How can we explain this epidemic of food allergies? The radical shift from hunting and gathering finally catching up with us? Radical advances in medical technology that allow us to identify conditions that went unnoticed a generation ago? A build-up of environmental toxins in common foods? Interaction of foods with strange new food-like products like high fructose corn syrup and artificial flavors?

Or maybe we’re imagining the whole thing.

That’s the conclusion suggested by a recent study in the UK that found that only 2% of people who claimed to suffer from food allergies were actually allergic. The rest are suffering from something else, namely, the belief that they suffer from food allergies.

Now, I don’t know much about medicine and physiology, but I do know a thing or two about belief, and when millions of people believe something that isn’t empirically verifiable (1 in 5 Britons, according to the article above), we’ve got some ‘splaining to do.

Now, my first reaction is what I think many food allergy sufferers will share: that the study is flawed, not in its procedure, but in its very medical-ness. That is, there’s a strain of anti-modernism in the recent explosion of food allergy awareness that simply doesn’t trust the mainstream medical industry to  recognize and treat food allergies. So when you get a bunch of mainstream medical researchers to study the issue, it’s no surprise that they don’t find anything.

I doubt that’s true, but here’s the thing: the belief that it’s true is part and parcel of the food allergy… can I call it a “movement”? In their rejection of modern medical knowledge and modern food processing technologies, as well as their yearning for a more “natural” diet and a greater connection to their bodily functions, food allergy advocates (if not food allergy sufferers) certainly have at least some of the hallmarks of a social movement. And they’ve certainly created social change, as well – modern supermarket shelves are packed with (ironically) high-tech allergen-free foods: gluten-free beer, bread made of spelt, soy milk and ice cream, and so on.

But leave aside the political aspects of today’s food allergies; what intrigues me is the almost religious asceticism imposed by many food allergies. A vast number of foods are made containing wheat, for instance, so the wheat allergy sufferer is constrained to a diet that eliminates a great many common foods – much like a Jew during Passover, when most wheat-containing foods must be avoided as “leavened”.

The author of the Telegraph piece above notes the similarities between food allergies and food taboos, drawing on Mary Douglas’ understanding of the way boundaries create meaning and order:

[W]hat we eat not only defines us as people but also helps us to feel control and mastery over an otherwise chaotic and random world. She argued that by ordering foods into those we can consume and those that we can’t, we create meaning, and the boundaries provide order in our lives.

As a set of dietary restrictions, rather than a medical phenomenon, it seems reasonable to see food allergies – along with vegetarianism/veganism, the Slow Food movement, the “buy local” movement, and the $30 billion-plus diet market (in the US) – as an attempt to wrest back control over an aspect of our lives that we are increasingly and maybe irretrievable disconnected with. Few of us have any connection with the food cycle except as consumers at the end of a very long and complicated food production cycle. Food allergies allow us to assert control – on pain of death – over what we ingest, and demands an attentiveness – again, on pain of death – to what’s in the foods that we buy.

But this fussiness is part of a larger yearning for control altogether, which is where the anti-modernism comes in. Food has long been not only a means of forging and asserting cultural identity but of resisting the onslaught of a homogenizing, enervating modernity that threatens to dissolve not just cultural identities but individual identities. From the health spa/retreats of the Kellogg brothers and their peers (that gave us corn flakes and granola) to the popularity of Sweet-n-Low in the ‘50s and ‘60s to the communes of the hippie era to the herbal remedies of today, food has been seen as a way to “get back” to a more “natural” way of life – as opposed to the high-stress,  low-community, detached and distracted way of life that is modernity.

None of this is to suggest that there are not very real food allergies – it’s hard to argue with anaphylactic shock. Nor, more importantly, is it to say that the 98% of food allergy sufferers in the study with no medically detectable food allergies do not, in a very real way, suffer. The bodily manifestations of the most obviously social disorders can still drastically limit a person’s quality of life.

What it does suggest is that treatment of food allergies needs to go much further than antihistamines and food avoidance to encompass the cultural psychological. If control is a central issue – as it is already recognized to be in anorexia nervosa and other eating disorders, which strike bright, ambitious young women with overbearing parents hardest precisely because they are the least in control of their lives and the most aware of it – then a) developing non-food strategies for regaining control, and b) developing a realistic relationship with the demands and pressures of daily life are also important to individual adjustment.

On a social level, food allergies and other dietary restrictions join a range of other control-seeking phenomena – pop psychology, personal productivity, conspiracy theorism, and religious fundamentalism, all of which attempt to throw a lasso around the neck of our stampeding lives. As a critique of modernity, there’s nothing original here; Georg Simmel’s The Metropolis and Mental Life addressed similar concerns about the loss of autonomy in 1903, and Emile Durkheim addressed similar concerns a decade earlier, noting the anomie inherent in industrial/commercial society in The Division of Labor in Society.

But over a century of social critique has done little to alleviate the real suffering of real people. The question is, do we have the resources and will to take on these challenges at a social level today? Or are food allergies, in fact, an adequate collective response to dehumanizing social conditions? Do food allergies, like, say, spirit possession on Chinese factory floors, provide the relief people need to cope with the impacts of modernity, even as they suffer?

the victim — we’ll call him “Bob” — was on a business trip alone somewhere in Europe, and went out to a bar one night to have a cocktail. Wouldn’t you know it, he woke up the next morning in an unfamiliar hotel room with severe pain in his lower back. He was taken to the emergency room, where doctors determined that, unbeknownst to himself, Bob had undergone major surgery the night before. One of his kidneys had been removed, cleanly and professionally.

