter 10 Discussion

10.1. Summary Findings

HIV risk is patterned structurally, experienced individually, and is the product of a complex tension between vulnerability and social resilience. The precise pathways through which this takes place are described in the following sections. First, men’s HIV risk is exacerbated by a risk environment context with physical, social, economic, and political risks derived from government policies and community context. Second, men experience inequality and unemployment, rooted in historical and political context in a way that is synergistic and broadly disadvantaging. Economic instability also contributes to experiences of uncertainty that have implications for HIV testing and treatment regimens that require regular engagement with the health service sector. However, men do attempt to manage uncertainty through strategic sexual partnerships and building social capital. This dissertation describes these sources of vulnerability and social resilience as a complex and fluid continuum.

This research is framed within and contributes to several bodies of medical anthropology and public health literature, including political economy of health, HIV, vulnerability, and social resilience (see Figure 10.1). These framings have been used to describe the structural and social underpinnings of epidemics around the world. These frameworks are employed to study a community that is at the intersection of the informal settlement and the informal economy. This social location structures the ways that men experience inequality and unemployment. The dissertation findings are reviewed here, followed by a discussion of their position within and contribution to existing literature.

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Risk Environment

Uncertainty Structural Vulnerabilities Synergistic (Individual- Building Social Level) Vulnerabilities Resilience • Urban migration • Perceived • Dislocation from • Music & Djing government social support • Working in the High HIV Prevalence corruption • Precarity lodge • Job instability and • Housing and food • Drug sales low-wage labor instability • Hustling • Rising cost of food • Alcohol and drug • Alignment with men and housing use in power • Police surveillance • Incarceration • Bar group and sweeps • Inability to fulfill participation

High HIV Prevalence HIV High • Exposure to violence gender norms • Reciprocity and • Generational status social relations • Sex worker partner

Economic Status

Power & Prestige in Kabalagala

Risk Environment

Figure 10.1. Final conceptual model 239

The quantitative findings demonstrate that this sample of men has a slightly higher-than-average knowledge of HIV transmission and positive attitudes toward HIV compared to all Ugandan urban-dwelling men. This is not, however, paired with lower rates of risky sexual behavior. A majority of participants engage in enough risky sexual behavior to warrant concern for HIV risk and potential infection. One significant driver of this risky sexual behavior, low regular employment, was identified through regression analysis. Notably, availability of health services is not problematic, as the community is located near one small clinic, one community hospital, one KCCA health center, and one free NGO-run HIV clinic. Men are able to afford services, as many of these services are free, at least for basic care and for HIV treatment, although more complicated cases would require fees. Despite these seemingly positive indicators for testing, men demonstrate lower HIV testing behavior than women. For those who have tested positive and know their status, a number of challenges arise that make it difficult to maintain a regular HIV treatment regimen.

Physical risks such as densely populated community, littered with bars, shapes risky sexual behavior in this study population. Regression analysis demonstrates that average risky sexual behavior scores differ by bar. This highlights several important, overlapping social risk factors in the community. The high prevalence of sex workers in the community makes sex readily available, which in conjunction with changing gender norms that result in men being unable to marry, increases the frequency with which men engage in less structured forms of sexual and intimate relationships. Working in the informal economy presents economic risk and uncertainty, such that men are not always able to plan for an economically secure future. Lastly, the political risks of regulatory laws geared toward the poor and development policies that are implemented with adverse immediate impact, makes the environment that much harder to thrive in. This describes the risk environment that shapes men’s experiences of structural vulnerability.

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A vulnerability framing describes how the risk environment actually structures risk, by relating HIV risk to social and economic hierarchies. Structural vulnerability is linked to an understanding of the political-economic context, to underscore the impact of men’s precarity derived, in part, from living in informal settlements., Structural vulnerabilities include migrating to the urban area, where men are dislocated from their social support systems. Uganda does not offer many free social services, making it harder for impoverished men to survive. Job instability, police surveillance, and violence contribute to an environment of uncertainty where it is hard to predict economic and social futures. Lastly, the entrenchment of generational status makes it more difficult for young men to climb the social ladder and do what is necessary to attain the status of a respected elder. The linkages between economic status and generation are important to note, where being “stuck” in a younger generational status contribute to feelings of uncertainty about the future.

Further, these vulnerabilities coalesce at the individual level, to make individuals more vulnerable to HIV. The intersections of various vulnerabilities are important, with men facing uncertain social support in Kabalagala, where new social groups replace the more traditional kin networks in the village. Additionally, unstable income, housing and food instability make it difficult to plan, with this uncertainty driving threats to survival.

Men are not necessarily able to plan for their future, are typically unable to save, and often rely on day-to-day wages or assistance from their friends to buffer this uncertainty.

