ARVs and ARTs: Medicoscapes and the Unequal Place-making for Biomedical Treatments in sub-Saharan Africa


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ARVs and ARTs: Medicoscapes and the Unequal Place-making for Biomedical Treatments in sub-Saharan Africa
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Medical Anthropology Quarterly (MAQ).
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Hörbst, Viola and Angelika Wolf
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Assisted reproduction


Asking why some diseases gain global attention whereas others are neglected, we present two case studies that demonstrate the unequal treatment and financing options available for HIV/AIDS versus infertility treatments. We track three key phenomena central to understanding the unequal public attention given to certain ailments: peace and security, subordination of the social to the biological, and a “global” quality. Existing concepts such as global assemblages or therapeutic citizenship are quite limited when it comes to bodily conditions that result in social suffering and do not satisfy the conditions of advocacy. Since it is not enough to observe “flowing” and “moving,” we propose the concept of medicoscapes, to acknowledge that such activities simultaneously entail channeling and carving out. Medicoscapes enhance the analysis of linkages between different health conditions regardless of whether they are biological or social and how they interconnect places, sites, and people.
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1 Viola H š rbst CEAF, Center for African Studies, ISCSP, Higher Institute for Social and Political Sciences University of Lisbon Max Planck Institute for the Study of Religous and Ethnic Diversity (E mail: hoerbst@lrz.uni Angelika Wolf Institute of Social and Cultural Anthropology Freie University of Berlin (E mail: angewolf@zedat.fu ARVs and ART s: Medicoscapes and the Unequal Place making for Biomedical Treatments in sub Saharan Africa ___________________________________________________________________________ Asking why some diseases gain global attention whereas others are neglected we present two case studies that demonstrate the unequal treatment and financing options available for HIV/AIDS versus infertility treatments. We track three key phenomena ce ntral to understanding the unequal public attention given to certain ailments: peace and security, subordination of the s ocial to the biological, and a global quality. Existing concepts such as global assemblages or therapeutic citizenship are quite limi ted when it comes to bodily conditions that result in social suffering and do not satisfy the conditions of advocacy. Since it is not enough to observe "flowing" and "moving we propose the concept of medicoscapes, to acknowledge that such activities simu ltaneously entail channeling and carving out. Medicoscapes enhance the analysis of linkages between different health conditions regardless of whether they are biological or social and how they interconnect places, sites and people. [citizenship, HIV/AIDS, assisted reproduction, Africa, medicoscapes] ___________________________________________________________________________ Introduction AIDS, malaria and tuberculosis are perceived in international health arenas as major threats to human health and wellbeing. They receive global attention and are targeted by intervention prog rams. However, there are many more infections, diseases and ailments that severely harm human well being. W hy do some diseases gain global attention while others are not tackled? W hich criteria play a role in triggering global interventions and financial support for international health programs? Taking these questions as our point of departure in this article we will focus on HIV and therapeutic policies of pharmaceutical treatments with antiretroviral therapies (ARVs) on the one hand and on infertility and the availability of assisted reproductive technologies (ARTs) in sub Saharan Africa on the other 1 Applying anthropological means of analysis, we will contrast both afflictions as well as their characteristic elements and critically reflect on the re asons for their distinct prominence on international levels as well as their potential in terms of attracting international solidarity and funding. T o conduct t his contrast our analysis embrace s globalization theories that deal with medical issues. Existi ng concepts such as global assemblages (Collier and Ong 2005) or therapeutic citizenship (Nguyen 2005) are helpful for describing the processes evolving around some of the afflictions that have become recognized as globally relevant over the last few decad es However, when analyzing the contrasting positioning of HIV/AIDS and infertility and their biomedical treatment options within the field of global health it becomes evident that the scope of the afore mentioned concepts is empirically and theoretically limited.


2 This is particularly so when it comes to diseases that do not serve the conditions of international advocacy and have not gained prominence within global health arenas. To fill this gap we suggest the concept of medicoscapes as an umbrella tool t o analyze a variety of dynamics of globalization at work in health related fields. We argue that this concept is very helpful for visualiz ing and grasp ing the complexity of intertwined local, national, and global relations wit hout neglecting the difference s, inequities and disparities between the distinct actors, practices, ideologies and dynamics currently shaping health related phenomena ( Hšrbst and Wolf 2003 ) In the first section, we outline our theoretical and methodological background before provid i ng a short description of the prevalence and characteristics of infertility and HIV/AIDS I n the second and third section s, we look at important features of their treatment options in sub Saharan Africa, particularly in Mali. In the next section we analyz e the two afflictions different positioning in global health arenas and the resulting unequal treatment and financing options. We also suggest and discuss three major aspects that are central to the unequal attention received by ARVs and ARTs in the globa lized public. In the fifth section we investigate the influence and success of social movements involved within these dynamics and processes and outline why the concept of medicoscapes provides a useful framework for analy z ing the interactions and complex ities of various diseases, scales and sites and the respective distinctions in the resulting dynamics. In the final section we argue that the concept of medicoscapes is useful as a prism for critically reflect ing on the distinct results of ongoing global ized entanglements in the international health arena. Medicoscapes, Power Topographies a nd Social Sites Over the last decade s it has become clear that medical issues can no longer be regarded within locally isolated frames of reference such as nation states This observation leaves us with the challenge of how to capture analytically and theoretically the highly complex and heterogeneous layers, processes and results of globalization in the field of health, care and international support. Collier an d Ong suggested the term global assemblages as a theoretical means of grasping the multifold, worldwide combinations of heterogeneo us elements. Assemblages, they argue, are produced by "multiple determinations that are not reducible to a single logic" (C ollier and Ong 2005:12). Building partially on the suggestions of Collier and Ong and on the work of Appadurai (1990), we propose the concept of medicoscapes to simultaneously grasp different processes and forms of entanglements on local, national, and int ernational layers in the domain of health. We offer the following working definition: Medicoscapes constitute globally dispersed landscapes of individuals ; national, transnational, and international organizations and institutions as well as heterogeneous p ractices, artifacts and things, which are connected to different policies power relations and regimes of medical knowledge, treatments and healing. While concentrated in certain localities, medicoscapes connect locations, persons and institutions via m ultiple and partially contradicting aims, practices and policies ( Hšrbst and Krause 2004:54 56 ; Hšrbst and Wolf 2003:4 ) In our analysis, we stick to the suffix scape because it draws on social topographies of power in relation to the idea of global lan dscapes. The term "landscape" enables the inclusion of the spatial expressions of power relations in the description, relatedness and movements between foregrounds and backgrounds, between different kinds of actors and agents and across political and soc ial boundaries. In a landscape certain areas are higher than others or are exclusive or hidden, are on a main road or are reachable only via small pathways. Simultaneously, landscapes are constituted by unequal types of elements (such as streets, houses, lakes, mountains, plants, animals etc.) which are grouped together in a