That story is an urban legend, and it has been so widely reported and debunked, that FBI and hospital officials would not believe anthropologist Nancy Scheper-Hughes when she told them of real traffic in organs by organized crime back in 2002. Eventually she got support from law enforcement in Brazil and South Africa, and the FBI finally came around. The recent FBI bust in NY and NJ, which was initially reported as a “money laundering” operation, turns out to have also involved some the organ traffickers reported by Scheper-Hughes. Newsweek has an in-depth story, and Somatosphere explores some of the more anthropological aspects of the story.

Local brands of sildenafil available in Egypt, including: Viagra, Virecta, Erec, Kemagra, Vigorama, Vigoran, Phragra, and Vigorex. Photo by Lisa Wynn

First, Americans might think of erectile dysfunction drugs (EDDs) as somewhat shameful (think about mocking attitudes towards Bob Dole’s decision to do Viagra ads), but they have a more positive connotation in Egypt. Two reasons:

1. As I’ve written elsewhere, in Egypt these drugs seem to be associated as much with the promise of exuberant, excessive sexuality rather than a shameful lack of erection. Maybe it would be more accurate to call them erection enhancement drugs rather than erectile dysfunction drugs.
2. Even though both EDDs and ECPs can be equally used in normative and non-normative sexual relationships, EDDs are seen by some as being less morally suspect. As my colleague, Dr Hosam Moustafa pointed out to me in an e-mail exchange,

“When we talk about marriage, which is the only state that makes sexual relations halal [religiously acceptable], we ask: What are the original aims of sexual relations? Answer: pleasure and getting kids. This what all humans have deep in their minds, whatever cultural background they come from. About the two drugs, how do they related with these two aims of sexual relations? Answer: erectile dysfunction drugs are associated with both positive sides of a sexual relation, i.e. both giving pleasure and ensuring having kids. EC and all contraceptives are associated with a negative outcome of sexual relations, i.e. not having kids.”

A pharmacy door in Cairo with ads for Cialis (top) and Viagra (bottom) on the front door. Photo by Hosam Moustafa.

Second: EDDs have a historical association with the black market / gift economy. When Viagra was first introduced and before lots of generic varieties were available, it was hard to get and expensive (it still is the most expensive brand on the market). People smuggled it into the country. It was given as gifts from one man to another. It is even used to grease the wheels of bureaucracy, being offered as a small bribe. Relationships with physicians are cultivated in order to access drugs that are hard to get. Even though sildenafil is now widely available in a range of prices, other drugs said to produce the same effect (Cialis and Tramadol are two such examples) still circulate semi-illicitly, in the category of a commodity that is thought to require both connections and expertise to obtain, and this is part of their appeal: they’re more than just commodities, they have a special aura.

So in asking why don’t ECPs have the same aura and circulate amongst women in the same way, maybe it’s partly because they’ve never been part of the black market. Packs of contraceptive pills, the kind you could cut up to equal a dose of emergency contraception, are government subsidized, widely available, and really cheap.

This sign at a Cairo restaurant stall advertises “Viagra soup.” The starred text on the bottom left reads, “For adults only.” Photo by Hosam Moustafa.

Finally: there are key continuities between modern pharmaceutical products for erectile dysfunction drugs and more “traditional” treatments, so the appeal of drugs like Viagra and Cialis is partly that they tie in with pre-existing ideas about how you can ingest certain substance to increase your virility. I’ve already written about Viagra sandwiches, and there’s also Viagra soup, dates, and who knows what else? This takes the notoriety of a global pharmaceutical product and maps it out over pre-existing notions about the virility-enhancing power of seafood. Using drug brand names to label food is not just a phenomenon in popular (sha`bi, as they say in Egypt) restaurants, either; a famous restaurant in an expensive mall in Alexandria offers the same soup (but wouldn’t let us photograph their menu!).It’s not just seafood that has this reputation. In the picture below is a wall of oils at a local apothecary, or `attar, which includes gargeer seeds or oil (that’s arugula to North Americans, rocket to Australians), about which there is a popular saying, “If women knew what gargeer could do for their men, they would grow it under the bed” (rhyming gargeer, arugula, with sareer, bed).

Salad = virility! It’s not exactly the American imagination of how food is gendered.

(Above) Apothecary wall with herbs, spices, and oils, including, on top, gargeer (rocket/arugula) oil. Photo by Hosam Moustafa.

Also I can’t resist including a picture of Cow Jam from the same pharmacy. A kind of vitamin supplement, the product contains neither cows nor jam. Photo by Hosam Moustafa.

But I put “traditional” in problematizing quotations above because it’s not like there’s a clear line between “traditional” remedies for erectile dysfunction and modern pharmaceutical products. Below is a picture of several products that Dr Moustafa and I bought in Cairo apothecaries. It’s not just oils and herbs. There are mysterious packaged products imported from all over the place, as well as local, “traditional” products. In the latter category, in the bottom right hand corner you can see shards of a resin — sold by the gram and very expensive — that is dissolved in hot water and then applied to the penis. It has a strong numbing effect and is supposed to make it possible for a man to perform longer.

Apothecary products purchased in Cairo. Photo: Lisa Wynn.

In the former category, notice on the right the package of Lina Sex, a gum which is supposed to increase the female libido, and which claims to be manufactured by “Astra zencesa group pharmaceuticals.” (As Dr Hosam Moustafa explains it, “All these drugs for women are used to treat decreased libido of women. It’s a main complaint here from most men that their women have decreased libido which I can explain as a kind ofself defense from men — I mean trying to say ‘the problem is not only me, my wife also has troubles’.”) The boxes with a crocodile and rhinoceros on them are made by the same local Egyptian company.