Police surveillance contributes to cycling in and out of custody, with bribes paid each time to be released. These payments chip away at whatever savings men have set aside to fund a future business or manage a future crisis. Men also experience everyday violence, whereby violence is a new “normal,” particularly in intimate relationships.

Despite the structural disadvantage that participants face, most are driven to rebuff these vulnerabilities and find locally-situated ways to improve their economic

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status, power, and prestige. This means engaging in activities to garner respect in

Kabalagala, where men with wealth, prestigious jobs, and strong social networks are valued. Men participate in the informal economy to earn income, turning to prestigious jobs like music DJs or working in the lodge. Selling drugs like marijuana is another way to make a small profit, usually enough to live on, but not enough to save. Lastly, men describe “hustling” as a way to make it work in these circumstances, using innovative techniques to identify opportunities and improve economic status. It is not only economic status that is sought, but men also build the quality of their social networks and rely on these networks to improve opportunities in Kabalagala. This means aligning with individuals in power, “belonging” to a bar group that can come through in times of need, and turning to female sex workers for an economic safety net and to fulfill basic needs.

In sum, pathways between the various themes are depicted in Figure 10.1 below.

The risk environment paired with a high HIV prevalence in the community demonstrates a general higher risk of HIV transmission in Kabalagala. However, this is not uniformly manifested, with men’s individual HIV risk patterned by structural factors that influence individual decision making, with implications for HIV. A political economy framing describes the structural vulnerabilities at the community level, including how higher inequality and low formal sector employment structurally disadvantage men in informal settlements. This structural vulnerability is further shaped by local context, where police sweeps and exposure to violence compound disadvantage. Men in Kabalagala face these vulnerabilities on an individual level, where vulnerabilities coalesce to further compound their risk of HIV. Precarity, housing instability, alcohol use, and incarceration shape men’s lives in varying ways, with implication for HIV risk. Importantly, these vulnerabilities converge to drive a feeling of uncertainty among men, who engage in resilience-building strategies to bolster their ability to rebuff economic crisis and instability. In other words, various strategies are employed to manage uncertainty. In

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turn, these resilience strategies, while seeking to build economic status, power, and prestige, often have the unintended consequence of adversely affecting HIV risk.

10.2. Social and Structural Drivers of Vulnerability

Feelings of uncertainty arise from participants’ experiences of generational blockage, inequality, and unemployment. The theories of vulnerability described in

Chapter 2 demonstrate the structuring of excess morbidity and mortality on account of political and economic stress. Structural vulnerability derives from political economy of health when it attends to the structural factors that influence hierarchies, and in this case, inequalities (Bourgois, 2017). These vulnerabilities link the risk environment to health outcomes, providing an important mediating pathway between political economy of health and individual outcomes. As the data show, men are more vulnerable when they have migrated from a rural area (Section 8.1.1), and when they are unable to find the work that they seek in the urban area (Section 8.1.3). Job instability is experienced by men in Kabalagala, indeed, this was a dominant theme in the interviews. It was also a significant predictor of risky sexual behavior. Younger men, who are the most frequently unemployed, find it frustrating that despite having job training or a university degree, they are precluded from participating in the formal economy because the barriers are too high, it is too difficult to access capital, or wages are so low that it does not make economic sense to take the job.

This research reports on the vulnerability experiences of 292 men. However, these themes are likely to apply beyond the community to other informal settlement residents (see Wyrod, 2016). Vulnerability restricts men’s ability to make healthy decisions (Bourgois, 2017), therefore negatively impacting their risk of HIV progression.

Meaning, not having enough income would translate to difficulty in adhering to ART. Not having enough independent income might mean relying on a sex worker partner for

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basic needs. Vulnerability itself has implications for potential political change in the future, as demonstrated in the literature on urban precarity (Han 2018).

These data are similar to work on precarity by researchers working in urban spaces (Butler, 2004; Han, 2018). Das and Randeria (2015) describe a relation between urban processes and the city as volatile, with the poor emerging as political actors. Pre-

Bobi Wine, Kabalagala’s men might have represented more classical interpretations of the urban poor and political action (Arendt, 1965) where it is theorized that individuals are too caught up in ensuring basic survival to exercise political change. Das and

Randeria (2015, p. S5) contradict this, arguing that this framing implies that the urban poor are unaware of their rights or uninterested in political change.

First, poverty and vulnerability are differently conjoined in different social and economic milieus, which opens possibilities but also sets limits to the kind of politics that the urban poor might engage in. Second, the waxing and waning, the different intensities with which politics are engaged, brings out the role of the milieu and its volatility not as the stable context but as constituted by a contingent coming together of different cascading scales at various points in time in the lives of the urban poor.

In this dissertation, the data show a renewed sense of political action, derived from Bobi

Wine’s rhetoric on government corruption and gerontocracy. Kabalagala’s milieu is both volatile and unstable, with everyday violence punctuated by acts of more extreme violence. To spend extended time there is to feel that something is bubbling below the surface, something that could manifest in political discontent in the coming year leading up to 2021 elections. This volatility also manifests as uncertainty.