3 certain way and thus form the specificity of a locale. As Tsing so brilliantly reminds us, the term also draws attention to the fact that globalization works in terms of movement c irculation and opening up of possibilities, whil e simultaneously bring ing about closure, exclusion and discrimination. Moreover, since the activity of flowing itself involves "carving out" and "making terrain there can be no territorial distinction bet ween the "global" transcending of place and the "local" making of places (Tsing 2000:338). Akin to Tsing, Massey (1994) argues that places can be imagined as far reaching networks of social relations being continually under going (re)construction. In these processes distinct social groups and individuals are differently positioned and form a specific "power geometry of time space compression" (Massey 1994:148). T o connect actors and practices and to discuss the formative power of cultural aspects, in our co ncept of medicoscapes we link Tsing s "place making" with Massey's "power geometry" to Schatzki s (2002) notions of the social site and the future organizing significance of values for both orders and practices (Schatzki 2003:196). 2 Conveying the significa nce of Schatzki s thoughts for medicoscapes requires investigating the orders and the practices of actors, things, and organisms in the medical field. Medical doctors, healers, NGOs, patients, state institutions, the W orld H ealth O rganization (WHO), and th e like constitute the actors of the medical field. These actors together with materials such as needles, ultrasound machines, money and so on, and organisms such as bacteria, viruses and so on, form the mesh of orders. These orders hang together with th e many distinct bundles of practices in medical settings like actions and decisions by single practitioners or patients, with tasks like surgeries, healing rituals or meetings of health insurance agencies or health related NGOs. Neither actors nor pract ices in medic o scapes are arranged on one level but are hierarchically positioned and constitute a specific power topography These notions nicely overlap with our idea of medicoscapes in which health practices and health orders intersect across time and sp ace, while their interrelations are traceable only in specific localities. To illustrate the validity of the theoretical concept of medicoscapes in connection with empirical data, we have chose n to contrast the treatment options for HIV/AIDS and infertili ty in sub Saharan Africa. Both ailments are chronic conditions and intimately linked to sexuality and reproduction. ARVs and ARTs are high tech therapeutic techniques originating from Euro American countries, wh ereas HIV/AIDS as well as infertility are mor e prevalent in low or middle resource countries in sub Saharan Africa than in Euro American contexts. Although a comparison might seem challenging as both afflictions and their therapies differ in many aspects, it is exactly these differences and similar ities that render them useful for show ing the limitations of current concepts in medical anthropology and beyond. C ontrast ing the international support flows for high ly sophisticated treatment options of HIV/AIDS with the ones for infertility makes evident the differences in commitment and attention to these afflictions within the academic world and in development areas. Our aim here is not to convince readers to equally finance treatments or to promote new interventions, but rather to encourage critical r eflection on the underlying assumptions and characteristics of international support for (biomedical) treatment options that are globally relevant. Working within a framework of critical medical anthropology we step back from an interv entionist frame when contrasting the international endorsement for HIV/AIDS and infertility treatments Instead we aim to provide insight into the ways in which international health arenas and academia define and produce the targets of intervention. As we will show some con cepts such as therapeutic citizenship only apply to the dynamics around certain ailments such as HIV/AIDS, in connection with specific configurations of global health arenas while t he concept of medicoscapes enables us to expand the analysis to include t he diverse and sometimes contradicting dynamics emerging within global health interventions.


