Edinburgh Medical Anthropology

News from the medical anthropologists at the University of Edinburgh

HIV/AIDS and the History of Sexual Networks

by Carlie DVC

Shane Doyle from the School of History at the University of Leeds presented on Wednesday in a seminar entitled Sexual Behavioural Change and the Origins of the HIV/AIDS Epidemic in East Africa. Doyle critiqued three prominent theories explaining the origins of the HIV/AIDS epidemic in East Africa, and particularly the rapidity at which the disease spread in southern Uganda and north-west Tanzania, in the regions of Buganda, Ankole and Bahaya. The disproportionate rates of infection during the epidemic’s initial stages have drawn a flood of researchers to the region. One of the main theories explaining the disproportionate rates of infection is attributed to the distinct ‘crisis’ of the 1970s. The growth of urban centres, unemployment and the oil crisis of 1973 led to the expansion of the black market, which subsequently expanded sexual networks and the rate of partner exchange. The second theoretical stance is typified by the work of John and Pat Caldwell, who suggest that ancient African sexual traditions and a culture of rapid partner exchange produced a ‘distinct African sexuality’ ideal for the transmission of HIV/AIDS. The third main theory, put forth by Epstein and Thornton, suggests that people in Uganda are not having more sexual partners, but that sexual partnership occurs concurrently which facilitates the spread of HIV/AIDS. Epstein’s concurrency model is highly influential and has been adopted by the Ugandan government through the current public health campaigns encouraging Ugandans to get off the ‘sexual network’.

Yet, Doyle suggests that all three approaches are inherently ahistorical and flawed. Taking a historical approach, relying on newspaper accounts beginning with the colonial period, Doyle tracks a shift in public attitudes surrounding sexual customs in Buganda. Additionally, interviews and surveys were heavily drawn upon, asking the same questions in all three societies. Caldwell’s assumption is monolithic and proves untrue, within the three societies and even within Ankole itself. The notion of a uniform sexual tradition is unsustainable. In Buganda extramarital affairs were viewed as common, but dangerous, in Ankole extramarital affairs and sex before marriage were an uncommon practice, and in Bahaya there was very little criticism of extramarital sex. In all three societies while elders frequently condemned sexual patterns of the young, when they related their own experiences they did not diverge from current youth practices. Lastly, Doyle compared people’s accounts with public records, particularly in Buganda where there is an abundance of medical research and historical accounts documenting patterns in sexual behaviour.

Epstein and Thornton understate the complexity of Ugandan sexual networks of the past, while Epstein downplays the contribution of casual or short-term sex to the transmission of HIV/AIDS. If Epstein’s model is true why would concurrent relationships respond to HIV/AIDS control programmes? Epstein fails to include the occurrence of short-term or individual sexual interactions, which can pose the greatest risk for transmitting HIV/AIDS.

Additionally, for Doyle the suggestion that Ugandans did not have more sexual partners is not supported by historical evidence, this claim is only supported if you rely on the period of the mid-1990s when sexual behavioural changes were already taking place, after the introduction of HIV/AIDS initiatives. Doyle further suggests that the scope of sexual networks are incredibly far-reaching. For HIV/AIDS programmes to be successful they must be based on a full and accurate sense of the complexity of patterns of sexual behaviour.

Notes from the field: Selling Nutraceuticals in Highlands Orissa

by Beckie Marsland

By Alice Street and Jamie Cross­­

When Bositu’s twin boys were three months old a government health worker visited her home in Goudaguda, a small village nestled amidst paddy fields in one of highland Orissa’s green valleys. She carried a weighing scale and a government issued weight graph. After examining the babies she told Bositu that they, like over 50 % of children born in the state, were underweight. In one of the village’s Adivasi enclaves Bositu and her husband stood out by virtue of his government job as headmaster in a neighbouring village school. He had heard of a special drink, Horlicks, which was meant to have health benefits for babies and children. The cost of one jar of the drink powder was 135 rupees. Each month for the next three months, Bositu’s husband travelled one hour by bus to Koraput in order to purchase the powder. It came in a brightly coloured jar, packaged in a shiny blue cardboard box, with Horlicks’ “five signs of growth” (more bone area, more muscles, better concentration, active nutrients and healthier blood) pictured on its side. Each morning and evening Bositu mixed the powder with milk from their cows and fed it to her sons from a bottle. By the time the babies were six months old, she thought they were looking plumper and healthier. Now they were ready to begin eating rice they would not be needing Horlicks anymore.

