LIVING WITH GLOBALIZATION: THE INTERSECTION OF INTIMATE PARTNER VIOLENCE AND HIV TREATMENT IN UGANDA by MARGARET SUSAN WINCHESTER Submitted in partial fulfillment of the requirements For the degree of Doctor of Philosophy Department of Anthropology CASE WESTERN RESERVE UNIVERSITY January 2011 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the thesis/dissertation of Margaret Susan Winchester___________________________ candidate for the __________Ph.D.____________degree *. (signed)_______Janet W. McGrath___________________ (chair of the committee) ________Jill Korbin_________________________________ _______Eileen Anderson- Fye________________________ _______Patricia Marshall____________________________ ________________________________________________ ________________________________________________ (date) ___05 August 2010_______ *We also certify that written approval has been obtained for anyproprietary material contained therein. Copyright © 2011 by Margaret Susan Winchester All rights reserved In loving memory of JPW 1 TABLE OF CONTENTS LIST OF TABLES 4 LIST OF FIGURES 5 ACKNOWLEDGMENTS 6 LIST OF ABBREVIATIONS 8 ABSTRACT 9 CHAPTER 1: INTRODUCTION 1.1 Framing the subject 11 1.2 Problem statement/ objectives 11 1.3 Significance 14 1.4 Chapter Overview 16 CHAPTER 2: BACKGROUND/ LITERATURE REVIEW 2.1 Introduction 18 2.2 Defining globalization 19 2.3 Theorizing globalization and HIV 23 2.4 Domestic violence research 37 2.5 Intersection of HIV and domestic violence 56 CHAPTER 3: THE UGANDAN CONTEXT 3.1 Introduction 61 3.2 Contextualizing research in Uganda 62 3.3 HIV in Uganda 77 3.4 Domestic violence in East Africa 83 3.5 Fieldsite 1: Urban Kampala 86 3.6 Fieldsite 2: Peri-urban Mbarara 87 3.7 Summary 88 CHAPTER 4: METHODS 4.1 Overview 89 4.2 Sampling procedures 90 4.3 Data gathering procedures 94 4.4 Data Analysis procedures 97 4.5 Scope and Limitations 101 4.6 Ethical Considerations 102 CHAPTER 5: POLICY ENVIRONMENT 5.1 Overview 104 5.2 Current and pending policy in Uganda 105 5.3 Views on government 115 5.4 Summary 123 CHAPTER 6: SERVICE PROVISION 6.1 Overview 125 6.2 Medical providers 126 2 6.3 Formal social service provision for intimate partner violence 134 6.4 Informal service providers 144 6.5 Summary 156 CHAPTER 7: SURVEY DATA 7.1 Introduction 160 7.2 Sample Characteristics 161 7.3 Marriage Practices and Gender Norms 165 7.4 Economic Considerations 174 7.5 Violence: Prevalence and Association Factors 177 7.6 Effects of and responses to violence 185 7.7 Summary 189 CHAPTER 8: ETHNOGRAPHIC DATA 8.1 Ethnographic sample 190 8.2 Marriage 192 8.3 Violence in marriage 204 8.4 Living with HIV 209 8.5 Resources and help seeking 221 8.6 Case studies 231 8.7 Summary 245 CHAPTER 9: DISCUSSION 9.1 Summary findings 247 9.2 In global context 250 9.3 HIV as a chronic disease 253 9.4 Living with HIV 255 9.5 Economic violence 257 9.6 DV in global perspective 260 9.7 Marriage 262 9.8 Summary 264 CHAPTER 10: CONCLUSIONS 10.1 Findings Summary 265 10.2 Applications and recommendations 265 10.4 Future directions for research 269 APPENDICES Appendix A: Standardized instrument for clinic interviews (English) 272 Appendix B: Table of variables associated with types of violence 300 Appendix C: Table of Ethnographic sample 301 REFERENCES 303 3 LIST OF TABLES Table 1- Policy and service- related interviews by site and gender 92 Table 2- Codes for narrative data 101 Table 3- Demographic characteristics of clinic sample 161 Table 4- Women’s health 164 Table 5- Marriage Practices 166 Table 6- Partner characteristics 167 Table 7- Gender vignette responses 169 Table 8- Acceptability of physical violence 171 Table 9- Views on women’s ability to refuse sex 172 Table 10- Overall perceptions of gender equality scale 173 Table 11- Economic practices 175 Table 12- Economic assessment of assets 176 Table 13- Controlling behavior and verbal violence 178 Table 14- Physical and sexual violence 180 Table 15- Factors associated with types of violence and overall violence 183 Table 16- Effects of violence 186 Table 17- Responses to violence 187 Table 18- Formal help seeking in response to violence 188 4 LIST OF FIGURES Figure 1: WHO Typology of Violence 40 5 ACKNOWLEDGMENTS Over the past six years, countless individuals and institutions have supported my work and inspired me in Cleveland and in Uganda. To all of them, mentioned here or not- I am unendingly grateful. This work was sponsored through a National Science Foundation Doctoral Dissertation Improvement Grant (DDIG#0823287) and write up was partially supported through the Richard B. Zdanis fellowship from Case Western Reserve University. Firstly I thank all of the women in this study for their openness, understanding, and humor. I am honored to have been so welcomed so intimately into your lives and am truly inspired by your daily strength and resolve. My research assistants in the field, Sheila Irene Kisakye and Judith Namanya are both exemplary young researchers who gave me fresh insight, invaluable daily assistance, and challenged me with their own questions. I look forward to being colleagues