I. Jean Hervé Bradol - Disciplining the sexual behaviour of Homa Bay men: a medical pipe dream?

Xavier Plaisancies’s study – a sociological survey done for his thesis in medicine – looks at “Representations of HIV and their impact on care seeking”. This investigation regarding the male population of Homa Bay, Kenya reveals the difference between public health aims and the concerns of patients being encouraged to change their social behaviour to meet health objectives.

In the case of HIV, success – defined by governments and global health actors like Médecins Sans Frontières – would mean 90% of adults getting tested each year, 90% of those testing positive agreeing to treatment, and 90% of cases adhering to treatment faithfully enough that their viral load becomes undetectable.https://www.unaids.org/fr/resources/909090This would stop person-to-person disease transmission. According to this mathematical model, adopting these virtuous behaviours would control the epidemic by 2020 and eradicate AIDS as a disease by 2030.

And while many institutions (medical, public health, political, religious, educational, and media) are acting locally via recommendations, instructions, and advice, Dr. Plaisancies’s survey shows that many of Homa Bay’s men are not informed about this policy, although it concerns them most of all. They have other equally legitimate interests besides being virtuous subjects of health policy – having lots of sexual partners (for some of the young men), getting married, having children, and providing for them financially.

More generally, the survey results raise the following question: “Are United Nations public health objectives for combatting HIV achievable?” This is an important question whenever there is strong political will to eradicate a disease but the medical knowledge and technology needed to achieve such an objective is insufficient. In this instance, the question arises in a context where there is no vaccine or definitive treatment for eliminating HIV from the body. There is little chance, in this case, that changing people’s social behaviour can compensate for medicine’s shortcomings. The vast majority of men are simply unaware of the goal, and even if they were, they have better things to do than be an HIV patient.

II. Marc Le Pape - What a qualitative survey adds

Xavier Plaisancie did his field work from April to June 2018 in Homa Bay County, Kenya, on the northeastern shore of Lake Victoria. Forty-six men were interviewed and recorded. He employed a number of different of survey methods. In addition to recorded interviews, Plaisancie used informal contacts, meetings, conversations, the scientific literature (in medicine, anthropology, and sociology), and observation of the activities of MSF and other institutions, door-to-door testing, moonlight consultation sessions, formal education sessions, patient advising and monitoring sessions.

I would like to underscore the specific ways in which a qualitative sociological and anthropological survey adds to the medical effort.

1. It relates and situates the actions and discourse of the main agents offering HIV-related recommendations – i.e., medical, religious, and educational institutions. It reveals the tension between what the medical establishment says about HIV, on one hand, and traditional Luo beliefs and practices (levirate marriage and polygamy, in particularWe should underscore the fact that while levirate marriage is commonly designated as a risk factor, but we do not know how common the practice is or, as a consequence, the actual effectiveness of such traditionalist determinism. Regarding the characteristics of levirate marriage as practiced in 1936, see E. E. Evans-Pritchard, “Marriage Customs of the Luo of Kenya”, Africa. Journal of the International African Institute, Vol. 20, No. 2, April 1950, pp.140-141. Evans-Pritchard was the first professional anthropologist to study the Luo.), on the other – that is, beliefs that conflict with the messages from institutions involved in fighting HIV. At the same time, consistent with the medical discourse, Christian messages frequently advocate abstinence first and then marriage as a preventive practice. But neither medical discourse nor Christian messages have brought about widespread, unvarying adherence to the normative recommendations or agreement on what constitutes protective behaviour or dangerous attitudes. Plaisancie identified those differences by examining how subjects expressed their sense of risk as a function of their generation, their relationship to tradition and formal education, their susceptibility to family influence, the quality of their relationship to medical professionals, and the intensity of their desires.

2. Dr. Plaisancie shows the influence of reputation as an explanatory factor for many behaviours: sex, marriage, the use of medical facilities (for testing and HIV care), church attendance, etc. He explains the dynamics of social recognition and how they accord or conflict with the recommendations on testing, treatment adherence, and protective sexual behaviour. For each man (teenagers in particular and single men more generally), protecting their reputation means being careful about daily practices – for example, being vigilant about the risk of being stigmatised if they are seen going into a medical facility (dispensary or hospital). If seen, you are suspected of having HIV.

3. Lastly, one specific contribution of the qualitative approach is that it reveals alternatives to recommended behaviours. Though rare, they are worth identifying because relating such behaviours serves as a reminder that men do not rely solely upon what the prevailing sources of advice (the medical establishment, religious institutions, the educational system, and their families) tell them.

Here is an example. Rejecting sexual competitiveness as a means of social recognition, some teenagers circumvent this reputation problem by prizing other behaviours. Plaisancie cites the case of one student he interviewed in 2017 (V. was born in 1998 and had just finished high school).V. stated: “Most of my friends haven’t seen my girlfriend they haven’t seen my girlfriend. They can ask the question why I didn’t have sexual intercourse yet so they could laugh at me.” But V. valued asceticism not as Christian respect for virginity before marriage, but as performance. This goes back to what Michel Foucault called “les pratiques de soi” (practices of the self); it is asceticism, “not in the sense of a morality of abnegation, but as an exercise of self over self (exercice de soi sur soi)Michel Foucault, “L’éthique du souci de soi comme pratique de la liberté”, texte n° 356, Dits et écrits IV 1980-1988, Paris, Gallimard, 1994, p. 709.”.

4. “Community”? There were three people present at the field interviews: the person being interviewed, the interpreter, and the physician/sociologist. The first spoke Luo, the second English and Luo, and the last English. This may have caused some difficulty for the non-Luo-speaking person. The interpreter often chose the term “community” to translate an expression by the Luo speaker. As a French-speaking social science researcher, this piqued my curiosity. To what reality does the term “community”, and its French equivalent “communauté”, refer? This is not self-evident, at least to a French-speaking researcher; the term “communauté” can refer to several different realities, which can be denoted by words that show the difference between them: household, church (or religious group), group of friends, entourage, loved ones, family circle, socioeconomic group, or village. Whenever such details are left out, the difficulty remains. And this is not specific to Luo – it applies to a lot of commonly-used terms at MSF and elsewhere.

5. In their own way, the accounts that the qualitative researcher collects of the subjects’ experiences and the stories of their journeys give us access to the world in which medical work is done, and to the realities that affect it; it is a world of tension, unequal social relationships, irreconcilable desires, stigmatisation, sexual competition, etc. Through his field work, Dr. Plaisancie has endeavoured to know those realities.

Read more : Introduction