The delightfully mysterious “Flower Jel” claims to be “Made in U.S.A.” and reads on the back of the package,

“For the Past Si years, Ben Huczek Has Suffered From impotered and, despitence and, despoint the cause fortuntcly, Ben of the First Britis men to take FLOWER JEL after being referred to aconsultant urolgist who w conducting clinical conducting clinical Trials of the sex pill.”

Somewhat less delightfully mysterious is “Germany Black widows Powder Fever (Ms. special Super Night)”, which seems to be marketing itself as a date rape drug, because it says on the side of the box:

“Powdery white, tasteless, can quickly dissolve in various beverages without being found, after a few minutes after drinking, quick wins, after taking Chunxindangyang, fast exciting, noodles dinner, shortness of breath, hot air, eager to head shot, body heat, impatient with the rest of your love, this time of women, warm and flowing.”

Germany Black widows Powder Fever. Photo by Lisa Wynn

Incidentally, despite the claims on the side of the box, the contents are a clump of brown sludge with a powerful odor (and hence, I presume, taste, but I haven’t tried it).

The point is that when you go to apothecaries to find “traditional” remedies, what you find is a range of products that circulate transnationally (lots have Chinese characters on them but claim to be manufactured in Germany, Japan, or the US because of the prestige associated with products from these countries), that make reference to international pharmaceutical companies and clinical trials and German pornography, and that borrow on globally circulating (and ancient) notions of what constitutes an aphrodisiac (such as the Egyptian product with the rhinoceros picture on the box, even though rhinoceroses disappeared from Egypt during the Pharaonic era). Even local remedies and herbal formulations are now taught in the Khedr El-Attar apothecary training school, mimicking modern university education formats.

– L.L. Wynn and Hosam Moustafa

These days it’s not that hard to do websites in Arabic, but six years ago, it was a real puzzle. I couldn’t find any Arabic language plug-ins for DreamWeaver or FrontPage, so as I cut and pasted the Arabic text into the HTML programs, it wouldn’t display the Arabic properly, so it was really hard to do the links on specific words. The Arabic phrase for emergency contraception, which looks like this in Arabic:

منع الحمل الطارئ

looks like this in HTML code:

منع الحمل الطارئ

So I just had to muck around, highlighting different phrases, counting off letters or doing searches for strings of HTML code like that above, putting in links and then seeing where the links showed up in the Arabic texts, and then shifting the links around accordingly. It was a stupidly slow process. There was probably a better way to do it, but I wasn’t able to figure it out, so I slogged through the slow way.

Translation vs adaptation
I’m getting off the topic. Angel had decided that we couldn’t simply translate the existing website into Arabic. It had to be adapted to fit the social and cultural context of the Arabic speaking world and meet users’ needs. So, for example, she decided to include specific questions in the FAQs section on the interpretation and acceptability of EC in Orthodox Christianity and in Islamic jurisprudence. We hunted around for any fatwas on EC, both in published compendia of fatawa as well as in online databases, but we couldn’t find any. In fact, in the past 5 years, I have only found 1 fatwa on EC in an one of the many online fatwa databases.

That’s where interest in this Egypt research project came from. What did it mean that there were no fatwas on EC? Either it meant that EC wasn’t on anyone’s radar screen and was so totally unknown that nobody was asking about its status in Islam – hard to believe since there were dedicated products available in several Middle Eastern countries (including Yemen, Egypt, Tunisia, and Lebanon) – OR it meant that EC was just wholly uncontroversial and subsumed under jurisprudential discussions about pre-coital hormonal contraceptives.

Well I thought that was a really interesting possibility, considering how in the U.S., as I previously described, EC’s status as a contraceptive vs. abortifacient has been contested, and debate often hinges on the mechanism of action.

Angel and I developed a working hypothesis, which we published in a little paper for Harvard Health Policy Review along with colleagues James Trussell and Aida Rouhana: that debate over EC in the Arab world was likely to hinge around the social and moral contexts of the sex that precedes EC use, rather than focusing on mechanism of action. We hypothesized this partly based on existing debates in Islamic jurisprudence about contraception, but also based on interpretations of abortion in Islamic law, where the acceptability of abortion is partly considered in light of when life begins. (Also considered is the relative value of the mother’s life versus the life of a fetus: in contrast to some extreme Christian interpretations, in Islamic law the woman’s life is always considered more valuable than the fetus’s life, because the woman is already embedded within existing kinship networks of sociality and obligation, whereas the fetus is not.)

In most of the interpretations of the four Sunni schools of Islamic jurisprudence, ensoulment, the joining of the soul with the developing fetus, is not believed to occur right at the moment of fertilization or implantation. Some jurists think ensoulment occurs at 40 days, while others opine that it does not occur until 4 months, the time when the pregnant woman can usually start to feel the movements on the fetus inside her. This, we speculated, would predict a lack of debate about EC’s mechanism of action in the Muslim world.

By the way, I’ve repeatedly submitted questions to several online fatwa websites, requesting a fatwa on EC. Nobody has ever responded! Next year we plan to submit a request directly to Dar al-Ifta in Egypt (the main body for issuing fatawa in Egypt) to get a formal ruling. But my colleague, Dr Hosam Moustafa, has carefully searched the Dar al-Ifta archives and not found a single existing ruling.

Egyptian archetypes of EC users
I’ve described the archetypes of EC users that appeared in US debates. What archetypes are there in Egypt? First, I should note that there really hasn’t been much public debate about the topic. A dedicated product is available in Egypt and since most non-narcotic pharmaceutical products are, in practice, available from pharmacists without prescription, there was no situation where Egyptians publicly debated the appropriateness of EC being available without the mediation of a physician, as there was in the U.S. and many other countries.