We are currently in rural Orissa, where the infant malnutrition rate is considered amongst the worst in India. Here multi-national food and beverage companies are beginning to work together with NGO’s and the state government to market “functional foods” and other “nutraceuticals” to the rural poor.

The nutraceuticals sector in India, which includes functional foods, functional beverages and nutritional supplements, is seen as a major growth area for the economy, with a current growth rate of 18% and an envisaged latent market of 148 million customers (Ernst & Young, 2012: 25). An urban, middle class market for products that cultivate “wellness” amidst growing awareness and fears about non-communicable diseases is well established.

This is where the malt-based health drink Horlicks, owned in India by the pharmaceuticals giant GlaxoSmithKline, has made its mark with a 50% share of the “functional beverages” market. Originally developed as an infant milk substitute during the 1870s in the United States, and then given to service men and women as a health supplement during the Second World War, before gradually receding into insignificance in the family drinks market, Horlicks has had a recent relaunch in India with specialist lines for school children, women and expectant mothers in a variety of flavours. Horlicks is currently the top selling packaged beverage in India after bottled water and sales are double that of Coca Cola and Pepsi.

Now food and beverage companies like Horlicks are seeing an opportunity for market expansion at the other end of the market, amongst those who have neither a sufficient calorific nor nutritional intake: the “rural poor”. As the rising costs of healthcare in India put curative medicine further out of reach for those living on less than two dollars a day investment analysts anticipate that they will become increasingly attracted to consumables that promise “wellness”. In 2009 Horlicks began marketing an affordable brand, Asha, to be sold in 2.5 rupee sachets, in villages across Andhra Pradesh. Pepsi is currently conducting market research for a new “nutribar” targeted at malnourished and nutrient deficient children. Coca-Cola is rolling out a new powder based micro-nutrient drink, called Vitingo, across 30 districts in Orissa.

Orissa has long been a hotspot for NGO, government and bilateral aid interventions around malnutrition. Today these organisations are increasingly looking to the private sector to facilitate the populations’ nutritional transformation. Both the World Bank and the United Kingdom’s Department for International Development are major donors to the state’s nutrition programme. The promotion of sustainable and healthy eating is slowly being replaced by the promotion of consumable goods that are sold as supplements to a nutrient deficient diet. Bositu’s story provides the first indication that these programmes are taking effect. But the story does not proceed quite as those organisations might have imagined and raises several questions for future research.

1. Horlicks is not being marketed as an infant milk substitute and does not meet current WHO standards for such substitutes. Nonetheless Bositu incorporated the drink into an established set of practices for supplementing breast milk when babies are seen to be underweight. Many of her Adivasi neighbours, who do not own livestock, feed their babies a milky-coloured fermented millett drink made from grain grown on their own land when they are considered too thin. Like the village’s high caste farming households Bositu was able to supplement breast milk with a store-bought powder and fresh cow milk. Does this imply that notions of “wellness” (an awareness of and responsibility for personal nutrition and healthy lifestyle) that multi-nationals imagine travel with their products are already present in rural households? Or are these established practices of dietary supplementation embedded in quite different understandings of health, personhood, and bodily substance?

2. Horlicks and other products such as Vitingo are marketed for their health-giving qualities. But a quick glance at the ingredients shows that they are also laced with sugar. What kinds of evidence is being harnessed to these companies’ health claims? Horlicks was relaunched as a clinically proven health drink following a study by India’s National Institute of Nutrition and they have now established their own “Horlicks Nutrition Academy” to carry out ongoing research. But nutritional experts also point out that supplements have little nutritional effect when consumed, as they often are in poor households, without other foods. Meanwhile, Bositu’s use of Horlicks as a breast milk supplement, which would greatly concern nutritionists, illustrates how consumer practices can deviate from “clinical studies” that purport to show the effectiveness of products. The lack of regulation of the nutraceutical sector in India is one reason why it has become attractive to investors. While nutraceuticals have lower profit margins than pharmaceuticals, they require a fraction of the R and D investment. GlaxoSmithKline, for example, is currently shedding its pharmaceutical portfolio in the United States at the same time as it is expanding its health foods portfolio in India and China. What role is science playing in the creation of new markets here?

