Who cares about Mr Mubanga?
Embracing challenges and being reflective led to a surprising and rewarding focus for my MSc Africa and International Development dissertation – the needs of men in the context of poverty and HIV/TB in Zambia – and perhaps helps explain why so many men are still dying from AIDS.
Following a long career in mental health, as an Art Psychotherapist in Scotland, enrolling on the MSc Africa and International Development programme 2012/2014 was already a challenge. The opportunity to do a work-based placement at ZAMBART[1] in Zambia was another step into uncertainty, but gave me scope to use my knowledge and skills as a psychotherapist in the secondary analysis of some fascinating HIV/TB data. The dynamics which ultimately resulted in my focus on men’s mental health and physical survival were inspiring and rewarding, and have motivated my ongoing research interests in this field.
My first weeks in Lusaka were spent familiarising myself with the data and beginning the struggle to find a research question out of such rich material. My supervisor at ZAMBART, Ginny Bond, recommended I meet the primary researchers and visit the field site. I was rather filled with awe at the prospect of meeting the Zambian researcher Mutale Chileshe and her assistant Florence Moyo, because their ethnographic research proved exceptionally harrowing.
The primary study[2]
Mutale and Florence lived in the rural community of Pemba, Southern Province, and followed 8 families where there was a new diagnosis of TB, for a period of 8 months – the period of TB treatment. Their focus was on food insecurity and poverty, and implications of this on health outcomes re: TB/HIV. They got to know the families well, visiting them at periods throughout the study to undertake semi-structured questionnaires and take notes. The lack of food and suffering caused by illness in these families was very harsh and painful to witness. They recorded seeing patients in a terrible state unable to breath and their hair falling out. Families were reduced to begging for food. Four TB patients died during the study.
Beatrice’s story stood out as a particularly sad series of events resulting in her death, aged 30 years. The researchers and I ‘compared notes’ and empathised with her dreadful situation. Mubanga, her husband, by contrast was seen by us as a ‘bad man’ – an agent in her death.
Beatrice
Beatrice met her husband Mubanga at the bar where she lived and worked. He moved into the bar with her, abandoning his first wife and 3 children. Beatrice got sick and was diagnosed with TB. Mubanga struggled to care for her, so took her home to his first wife, Enesia, so that she could care for Beatrice (now his second wife). The family were significantly short of food: Enesia voiced the dilemma of not knowing whether to feed the children or ‘the patient’. Beatrice was subsequently diagnosed with HIV but Mubanga refused to let her take medication in ‘his house’. The delay to her accessing treatment is likely to have been a major factor in her death.
Seeing Mubanga
The means whereby I came to see Mubanga’s needs are threefold: firstly, the incongruence of my socialised response, i.e. in defence of women and a judgmental attitude towards ‘bad men’, versus my strictly non-judgmental attitude as a psychotherapist; secondly, my reflections in research domains were validated by qualitative approaches that value reflexivity methodologically, and lastly my personality which has an eye out for those who suffer.
Mubanga
A startling, sad and sorry picture of despair and hopelessness emerges if Mubanga’s needs are considered in relation to the likely psychological and social factors at play in the context of the HIV epidemic and poverty. I draw on concepts of masculinity, psychotherapeutic theory on shame and theories of men’s mental health in my analysis.
Understanding Mubanga in relation to psychological and social dynamics
| Sequence of events in Mubanga’s life | Psychological significance and links to masculinity |
| Mubanga’s mother died | In Zambia, the relationship between mothers and sons tends to be the closest of all family relationships – so represents a significant loss, increasing his vulnerability. |
| Inability to provide for his family due to problems in subsistence farming and limited opportunities for earning money | Traditional masculine role means that he is responsible for ‘provision’; failure to ‘provide’ impacts on his sense of identity, causing shame. |
| Running away from his family | Avoidance is a common response in men’s depression. ‘Masculinities’ where men are expected to be strong and un-expressive can mean accessing support is not an option. |
| Inability to care for Beatrice and the return to Enesia | This is likely due to the fact that it is seen as a woman’s role to provide personal care – and Enesia is the only woman he can call on to do this. |
| Refusal to let Beatrice take ARVS[3] in his house | This threatens his male ‘head of household’ position – it will look like he has lost control of his wives. The specific stigma of HIV exacerbates this. |
| Presents to the researchers as ‘his usual cool and smiling self’ | Mubanga, like men (the world over) suffering from shame and/ or depression often develop a mask – a barrier in order to maintain an image of success – but which hides the despair and troubles within. |
| Is diagnosed as HIV+ but continues to have unprotected sex with Enesia | Avoidance, shame and holding onto a traditional male identity serve to prevent Mubanga behaving in less risky ways. |
| Chooses not to access ARV treatment for his HIV and dies of AIDS, aged 34 years | The extent of his shame and despair at being unable to achieve his masculine provider and identity, means that death is the only way out – a common response[4]. |
Thus a question emerges from my research which warrants further enquiry:
What part might poor mental health in men – linked to gender norms – play in fuelling the ongoing infection and death rates from HIV/AIDS in Sub-Saharan Africa?
Why has this relationship not yet been explored?
The lack of consideration of men’s mental health in the field of HIV/TB is startling. Such blind spots can occur due to ‘structural violence’ [5]. Development’s focus on ‘gender’ inadvertently diverts attention from the needs of men, with men becoming routinely labelled as ‘the problem’. In addition the everyday assumption that men are strong and somehow invulnerable prevents their human needs being noticed and addressed. This occurs in the world of research too, where a focus on men’s outward expressions of anger predominates over exploring inner feelings of despair.
So what now?
Touched by the deaths and suffering in these families and invigorated by the research process in my dissertation study, I will continue to research the possible relationships between men’s mental health and HIV/AIDS. If these relationships hold water then there are major implications for how development initiatives address health risks, and potential benefits for men, women and children.
This blog is dedicated to Mubanga, Enesia and Beatrice who allowed their stories to be heard – not for the benefit of themselves but for others; and to Mutale and Florence, who were brave and strong enough to hear them.
Lesley Hill, MSc Africa and International Development (2014)
[1] ZAMBART – a non-for profit research organisation based within the University of Zambia that is also a research collaborating centre for the London School of Hygiene and Tropical Medicine
[2] Chileshe, M., Bond,V, 2010. Barriers and Outcomes: TB patients co-infected with HIV accessing antiretroviral therapy in rural Zambia.. AIDS Care, 22(Supplement 1), pp. 51-59.
[3] ARVS – Antiretroviral drugs for HIV
[4] Rakgoasi, S.O.2013. ‘Women get infected but men die…! Narratives on Men, masculinities and HIV/AIDS in Botswana’ International Journal of men’s health, 12 (summer), pp. 166-182
[5] Farmer, P., 2006. Structural Violence and Clinical Medicine. PLoS Med , 3(10), p. e449. doi:10.1371/journal.pmed.0030449
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