Nevertheless, there seems to be a widespread assumption that emergency contraception will be used by women who are engaging in illicit, premarital sex. In short, EC has “the reputation of being used by teenagers and prostitutes,” as one informant put it. Why? As the same informant said,

“Pregnancy? Is this emergency? It is just a normal result. When will it be an emergency? When it is really negative with the sexual relation. This happens only when the sexual relation is not an accepted one, I mean haram [i.e. forbidden, illicit].”

The assumption is also that people who are having sex within a proper marital relationship will be able to plan their contraceptive use properly, so there won’t be accidents and emergencies – and if they accidentally get pregnant, well then that’s a gift from God, not a disaster.

The advertising used to promote Contraplan II (the dedicated brand of EC available in Egypt) works hard to dispel this association between EC use and illicit sex. The promotional materials published in major Egyptian newspapers in the last year suggests a list of likely EC users:

- People who are regularly using contraceptives but they missed a dose, a condom tore, or they had a problem with their IUD;
- People who had sexual intercourse without protection and the husband and wife don’t currently want to get pregnant;
- The husband suddenly returns from travel or from work abroad and there was no time to get started on a regular contraceptive method before they had sex; and finally,
- In case of rape.

The language makes it clear that most users will be married couples, with the rare exception of sexual assault.

But the marketing strategy of the company belies this portrait of the respectable married EC user. The radio ads promoting the product aired on Nogoom FM (“Stars FM”), a radio station that is directed towards teens and young adults – who are not likely to be married. The strategy seems to be to publicly put a respectable face on EC use, but to simultaneously make sure that info circulates amongst the community where need for EC is most acute: unmarried people who have sex.

OK that’s enough info on EC in Egypt. Next up, Viagra soup – but I’ll come back to EC in a later post when I write about our methods and the different kinds of info that a team of a female American anthropologist and a male Egyptian small-town physician are able to get…

References:

Foster A, Wynn L, Rouhana A, Polis C, Trussell J. Disseminating on-line reproductive health information in Arabic: Results from a survey of users of an emergency contraception website. CyberOrient: Online journal of the virtual Middle East. April 2006

Wynn L, Foster A, Rouhana A, Trussell J. The politics of emergency contraception in the Arab world: Reflections on Western assumptions and the potential influence of religious and social factors. Harvard Health Policy Review. Spring 2005; 6(1):38-47.

Foster A, Wynn L, Rouhana A, Polis C, Trussell J. Reproductive health, the Arab world and the internet: usage patterns of an Arabic-language emergency contraception website. Contraception. Spring 2005; 72;130-137.

I promised that the next post would be about emergency contraception in Egypt, but I couldn’t resist first writing about EC more generally and describing debates about EC in the U.S.

From rape treatment to mainstream contraception

For more than four decades, medical researchers have known that there are methods you can use after sex to prevent – not terminate – pregnancy. Emergency contraception (EC) was first researched in the 1960s by physician-researchers trying to find a way to prevent pregnancies in survivors of sexual assault. They experimented in giving rape survivors high doses of regular oral contraceptive pills (OCPs). Later it was established that inserting a copper-bearing IUD after sex was even more effective at reducing pregnancy risk.

Remember that this was during the pre-Roe v. Wade era so there were political reasons for looking for a way of preventing pregnancy, rather than expecting to be able to resort to abortion, for women who got pregnant after sexual assault. But of course there are also enduring religious and public health reasons for wanting to find ways to prevent pregnancy, rather than end it with abortion.

Increasingly, knowledge about this contraceptive technique filtered out to a wider public and in the 1970s through the 1990s, there was an underground movement of women and doctors spreading the word about do-it-yourself emergency contraception. You just take several pills from a regular pack of birth control pills within 5 days after sex.

(There’s a website run by Princeton University’s Office of Population Research that tells you exactly how many pills to take depending on what brand of Pill you’ve got, and as far as I can tell, this website was actually the first health information website on the Internet.)

Even though this form of contraception has been known for decades, it’s only in the past ten years or so that emergency contraceptive pills (ECPs) have become more widely known and marketed as a contraceptive option for all women, not just rape survivors. There’s been a global movement to introduce “dedicated products” worldwide and to lobby for them to be made available without prescription. (A “dedicated product” is when emergency contraceptive pills are packaged and marketed specifically for that purpose. Activists have long argued that this is an important improvement on the DIY culture of cutting up packets of pills because it increases awareness of EC and lends the method popular legitimacy.)

EC is an intrinsically liminal technology

I spent 5 years or so following debates over EC in the U.S., before I decided to look at EC in Egypt. I think there are three curious properties of EC and EC users that make this a particularly interesting technology to study.

1. To paraphrase Victor Turner, EC is “betwixt and between.” Classified as a contraceptive, but used after sex, it is often confused with medication (aka medical) abortion. The hormonal version consists of higher doses of the same drugs used in regular daily oral contraceptive pills. Another version of EC that has been tested (but is little used outside of China) is mifepristone, the same drug that is used to induce early abortions (also known as RU486 or the “French abortion pill”), but at a much smaller dose than what is required to terminate a pregnancy.

These properties contribute to EC being imagined as simultaneously more than a contraceptive and less than an abortion. This makes EC particularly fertile ground for debate and contestation. During U.S. debates, there were a lot of attempts by opponents to classify the method as an abortifacient, not contraception, even though medical authorities define it as a contraceptive.

2. Another reason why this technology is ambiguous is because its mechanism of action – the way it works inside the body to prevent pregnancy – is hidden from view and essentially unknown. Scientists postulate that that EC may work through three mechanisms: inhibiting or delaying ovulation, preventing fertilization by altering the tubal transport of sperm or egg, or preventing the implantation of a fertilized egg in the uterus. It’s the last possible mechanism of action that is fiercely contested, because even though medical authorities define pregnancy as beginning with implantation, some religious interpretations define the beginning of life at fertilization.