Participants linked their experiences of poverty as a challenge in graduating to an older generational status, a status that is linked to material wealth and a home. Other literature on the Ganda demonstrates challenges facing youth who are unable to move up in social status because of these impoverished circumstances (Summers, 2005). This research moves further, and argues that generational status patterns vulnerability, which

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has implications for men’s health more broadly. Being “stuck” with a social label of youth contributes to men’s feelings of uncertainty.

Reynolds-Whyte (1997) describes uncertainty as a gradient, with challenges arranged in order of increasing uncertainty. Applied here, Kabalagala’s men experience challenges from police arrest (low uncertainty), to urban migration (medium uncertainty), and unstable employment (high uncertainty), and so on, in what can be called “the failure of the good life” (Reynolds-Whyte, 1997, p. 13). Men are not able to establish a homestead or marry and have children, as they are not able to afford those luxuries. Yet, this is what society expects. Men are expected to have land, have a stable income, purchase a separate family home, and start a family (Wyrod, 2016). Kabalagala’s men talk about wanting that in the future, and compare it with the realities of their day-to-day.

10.3. The Informal Economy: Uncertainty and Precarity

This section links the data to literature on the informal economy, uncertainty, and precarity, with implications for HIV vulnerability more broadly. The informal economy drives experiences of uncertainty in the informal settlement. This applies Reynolds-

Whyte (1997) conceptualization of uncertainty among the Nyole to uncertainty among mostly Baganda men in urban Uganda. The linkage between the informal economy and uncertainty draws on literature from both traditions, with implication for men’s resilience responses and HIV vulnerability.

In Kabalagala’s informal settlement, the informal economy is posited to be both a source of vulnerability and of resilience. Namely, it is conceptualized as a vulnerability when it shapes job instability, keeps wages low, and structures men’s precarity. Men also rely on informal sector income-generating activities (music, DJing, the hustle) to buffer this uncertainty. Uncertainty is a concept that arises from the data presented in this dissertation, signaling the mechanism through which inequality and formal sector

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unemployment drives vulnerability, and in turn, resilience responses. Similar to Reynolds

Whyte’s work (1997), this dissertation also posits that Kabalagala’s men are searching for certainty and engage in pragmatic actions to manage uncertainty.

Unstable wage labor, as characterized by many jobs in the informal economy, hampers men’s ability to plan for the future. Reynolds-Whyte (1997, p. 4) describes uncertainty that results from a mismatch between available financial resources and a plan or hope for the future.

People do not experience history and political economy directly. They live in an everyday world of social interaction where prosperity is pursued amidst the micro-politics of domestic life…The precarious nature of existence is a cultural phenomenon in the sense that experience of peril and response to it are socially mediated in ways that are shared….uncertainty is formally constructed in an attempt not to resolve it conclusively, but to lay a course of action.

The data show this mismatch is experienced by men in Kabalagala, who detail their earnings and compare income to any prospect of starting a business or full-time occupation. Uncertainty is demonstrated when men do not know where they will sleep on a given night, or where they will get their next meal.

Against this backdrop of uncertainty, men build in responses to ensure some measure of control. Men may not be able to consistently access medication, underscoring Reynolds-Whyte’s (2014) point that it is difficult to maintain regimented treatment while facing multiple socio-economic uncertainties. Perhaps one pragmatic response is that participating in a bar group means that men can go to the same bar every day, and be sure that they can get something to eat or drink from their friends.

Having multiple girlfriends makes economic sense, when men can be sure to have somewhere to sleep at night. In other words, these data demonstrate that men respond in proactive ways to manage uncertainty derived from inequality and formal sector unemployment. As discussed in the following section, managing socio-economic uncertainty does not always translate to reduced HIV vulnerability.

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10.4. Managing Uncertainty: Social Resilience-Building Responses and Perverse Implications

As Das and Randeria (2015) argue, the urban poor are not passive spectators, but they struggle within political and economic constraints to improve their own access to basic needs and services. Similarly, men in this study liaise with others in power to improve economic status and align with those who might be able to link to jobs or other forms of opportunity. It is in this vein that the literature on social resilience demonstrates that men are not passive spectators, but attempt to create opportunities where there are none. One manifestation is the increasing attention to national politics, and increasing dissent. Men might see their support of Bobi Wine as one way to manage uncertainty, when other measures have failed. By engaging in political rhetoric and resistance, men may be attempting to remove the perceived blockages to economic stability that are driven by government policies. This will likely have implications for Uganda’s 2021 election, as men increasingly seek to take control over their own futures in a time of uncertainty.