4 This focus as well as the questions we address in this article emerged out of our intensive exchanges as colleagues on the similarities and differences, impacts and characteristics of ARVs and ARTs. Angelika Wolf is committed to research on HIV/AIDS in Germany, Malawi and South Africa while Viola Hšrbst focus es on infertility and ARTs in Mali, Senegal, Togo and recently Uganda. While the data on the flow of te chniques and money for ARVs are mainly drawn from an intensive I nternet search, the data concerning infertility come from fieldwork carried out in Mali between 2004 and 2011. This research included nonparticipating observation, detailed follow up interview s with treatment providers and infertile couples with and without experience of ART treatments and interviews with focus group and policymakers. HIV/AIDS and Infertility: Two Afflictions and their Characteristics of Stigmatization W e compare the pre valence, local perception and therapy of HIV/AIDS and infertility in sub Saharan Africa to delineate similarities of and differences between the international reactions to the two afflictions. Since the outbreak of the HIV/AIDS epidemic at the beginning o f the 1980s, nearly 30 million people have died from AIDS related diseases worldwide. An estimated 33 million people are currently living with the virus globally. Sub Saharan Africa remains the most affected continent in the world: 68% of people living wit h HIV are found there, although it is home to only 10% of the world's overall population. AIDS is the leading cause of death in this region : O f all global AIDS deaths in 2009, 72% occurred in sub Saharan Africa (UNAIDS 2010:2). C ountries in the southern pa rts of s ub Saharan Africa have especially been struck by the epidemic. Whereas in Swaziland the prevalence is highest with 26% of the population infected, in Mali it has declined to 1% among the adults between the ages of 15 to 49 (UNAIDS 2012). The AIDS epidemic affects the demographic structures of entire populations and thereby the political, economic, and social aspects of societies In some African countries, it has led to a drastic decline in life expectancy and to a severe reduction of the labor for ce. Looking at the numbers it becomes apparent that fertility problems are also a phenomenon that affects mil lions of people around the world. While infertility rates in more developed countries are estimated to range between 3.5 % and 16.7 % of the populat ion with an assumed rate of around 11.3 % in Europe (Boivin et al. 2007:1508), in developing countries "one in four ever married women of reproducti ve age" may be infertile according to the WHO (2010 a ). In sub Saharan Africa a total of 34 million ever mar ried women are estimated to suffer from infertility ( Rutstein and Shah 2004:25). T he rates for sub Sah a ran countries on average range between 5 % and 23% ( Larsen 2000 ), and in some countries they are as high as 29%. Of the total population of 14.5 million i n Mali 2.3 % of women between 25 and 49 are indicated for primary infecundity, and within the same group 27.9 % are classified under secondary infecundity (Rutstein and Shah 2004: 23, 32). In many African countries AIDS is placed in relation to local diseas e concepts that are associated with pollution, adultery and moral transgression ( Ingstad et al. 1997 ; Mogensen 1997 ; Wolf 2001 ) The symptoms of AIDS such as diarrhea, vomiting and excessive weight loss are often similar to the ones that signify a breach of the taboos that regulate sex life. This social etiology contributes to labeling HIV/AIDS as a punishment from God and as resulting from deviant behavior. Such labeling goes hand in hand with fear of contagion, exclusion from social activities and as signing stigmatizing stereotypes like the "walking dead" (Robins 2004:96). Shame, denial and even the hiding of ARVs are widespread consequences of such stigmatization. O nce the side effects are under control, most HIV/AIDS patients gain weight and feel s trong again yet even then many of them do not disclose their


5 status beyond their support group fearing the social consequences ( Mattes 201 1 ; Sow and Desclaux 2002 ; Steuer 2012 ) In the same vein, people with infertility problems in sub Saharan Africa fac e strong stigmatization. When marriage is not followed by children many women are subject to daily teasing and provocative allusions by members of their husbands families but also to stigmatization from the wider social environment such as neighbors, c olleagues and friends (Feldman Savelsberg 1994 ; Kielman 1998 ; Leonard 2002 ; Opara 2006) In Mali, this stigmatization is often perpetuated by notions regarding the maliciousness and worthlessness of childless women. O ffending remarks are made frequently such as "my son sleeps with a man" a comment that refers to the fact that childless women are not see n as completely female persons. Although married men may also be teased about their childless wives in the public narrative male infertility is usually no t considered a reason for marital childlessness and is seen as the ultimate shame and disgrace for a man ( Hšrbst 2010 ). Within the locally specific configuration in Mali successful reproduction is a strong social expectation for women and a basic prerequi site for a woman's social respect and capital. Remaining childless becomes equivalent to social death as such women are excluded from many daily practices centered on children and the care for them. Remaining childless is not desirable for men or women in Mali and the need for children arises from the couple as well as from the extended family. As has been reported from across sub Saharan Africa, children are highly valued first and foremost because they provide families and parents with working hands. Th ey provide economic as well as physical support in old age and ensure continuity of the lineage and the family's connection with ancestral spirits ( Gerrits 2002 ; Hšrbst 2006; Kielman 1998 ; Leonard 2002 ; Wolf 2010 ) According to fieldwork data, produc ing ch ildren is essential in Mali for being recognized as a fully fledged social person and it is also a major objective for marriage. Moreover, for Malian women who liv e within extended families, with co wives and often demanding sisters and mothers in law, ch ildren are often the only people they can totally rely on ( Hšrbst 2006 ) HIV/AIDS and Infertility: Two Afflic tions and Their Treatment Cont exts in sub Saharan Africa Looking at therapy and its availability for AIDS biomedical options to address the ep idemic have shifted in the last decades from focusing on prevention to emphasiz ing treatment and, most recently, to underlin ing treatment for prevention (Hardon and Dilger 2011:150). These chang es in practices emerged when the first ARVs were made availa ble. For most people in Euro American societies as well as for the rich in sub Saharan Africa, ARVs became a symbol for survival and helped reduce stigmatization. However, the costs of ARV treatment were initially very high and ARVs are still a symbol of unattainable opportunities for many poorer Africans At the end of 2009, t he total number of people estimated to be in need of antiretroviral therapy in low and middle income countries was 14.6 million. Only 5.25 million of them received treatment that sa me year (WHO 2010 b :51 54). Generic drugs became affordable on a broader basis through a joint effort of activists from the South African Treatment Action Campaign (TAC) and Doctors Without Borders (MŽdecins Sans Frontires) (Robins 2004). As a result of in ternational public pressure, the annual cost of the recommended antiretroviral therapy decreased from over US$ 10,000 to an average of US$ 137 per person in 2009 (WHO 2010 b :70). In Mali, the first antiretroviral drugs became available in 2001. Due to the no rmative pressure to bear children and the drastic social suffering related to childlessness women in Mali (as in many other countries in sub Saharan Africa) are ready to undergo any treatment possible to overcome this ailment Apart from so called traditi onal