But basically no one knows for sure. You can prove a post-fertilization effect of EC either way, because there is no clinical evidence in humans that can either prove or disprove whether EC actually might have a post-fertilization effect. Why? Basically because you can’t figure this out without cutting up women. There are studies in the monkey and the rat (that show no post-fertilization effect), but the extent to which these can be extrapolated from to describe what’s going on in human reproductive tracts is unknown. So the chance that EC has a post-fertilization effect can only be statistically modeled and indirectly inferred. It is this peculiar characteristic of EC that further lends itself to imagination about the inner workings of a woman’s reproductive tract when the medication is taken.

You can see this in the public hearing the FDA held when considering whether to make ECPs available over the counter or not. First, consider the testimony of Carole Ben Maimon, the CEO of Barr Pharmaceuticals:

“Plan B works like other progestin-only oral contraceptives and prevents ovulation. Plan B is an oral contraceptive, not an abortion pill. The direct evidence is highly in favor of the fact that the primary mechanism of action, if not the sole mechanism of action, is prevention of ovulation.”

She was clearly at pains to make the point. NOT AN ABORTIFACIENT. In contrast, here’s what Judie Brown, the president of American Life League, said in her testimony:

“Emergency contraception, first of all, is not contraception. So-called emergency contraception can by definition abort a child before that child implants. A human being beings at conception, not implantation. …If a human zygote cannot implant, he or she will die. This means that the pills act to prevent pregnancy by aborting a child…”

3. The third characteristic of this technology to consider here is that we don’t know much about EC users. There are structural reasons why there are very few qualitative, in-depth studies of the characteristics of users of EC. With many medical technologies, access to the technology is mediated through a specific point of entry into medical bureaucracies, and researchers can take advantage of this to study users of the technology. So if, say, you want to study people using in vitro fertilization (IVF), you stake out an IVF clinic and find a cooperative doctor that will let you talk to her/his patients. But with EC, there’s no one easily identified point of access. Some women go to their doctor to get it, but it’s not like there are doctors who specialize in EC like there are with IVF. You can get it from your family physician or from your gynaecologist. Some women get it straight from a pharmacist. Other women borrow a friend’s pack of pills and cut it up.

That’s part of the reason why it’s hard to find people who are using it. The other is that use is relatively rare. An individual woman’s need for EC is predicated on non-consensual sex or a contraceptive accident, so it’s unpredictable. Many women have never used EC. There have been a few large scale demographic studies of user populations, but very little qualitative description of the sexual and contraceptive experiences of individual users.

The result has been a great deal of speculation about the characteristics-and morals-of women who use (or need) EC and the men they had sex with. The debates about making EC available over-the-counter revolve around the imaginations of users: who is using it, who they’re having sex with, and why they need EC. Basically, in the FDA debates over EC, 2 poles of sexual behavior were theorized:

1. An exploitative male sexual predator, either a teen playboy who will use access to ECPs to convince women to engage in unprotected sex, or an adult sexual molester who will administer the pills to his victims to cover up his crimes. In this imagination of EC use, women are cast in the role of weak sexual gatekeeper whose ability to say no will fall apart in the face of new technologies.

Consider, for example, the testimony at the FDA hearings from Robert Marshall, a state legislator from Virginia. He said:

“One name that should be on this NDA [New Drug Application] is Hugh Hefner. Playboys, adolescent adult males are going to be the primary beneficiaries of this.”

Or Susan Crockett, a pro-life Bush-appointed representative on the FDA advisory board reviewing the EC application:

“Making ECs available would be a welcome tool for adult sexual predators who molest family members, children of friends or students. They could keep a stash in their bedroom drawer or their pocket to give their victims after committing each rape.”

2. The other archetype of EC user advanced at those FDA hearings was the image of a responsible, condom-using woman in a committed relationship with an equally responsible man. Eight members of the National Organization of Women (NOW) spoke at the FDA public hearing describing their own personal experiences using EC after consensual sex. In those accounts, 6 described a contraceptive failure, and 6 described the women being in a committed sexual relationship.

Btw, Kimala Price has a great piece in Anthropology News discussing these archetypes and mythologies of EC users.

In considering the kinds of sexual encounters that are portrayed as typical in this debate, it’s also interesting to consider what portrayals of sex are *absent*. First, there’s no mention of non-heterosexual, non-penetrative sex, but we’ll bracket that off since this is a debate about contraception. Also absent is any depiction of:

● Consensual sex under the influence of alcohol, or
● getting “caught up in the heat of the moment” – i.e. no contraceptive used in the first place.

Much of the testimony from the NOW representatives described needing EC after a condom broke, but what about people who have sex without a condom in the first place? Don’t they have the same right to contraception as women who use condoms?

Incidentally, research strongly supports the idea that neither of the two poles of hypothetical sexuality portrayed in this debate are the face of “typical” American sexuality or, especially, of unintended pregnancy. A lot of people have consensual, unprotected sex, and these are the people who are overwhelmingly those who end up with unintended pregnancies.

But note that also absent in these two polar versions of the archetypical EC user is the possibility that women might be the exploiters, rather than men. The highly gendered portrayal of sexual encounters in the anti-EC position is revealed if we try a little thought exercise: can we imagine an alternative scenario in which the roles are switched? Imagine an older woman, figuratively hopping with STDs, who is trying to seduce a younger man into having sex without a barrier contraceptive by whispering into his ear, “Don’t worry, baby, you won’t be stuck paying child support payments for the next 20 years – I’ll take Plan B tomorrow morning.”