In the meantime, men manage uncertainty in more subtle ways. This discussion on the social resilience literature argues three points: 1) men’s strategies for “surviving” can be considered social resilience-building, 2) unlike the prevailing literature, social resilience is not conceptualized here as resilience to a future threat, but rather resilience to an ongoing threat, and 3) social resilience strategies often result in unintended harmful health outcomes, termed here “perverse resilience” (Panter-Brick, 2014).

Social resilience was defined by Obrist (2010, p. 327) as “the capacity of actors to access capitals in order to not only cope with and adjust to adverse conditions (i.e. reactive capacity) but search for and create options (i.e. proactive capacity), and thus develop increased competence (i.e. positive outcomes) in dealing with a threat.”

Researchers working on social resilience have called for new research to consider the

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“cultural and political context of resilience” (Panter-Brick, 2014, p. 439). In this dissertation, social resilience strategies are used to buffer economic stress driven by inequality and high unemployment in the formal sector. This broad framing is scaffolded by an understanding of the cultural and political context of resilience. These data demonstrate that there are several resilience-building strategies, categorized here as strategies in the informal economy and strategies in leveraging social capitals. In the informal economy, men use hustling and other innovative strategies to cope with and adjust to economic stress and exclusion from the formal economy. Similarly, they seek to create options such as creating a small business, working in the lodge, training as a

DJ, and so on, to expand the opportunities and hopefully improve their economic status.

Every strategy acts as a layer upon which competence is built to deal with the threat of economic stress (Dongus, Pfeiffer, Metta, Mbuyita, & Obrist, 2010). However, as discussed in Chapter 9, work in the informal economy often engenders precarity through unregulated labor, low wages, lack of benefits, and so on. Obrist (2010) delineates typologies of capital available to residents of rural Tanzania, which can be drawn on to manage illness in the family. Men’s strategies in Kabalagala’s informal economy demonstrate ways of increasing financial capital, used to pursue livelihood objectives

(Obrist, 2010).

Social capital, on the other hand, describes social resources on which people draw to pursue livelihood objectives (Obrist, 2010). Cultural and social systems in

Kabalagala help to manage conditions of stress, an important aspect of social resilience

(Keck & Sakdapolrak, 2013). In Kabalagala, men rely on their bar groups to receive food, drinks, or mira during times of low earning. Men also build relationships with female sex workers, who provide for their basic needs, a system that primarily draws the younger, less economically-stable men. Men rely on these intimate relationships, sometimes maintaining relationships with multiple women, to ensure that they will have

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somewhere to sleep on any given night. These relationships have dramatically shifted

Kabalagala’s view of the young men, who are derisively termed “women” who are unable to be responsible or fulfill their role as a man. As Wyrod (2016) aptly describes, this inability to fulfill socially-prescribed gender roles has negative impact for men’s risk- taking strategies.

This dissertation re-shapes a concept of social resilience not as a strategy to rebuff potential future crisis, but to rebuff ongoing crisis. While the specter of future crisis is uncertain and acute, ongoing crisis becomes almost quotidian or “normalized.” Men struggle to make ends meet every day. The prevailing literature on social resilience

(Berkes & Ross, 2013; Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008;

Obrist, Pfeiffer, & Henley, 2010; Sherrieb, Norris, & Galea, 2010) focuses on community capacity to buffer future threat, typically disaster-related threat. Instead, this dissertation demonstrates that crisis can be less acute. It can be slow, and it can be politically and economically produced rather than naturally produced. By shifting what constitutes crisis, I argue that a social resilience frame can also shift dialogue on informal settlement residents toward resilience-building approaches predicated on strengths.

This research also uses a conceptualization of “perverse resilience” (Panter-

Brick, 2014) to describe how men’s resilience strategies often have the unintended consequence of being harmful for health. For example, spending more time in the bar and relying on bar groups encourages alcohol use. Meanwhile, relying on female sex work partners and engaging in longer-term relationships with childbearing expectations has implications for condom use and HIV risk. The men in this study who disclosed their

HIV status and knew how they became HIV positive are evidence of this, where low condom use within sexual partnerships facilitates transmission. This adds to the already lengthy literature on the social context of condom use (Bond, Kreniske, Susser, &

Vincent, 2018; Campbell, 2000; Sibthorpe, 1992).

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These trade-offs of resilience demonstrate how “adherence to cultural and social norms can prove negative for health and well-being in ways that make resilience perverse” (Panter-Brick, 2014, p. 443). Bourgois (2002) described a similar phenomenon whereby street culture in the US includes the building of “networks of solidarity” to resist social marginalization, but trapping youth in the illicit drug trade, resulting in death or incarceration. Here, in Kabalagala, men similarly participate in bar groups, a social structure in the community that buffers marginalization in the informal settlement. On the other hand, participation in these groups increases alcohol and drug use, which is associated with a variety of harms when taken to the extreme.