3. Bositu gave her babies the classic version of Horlicks rather than the new “bottom of the pyramid” Asha version. In fact there is no evidence of Asha being distributed in this part of Southern Orissa, despite having been rolled out in neighbouring districts of Andhra Pradesh as far back as 2009. Horlicks remains too expensive for the majority of Bositu’s Adivasi neighbours, although it is now being sold in a town four kilometres away. On the one hand places like Goudaguda represent untapped opportunities for the expansion of existing product lines. On the other hand, as frontier markets for “bottom of the pyramid” goods, they are spaces where people have to be actively moulded into reliable consumers, for example by introducing scientific objects such as “vitamins” and “minerals” and concepts such as ‘nutrition’ and ‘wellness’.

In frontier markets, Bositu’s case suggests, the future trajectories of nutraceuticals remain underdetermined by their mechanisms of marketing and distribution.

We will be addressing these questions about the kinds of persons, relationships, bodies and institutions that are being shaped by the introduction and expansion of nutraceuticals in India through future research in the area.



Bodies, Politics and African Healing in Tanzania

by Beckie Marsland

The editors of Anthropos have kindly given me permission to reproduce this book review here.

Langwick, Stacey A.: Bodies, Politics, and African Healing. The Matter of Maladies in Tanzania. Bloomington: Indiana University Press, 2011. 300 pp. ISBN 978-0-253-22245-9. Price: $ 24.95

Traditional medicine in Tanzania is a political matter. Historically traditional healers were entwined in matters of statecraft – being seen to care for the health of a country, especially the fertility of land and people – once helped to ensure the political legitimacy of chiefs. These days traditional medicine is framed in the biomedical language of “efficacy.” Healers are subject to state control – they are dangerous because they harm sick people or divert them from hospitals, or they provide a resource – an untapped pool of pharmacopeia, an army of potential barefoot doctors. In her ethnography of traditional healers on the Makonde Plateau, Stacey Langwick takes us to a less trodden political path: the struggle to control what counts as real – asking which therapeutic objects (spirits, malaria parasites, clinic cards) have “the right to exist.”

The book is informed by fieldwork in the town of Newala and spans the period between 1998 and 2008. Working closely with local healers, most notably two women – Binti Dadi and her daughter Mariamu – in addition to fieldwork in biomedical spaces, Langwick presents a nuanced account of contemporary healing practice with a focus on ailments, which afflict women and young children.

Analytically, Langwick draws on science studies – a discipline which has allowed us to see the cultural and historical contingencies of scientific facts. This enables her to place traditional medicine and biomedicine under the same ethnographic lens. This marriage of science studies with what has become a quite conventional area of ethnographic study (the African traditional healer) leads to some interesting innovations. What are the different conditions under which spirits or malaria parasites can be said to exist? How does therapy “make” the afflictions from which women and children in Newala suffer? What kind of “ontological politics” are produced by the domination of biomedicine over traditional medicine? Whilst the tools of science studies allow Langwick to offer excitingly original and nuanced ethnography, its language may be a barrier to some readers who are less familiar with its terminology. Technical concepts such as “objectification,” “entities,” “enact,” “purification” are sometimes dropped into sentences without much in the way of clarification, so the reader is obliged to re-read some complex sections several times in order to grasp their meaning.

In the first chapter “Orientations” Langwick sets out her approach. Her aim is to depart from conventional ideas about medical pluralism and get to the heart of some very political questions. Which are real: Devils or malaria parasites, and who gets to decide? Why are some therapeutic objects designated as the artefacts of “belief,” whilst others represent the real? How can the making of medical categories be political? Her emphasis on the material is an important departure in this area of anthropology, in which matters such as witchcraft or spirit possession are more usually subsumed under headings such as symbolism, meaning, and discourse. By paying attention to the politics of being and materiality, Langwick takes seriously the world of the healers and their clients.

The first part of the book maps out the political space in which traditional medicine is located. Chapter 2, “Witchcraft, Oracles, and Native Medicine,” traces the history of anti-witchcraft legislation in colonial Tanganyika and its role in differentiating the practice of witchcraft from that of healing. This colonial distinction had more to do with regulating healing in courts and laboratories than it ever had to do with regulating witchcraft.

