Embrace privatization, marketization and deregulation. Consider the “free market” as the most efficient way to produce and distribute resources and services.

• The “Risk group” as stigmatizing: focus on risk groups: reinforces stigma; encourages “othering”; implies that those “outside” category are not at risk
• The autonomous individual: Biomedical models incorporate assumptions about health resulting from individually chosen lifestyles; reinforces individual responsibility and blame for HIV infection

·         •Attempt to find intersection between indigenous and biomedical constructions of STIs

·         •Project extends PHC work

·         •“Khoma” (polluting material) intersects with viral transmission model (condom use)

·         •Workshops sought to train healers using indigenous term

    Program briefly replicated and now defunct

•          Institutional ethnography of ARV scale-up, vaccine, and other RTC trials

–        Effects of circumcision campaigns

–        Global Politics of pharmaceuticalization of AIDS

–        Schoepf: “Institutions have become quasi-states”

•          Studies of “aging” and mental health among long-term survivors of HIV

•          Studies of changing stigma as AIDS becomes a more common chronic disease

•          Filling the gap in multi-level theoretical approaches

–        Coates et al: “The theories guiding most interventions are essentially cognitive and individualistic and do not address the fact that HIV transmission is a social event.”

–        Growing recognition of need for structural approaches, but few actual models

–        Such projects require concepts and methods not typical in most PH approaches, and call for anthropological involvement

•          Few full-length ethnographic treatments of AIDS in specific locations

—N= 533 women and 206 (het. & bi) men, HIV+

—Desire to have children (in this sample) was more frequent among men than among women and it was reported by 27.9% of participants (50.1% of men versus 19.2% of women).

—Male gender, younger age (17-24, OR 6.1), having no children (OR 8.4), and being in a heterosexual partnership were independently associated with desire to have children.

—The childless as well as the youngest should be regarded as groups to be particularly targeted in RH.

Benefits to this approach:

Programs should connect global, political economic factors to local practices and identities

Programs should incorporate the issues of the economic migration

Work to target the right populations and emphasize the right things.

Conside the issues of stigma when developing a program.

How can you recruit for an HIV prevention program specifically targeting self-identified heterosexual men who engage in sex with men How would you recommend developing an HIV prevention program for this particular population? Are there others that you would include in the prevention programs?

•       Humanitarian view: Reductions in family size will benefit the health of women and children.

•       Malthusian argument: 19^th Century Demographer who predicted exponential population growth/doomsday scenario. Concern about who is reproducing (eugenics).

•       Environmental Concern: Summit in Rio emphasized global deforestation and toxic waste build up.

•       Economic concerns: Addressing poverty by controlling fertility. BUT, why not the other way around?

Metaphor of control normalizes coercion

Polices do not create user demand or “user pull”

Can lead to ethical violations

Rights of individuals less important than goals  of population control.

Whose fertility is controlled? Right to reproduce is stratified by race, class etc.

“Reproduction lies at the heart of a culture’s representation of itself; it is in large measure through imagining reproduction that individuals families and social groups conceive the future toward which they aspire for themselves and the next generation”

1. Bodies as economic resources - women use their bodies for security

2. Proscriptions against premartial sex - taboo against premarital sex results in lack of reproductive health information among unmarried women

3. Mother worship - strong desire to begin reproducing immediately upon marriage, competition between co-wives for status

•Cairo International Conference on Population and Development emphasized permitting individuals to achieve their reproductive intentions (emphasis on individual reproductive rights)

•Policies have been ineffective in lowering fertility in West Africa, where women face strong pronatalist norms regarding high fertility

•          Policy-makers’ interest in fertility reduction conflicts with the empowerment and “self-determination” philosophy of Cairo

•          High FP investments have little effect in places such as Senegal (esp. in marriage)

•          Foley: The policies and philosophy of USAID programs miss the mark entirely

–        They assume that the primary barriers to contraceptive use are access and quality

Methods:

•          Used semi-structured interviews and focus groups to study cultural context of FP

•          Key informants guided subject selection of policy-makers, FP providers, consumers

•          Interview instruments “back-translated” and then validated / pretested

•          Analysis: Codebook development, transcript coding / recoding, write-up

 Results:

•          Corporate family structure

–        Extended family unit valorized, despite recent growth in constraints on size

–        Desire to maintain solidarity despite change

–        Fosterage and resource sharing w/ family influence FP choices

•          Quality of FP service, education = priorities

•          Gender and resources

–        Children as “anchors” for established men

–        Marriage requires male financial success

•          Short code names (mnemonics) and definitions

–        E.g., “HIVFEARS” = Expresses fear or anxiety related to HIV/AIDS

•          Definition of inclusion

–        E.g., Includes fear of getting HIV for self or others; also includes fear of people with AIDS

•          Definition of exclusion criteria

–        E.g., Excludes any statement about fears related to passing HIV to others, in the case that participant is HIV-positive (See code FEARTRANS)

• What are the different kinds of governance that women in Ecuador encounter/confront?

Two kinds of biopower:

Up until the 15-1600s most power was in the form of "sovereign power" meaning "do this or I'll kill you." Biopower arises when life becomes less precarious and we can make people live rather than just make them die. (Agrarian revolution.)

In Ecuador, essentially nobody wants to be a "citizen" because it means you are devalued. If you have money, you can bypass the state in things like healthcare and security.