in the future and thank you both for your patience. To my committee members, Drs. Janet McGrath, Jill Korbin, Eileen Anderson-Fye and Patricia Marshall- thank you for your guidance, understanding, inspiration, and exemplary scholarship. Your own work and support motivates me in my own. In particular, Dr. Janet McGrath has served as an advisor, mentor, and strong support over the past six years. In Uganda, the Center for Social Science Research (CeSSRA) team has acted as resources and supporters for the past several years. I am grateful to know all of you and honored to work with you. Dr. David Kaawa- Mafigiri, Dr. Charles Rwabukwali, Judith Birungi, Florence Namutiibwa, Amina Nalwoga, 6 George Ssendegye and Emily Kyarikuna- thank you all for your encouragement, your patience with my questions, and tireless work. Jenny Zabel in Cleveland has assisted in data analysis, and general organization- without which I would be lost. Thank you! To the patient and accommodating staff at the Joint Clinical Research Centre (Kampala), ISS Clinic (Mbarara), and the Center for Domestic Violence Prevention, thank you for your welcome and support. I am grateful to all of my friends in Uganda who have over the past seven years welcomed me and helped me to build a home there. Particular thanks to Alex Q. Matovu, Phoebe Sullivan, and Alex Kintu for their friendship, insight, love, and support. I am grateful to my colleagues at Case Western Reserve University. My fellow graduate students are an inspiration and I am so lucky to have such supportive, brilliant, and exemplary colleagues and friends. And lastly, thank you to the Winchesters (yes, all of you)- in particular my ceaselessly supportive and patient parents- for your strength, humor, love, and support. 7 LIST OF ABBREVIATIONS ABC- Abstinence, Be Faithful, Condom use AIDS- Acquired Immunodeficiency Syndrome ARV- antiretroviral CD4- T-lymphocyte bearing CD4+ receptor CEDAW- Convention for the Elimination of All Forms of Discrimination against Women CFPU- Child and Family Protection Unit CHOGM- Commonwealth Heads of Government Meeting CPS- Central Police Station DV- domestic violence EAISR- East African Institute for Social Research HAART- highly active antiretroviral treatment HIV- Human Immunodeficiency Virus HRAF- Human Relations Area Files IMF- International Monetary Fund IPV- intimate partner violence ISS- Immune Suppression Syndrome JCRC- Joint Clinical Research Center LC- local councilor MUST- Mbarara University of Science and Technology NGO- nongovernmental organization NIECO- new international economic order NRM- National Resistance Movement PEPFAR- President's Emergency Plan for AIDS Relief SAP- structural adjustment programs STI- sexually transmitted infection TASO- The AIDS Support Organization TRIPS- Trade-related Intellectual Property Agreement UDHS- Uganda Demographic and Health Survey UNAIDS- Joint United Nations Programme on HIV and AIDS VAW- violence against women VCT- voluntary counseling and testing VAAW- violence and abuse against women WB- World Bank WHO- World Health Organization WTO- World Trade Organization 8 Living with Globalization: The Intersection of Intimate Partner Violence and HIV Infection in Uganda Abstract by MARGARET SUSAN WINCHESTER Intimate partner violence (IPV) and HIV treatment intersect as synergistic vulnerabilities for women. This study examines how women in two regions of Uganda live with and respond to both issues in the context of globalization, including the perspectives of policy makers, service providers, and HIV positive women. Women in Uganda have few formal means of dealing with IPV, and even where services are available, they may choose not to seek help or disrupt their relationships. Most women who seek help do so informally, through family or local and religious leaders. Providers also have limited ability to assist women because of a lack of resources and the limited legal sanctions available. Legal sanctions for responding to women’s needs are in transition, but currently limited in their effectiveness. All of the women in this study are already living with HIV and enrolled in treatment. Those who face or have experienced violence are faced with another set of challenges. IPV frequently occurs in conjunction with economic difficulties, alcohol use, and polygamous marital practices within a home. Women only have legal rights for maintenance in formal marriages, but many are in informal or polygamous partnerships. 9 Women in this study are part of an emerging era of HIV, in which HIV can be lived with as a chronic disease. Globalization impacts their daily experiences through the availability of life-saving treatment. In this context women’s concerns are frequently outside the purview of health. They have a previously unknown luxury of being able to “not worry” on a daily basis about maintaining their health. Economic concerns are of the utmost importance and when women are deprived of resources from their partners in acts of economic violence they are more likely to seek assistance than when experiencing physical or sexual violence.