Amy Kaler

Health interventions and the persistence of rumour: The circulation of sterility stories in African public health campaigns

Public health programmes have done enormous good in Africa and elsewhere in the global south, but have also been met with skepticism. This skepticism often takes the form of rumours about the motives or the results of the public health intervention. One recurrent theme in such rumours is the centrality of reproductive bodies (both male and female), and the perception that these bodies are being rendered sterile by toxic compounds given under the guise of improving health. Public health operations research has identified these rumours as significant obstacles to programme delivery, but they have been treated primarily as failures in communication, to be rectified by the provision of more accurate information. Using reports of such rumours from public health interventions in Africa, with emphasis on vaccines, I argue that these rumours are more than simply stories which are not true. The widespread rumour of sterility is a way of articulating broadly shared understandings about reproductive bodies, collective survival, and global asymmetries of power. I use Foucaults notion of biopolitics to theorize international public health programmes, and introduce the concept of counter-epistemic convergence to account for the ubiquity and persistence of sterility rumours.

“Many Divorces and Many Spinsters”: Marriage as an Invented Tradition in Southern Malawi, 1946-1999:

In the author’s 1999 interviews, elders in a district of southern Malawi insisted that the marriages of their children and grandchildren are a weakened and degenerate form of the marriages of their own youth. However, data from the 1940s shows that identical beliefs about marriage were held even then. Marriage is thus constantly presented as an institution in crisis, deteriorating from an Arcadian form located in the ever-receding past. The author uses an expansion of the notion of invented tradition to describe this historically consistent rhetorical presentation of marriage and suggests questions that this invented tradition presents for family historians.

Gender differences in antiretroviral treatment outcomes of HIV patients in rural Uganda.

Abstract Gender differences in treatment outcomes of 305 persons living with HIV receiving antiretroviral treatment (ART) in Kabarole district, western Uganda, were evaluated. The primary treatment outcome was virological suppression defined as HIV-1 RNA viral load (VL) <400 copies/ml and the secondary outcome measure was the increase in the CD4 cell count after six months on ART. Statistical analysis included descriptive, univariate, and multivariate methods. Proportionally, more females chose to seek treatment compared to males. After six months of treatment, females were more likely to have viral suppression (VL > 400 copies/ml) as compared to males (odds ratio 2.14, 95% confidence interval 0.99–4.63, p=0.05). While females had a significantly higher baseline CD4 cell count at initiation of treatment compared to males, the increase in CD4 cell count after six months on ART was similar in males and females. The reasons for better ART outcomes for females should be further investigated. Ideally, ART programs should work toward equitable treatment outcomes for men and women, if the cause of the gender differential lies in patient behavior and the way ART services are delivered.

Gender-related mortality for HIV-infected patients on highly active antiretroviral therapy (HAART) in rural Uganda

The purpose of this study was to examine gender differences in mortality for human immunodeficiency virus (HIV) patients in rural Western Uganda after six months of highly active antiretroviral therapy (HAART). Three hundred eighty five patients were followed up for six months after initiating HAART. Statistical analysis included descriptive, univariate and multivariate methods, using Kaplan-Meier estimates of survival distribution and Cox proportional hazards regression. Mortality in female patients (9.0%) was lower than mortality in males (13.5%), with the difference being almost statistically significant (adjusted hazard ratio for females 0.55; 95% confidence interval [CI]: 0.28-1.07; P = 0.08). At baseline, female patients had a significantly higher CD4+ cell count than male patients (median 147 cells/μL vs 120 cells/μL; P < 0.01). A higher CD4+ cell count and primary level education were strongly associated with better survival. The higher CD4+ cell count in females may indicate that they accessed HAART services at an earlier stage of their disease progression than males. A borderline statistically significant lower mortality rate in females shows that females fare better on treatment in this context than males. The association between lower mortality and higher CD4+ levels suggest that males are not accessing treatment early enough and that more concerted efforts need to be made by HAART programs to reach male HIV patients.

The Female Condom in North America: Selling the Technology of ‘Empowerment’

In this paper, I examine the selling of the female condom and the predominantly negative response it garnered in the North American media during the 1990s. I situate the female condom as a technology that emerged at the convergence of the twentieth century women’s health movement and the much more recent HIV-prevention movement, both of which stressed ideals of individual self-control and empowerment for women as the keys to sexual health. However, the female condom was constructed in media accounts as a joke or an insult. The idea of women’s empowerment embodied in the device was taken as an unwelcome reminder of the dangers and risks of heterosexuality in the age of AIDS – thus, the female condom was perceived as more depressing than emancipating. It has since found a substantial market and receptive users in HIV-prevention programmes in Asia and Africa. I conclude that the episode of the female condom complicates the narrative of the women’s health movement as a drive towards women’s empowerment, by pointing out that empowerment is an ambiguous concept which can evoke an ambivalent response from its intended audience.