6 treatments, where by couples rely on marabous, herbal remedies or animistic hunters, most couples simultaneously consult biomedical doctors in the public health sector. Many also frequent gynecologists in the private sector, as they are regarded as del ivering better services than their colleagues in the public system. Since infertility treatments (including traditional ones) are not free of charge, a couple's therapeutic options for becoming pregnant depend on their and their families access to financi al resources ( Hšrbst 2012a ) Formal adoption or raising foster children as well as marrying a second wife are all alternatives to overcome infertility in sub Saharan African countries. The data from Mali clearly reveal that these options are no t a solution for many women: R ather, these three practices trigger further problems within the family for them and do not reduce social stigmatization. Involuntar il y childless women in Mali clearly favor solutions that enable them to become pregnant as the visibility of pregnancy is the most effective way to seriously reduce or stop social stigmatization ( Hšrbst 2012b ). One major cause of infertility i n sub Saharan countries including Mali, is sexually transmitted diseases which are largely responsible for the high prevalence of blocked fallopian tubes and azoospermia among the population of this region ( Mayaud 2001 ). Besides campaigns for prevention, classical biomedical interventions embrace hormonal stimulation, tubal operations, the application of hormonal cockta ils or insemination without sperm treatment and so on A biomedical milestone was reached in the late 1970s when in vitro fertilization (IVF) was successfully carried out in the U nited K ingdom Since then ARTs (including insemination [ IUI ] IVF and intr acytoplasmic sperm injection [ ICSI ]) have been biomedicine's most sophisticated means of treatment for both primary and secondary female and male factor infertility. In many countries in the Western Hemisphere treatments with ARTs are provided and in som e states are even paid for by health insurance or national funds ; this is not the case in most African countries ( Hšrbst 2012b ). Although ARTs have since made their way to many African countries, these treatments are mainly available in the private health sector. So far, n either international donors nor governments fund treatment with ARTs for involuntar il y childless couples in sub Saharan Africa. A lthough costs for ARTs in Mali are on average lower than in Europe or the U nited S tates, s ince the average pe r capita income in Mali is very low ( estimated at US $470 in 2006 [USAID 2009]) and no public financial support exists for this ailment only more affluent Malians can afford to undergo such treatments. In Bamako, for instance, one insemination attempt cost s US$ 1,700 $ 2,600 including pharmaceuticals, analysis an d doctor's fees. For one classical IVF cycle expenses can reach US$3,300 $ 4,000. For ICSI one cycle adds up to US$4,800. Additionally, foreign travel and accommodation expenses for two people are saved when ARTs are carried out in Mali. This substantial drop in costs puts ARTs within reach of more persons belonging to the emerging middle class in Mali Both HIV/AIDS and infertility have strong links to sexualit y to the mainstream construction of g ender relations and to normative questions with regard to prestige within sub Saharan African societies. In both cases, the materials and know how for treatment were initially accessible only to sub Saharan Africans with transnational networks, substantia l capital and those without visa problems as treatment required international travel Another similarity shared by ARVs and ARTs is that they were initially extremely costly and hence beyond the means of most sub Saharan Africans. Both the treatment with ARTs as well as with ARVs requires speci alized knowledge and skills, specific laboratory equipment and sophisticat ed pharmaceutical supply lines. Yet for ARVs, specific configurations of trans national and international actors collaborated to expand acces s to generic drugs over time massively reducing treatment costs in sub Saharan African countries. International philanthropic organizations, political activists and multilateral governmental programs played a key role in increasing cost free provision of ARVs to patients in many African states. T h us


7 far, th ere have been no such movements f or treatment of infertility with ARTs T o investigate these differences, we will now explore the positioning of both afflictions in global health arenas. ARVs and AR Ts: Different Positioning i n Global Medicoscapes When analyzing the positioning of HIV/AIDS and infertility in the field of global health, crucial differen ces emerge in terms of the support for treatment and financing available to sub Saharan Africans. Pol icy decisions, the flow of finances, knowledge and technology, drug distribution and treatment applications interact within glob al medicoscapes involving different actors such as NGOs, transnational organizations, the pharmaceutical industry, multilateral governmental programs, activists, individual health person ne l and patients. Each actor bring s in different perspectives, targets, knowledge regimes and sociocultural values that may partially overlap or be incompatible. These aspects interweave with eac h other through orders and practices and form the foundation for hierarchical configurations in intended and unintended ways. They bring to the fore the underpinning values and aims of international and transnational support for global health that intimate ly influence the effectiveness of some social movements while failing to provide similar support for other serious afflictions. In our opinion, three major factors are c entral to the diverg ence in the treatment and financial handling of HIV/AIDS and infert ility: (1) peace and security; (2) the subordination of the social to the biological; and (3) a certain global public quality First, an ailment's supposed importance in terms of global security matters: HIV/AIDS may determine the fate of whole nation stat es, and the epidemic is publicly perceived as a clear worldwide threat to peace and security. In 2000, the UN Security Council for the first time debated security not in terms of war and peace but in regard to health and began considering AIDS as a worldwi de threat to economic, social and political stability. Moreover, the vi rus itself carries the notion of an angst ridden entity. As a "virus sociologicus" ( O'Neill 1990:329 ) it is not only able to cross borders without being recognized but due to its mob ility and flexibility it has also bec o me a symbol of fear in a globalized world. While AIDS is a contagious syndrome, infertility is not an infectious condition and definitely is not considered disrupt ive to worldwide security and peace. On the contrary, among the international public and the policy making world it is the perceived overpopulation and high birthrates that are regarded as a matter of global concern as they are, generally speaking, considered an obstacle to development ( Daar and Merali 2002 :15 ; van Balen and Inhorn 2002 : 6 7 ). This perception has led to development programs such as family planning, child spacing and contraceptive promoti on while no substantial international activities have emerged to support biomedical solutions for involun tary childlessness. Monitoring population growth has become a global agenda due to fear of overpopulation. In this arena hyperfertility and overpopulation are still seen as major obstacles for economic and social development despite the estimation that by 2050 population growth will have come to a halt and will then decline worldwide (Ombelet et al. 2008: 60 9). The overpopulation argument is often combined with financial concerns when referring to resource poor countries. According to this reasoning, sc arce public resources are needed to provide primary health care and to cope with principal public health problems such as malaria, tuberculosis and HIV/AIDS. In this way specific power topographies concerning different health conditions and priorities of treatment are carved out on international and subsequently national levels. This situation is mirrored in the Malian case Mali signed the statements from the International Conference on Population and Development (ICPD) 1994 in Cairo (Daar and