10.5. The Political Economy of HIV

Figure 10.2. The political economy of HIV risk

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Figure 10.2 describes aspects of the political economy that pattern HIV risk to individuals. This section underscores connections to existing literature on the political economy of HIV. This dissertation contributes to this literature in the following ways: 1) placing men’s HIV risk in a broader context, 2) pinpointing the role of inequality in HIV vulnerabilities, 3) linking the informal economy to the political economy of HIV, 4) describing linkages between formal economy unemployment, uncertainty, and HIV vulnerability, and 5) examining the materiality of sex in this context.

Men’s HIV Risk in Context

The quantitative results from this dissertation demonstrate the challenges in quantifying men’s HIV risk. Using risky sexual behavior as a proxy for HIV risk, variables based on past literature (Mathur et al., 2015; Siu et al., 2014) such as HIV KAP or alcohol use were found to be insignificant or non-explanatory of HIV risk. However, stable employment predicted risky sexual behavior, controlling for other predictor variables. This relationship is mirrored in the abundance of interview data that support the importance of job stability in shaping decision-making, including sexual decision- making. Moving beyond individual risk, nesting an individual within a risk environment draws attention to the connections between risk and political-economic factors in the environment that structure risk. These data demonstrate multiple aspects of the risk environment – physical, social, economic, and political – that influence social and individual practices within that environment (Rhodes, 2002). While most risk environment literature relates to injection drug use, the framework is used here to describe the environment of risk for men in a female sex work community.

Inequality and HIV Vulnerability

The connection between inequalities and HIV has long occupied researchers

(Moyer, 2015). Moyer (2015) argues that while HIV treatment saves lives, it does not end poverty and inequality. These issues continue to shape individual’s access to

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treatment, with those at the bottom of the socioeconomic ladder unable to reliably access medication due to challenges with housing, food, and job instability (see Chapter

6). This framing fits with Russell & Seeley’s (2010) argument that living with HIV in

Uganda means returning to a life characterized by economic insecurity, with money and food worries forefront in most people’s minds. It also fits within Moyer and Hardon’s

(2014) work on continuous uncertainty, in which individuals who begin ART are unable to find clear meaning in their lives due to issues of economic insecurity. My data show that men are first concerned with managing economic insecurity. For those who become

HIV positive, they face a myriad of additional challenges managing stable housing and food access. In this sense, this work aligns with the literature that argues that HIV is not a chronic disease for its most vulnerable who still struggle with the day-to-day economic stress (McGrath et al., 2014; Moyer & Hardon, 2014).

The Informal Economy and PEH

The informal economy provides an opportunity to study issues of political economy, as it links with inequality and unemployment (Young, 2019), engenders precarity (Han, 2018), and describes the economic aspect of life for most in an informal settlement (Wyrod, 2016). While the informal economy does provide opportunity to earn income in the short-term, or for “survival,” it does not provide a path to long-term financial security except for the very few who are able to truly capitalize on Kabalagala’s businesses. This dissertation uses a political economy framing to describe how the informal economy shapes precarity for those who live at the juncture of unstable wage labor and a loss of state sponsored social protections. Men in this study population face formal economy unemployment, and are essentially dependent on participation in the informal sector (Han, 2018). This aligns with studies of the informal economy that recognize it as essentially involuntary in nature (Kanbur, 2009; Moser, 1978). In the informal economy, men experience both flexibility and potential exploitation and

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increased dependence on relationships with powerful men. A marker of precarity in

Kabalagala is the cycle of arbitrary arrest and detention that men face due to draconian colonial vagrancy laws that punish the poor.

Another dimension of precarity engendered by the informal economy is how it has shifts structures of social organization. My research findings align with Parry’s

(1999) study of the informal sector in India, where neoliberal economic policies have transformed the relevance of long-standing markers of social class. Similarly,

Kabalagala’s men are unable to transcend their marked “youth status,” relegated to the status of a boy well into their 30s. Finkelstein (2019, p. 53) captures this notion of being left behind in an ethnography of Bombay’s mill workers:

Current trends in anthropology privilege a forward form of looking: forms of development and institutional ethnographies that unravel how government structures and bureaucratic institutions fuel a teleological conception of progress. While I do not dispute the importance of such engagements, I want to suggest that such a lens simultaneously renders those on the margins intelligible only as leftovers and archaic spaces: as cities redevelop, as markets restructure, and as communities are formed and reformed, the traces of such forward motion – those who are “left behind” or continue to struggle at the margins – become the unseen casualties of more convenient stories.

In congruence, I argue that Kabalagala’s men are “unseen casualties of more convenient stories.” KCCA rhetoric of progress is not always human-centered or implemented in a manner that benefits the residents in the Slum Upgrading Project.

Rather than accept the outcome, Kabalagala’s men rebuff the more convenient stories.

This is certainly present in the rumblings of political dissent that emerge from men’s narratives.