So that’s what EC debate has looked like in the US. What about elsewhere?
Debates over EC have taken strikingly different forms in the different countries in which it has been introduced, shaped by the social, cultural, religious, and political contexts. For example, in Latin America and Catholic-dominated countries, debate has often centred on EC’s mechanism of action and the moral status of a just-fertilized egg. In contrast, in most of the Muslim world, mechanism of action has not been a key issue, in part because of Islam’s very different religious interpretations of when life begins.

Now that I’ve set the stage by describing what EC is and why it’s such fertile ground (no pun intended) for societies to debate sexuality morality and when life begins, in the next posting I’ll talk about emergency contraception in the Arab world and in Egypt.

–
In this post I’ve summarized work I’ve done with several colleagues: Angel Foster of Ibis Reproductive Health, who is both a medical anthropologist and a physician; James Trussell, the director of the Office of Population Research at Princeton University; and Joanna Erdman, a legal scholar who is the co-director of the International Reproductive and Sexual Health Law Programme in the Faculty of Law at the University of Toronto.

Further reading:

1. Wynn LL, Trussell J. The social life of emergency contraception in the United States: disciplining pharmaceutical use, disciplining women’s sexuality, and constructing zygotic bodies. Medical Anthropology Quarterly 2006;20:297-320.

2. Wynn LL, Trussell J. Images of American sexuality in debates over nonprescription access to emergency contraceptive pills. Obstetrics & Gynecology 2006;108:1272-1276.

3. Wynn LL, Erdman JN, Foster AM, Trussell J. Harm reduction or women’s rights? Debating access to emergency contraceptive pills in Canada and the United States. Studies in Family Planning. December 2007; 38(4):253-267.

Some interesting paradoxes to contemplate:

• Why are there at least a dozen local brands of sildenafil available from Egyptian pharmacies, and “Viagra sandwiches” or “Viagra soup” is on the menu at almost every restaurant that specializes in seafood, but there is only one brand of emergency contraceptive pill in Egypt, which is sold by an NGO because it’s not considered commercially viable enough for the mainstream pharmaceutical companies to bother with it?

The tap in the bathroom of the apartment where I stay when I’m doing research in Egypt. My roommate and I have often wondered where these came from. Was it a marketing campaign by Pfizer during the era when they weren’t allowed to engage in direct-to-consumer advertising for their product? Or did some sink manufacturer just think it would be cool to put Viagra on the handles?

• A number of studies show that induced abortion (as opposed to “spontaneous abortion” aka miscarriages) is quite common in Egypt; one carefully designed study showed that there are probably as many per capita abortions in Egypt (where abortion is prohibited unless two doctors certify that it’s necessary to protect the health of the mother) as there are abortions in the United States (where it is constitutionally protected but often restricted). Misoprostol, a medication used to treat ulcers, can be used very effectively to induce early abortion, and it’s readily available without prescription from pharmacies in Egypt. Yet preliminary research suggests that its abortifacient properties are virtually unknown to Egyptians. It’s super cheap, and a lot safer than illegal surgical abortions. Women could induce abortions themselves for a few dollars, but instead they risk their future fertility, their health and their lives having unsafe abortions, or they pay huge sums of money to have illegal surgical abortions performed by qualified doctors outside of regular office hours. Why?
  .
• A recent fatwa (a ruling of Islamic jurisprudence) by a leading Egyptian jurist holds that, under certain circumstances, it’s OK for a woman to have surgery to repair her hymen before getting married, to hide the evidence of premarital sex. This fatwa is somewhat controversial, but the person who pronounced the fatwa is no rogue; he’s a highly respected cleric. So if one Islamic authority says it’s OK, why is hymenoplasty not taught in Egyptian medical schools, and why do physicians get nervous or angry when you ask them about it?

I think these are really interesting questions. I’m especially interested in the links between religion and medicine: Like how does the interpretation of a technology by Islamic jurists influence whether something appears on the medical curricula? And when experts in Islamic jurisprudence are asked to provide a ruling on a new technology that they know nothing about, how do they educate themselves about that technology in order to be able to make a ruling about its permissibility in Islam? Who do they go to for answers? Do they go online (like I do)? Do they consult local doctors? International experts?

Beyond the scope of expertise, it’s important to consider what people actually do, sexually and contraceptively, and what extent they are influenced by expert opinion. What about people whose sexual and reproductive lives defy religious codes and cultural norms? What about Christian Egyptians? How do they use these technologies, and do they care about formal religious opinions about these technologies? What about unmarried women who are sexually active? What do they think about expert opinion, how do they navigate fatawa (plural of fatwa) and medical bureaucracies to prevent a pregnancy, or terminate one, or hide evidence that they aren’t virgins when they marry? Things like emergency contraception, medical abortion, and hymenoplasty are technologies that can be used to disguise evidence of non-normative sexuality, and the stakes are particularly high for women, as it is primarily women who bear the consequences of extramarital sex in Egypt – as elsewhere in the world.

But I’m still struggling with the *why* of this research. Why is this important to study? I was at a dinner party a few months ago with some physicists and I was talking to Professor Ewa Goldys who asked me about my research. Ewa is a big grant-getter in the Physics Department at Macquarie. She listened politely while I talked all about these titillating topics – sex and drugs and abortion and fatwas – and then she said, “But why does this matter? Why is the research important?” I was like, “Because it’s interesting. Duh!”

Unfortunately I have to provide a better answer than “it’s interesting” to get a grant for this research (right now I have a small grant from my university but I’m angling for a big national research grant). So I’ve been thinking about how to frame this as Really Important Research. Maybe someone can help me? Obviously there’s a public health case to be made about women’s health, fertility, and morbidity. And yes, the subject matter is inherently interesting, because it’s fundamentally a story about sex, science, and religion.