8 Merali 200 2:19), in which access to adequate infertility treatments was formulated as a major objective But Malian state activities focus on preventive programs concerning infertility while improvement of treatments for childless couples seems rather marginal in t he public health sector (Malian Ministry of Health 2006). National Malian policies officially aim to further reduce birth rates, an objective in line with the opinions of potential international donors, yet Malian birth rates remain quite high with an ave rage of 6. 3 children per woman (Worldbank 2012) Second, the ongoing reduction of the social to the biological within biomedicine and biopolitics is crucial for developments in this field In contrast to the biomedical condition of being HIV positive, fram ed primarily as a global public health issue, infertility is typically regarde d as a personal problem within international public and biomedical discourses. Despite this international view of infertility in many sub Saharan African societies it is perceiv ed as a major public health issue (Feldman Savelsberg 2002), a devastating threat resulting in hardship, ostracism and immense social suffering (Kielman 1998 ; Leonard 2002 ; Ombelet et al. 2008 ; Opara 2006 ). A lthough infertility can lead to social death, f rom the biological point of view it is not life threatening. According to Fassin (2001:5), within the field of health there is a noticeable intensification of ongoing biopolitics that must "be understood as an extreme reduction of the social to the biologi cal: the body appears to be the ultimate refuge of a common humanity thereby giving the body a level of priority in health discourses and interventions that far eclipses the social aspects of health If biological life is not endangered as is the case wi th infertility the claims surrounding the significance of this issue do not carry the same weight or command the same attention that triggers flows of money and support to Africa for HIV/AIDS. Clearly, suffering from infertility is assigned to the realm of social health, which is not an issue of concern for international health actors, while HIV/AIDS and the efforts to make treatment via ARVs accessible in sub Saharan Africa have risen to global prominence in the last decades. Third, syndromes or diseases need to achieve a certain global quality to gain worldwide attention. Although infertility is more prevalent in many African societies than in Euro American ones, and despite the fact that infertility can have the effect of social death in sub Saharan Afri ca, it does not generate enough dismay and shock in the West to qualify for attention on a global scale l ike AIDS. The notion of infertility being a public health need (Feldman Savelsberg 2002) in developing countries with high birth rates is underestimate d in the international charity world. This is also linked to a Euro American attitude according to which living without children is widely accepted and has no severe social consequences. As a result a Western biased notion emerges that to have children o r not is a life style decision rather than an essential social norm. Additionally, widespread preoccupation with overpopulation, high birth rates and HIV/AIDS in sub Saharan Africa renders invisible the high prevalence and the dramatic local social conseq uences of infertility. D istinct meaning and importance are assigned to each of the two health problems outlined here according to different prefiguring values in relation to orders and practices of health governance and international activism However, w i thin the intersection of biology, social relations and moral political claims there are only certain infections such as HIV that disrupt the biological survival of individuals to a major extent and thus can accumulate enough global quality to serve as a frame of reference for what we would term playing the ethical card of humanity. Global attention seems to result from different constellations as argued here and at the same time forms a prerequisite for international support in providing access to or denial of biomedical treatment. Although peace and security, the subordination of the social to the biological, and a certain global quality are central aspects of ARVs and ARTs positioning, intimately