'When They See Money, They Think it's Life': Money, Modernity and Morality in Two Sites in Rural Malawi

In this article, I draw on archival documents and interviews with elderly Malawian men and women to elaborate a ‘philosophy of money’ very different from the mainstream classical view in social history. While social theorists in the classical Euro-American tradition have until now associated money with rationality, calculability and the draining of affect and emotion from daily life, Malawian elders looking back on the monetisation of their community see it as an agent of chaos, discord and irrational behaviour. This function of money is particularly pronounced in the realms of marriage and sexuality, as money is blamed for the perceived deterioration of relations between the genders. I argue that this view of money and economic change, while not empirically verifiable, provides a thought-provoking alternative to the tendency among Euro-American social theorists to associate money with rationalisation and the decline of emotion as a governing principle in social relations. Interviewer: Do you see that your grandchildren, or those of other people, will they have a good life like you had in the past? Esther Nambebwe: No, because the doing of today, they like wealth, this one is running after wealth, this one too, and when they are running for wealth, there they find death. (Interview with Esther Nambewe)

Accurate information as a tool to decrease HIV test refusals in research studies.

It has been argued that researchers conducting surveys that include testing for human immunodeficiency virus (HIV) have a duty to tell potential subjects that they do not have the right to participate if they refuse to receive their HIV test results.1,2 Furthermore, promotion of the routine feedback of such test results has been based on the grounds that knowledge is power and information is liberation.3 However, other researchers argue that, although it is desirable to offer study participants post-test counselling, for practical and ethical reasons some study participants should be given the right to refuse such counselling.4 Although we support the right of participants to opt out of post-test counselling and thus not to receive their test results, we also propose that subjects who are – or may be – tested for HIV should be given information that may decrease their resistance to learning their test results. We draw on data, collected between 1998 and 2013, on rural Malawians’ experience with – and perceptions of – HIV testing. From the perspective of the organizations that promote HIV testing, it is axiomatic that people will benefit from knowing their HIV status. In Maher’s view, such benefit justifies sanctioning those who refuse to receive their test results.2 We disagree, for two reasons. First, the experience of many Malawians is that refusal to consent to testing may have serious consequences. For example, although the policy for antenatal HIV testing in Malawi includes an opt-out provision, accounts from pregnant women attending antenatal clinics show that HIV testing is compulsory if the women are to receive antenatal care.5 Moreover, in population-based HIV surveys, fieldworkers are always under pressure to minimize the numbers of test refusals and may exert undue pressure on individuals who do not want to receive their test results. While exclusion from antenatal services is, presumably, much more serious than exclusion from survey participation, in both of these examples people are sanctioned for not giving consent – which is a clear ethical violation. Second, our ethnographic data depict the anguish that many suffer as they anticipate the future receipt of their test results – an issue that has rarely been discussed in the public health and social science literature.6 Two common misperceptions among rural Malawian adults are that the result of an HIV test will almost always be positive and that a positive result will inevitably be followed by hastening psychological deterioration, suicidal thoughts and death. Yet survey data from people living in rural Malawi show that between 80% and 90% of respondents who believed that they were HIV-positive before they were tested learned that they were HIV-negative.7,8 That so many are convinced, wrongly, that an HIV test will inevitably produce a positive diagnosis is the consequence of rural Malawians’ incorrect understanding of the probabilities of HIV transmission. For example, most of our survey respondents believed that an uninfected individual was certainly or highly likely to be infected with HIV during a single act of unprotected intercourse with an infected person.8 Would it not be preferable to treat those living amidst the HIV epidemic as having an ethical right to accurate information on the probabilities of transmission? Efforts should be made to evaluate the potential benefits of disseminating accurate information on the probabilities of transmission, the approximate prevalence of HIV infection and the probability of a positive result in an HIV test – such that consent for HIV testing in surveys is fully, rather than incompletely, informed. We need to know whether such health education would be a liberation, lead to fewer test refusals in research studies and, importantly, increase the number of people who are willing to know their HIV status.