But what’s theoretically interesting about this? Yes, religion and medicine mutually influence each other, but that’s hardly a cutting edge insight for medical anthropology. I can say that the project hasn’t been much done before. There’s no work on EC in Egypt, very little written about erectile dysfunction drugs, and not much on hymenoplasty. There have been some fantastic anthropological studies of reproductive health technologies (RHTs) surrounding normative sexualities in Egypt, like Marcia Inhorn’s work on IVF for married couples, but very little work on RHTs that are popularly associated with non-normative sexualities, i.e. for people having extramarital sex. But just saying that “I’m writing about something new” doesn’t get you grant funding.

This is an ongoing project, so any suggestions or criticism are most welcome. You don’t have to know much at all about Islamic jurisprudence or reproductive health medicine to have anything interesting to say about the topic, because the technologies I’m researching are all over the news in the U.S. and elsewhere, and I’m particularly interested in comparative perspectives. Is anyone out there looking at these technologies in other parts of the world?

Next post my Egyptian colleague Dr Hosam Moustafa will join me and we’ll write more about emergency contraception, aka the “morning after pill,” in Egypt. Then we’ll cover erectile dysfunction drugs, medication abortion, and hymen reconstruction surgery. Stay tuned…

The other thing i like about it is that it is a specialized scholarly blog; that’s something i’d really like to see more of because it gives me hope for the future of the field to see people openly and enthusiastically sharing ideas, research, new finds and new theories, rather than squirreling them away in the hopes of being first, and honor that seems increasingly less important.

Joy.

http://neuroanthropology.wordpress.com/

Linking, for the first time, causes of death to specific weights, they report that overweight people have a lower death rate because they are much less likely to die from a grab bag of diseases that includes Alzheimer’s and Parkinson’s, infections and lung disease. And that lower risk is not counteracted by increased risks of dying from any other disease, including cancer, diabetes or heart disease.

As a consequence, the group from the Centers for Disease Control and Prevention and the National Cancer Institute reports, there were more than 100,000 fewer deaths among the overweight in 2004, the most recent year for which data were available, than would have expected if those people had been of normal weight.

One expert, a Dr. JoAnn Manson from Brigham and Women’s Hospital in Boston, comments critically that “Health extends far beyond mortality rates… [The public needs to look at] the big picture in terms of health outcomes.” However, that’s what Health at Any Size advocates ave been advocating for year, rather than the simple-minded focus on BMI sorting people into “overweight” and “underweight” categories and automatically assuming these were “unhealthy” — and that the “normals” were “healthier”.

This new report gnaws at the seams of this construction, calling into question the meaning of normalcy and healthiness; although Dr. Manson and her “fat is bad” family are correct that some people experience quality of life issues (another huge construction), many don’t other than people — including doctors — pointing at them and yelling “fat bad, skinny good, you ugly and lazy and nasty”! Meanwhile, I think most people would rather not die this year, and would consider dying to be a sign of poor health (and something that also has some quality of life issues…).

‘Biosocial’ is a new word, but its pedigree, although brief, is the best. Paul Rabinow, the anthropologist of the genome industry, wrote about ‘biosociality’ in 1992. He invented the word partly as a joke, to counter the sociobiology that had been fashionable for some time.

Hacking’s piece is an essay, and something of an exchange (Rabinow has put Hacking’s memorable phrase ‘representation and intervention’ to good use over the years) — so it doesn’t get bogged down in too many details. The main gist is that while sociobiology is out, the social fact of biology is in: reflexive genetic knowledge is more and more shaping the way that people imagine themselves and their relations. He touches on new developments in the science of ‘race,’ developments that my friend Duana Fullwiley calls ‘the molecularization of race.’ And he mentions Beck (‘risk’) and Fukuyama (‘transhumanism’) on the human future. The essay ends with a thought provoking vignette:

Last year, I agreed to give a talk for an adult-education series run by a good university department. Its main customers are alert retired people. The format was monthly discussions on the topic of ‘the person.’ My title was “People and Cyborgs.” When I arrived, the organizers were astonished to see a far larger audience than usual. Many of the newcomers were not in their seventies but in their thirties–well-dressed, courteous, but, well, different. The man whose job was to keep the event running smoothly happened to be a gay friend. I thought he might know who the newcomers were. “No idea,” he said quietly, “but perhaps they are from the liberal community.”
…After quoting Fukuyama, I then asked the people in the room, “What do you think is the most dangerous idea around today?” I received the expected answers from people my age: genetically modified food and so forth. Then a young woman said very quietly, “The idea that we should not evolve.” I would have said she was an impeccably groomed woman of about thirty, of Chinese ancestry, her accent standard Ontario well-educated. I ought to have been prepared, for I had given a more highbrow talk with a similar theme in Montreal a few weeks earlier. There, a young black man asked me very strong direct questions in standard educated French. I was later told he was an officer in the local transhumanist society.

As the discussion proceeded with various members of the audience, the penny dropped more slowly than it should have. Half the population in this audience already knew all about transhumanism. ‘Cyborg’ had been my unwitting bait. Moreover, a fair number of them had chosen their identities–in some cases, perhaps only for the day. I, the bland permissive liberal, became more and more uncomfortable. I realized how much I depend on knowing to whom I am speaking. I had no reason to think that the respondent was female, thirty, or Chinese. Yet, I wanted to know ‘who’ she was–and the same for a number of others.

But they were rejecting that question. Refusing to choose a society or a biology, they were denying in every gesture the very concept of a biosocial identity.