9 entangled with these constellations are the role an d efficacy of social activist movement s around ARTs and ARVs which we explore next ARVs and ARTs: S ocial Movements a nd Culturally Coined Values i n Contrast N o global social activist movement currently exist s regarding ARTs Neither campaigns nor huge flows of money support this issue So far, the provision of infertility treatment s is barely supported by sub Saharan African states and NGOs. In Mali no NGO provi des significant information or funding for ARTs. Similarly, no self support groups for invo luntar il y childless couples are initiated or backed up by local NGOs in cooperation with transnational NGOs, philanthropic organizations or health activist movements. The option for treating infertility with ART in sub Saharan Africa (besides South Africa ) is mainly provided in the private health sphere and general ly established only with the support of private individual transnational networks or by gynecological professional organizations. Treatment with ARTs is now offered in more than two dozen inferti lity clinics in sub Saharan Africa (Pilcher 2006:976), of which seven are located in F rancophone West Africa. In Mali for example, one clinic has been invest ing serious amounts of its private capital to acquire skills and technological equipment for ART s ince 2004 Initially, the clinic mainly purchased second hand devices, bought from European medical equipment retailers or directly from clinics or retiring practitioners. To acquire know how and practical skills the staff members also invested time and m oney to conduct several internships in Europe and elsewhere overseas. This example demonstrates that when it comes to support for ARTs, the inter national trans national, and national linkages of materials people and activities mainly form loose networks organized on professional but mainly individual levels. Regarding infertility, the women's health movement of the 1990s was only partially successful and has so far not succeeded in expanding access to ARTs for sub Saharan African women yet. As outlined above, the three aspects (peace and security, subordination of the social to the biological, and a certain global quality) play crucial role s in limiting international solidarity or a flow of financial resources for infertility and ARTs But some aspects of this failure of the women's health movement in regard to ARTs are tied to its intimate link to the women's liberation movement and some of its specific socio cultural ly configured aims and values. With regard to ARTs, Western feminist critique oscillated between two positions: A rather liberal part regarded ARTs as having the potential to augment reproductive choices for women, while a more radical position saw the enhancement of motherhood through ARTs as further supporting the main obstacle to women's l iberation ( Thompson 2002:54 ; van Balen and Inhorn 2002:15). On the one hand, many feminists perceived ARTs as "increasing the subservience to one's biology" and "an ever greater surveillance" ( Thompson 2002:54 ) of women and their bodies by biomedicine. Fur ther, t he notion that ART patients are not suffering life threatening conditions but are instead pursuing life style goals and that most of them are high paying consumers added other problematic aspects ( Thompson 2002:57 ) to the debate within feminist move ments In addition, concerns against technical interventions pervade parts of the movement leading to the formulation of demands for alternative options (such as adoption or child free living). On the other hand, s ome feminists supported ARTs because they saw in them "the potential to articulate new ways of embodying reproduction, some of which would disrupt conventional families and gender stereotypes" (like access for homosexual women to reproduction) ( Thompson 2002:64 ). They critically argued that "repr oductive services were still tied into broader state policies of selective pro and anti natalism" (Thompson 2002:67 )


10 In the 1990s, the women's health movement called for global adherence to reproductive rights. Ironically, HIV/AIDS played a role in bring ing some attention to infertility, as women wishing to become pregnant are less likely to use condoms and are thus at higher risk of becom ing infected ( v an Balen and Inhorn 2002: 17). In 1994 various NGOs and feminist groups were present at the ICPD in Cai ro where t he right to reproduction was acknowl edged as a basic human right ( Daar and Merali 2002:19; Inhorn and Bharadwaj 2007: 78 ). As a result, i nfertility problems and access to adequate treatment have been at least formally recognized on international health agendas and in international population and development circles (van Balen and Inhorn 2002:17). Nevertheless, these agreements neither substantially increased the flow of money for ARTs, support ive activities by Western social movements or the issu e's visibility among the global public. Lacking this public movement component infertility patients in sub Saharan Africa generally try to remain invisible and interrelations between the actors doctors, patients, relatives are traceable only in specifi c localities. In Mali infertile couples perceive public disclosure as disrupting the mainstream normality and status they are trying to achieve. They also argue that public disclosure would put the children at risk of social stigmatization. As a result, o nly few groups or individual contacts are possible between infertile couples from the northern hemisphere and the southern one While patient self help groups offering information and counseling for infertile couples have been founded in several North Ame rican and Western European countries ( van Balen 2002:92 ), their role in policy making i s seldom visible to a broader public. No activist campaign for ARTs has managed to bec o me globally prominent in either European or other industrialized countries around the world. This lack of broad visibility together with a strong privatization of treatment markets ( Thompson 2002: 58 ) has rendered ARTs in the U nited S tates and Europe a mainly private affair an aspect mirrored in sub Saharan Africa and tends to impede soc ial activists and their attempts to establish transnational or international linkages Further more although social movements often stri v e to change local social norms of gender understanding and practices into more progressive, liberal and equity based ones (according to U S and West European understanding), infertile couples more often stick to locally shaped reproductive social norms of having children and try to fulfill th ose norms For mainstream feminist perceptions ARTs enhance motherhood and te nd to stabilize locally reigning social orders that are oppressive for women instead of challenging and breaking up these orders From this perspective, strong pro natali sm together with the importance of motherhood in many African countries is not perce ived as advancing women's liberation but rather creates friction with broader European and U S values. Together with the low resource and overpopulation argument and with the subordination of social suffering to biological life ending threats this percep tion seems to further strengthen the barriers against global interventions by social activist movements about infertility issues in African countries A sharp contrast exists between ARV intervention programs and treatment via ART. In the last two decades a whole "AIDS Service Industry" (Patton 1990:5) has been established. The evolving relationship between the epidemic and global response processes has led to the foundation of institutions that operate on inter national and transnational levels as well as to constant and increasing flows of money into affected countries in sub Saharan Africa. The new millennium brought about a number of worldwide interventions, among them the Global Fund to Fight AIDS, Tuberculosis and Malaria 3 and PEPFAR (the [U.S.] Presid ent s Emergency Plan for AIDS Relief). Since 2002, the Global Fund has approved US$12.0 billion and disbursed US$7.3 billion to cover HIV/AIDS programs in 146 countries worldwide. There is frequent overlapping of ARV treatment at the national level between the Global Fund and PEPFAR.