Unemployment and HIV Vulnerability

This dissertation has traced colonial and post-colonial political, economic, and city planning policies (Young, 2019) to contemporary urban stratification, insufficient job creation, and the creation of the informal economy. Thus, I argue that formal sector unemployment experienced in the informal settlement patterns men’s lives in ways that

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extend beyond economic instability. Unstable wage labor drives patterns of alcohol and drug use, unreliable access to HIV treatment, an inability to fulfill masculine gender expectations, and dependent sexual relationships with female sex work partners, forming a synergy of vulnerabilities.

The Materiality of Sex and HIV

A helpful analytical frame is Hunter’s (2002; 2010) description of the “materiality of everyday sex” as historically rooted with long-term drivers of inequality shaping the ways that sexual relationships shift in the informal settlement. These data highlight the complexities of relationships in Kabalagala, whereby partnerships are characterized by aspects of love (perhaps not the romantic, or true, kind) and transaction. Hunter (2010) details this in a similar situation in South Africa, but where the women are dependent on men. This Kabalagala case presents a unique configuration of love that is not captured in other literature where the power dynamic is decidedly in men’s favor. In Kabalagala, the women have more money, and therefore occupy a higher economic ground. They can decide who to “marry,” who to provide for, and when to separate. Men, on the other hand, are dependent on their relationships and find it difficult to leave when there is nowhere else to go. It is this uncertainty about their future (Reynolds Whyte 1997) that forces men to make choices that protect their ability to survive, rather than choose what may be the healthiest option. Moreover, men who have moved to Kampala from a village find new opportunities outside of traditional typologies of marriage and might be comfortable being the dependent rather than the provider (Wyrod 2016)

The ways young men depend on their relationships for survival has broader implications for their HIV vulnerability, due to limited capacity to negotiate for safe sex or

HIV prevention services. Similar to work by Syvertsen (2013; 2015) and many others, this research has demonstrated the relationship between love, trust, and low condom use. Men in this study reported not using a condom with their intimate partners,

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especially after the one-month mark, where partners have come to trust each other.

Using a condom was a marker of distrust, one which might bring conflict and quarreling to the relationship. Hunter’s (2010) work on the political economy of love and HIV in

South Africa came to similar conclusions, albeit with a focus on women. The Ugandan context shows a complex tension among men between economic needs on the one hand, and HIV vulnerability on the other hand. Young men in Kabalagala must prioritize one or the other, and typically are not able to make a choice when they have no other option than to stay with their partner. Also, the complicated dynamics of their relationships, characterized by some kind of love, contributes to an unwillingness or an inability to engage in behavior protective against HIV.

This also has implications for HIV programming that target male partners of sex workers – indicating that moralistic counseling that emphasizes “being faithful” may not be relevant when talking to sex workers or their male partners (Parikh 2016). Parikh’s

(2016) work among youth similarly demonstrates that moralistic HIV interventions that propagate risk-averse behavior may not reconcile with youth romance. With Uganda’s

HIV epidemic increasingly concentrated in key populations, it will be necessary to implement interventions that account for the complexity of men’s lives in places like

Kabalagala.

10.6. Theoretical Contributions

This dissertation speaks to several themes, one is HIV in urban Uganda, another is the quotidian challenge to survival in an informal settlement, and a final is how men negotiate strategies to manage uncertainty. These themes overlap, and taken together, describe the political economy of a place like Kabalagala in the context of HIV/AIDS.

Indeed, this research is situated within and contributes to the body of literature on the

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political economy of health. Specifically, this research contributes to understanding the colonial, political, and economic context of HIV risk in urban Uganda.

This research begins with HIV risk and builds out a more comprehensive framework for understanding men’s decisions, behavior, and indeed, risk. A risk environment framework (Rhodes, 2002) is utilized to demonstrate how risk is contoured by life in an informal settlement where myriad risks are negotiated on a daily basis.

While the risk environment framework has been used to describe the context of drug use

(Strathdee et al., 2010) or sex work (Andrade et al., 2018), it has not been used to investigate the context of HIV risk among male partners of sex workers. This research adds a new link between these bodies of literature, more clearly articulating how a risk environment framework is scaffolded by political economy theory, acknowledging the legacies of colonialism in postcolonial states.

Participants in this study describe not only vulnerabilities in this space, but also opportunities for social resilience. By demonstrating the linkages of these themes to the political and economic context, this research demonstrates the nondeterministic effects of political-economic context, and how this context is filtered through myriad community- level factors that ultimately pattern risk outcomes (Birn et al., 2017). Participants are not passive spectators in the face of economic challenge, but seek opportunities to hustle, grow their social capital, and even use sexual relationships as a way to manage uncertainty.

