How come the antiretroviral therapy is failing in a continent like Africa where the importance of these treatments is crucial? (FR)
Written by Aurélie Benoit
Text reference: “Les antirétroviraux en Afrique : de la culture dans une économie mondialisée (Antiretroviral treatments in Africa : when culture meets globalized economy”) by Alice Desclaux in Anthropologie et Sociétés, Volume 27, numéro 2, 2003, pp. 41-58
The article « Les antirétroviraux en Afrique : de la culture dans une économie mondialisée » (« Antiretroviral therapy in Africa: Culture in a globalised economy ») deals with the case of antiretroviral therapy in Africa, which is not quite as effective as in the North, in spite of its crucial importance in fighting sexually transmittable diseases (STDs) in that continent. That ineffectiveness seems to be the result of “local drug use not meeting the international recommendations”. It has therefore to be asked for what reasons drugs are used in an “improper” way.
Why the treatment is not taken? The misleading cultural reasons
First of all, Alice Desclaux recalls that this failure is commonly explained by “culturalist” views: STDs and the medication linked to them are subject to cultural constructions that have been largely studied by the anthropologist of medication. But here, the author immediately stands against the suggestion of a cultural cause, especially when it comes to compliance with medication, in other words: “a patient’s behaviour that matches the recommended therapy”, “compliance with the follow-up, with hygiene and dietary rules as well as the medication”. Antiretroviral drugs can be considered as effective by medical professionals only if their observance exceeds 90%. In addition to the causes also found in the North, the reasons for a possible observance failure are principally economic or caused by health system malfunctions in those countries, for instance by the physician’s absence at the monthly appointment. In another article she wrote in 2001, « L’observance en Afrique: question de culture ou « vieux problème »de santé publique? » (“Compliance in Africa: a cultural issue or an old public health problem?”), the author declares that cultural-related issues actually exist (a statement which does not necessarily contradict this article, in which she treats the subject in a more evasive way) but, in this particular case, she considers these explanations to obscure other possible reasons.
Explanations are more likely to be found in physical or economic reasons
The causes she mentions are more physical; indeed, antiretroviral therapies lead the patients’ symptoms disappearing. Therefore, the patients are seen as cured and their entourage expects a form of counter-gift, due to the concessions it had to do while supporting their care. This is an interesting point, because it highlights a different vision of solidarity, based on a “give and take” principle.
Alice Desclaux then insists on the economic aspect, that is the want of free access to antiretroviral therapies. “Children, health professionals and patients formerly involved in clinical trials” actually have free access. Similarly, in almost every African country, “members of associations for people living with HIV received subsidies that partially or totally covered the therapy costs, so did widows with dependent children”. There is a categorisation, therefore, which involves a hierarchy between patients (as well as more specific categories exceptions depending on the countries). The author raises the question of the value ascribed to a human life. For the rest, indeed, the prices exceed 100 dollars a month, in a region where over one in three people earn less than one dollar a day.
An alternative to foreign medication: the neo-traditional drug
Consequently, in an effort to increase the access, “neo-traditional” therapies are developing. But these alternative drugs eventually cost quite as much as the classical antiretroviral drugs they are supposed to substitute for. The emergence of this new market is due to African health professionals taking advantage of “a space left vacant by biomedicine and recently created by the social construction of antiretroviral drugs”. Here lies, in fact, the point of this article: in the ambivalence of these drugs labelled as “neo-traditional”. They are supposed to originate from traditional medicine; nonetheless, they are legitimated by “business owners” using more scientific, “Northern”, arguments. This was born as a defensive strategy based on alien roots.
Medication as meaningful objects
The author explains the emergence of this vacant space by the “double lack of access as well as the identity meaning”. A drug isn’t a neutral item: in fact, classical antiretroviral drugs come from the North and are meaningful. Developing “neo-traditional” drug is also a means to reclaim an item laden with meaning.
Conclusion: Neo-traditional treatment as a means to re-appropriate a foreign object
Moreover, the behaviour towards antiretroviral therapy is to be understood in an economic context which is also subject to power struggles. In response to globalisation and the following inequalities, the use of antiretroviral drugs shows a resistance strategy by making drugs, as a symbolic object, local again. Drugs are in fact full of meaning, economically (because of the categorisation resulting from its accessibility) as well as socially (for business owners using it in their individual strategies).
These antiretroviral drugs also favour the legitimacy of biomedicine as well as new forms called “neo-traditional”, because of several advantages they bring to local people: an increased accessibility to medication; an efficacy similar to that of scientific methods; a means to defend an African identity through the symbolic load of the drugs.
The author does not clearly establish if this specific use of medication is a problem or not, she just highlights the symbolic place of the medication to some people, and how their utilisation influences a new “medical system geography”, but also how they are a illustration of social dynamics.