Chapter 3, “Making Tanzanian Traditional Medicine” follows these developments into the post-independence period. Links with China and its policies on Traditional Chinese Medicine developed during the socialist years have fuelled hopes that medicinal plants could be used to make Tanzania self-reliant in its production of pharmaceuticals. More recently, there are hopes that traditional medicine might be reconfigured as a global commodity – could it be produced and packaged in factories as the Chinese have with artemesinin products? When, in Tanzania, traditional medicine was “legalised” in 2002, it was hoped that it could be “modernised” still further through laboratory testing, and incorporating public health messages into the daily work of healers.

The second part of the book “Hailing Traditional Experts” takes a closer look at individual healers. In chapter 4, “Healers and Their Intimate Becomings,” Langwick traces the biographies of Islamic healers, whose knowledge depends on a hermeneutics of the written word in the Qu’ran, astrology and numerology, and “African” healers whose expertise depends on a personal relationship with medicines and is mediated by spirits and ancestors in visions and dreams. Chapter 5, “Traditional Birth Attendants as Institutional Evocations,” teaches us that the traditional birth attendants (TBAs) trained by the development state were never really traditional. Instead, these women are almost always oriented towards biomedicine, and must learn that they are no more than ajuncts to the national health system – monitoring hygiene at normal births, and referring difficult cases to the clinic.

Part 3 gets to the heart of the “ontological politics” that Langwick wishes to address. In chapter 6, “Alternative Materialities,” she examines how different kinds of therapeutic object are made in practice. This is where the contribution of science studies really comes into its own: we can see the parallels between the making of boundaries between a child’s body and a spirit through repeated washing with traditional medicines, and the “rendering” of future patients and populations with the bureaucratic technology of the clinic card. Chapter 7, “Interferences and Inclusions” is the best analysis of degedege and malaria that I have read to date. Degedege has been translated as the convulsions of cerebral malaria in children, and is targeted by health education programmes, because it is feared that parents fatally delay taking children for emergency treatment and instead visit a traditional healer. Langwick is interested in the struggles over different realities that are taking place. Children with degedege are startled by spirits, because their bodies are not fully bounded and so they must be closed, and made visible, with medicines. Malaria is defined in the laboratory – as parasites are visualized under the microscope (although, I would add, not always as microscopes are more often unavailable). The objects of therapy – malaria parasites, spirits, the body of a child – emerge as they are acted upon, they do not pre-exist as signs awaiting a doctor’s diagnostic and classifying gaze. Finally, in chapter 8, “Shifting Existences, or Being and Not-Being,” Langwick draws our attention to maladies which are invisible to biomedicine – tiny growths inside the vagina and nose which house devils after they have raped women in their sleep, breast milk which can be infected with the dirt of adulterous sex and make a child ill, and the oversized heads of children who have not had cysts in their throats removed. To biomedicine these things are innocuous and irrelevant, and this disinterest leaves a space in which traditional healers can assert their expertise.

This book contributes to the understanding of traditional medicine in a contemporary African setting. It makes clear the inequalities that shape the space under which healers must operate, and their efforts to work this to their advantage. Through its emphasis on the material it draws attention to the struggles over what is and what is not real – the “ontological politics” that defines what kind of therapeutic practice is possible.

RHID Reading Group

by Carlie DVC

Are you interested in issues of human rights, humanitarianism, and development?

The Rights, Humanitarianism and International Development Network will be hosting its first reading group on Friday, 19 October at 1:00 pm in the conference room on the ground floor of David Hume Tower in George Square.

We will be discussing Marc Epprecht’s (2008) book ‘Heterosexual Africa? The History of an idea from the age of exploration to the age of AIDS’. Or you can read these journal articles by Epprecht instead:

Epprecht, M. 2005. ‘Hidden Histories of African Homosexuality’ Canadian Womens Studies. 23(2-3). 138-144.

Epprecht, M. 2012. ‘Sexual Minorities, Human Rights, and Public Health Strategies in Africa’ 111(443). 223-243.

This month we will be discussing the issue of sexuality within the African context, and the creation of a singular heterosexual African identity. How has Africa become increasingly defined as a ‘homosexual-free zone’ and what are the implications of imaginings of such a singular identity?

Please feel free to take part in the reading group, we will be holding it monthly and are open to reading suggestions. We aim to create an multidisciplinary community wherein we can facilitate meaningful collaboration.