While a large body of literature exists using a political economy lens to frame

HIV, this research extends Singer’s (1998) and Pfeiffer and Chapman’s (2010) work to demonstrate the effects of inequality and unemployment on men’s experiences with HIV risk. Positioned next to Hunter’s (2010) work in South Africa, this research tackles similar questions of economic struggle, albeit among men in the informal settlement. Lastly, this research integrates an understanding of the informal economy (Young, 2019) into

256

political economy of health, demonstrating that the informal economy might present opportunities for economic gain, but it also patterns uncertainty and economic instability.

In fact, studies of the informal economy (Richmond et al., 2018; Young, 2019) have not sufficiently linked to studies of health. I argue that understanding the informal economy is critical to understanding life in the informal settlement, notions of precarity, and experiences of uncertainty, all of which contribute to HIV risk. Dangerous and unstable work chips away at economic stability and shapes experiences of vulnerability.

Han (2018) details the link between the informal economy and experiences of precarity, or what is called “surviving” by some of Kabalagala’s men. Living with the bare minimum may enable a difficult survival, but it also puts extraordinary focus on maintaining that economic survival, and not necessarily leaving time to consider health needs.

Participants reminded me that they did not consider HIV a top priority, but they were more concerned with finding food to eat that day. This precarity is manifested both in the higher HIV risk among Kabalagala’s men, but also in the growing political tensions in the country where dire economic circumstances are leading men to seek more drastic solutions. In this sense, men’s experiences of macro political-economic forces and HIV risk could relate to the unfolding political situation in the country, with implications for

2021’s presidential elections.

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10.7. Future Directions

This research set out to answer key questions related to the political economy of

HIV risk. Men’s experiences of inequality and unemployment are acutely felt in the informal settlement, which acts as a sort of pressure cooker whereby multiple stressors are synergistically experienced. Kabalagala provides a vessel for exploring the invisible line that runs through Kampala, bifurcating the city for those who have, and one for those who have not. Men describe feeling “left out,” and progressively restricted by state policies to regulate the informal economy (e.g., via KCCA regulations) and the informal settlement (e.g., through policing practices). Men’s HIV risk is embedded in these experiences and shaped by a context that is fraught with uncertainty. This research has demonstrated not only how men experience uncertainty, but how they actively manage it with implications for future survival.

Future research can build on this work to examine other aspects of social resilience, like diversifying income sources, or maintaining linkages to a home village or extended kin. Future research can focus on the reciprocity mechanisms within bar groups. There are many opportunities to further examine the informal economy, and how young men engage with strategies for survival. Others may want to investigate the aspects of generation described in this dissertation. As described, men face increasing inequality and difficulty moving up the generational ladder. These “blockages” contour generational tensions between older and younger men. The implications of these generational tensions are seen on the national stage, with current political rhetoric between President Museveni and MP Kyagulanyi. These tensions will also have implication for other countries on the African continent with a rising young population and an ageing, gerontocratic state. How states manage policies that target the young has wide-sweeping implications beyond this community where this study took place.

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Appendix

I. Survey tool

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260

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INTERVIEW GUIDE INTERVIEW

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• • • • • • • • • • • • • • • • • • • •

Economic Stability & Housing Alcohol Use Drug Use Social Men's Norms

269

and Bar groups betting and Valuesattitudes from developed friends of aas Friendssource support of aas Friendssource information root andViolence its causes you how Describe would react theif now here police came Generational differences in leadership

vs. detained vs. vs. detained vs.

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or sex or sex

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• • • • • • • • • • • • • • •

Bar Groups and Barand Groups Support Social Violence Experiences with Police Arrest Community Context

270

economic

KCCA and and KCCA constrained opportunities Partner selection and making Decision negotiation Partner selection and making Decision negotiation sex Partnerships with workers of aspects Emotional partnership

bout ge / / ge

Prompt: What should chan should What Prompt: to allowleaders local continue to beeffective? or try vote you ever Prompt: Do in get tocommunity involved meetings? is the KCCA that Do you think adoing work? good street and keepers Do shop KCCA? thefear vendors KCCA of acase Describe recent arrest. describe you Prompt: How would your Did relationship? your first all? at you counsel parents a you feel did Prompt: How relationship? the influence anyone Did Prompt: Where partner? yourof choice how? and meet you did one have you only Prompt: Do wife? or girlfriend sexual have other Do you partners? your does What work do? girlfriend/wife girls? meet do you mostly Where

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• • • • • • • • •

- -

KCCA Partner Status History Partner Status Current

271

nd locus of of nd locus STI knowledge and and knowledge STI attitudes use of Effective contraception testing HIV Consistent behavior & Transactional love survival Hope as a cultural local concept and hope definitions of Lucka control

igma?

term partner -

why why not?