Paradox = if inequality shapes health, women should have worse health outcomes (longevity, morbidity, mortality), yet men often more at risk:

Courtney (1998): Men’s elevated risks due to the fact that males in U.S. with traditional beliefs about manhood more likely to:

–        Failure to adopt health-promoting behaviors

–        Propensity to engage in risky behaviors

–        Beliefs about manhood

–        Attitudes concerning vulnerability

–        Limited knowledge about health

1. Sex role theory: how masculine socialization influences men’s health

2. “Masculinities and health”: examines gender hierarchies among masculinities        

3. Masculinity and the body: Examining biocultural bases of men’s health (bodily functioning; technologies of the body; the body politic)

•          No Sissy Stuff: The need to be different from women (and, implicitly, homosexuals)

•          The Big Wheel: The need to be superior to others

•          The Sturdy Oak: The need to be independent and self-reliant

•          Give ‘em hell: The need to be more powerful than others (through aggression)

1. Hegemonic masculinity:

the prevailing, most lauded, idealized, and valorized form of masculinity in an historical setting

2.Complicit masculinity

A term associated with R. W. Connell’s writings on the gender hierarchy in society. Complicit masculinity is embodied by the many men in society who do not themselves live up to the ideal of hegemonic masculinity, yet benefit from its dominant position in the patriarchal order.

3. Marginal masculinity

4. Subordinate masculinity - homosexuality, transgendered...

1. “Women’s Rights and Men’s Responsibilities”

•          Sees men as primarily the “problem”

•          Seeks to achieve reproductive health equity by targeting services to women (and often excluding men)

•          “Interventions that exclude men may do less to achieve reproductive health equity than those that include them”

•          Problems with this approach

•          Assumes that one individual’s rights are separable from another’s

•          Neglects the possibility of co-existing reproductive rights for men and women in relation to one another

•          Avoids questions about men’s rights in relation to women: e.g., the right to influence women’s pregnancy? The right to have multiple partners?

2. The “Men as Partners” approach:

•          Focuses on men insofar as they are involved in the reproductive decision-making of their partners

•          Assumes heterosexual monogamy and fidelity

•          Problems with this approach

•          Neglects men’s involvement in their own reproductive / sexual decisions outside of partnerships (extramarital), or the non-reproductive dimensions

•          Promoted by international industries and media

•          Assumes women are primary consumers and users of contraceptives (no “oferta sistematica” for men)

•          Entirely neglects men as actual users (e.g., vasectomy rarely taught in schools)

•          Constrains the utilization of services by men in local contexts (problematizing “cultural barriers” like “machismo”)

•          Question: How do Mexican men decide to have vasectomy?

–        Some men sensitive to women’s suffering: “you’ve already suffered…with the kids…”

–        “I try to help my wife a little in family planning”

–        Women’s empowerment with husbands

•          “Just think about what it’s like to have kids!”

•          Emphasizing simplicity of vasectomy as ”la cortadita”

•          “It’s your turn to suffer a little”

–        Men influencing other men:

•          “It’s no big deal”

1. Class and the fact that the cost of these technologies is high influences the degree to which they can access these resources and it informs their decisions as to whether or not to engage in it, and how many times. It also has many influences on quality of care, the relationship to the provider.

2. Access to knowledge - influenced by class because people have educational opportunities that are correlated to class status so they have varying levels of access to information about ARTs

3. Access to technologies - rich go to private clinics where different types of therapies are available (including ability to access Europe and the US) , middle class often only have money for one trial

4. Religious constraints - what ART can be used (such as using a third party as part of the process)

5. The suffering body, stigma and gender (such as male infertility being ignored so it falls on women)

6. The religious framework means that there is no accountability because if the IVF procedure doesn't succeed, it was "god's will" and not because of a poor quality of care

??

Inhorn has a tendency to contrast "The West" with "The Middle East" while ignoring local differences within a culture.

Methodological limitations - she tries to simplify language and tends to be less anthropological (questionable sweeping statements) and presumes an audience that is Western

•          “Death without weeping” suggests angel baby beliefs socialize people to understand death differently: “Angel-baby beliefs not only ‘console’ [mourners], they shape and determine the way that death is experienced”

•          Mothers are socialized into “resignation” toward infants <1; they are not merely “coping” with an underlying (“natural”) grief

•          Question: Do all people feel the same fundamental grief but are obliged to mask it? Does S-H suggest socialized parental “neglect” by mothers?

Step 1: Fieldwork

–        Site visits, rapport-building, observation of “natural” tasks

–        Uses skills of ethnography and qual interviewing, but with a specific behavioral and applied task

Step 2: Negotiation

–        Regular visits involving “teaching” and “providing options” for change

–        Continued observation of trial behaviors and conversations about “what works” and why

–        Ends in the “trainee” selecting one of the options for behavior change

Step 3: Analysis

–        Asks questions of observational data:

•          How many mothers (etc.) had each particular problem or situation?

•          How many accepted which improved behaviors?

•          What were the most effective motivations?

•          What was their experience and success during the trial?

•          What modifications in the suggestions did they make and why? 

•          Who in the family and community influenced their behavior?

•          What were the main barriers they had to overcome and how did they do this?

•          What were their perceived benefits; and what is their intention to continue the new practice(s)?

Step 4:

–        Create recommendations, considering:

•          Training needs

•          Costs

•          Expertise

Important concepts for success in Indonesia:

•          “Pleasing” the family

•          Parental aspirations for the future

•          Desirable balance in physical and psychological development (e.g., ‘greed’)

•          Concerns of costs and time

•          Mix of traditional and modern concepts of child care

•          Need to emphasize larger quantities of food not “bad”

These behaviors are the primary risk factors for HIVB infection:

1. Having many sex partners in a lifetime

2. Having concurrent partners

3. Having sex soon after meeting someone

4. Having one-night stands

5. Having more than one partner in the same month

6. Having overlapping partnerships

7. Having a "main" partner as well as other partners

Prevention messages should focus on:

1. Limiting sexual partners

2. Always using condoms

3. Knowing your HIV status