11 For example, b oth organizations jointly financed ARVs for 1.54 m illion people resulting in 4.67 million patients be ing provided with ARVs in low and middle income countries by September 2010 (PEPFAR 2011:10). Of these funds, US$4.1 billion (56%) went to the sub Sahara n Africa region (Global Fund 2011:42). Mali received US$52 million for ARV treatments between 2005 and 2009 through the Global Fund, and another US$ 40 million were approved at the beginning of 2010 for this purpos e (Global Fund 2011:105). The development of t hese flows and dynamics was enabled by international AIDS activists' engagements extending back to the early times of the gay rights movement in the U nited S tates Gay rights groups reorganized themselves to fight the epidemic soon after it emerged in the beginning of the 1980s. In San Francisco, New York and Los Angeles AIDS activists arranged demonstrations and actions related to AIDS issues in the 1990s They organized community mobilization, self help gr oups, advocacy and fundraising (Engel 2006: 23 26 ). In the face of a life threatening illness and the need for new treatment AIDS activists and members of the gay rights movement also challenged the practice of the clinical trials system. They demanded la rger enrollment and criticized the slow pace of the trials. Finally, the movement had an impact on the drug approval process and experimental drugs were made available to those unable to participate in clinical trials (Smith 1998:184 188). Many methods of activism used by the gay and civil rights movements in the U nited S tates and Western Europe proved their value in the struggle for treatment in South Africa: A mobilizing process with demonstrations and public awareness campaigns took place; self perceptio n as a growing community spread; public suffering or even the death of prominent figures brought publicity; powerful symbols such as the red ribbon s sold at each World AIDS Day were used ; and powerful concepts such as living positHIVely arose (Dilger 200 1). These dynamics helped establish global ties between diverse communities that communicate worldwide via the I nternet and the media. In his article Robins (2004) shows how TAC and Doctors Without Borders strategically positioned themselves within the f ight for treatment in Africa Contacts were established between the se organizations at international AIDS conferences and maintained via electronic mass communication (Smith and Siplon 2006: 85). However, it was a prominent figure Zackie Achmat, anti aparth eid and gay activist and one of the founders of TAC and his international ties who triggered global public attention regarding the issue of affordable ARVs Regulations of the World Trade Organization had blocked the production and distribution of generic antiretroviral drugs and international drug companies had brought a law suit against South Africa because of its intended import of generic ARVs, which it desperately needed to treat the large numbers of patients in the country Zackie Achmat visited Thai land in October 2000 and brought back 5,000 capsules of a cheap generic ARV drug that TAC presented at a press conference This caused international moral outrage about the high cost of treatment in light of the possibility of buy ing ARVs for a very low pr ice ( Jones 2009 ; Robins 2004 ) In 2001 the international pharmaceutical industry submitted to public pressure and withdrew the case ( Dilger and Wolf 2006 ). The support for ARV treatment by social activist movements shows a high density of inter nationall y trans nationally and nationally organized orders and practices in specific social sites. In the case s of TAC and other social activist movements in support of ARVs, global alliances and ties to specific people in Europe, Asia or the U nited S tates made the movement successful. These alliances and ties are based on overlapping values and targets, particularly oriented to a change of social order. Compatible social values and aims in connection with diseases and their treatments are further factors that se em to strengthen global interventions through social activist movements. Meanwhile, i n regard to infertility opposing social norms and values between patients and potential donors and activists make this issue less attractive to international agenda


12 sett ers I nterventions in this field will not directly promote and trigger the type of social change envisioned by the major players in the field of global health and development M edicoscapes and Therapeutic Citizenship The concept of biological or therap eutic citizenship has been developed as an important element of analysis i n the context of the specific configuring orders and activities around HIV/AIDS summarized here. D rawing on the concepts of governmentality and biopower ( Foucault 1977) and the conce pt of biosociality (Rabinow 1996) Petryna (2002) as well as Rose and Novas (2005) use the term biological citizenship to capture the double faced situation of how people simultaneously become subjects and actors in relation to health issues : Being a cit izen means subjecting oneself to an authority that grants protection and certain rights. Simultaneously this authority demands to be recognized as such and only grants these rights on its own terms thus it sets the rules of how to become this subject. Loo king at global health, Nguyen (2005:142) argues that i n the "dialectic between a global therapeutic economy, local tactics for mobilizing resources, and the biopolitical processes through which humanitarian interventions produce particular subjectivities another form of citizenship grounded on biology emerges. Nguyen (2005:142) calls this therapeutic citizenship and defines it as "a form of stateless citizenship whereby claims are made on a global order on the basis of one's biomedical condition, and re sponsibilities worked out in the context of local moral economies Kistner argues that the term biological citizenship in general is paradoxical: On the one hand it is "complicit with neoliberal governmentality ; on the other hand, it is marked as an e thical project" (Kistner 2009:4). In this way a division results into "two populations: those who are protected and those who are not" (Kistner 2009:1). Moreover, these moral claims based on therapeutic citizenship are made to a global but lawless arrange ment of power, economics, cultural values, and biased understandings of treatments. Based on biological interpretation transnational ly active groups such as TAC may successfully claim patients' right s to ARV therapy and support on a global scale, because these claims "carry more weight than those based on poverty, injustice, or structural violence" (Nguyen 2005:143). In combination with human rights a global solidarity and lobby may evolve and for some ailments like AIDS this may result in therapeutic c itizenship for patients However, in localities where the links to activist movements are weak or missing, the concept of therapeutic citizenship meets its limits. When TAC members tried to replicate its urban based ARV program in rural sites they face d s evere challenges. Local teachers questioned the scientific knowledge and authority of youthful AIDS activists and older people were offended by "sex talk" from young people, esp ecially when young women spoke about sex and condom use (Robins 2009:96). It seems that both biological as well as therapeutic citizenship are confined to specific settings described by Dilger as "islands of biopower" (Dilger 2012 :74 ).They can only develop in the context of intervening transnational NGOs and internat ional philanthr opic organizations orders and practices that are lacking in the case of infertility treatment in sub Saharan Africa. In light of the contrast between global responses to AIDS and infertility, it becomes clear that therapeutic citizenship merely comprises o ne kind of dynamic emerging through globalization processes while the medicoscapes approach allows us to explor e and explain the emergence of distinct kinds of dynamics and their interrelation. The concept enables us to follow the ways in which orders and things, practices, organisms and sociocultural values interact and differently combine within globalization processes and thus