it easy to discuss the discuss easy to it -

you ever exchange money for money exchange ever you Do sex? by 'secret', Prompt: what is meant private vs. secret parsing out friends discuss Prompt: do your st HIV IsHIV? there STIs? you HIV? fear Prompt: Do anot was Prompt: Why/why used? condom or Wereconsidered any risks discussed? Did you find partner? issue your with and used were What methods why? tested If not partner first with Prompt: feelings casual partner, vs. current long partner vs. positive a have Prompt: do you you think Do view the of future? a havefuture? Do that you have group friend your in people future? the for hope fordesires or Prompt: aspirations future the

wantthem to

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• • • • • • • • • • • • • • •

- Health Knowledge, Attitudes, Services Health Behavior (HIV Testing, Condom Use) Love &Romantic Transactional Hope & Aspirations

272

Perceptions of Perceptions risk and (probabilistic) uncertainty (imperfect information)

Prompt: do you feel you've been feel you've Prompt: do you in opportunities given enough your life? or bad something Prompt: when go? do you where happens, good

Do you feel that you have control over control have that Doyou you feel your future? Is your in whathappens on luck? dependent future in happen your will Do what you know knowing to exist barriers future? What come? whatto is place where a have you Do you feel like youbelong? things bad for the Whatreason is things? Good happening?

• • • •

Uncertainty

273

– t.” t.”

163_14 Feb

–

of all, which leads to poverty and poverty to all,leads of which

102_29 Jan 102_29

– Example Quotes Example first “Unemployment people you find desperatism, real and desperatism, happy are think they you loud music, here drinking, the life, plastic desparatism, theare but theykilling plastic.” thisis really life the us tellthat they because “Sometimes, sometimes these but sometimes keepto law, there police are stay we who find you like you can Uganda, police of are you when find you there can ghetto in,they the ask they and ganja, smoking of anything not doing your have you don’t here, doingif you youare what youtake they can the wallet, in IDs, orwhatever your of some luzira, up to take you they can for no reason, so ourhave relatives don’t we us Kampala, here in you come that from Jinja someone youcall cannot have we when find we sometimes so me help and anyone have don’t we luzira to when takenbeen bring you can tell they there, we becausereach when in are you when up end you and 300 bring 200, Luzira.” feel groups,you the when from we“Sometimes learn because you they teach do it,to like you want you touch then tie yourself, you can sometimes you start than this, do like and you something hard ou comes it slowly then slowly veins seeing the Jan 102_29

poor positive

– –

eventers es

Teetotal Drinking (rarely) Drinking (sometimes) Drinking (daily) drunk being Experience with alcoholBuying alcoholSharing alcoholofCost Bad decisions Crime pr police and Local leaders defense Local Mob justice andPolice corruption Police referrals bribes Police with Police relationship community with Police relationship community Marijuana Heroin/Cocaine drug for name Local drugs Illegal Drug sal Drug use

• • • • • • • • • • • • • • • • • • • • • • • • Code Categories

Example Thematic Analysis Themes Alcohol Policing useand Drugsdrug III.

274

– , don’t don’t

159_22 Feb

–

163_14 Feb

ing them, taking these drugs and admiring admiring drugs and these them, ingtaking ensive so we find ourselves squeezed because because squeezed find ourselves weensive so Some are in denial, they may not have got enough enough have got not may they Some aredenial, in o construct of which you cannot afford a plan from plan from a afford you cannot of o which construct “That putting Kampala on standard, that they that on standard, putting Kampala “That here. They even see you structures, want temporary structures temporary those container, broke every find and we broke them they and made wood, of of side. cost The the road by ourselves working is property landlord’s a a in building constructing exp hard really very It is a business…. of therelot is again and the tolandlord, talkto have because you to have the you building, construct to get the money what you want of a plan you give to KCCA talk the to t KCCA.” the foursenior in stopped perfectly I studying “In fact, for myself, money paying was I two senior cause from then leave decided to I so finish to difficult it was very the to maximum.” now am fighting I world, I fight the Feb 6 169_ I and ghettos tousedand love I street “I used love to I and groups Igroups, joined peer in found myself like was admir their independency.” “ got adequate had they because if counselling, them give you can’t because food counselling and

low high

– – –

low high

– –

Perceived social status status social Perceived status social Perceived middle status social Perceived Homelessness Skilled work Unskilled work Small business Stress means What work Completed S1 Completed S4 Completed S6 fees school Lackof toschool Wanted continue job to not did lead Education Jealousy biting Back Sharing items/food Rules/norms support Social about Things talk to group Trust in group Trust in need of Help times in influence Peergroup Food is costly affordable Food is buy kikkomando I can only

• • • • • • • • • • • • • • • • • • • • • • • • • • • •

Economic status Education Barand Groups Friends Food stability

275

130_14 March

– ”

m to take the medicine. take to m that tin of medicine when they don’t have food to eat to food don’t have they when medicine thatof tin do you how the medicine, throw mayso just they the expect

Food treatmentHIV and

•

276

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