In Birth in the Age of AIDS, Cecilia Van Hollen explores the ways public health programming directed at parent-to-child transmission of HIV is reshaping the landscape of reproductive health in south India. In a setting in which prevalence rates are low but actual numbers high, Van Hollen addresses the experiences of women navigating systems of care and management: How are lives and decisions mediated by stigma? How is care offered and withheld? How do women make decisions about childbearing and -rearing in the context of interventions? Considering the gendering of disease, responsibility, and blame, she provides an insightful portrayal of lives and intimacies at the crux of illness and uncertainty. As in the best medical anthropology writing, attention to voices that diverge from expectation reveals the surprising, often detrimental, results of health programming, including vivid forms of exclusion and discrimination in hospitals, neighborhoods, and homes. With empathetic attention to the material, affective, and symbolic formulas of stigma, Van Hollen explores the work of creating new possibilities amid circumscribed worlds, work that ranges from delicate negotiations of knowledge within households to engaged public activism.
Among important contributions are portrayals of the reshaping of conjugality amid HIV positivity, within and against the grain of normative expectations on reproduction. This includes new options for what is typically referred to as “widow remarriage.” It also includes uneven distributions of blame as women are diagnosed before husbands, an outcome of government programming with dire effects on women's treatment in households. Women make the important distinction between negative attitudes HIV-positive women face in households and reactions they encounter in public, responses that tend toward pity. In an artful discussion of this distinction, Van Hollen argues that stigmatization of women with HIV/AIDS is rooted in more than sexual double standards, involving the ways women's bodies are understood to function, cultural models that are inextricable from power structures. She also shows that some problems are more basic: informed consent for HIV testing is less a production of the “bioavailability” of poor women's bodies through quasi-legitimate means than a matter of sheer uncertainty about whether consent is attained; discrimination against HIV-positive women in maternity wards can be dramatic and disturbing; vital therapies are available to many women only as a condition of being experimental subjects.
The strongest chapter, chapter 8, “Breast or Bottle?” addresses women's decisions about infant care at the intersection of public health efforts to discourage breastfeeding for HIV-positive mothers and aggressive government campaigns promoting it in the general population. Drawing more extensively from ethnographic material beyond the interview data that dominates the rest of the book, this chapter connects Van Hollen's earlier work on the place of breastfeeding in clinical performances of power to new moral paradigms emergent amid institutional practices that are flush with contradictions.
This chapter's strength highlights a shortcoming of other chapters. Often, when Birth in the Age of AIDS refers to ethnographic material beyond interview data (especially in anthropological literature), it does so to explain the things women say and do. This use of ethnography as explanation for behavior may be directed at a public health audience (and to readers with little exposure to South Asia or literatures about it). In itself, this is not a problem, and the book will be satisfying for those looking to understand “how global health policies and discourses about HIV/AIDS and reproduction intersect with local realities and inform everyday practices” (p. 10). However, the effect is a somewhat static representation of “culture,” in which change is portrayed as only recently induced by epidemic and intervention. For readers with knowledge of South Asian history and an interest in unpacking the map that situates the “global” as purveyor of “discourse” and the “local” as site of “realities” and effects, the dominance of cultural explanation as analytic method (and at a remove from historical and discursive elements) obstructs a more nuanced consideration of social action and cultural production. This is especially so when cultural explanations interrupt narratives rich with nuance and possibility. The voices in this book show that more robust theorizing of intervention is possible.
This effect may also have to do with the book's reliance on interview data (for methodological reasons that may be entirely understandable). While the introduction describes an effort to approach women's “lived experiences”—the things women do and feel—descriptions are overwhelmingly of narrated experience—the things women say about what they do and feel. Though this suggests insurmountable ontological dilemmas, I wager that this is less a problem than a missed opportunity—to consider self-making in the face of illness, to ask how expression (and its structured opportunities) provides means of grappling with illness, and to consider the ways selves are performed in the face of demands on moral behavior, indeed, in the face of death.
Other fascinating elements warrant further exploration: the recurrence of property disputes in negotiations of illness and blame; dynamics of communication and silence that shape intimacy between spouses; emergent theologies and their relationship to casted concepts of the body; and the figuring of law in the concept of “illegal sex,” often posed as a source of HIV/AIDS.
In spite of some dropped threads, this book offers a powerful and accessible portrayal of resilience, showing the richness of lives made and remade in moments of illness and discrimination as well as in interactions rich with care and hope. As in her earlier work, Van Hollen challenges received knowledge about Indian women's agency, offering astute insights into the ways they find places for themselves in worlds made new by illness and intervention.