13 distinctly prefigure the grounds that give way to specific place making and hierarchical power geometries around various ailme nts. As HIV/AIDS meets the peace and security argument and has a biological life threatening dimension that is regarded as superordinate to social suffering, it is able to achieve a certain global public quality. This attract s the attention of social acti vist movements in the West and connect s activists in other regions of the world. This move is additionally facilitated by the specific values inherent in many Western social movements as well as nurtured by them These values include promoting equity and j ustice and the transformation of social orders, which in turn enhances and increases the global quality of HIV/AIDS and the attention of the global community for supporting the accessibility of treatment by ARVs worldwide. Thus i n the case of ARVs a po werful dynamic of connecting actors and sociocultural values and (financial) flows emerge s as a globalization process. These intersections and arrangement s of actors and things, values and practices are different in the case of infertility. T he powerful logics of peace and security and the biological life threatening aspect do not apply to this affliction, thus th is health issue remains low on the global agenda and faces greater obstacles in attract ing public attention and mobiliz ing social activist movem ents in the West (comp are Gerrets 2012 ; Redfield 2012 ) 4 Further more the tendency of infertile couples to remain invisible to the public addition ally undermines attempts to connect activities across different countries and continents. At the same time, op posing values within mainstream Western feminist groups about enhancing motherhood and using biomedical technologies result s in frictions within the movement and further impede s transnational and global connecti ons As a result of these various conditions, no therapeutic citizenship has evolved around infertility and treatment with ARTs in sub Saharan Africa. Conclusion In our contrasting analysis we have shown that globalizing processes in health fields trigger different impacts on two health conditio ns and thus contribute to distinct forms of place and space making for biomedical treatments in sub Saharan Africa To answer the question of how globalizing processes exert these distinct influences, we tracked three key overlapping phenomena: peace and security, the subordination of the social to the biological, and a global q uality. In the case of ARTs we show that these key characteristics are not fulfilled and th at values and objectives across spaces and places to support biomedical treatment of infe rtility remain rather intransigent, while actors and institutions within and across places remain generally disconnected. In the case of ARVs we delineate how these characteristics allow on the one hand, the connection of distinct places and actors via o verlapping values and objectives and, on the other hand, the creation of powerful movements and symbols. We also describe how these key forces privilege support for specific suffering such as HIV/AIDS and, by doing so, enable some people to claim therapeut ic citizenship and receive treatment for a specific ailm ent while excluding people suffering from other afflictions (e.g., infertility ) from global support for appropriate treatment. Besides describing how these key forces prefigure global attention and e conomic flows on inter national trans national, and national levels we also demonstrated how tracing the continuity or discontinuity of values within social activist movements provides further insight into the factors that contribute to specific power geom etries around HIV/AIDS and ARVs versus infertility and ARTs. Through these conflating processes that either link or do not link specific places, practices and values within and across different spaces in the world


14 distinct forms of place making are enact ed in sub Saharan Africa around treatment opportunities for infertility and HIV/AIDS. Having shown that the concept of biological or therapeutic citizenship does not accurately reflect the current situation in regard to infertility and ARTs in sub Saharan Africa, we have instead chosen to apply the concept of medicoscapes in our comparison of HIV/AIDS and infertility in global health issues T his enables to include a variety of emerging dynamics around different ailments by contrasting sociocultural values practices and artifacts at different social sites and their interacti on with global ideas and practices The concept of medicoscapes provides a theoretical framework and target oriented p er spective to describe and analyze the ongoing interactions on var ious scales by actors embedded in different sites It gains additional analytical value by highlighting the cultural, local, and international forces and actors through its attention to temporal and spatial discontinuity. All of these actors bring in diffe rent perspectives, targets, knowledge regimes and sociocultural values, which may partially overlap or be incompatible with each other. These aspects become entwined through orders and practices and form the ground for hierarchical configurations in inten ded and unintended ways. T he concept of medicoscapes overcomes geographic and cultural boundaries enabling us to take the global scope of the issue into account but simultaneously underlin ing the importance of individual localities as tangible places of p ractices and research. In our view, medicoscapes are useful as a n umbrella concept for bringing together various trajectories of health issues on the global agenda allowing for the analysis of specific conjunctures, the phenomena and processes that produc e them and their interrelations from different vantage points. Thus, we use medicoscapes to focus on complex and asymmetric constellations of orders and practices in health related fields around the world that include and exclude, enable and constrain, an d channel and prefigure certain flows and specific closures of medical aid. Medicoscapes put a lens on the multiplicity of even opposing processes of globalization and their emergence in one place or site of the health field. Different configurative settin gs at a given historical, spatial and sociocultural moment can be analytically approached in comparative ways through the concept of medicoscapes thereby providing greater insight into the distinct dynamics and power relations unfolding around different ailments within globaliz ation processes in the field of health care Notes Acknowledgment We are grateful to Kristine Krause, Rene Gerrets and Bernhard Hadolt as well as to two anonymous reviewers for their comments on former drafts of this article, which improved the thoughts and conclusions laid out here We also would like to thank the German Research Association that funded fieldwork in Mali and the Portuguese Foundation for Science and Technology for financing further field stays. 1. So as not to confuse the reader and assist the differentiation between the two different ART treatments, we refer to assisted reproductive technologies as ART and to antiretroviral therapies as ARV. 2. Schatzki (2002) spotlights the concrete location as essent ial for actors and their practices. He describes it as the place where social life occurs and where cultural values are one factor of future organizing significance. 3. The Global Fund is a public private partnership and international financing institutio n consisting of governments, civil society, the private sector and affected communities.


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