Making meaning in the time of AIDS: longitudinal narratives from the Malawi Journals Project

The Malawi Journals Project is one of the longest-running observational field studies in rural sub-Saharan Africa, ongoing since 1999. The journals provide real-time accounts of the unfolding epidemic, from the days when AIDS was considered by rural Malawians to be a death sentence, through the advent of international AIDS organisations bearing advice on avoiding infections by self-control, and then the turn to institutionally-based efforts to control infection through HIV testing and antiretroviral medications. This paper examines the epistemological and substantive contributions of the Journals Project, which we and others who have analysed the journals have made to understanding the AIDS epidemic. The paper has three primary aims. The first is to provide evidence of the chasm between the top-down perspectives of global actors with a mandate to address the pandemic and the bottom-up perspectives of local actors trying to avoid dying from AIDS, perspectives that are often contradictory. Second, beyond what can be learned from the journals about individual and collective responses to AIDS, they suggest the value of longitudinal observational field studies as a method for understanding how cultural change occurs. And third, as an example of the potential of longitudinal field studies as a research method on AIDS as well as other topics, we have structured our argument around the broader empirical and theoretical debates in the social sciences featured in published and presented analyses of the Malawi journals data: multiple moral logics, the course of global flows of information and injunctions, and the collective deliberation that produces authoritative local knowledge.

Revelations of HIV-infected patients treated with highly active antiretroviral therapy (HAART) in rural Uganda

The purpose of this qualitative study was to explore the psychosocial changes revealed by persons living with HIV/AIDS (PLWHA) in western Uganda as a result of the introduction of highly active antiretroviral therapy (HAART). Fourteen participants were interviewed on two occasions. Two focus groups discussions were also conducted. Patients experienced important personal benefits as a result of HAART and the resulting clinical improvement. These benefits included a restoration of hope, self-esteem and personal agency. Patients were also relieved of the great fear which they had about the conditions of their death. The financial and social struggles introduced by AIDS illness continued after the introduction of HAART. The conclusion is that the HAART programs should provide more holistic care to patients to address the persistent family issues identified in this study.

Modernizing Sexuality: U.S. HIV Prevention in Sub-Saharan AfricaModernizing Sexuality: U.S. HIV Prevention in Sub-Saharan Africa, by EsacoveAnne. New York: Oxford University Press, 2016. 197 pp.

With Modernizing Sexuality: U.S. HIV Prevention in Sub-Saharan Africa, Anne Esacove makes an important contribution to understanding the discursive and social facets of the HIV epidemic. Her work is rooted in cultural studies and rhetoric but is eminently practical and useful for practitioners and people tasked with designing and delivering HIV prevention programs. Esacove uses three sets of data—official documents, interviews with AIDS bureaucrats and officials, and observational journals of village life—to identify what she calls the major narratives of AIDS. Narrative methods are not new to AIDS scholarship, but Esacove decouples narrative from individual accounts of lives and attaches it to common-sense understandings of the world. These narratives, which she deduces from the ways that people talk about HIV risk and prevention, offer causal explanations for why one event results in another and produce predictions about what will (or won’t) happen if certain other things happen. These narratives might also be understood as theories, in the classic social science sense—generalized accounts of why things have happened in the past and what will, or might, happen in the future, based on the presumed relationships between elements of the theory. This description of Esacove’s theorynarratives may sound dry, but she brings them to life with extended quotations from transcripts and documents about sex, death, gender, medicine, and modernity. (Indeed, I wish she had included more direct source material, rather than relying on general statements about what is in this material.) Her work is an excellent example of how to do rigorous thematic content analysis, in which the salient concepts arise inductively from the data, and present it in an engaging way. Esacove finds, perhaps not surprisingly, that narratives about HIV risk are quite different in the global policy world (synecdochically represented by U.S. policy documents), the world of professionals and volunteers working on HIV prevention in Malawi, (the ‘‘AIDS industry’’), and the world of people living in the villages, who are the targets of omnipresent interventions to help them avoid AIDS. In policy documents, the cause of HIV is profoundly sociological: the epidemic exists because gender inequalities exist. Women are powerless to resist men’s desires to have sex with them, and their plight is compounded by poverty. In the world of the industry, the diagnosis of AIDS risk switches to culture: the epidemic exists because of backward, primitive practices carried out in deep rural settings, such as child marriage and de facto polygamy. This diagnosis also serves as border work, establishing the distinction between the professionals, who are highly educated and employed, and their fellow-Malawians in the villages. In the villages (or at least in the villages as represented through observational journals), however, the narrative is less reductive and more context-dependent. AIDS is closely linked with the changes brought by modern times (which Esacove might have made more of, had she contrasted it with the assumed ahistorical primitiveness of the villages in the industry narrative). AIDS risk goes along with sex: because sex is natural and both men and women enjoy it, AIDS gets passed along. It’s possible to avoid AIDS if one is really committed, but going against such a powerful drive as sexuality is very difficult. Like the narratives of risk, the narratives of prevention—the actions that would lead to reduced risk or zero risk—are also divergent across the three data sources. In the village, people rely on a calculus of risk based on collectively produced biographical knowledge about the people they interact with that assigns them to different tiers of danger as sexual partners. In the industry and U.S. policy narratives, however, individual and collective modernization—turning Malawi into a nation of rational, autonomous actors who engage in gender-equitable sex in the Reviews 175