Medical Trials in Africa and South Asia

by Beckie Marsland

***Post from Pete Kingsley, INZI Research Fellow, Centre of African Studies, University of Edinburgh

Although I’m an impostor on this blog (I’m more of a sociologist by training), I’d like to introduce an exciting new project to you. It’s called Investigating Networks of Zoonotic Innovation (INZI), primarily involving Lawrence Dritsas, Emma Michelle, James Smith, Sue Welburn, and myself.

INZI is a five-year project to explore how sleeping sickness is researched, controlled and treated in Africa since the Second World War to the present day. The project began in 2012. It is based at the University of Edinburgh, and funded by the European Research Council.

We’ll have more to say about sleeping sickness as our project develops. But for now, I wanted to mention how exciting Dr Jeevan Sharma and Dr Ian Harper’s talk this Monday was, and how much it thematically overlaps with our work at INZI.

The talk – part of their ‘Biomedical and Health Experimentation in South Asia’ project (http://www.bhesa.org/) – described a series of pilot studies in Nepal of a drug called misoprostol, used to treat (amongst other things) post-partum haemorrhages.

The seminar discussed a brave new world in which there is an ever-increasing appetite for evidence for health interventions, increasingly sharp disagreements over what constitutes acceptable evidence, and increasingly complex relationships between evidence and policy. Most of all, it is a world of privatisation, in which a whole diverse range of profit and non-profit organisations are carrying out what was once predominantly a task for government.

It is in mapping these new institutional structures that Ian and Jeevan’s agenda most overlaps with INZI’s. These new ways of doing medical research will be grist for the medical anthropologist’s research mill for many years to come. Medical research, more than ever, is becoming a volatile, contentious, and ideologically charged field: one in which revolutionary, life-saving projects are delivered by rapacious capitalists, and emancipatory knowledge is created by elitist and higly stratified networks.

I hope medical anthropologists at the University will find some interesting ideas in Jeevan and Ian’s BHESA project, and in time, in INZI’s – watch this space for future events and publications!

Sperm Donation and the Quality Population in China

by Beckie Marsland

Last Friday’s Social Anthropology seminar paper was presented by Dr Ayo Wahlberg from the University of Copenhagen, who spoke about his fieldwork in China’s largest sperm bank. Infertility is a huge problem in China, something that might not be immediately obvious to those of us who know it for its one child policy. There are reports of a “sperm crisis” – some (contested) studies suggest that there may be as many as 2.5 million azoospermatic men in China, and the consequent demand for sperm must cope with a chronic lack of sperm donors – there are eleven sperm banks in the country, with just 2-3000 donors.

The sheer scale of the enterprise is astounding – 20,000 IVF cycles a year are processed in the one building. People line up outside the IVF clinic overnight in order to gain entry the following morning, and so that people are dealt with in the most efficient way, they are sorted on arrival into different channels: “female infertility”, “male infertility”, and “not known”. If everyone is to gain access to treatment, one-to-one consultations are impractical, and so lectures are delivered to rooms of hopeful couples.

The science of sperm donation has its own history in China. The sperm bank itself was established in 1981, after scientists experimented with existing techniques used in the countryside to freeze sperm from cows and pigs. Developing this work was not easy at a time when scientists were not being encouraged to do this kind of research. From this has grown the largest sperm bank (or “warehouse”) in China, with high-tech facilities.

The concept of quality is important if we are to understand what sperm donation means in China, and Ayo’s strategy is to “follow the concept” as it travels through different levels of discourse about infertility, biology and population. As in other countries, it has taken time for infertility to be accepted as a medical problem – and for this to happen infertility has been defined in terms of quality of life. Childless couples have a low quality of life, and it takes IVF to help them. This in turn links to population quality and the desire of the state to ensure that the nation is made up of the highest quality people. Sperm donation is an opportunity to do something about this desire for high quality – and this is why university students are targeted by sperm banks. This well-educated, hard-working “high quality generation” will help ensure superior births for the benefit of the nation. For the donors, making the grade can be a nerve-wracking process – rigorous screening procedures mean that many are rejected. As one successful donor stated “not every man can be selected for the national sperm bank”.

Hello world!

by Beckie Marsland

Welcome to the University of Edinburgh Medical Anthropology Blog. On these pages we will bring you news about events, debates, publications, and research that is happening here in Edinburgh.

If you would like to contribute, please get in touch. Email us at r.marsland@ed.ac.uk