The book recounts the 1992-1993 cholera outbreak that killed some 500 people, mostly indigenous, in eastern Venezuela’s Orinoco River Delta. The disease had been absent from Latin American for nearly a century. Cholera can kill healthy adults in as little as 12 hours and can make a 15-year-old appear geriatric, Briggs and Mantini-Briggs note in the book, but is prevented easily by the provision of uncontaminated food and water and is easily treated.

… The book draws from hundreds of interviews conducted from 1992-1999 with people from a cross-section of ages, occupations, social positions and degrees of bilingualism in the delta region, and the Venezuelan capital of Caracas. The authors recorded the stories of medical personnel, journalists, families of those killed by cholera, disease survivors, community leaders and government officials, traditional healers, missionaries, and others.

… In November 2006, [Charles] Briggs won the Edward Sapir Book Prize, the highest award in linguistic anthropology for co-authoring [with Richard Bauman], Voices of Modernity: Language Ideologies and the Politics of Inequality…

Earlier on Savage Minds, I asked about contemporary shifts in the symbolism and sociality of HIV/AIDS — a global epidemic. The question concerns me as someone who found himself along with other members of ACT UP, in the early mid-90s, in places like the parking lot of the Astrodome yelling at delegates to the Republican National Convention about funding for healthcare. It concerns me as someone who, in the late mid-90s, was employed as a professional ethnographer (!) tracking social knowledge related to sexual risk in San Francisco. These days, I am interested in the meaning of HIV and the ways in which that meaning is mediated and manifested specifically through what might be called technologies of public persuasion, whether they are relatively complex, such as social marketing campaigns (on the left above), or fairly simple, such as political protest posters (on the right).

A pointed exchange of sorts in the pages of Anthropology News last fall highlights the role that anthropologists are playing in ongoing efforts to respond to–and shape–the HIV/AIDS epidemic and its meaning today. An initial article (read: puff piece) lauded the research of Ted Green, who has worked closely with the Bush administration on its AIDS strategy. Green has embraced ‘risk elimination’ programs for HIV prevention — especially those that (according to Green) primarily prioritize abstinence and partner reduction over condom use and education. By his own account, this represents a paradigm shift in thinking on HIV prevention:

Green believes that the transformation of his maverick and unorthodox ideas into official US policy has been nothing short of groundbreaking.

The article works hard to place Green gingerly in between ‘fashionable academic anthropology’ and the conservative government he apparently works with quite closely, despite being a Democrat (we read of him on a private trip to Africa with CEOs of major pharmaceutical concerns and top Bush administration officials). Green sees Uganda’s famous ‘ABC’ approach as reflecting an ‘indigenous’ Ugandan response to AIDS, and apparently he emphasizes the need for HIV/AIDS agencies to take into account local perspective(s). His political party affiliation notwithstanding, Green’s research is embraced by the right wing of the political spectrum.

Douglas Feldman and Tom Boellstorff each published sharp letters in response to the AN piece.While Feldman details the failures of Bush’s policies, Boellstorff criticizes Green’s notion of ‘risk elimination’ and his simplistic model of indigenous point of view. Boellstorff writes:

Green’s notion of ‘indigenous prevention models’ is rooted in an incorrect understanding of cultural relativism. The notion of ‘the indigenous’ upon which Green relies, and which was disproven by ‘fashionable academic anthropology’ a couple decades ago, presumes a singular ‘indigenous perspective’ and ignores inequality and culture change. What if the supposed ‘indigenous worldview’ is that women are inferior, or homosexuality a foreign import? What appear to be ‘indigenous worldviews’ may be shaped by colonialism, reflecting the values of, say, Victorian England.

As it happens, the question of ‘indigenous’ models for prevention is on the minds of the gay men of San Francisco. A risk reduction strategy known locally as ‘serosorting,’ a prevention model that ‘organically’ emerged within SF’s gay sexual subculture, has received the imprimatur of municipal health authorities. Serosorting consists principally in sex partners disclosing HIV status and then sticking to partners of the same status. One of the main reasons for this ‘sorting’ is so that men can engage in what is known as ‘unsafe’ sex while reducing the actual risk of transmission from a positive man to a negative one.

Here, indeed, is a paradigm shift in prevention. Boellstorff and Feldman intimate that Green’s (and by extension, the U.S. government’s) picture of Ugandan policy performs a problematic slippage between local (‘Ugandan’) emphases and U.S. derived conservative imperatives, so that what Green trumpets as ‘groundbreaking’ prevention is actually U.S. conservative ideology in disguise. But in San Francisco, a government agency is openly embracing local forms through which people negotiate risk. The idea is not without it’s detractors. I bullet some considerations:

• In the U.S., efforts are underway nationally to ‘normalize’ HIV and HIV-testing. Health agencies and companies are looking for ways to streamline testing so that more people will get HIV tests, resulting in greater awareness of sero-status and therefore more informed decision making with regard to sexual risk. Last year, Washington, D.C., authorities announced a plan to get all residents over age 14 tested. Last year, San Francisco authorities briefly rescinded the requirement that city clinics obtain written consent for HIV tests. (The requirement was later re-affirmed.)
• Continued federal funding for state administered AIDS programs under the Ryan White Care Act was tied to the surveillance of infected individuals through “names reporting.” In order to obtain federal funding for AIDS care, states were and are forced to abide by the order that the names of those who get an HIV+ test result are reported to the CDC. AIDS agencies that had previously strongly opposed such measures were forced to reassess their stances.
• The California Supreme Court ruled in July that a person may be held liable in civil court for infecting someone even if s/he did not know at the time of the encounter that s/he was positive. In a complicated decision positing the existence of ‘constructive’ (versus ‘active’) knowledge of infection, the court argued that anyone who had ever engaged in high risk sex should, essentially, know and reveal that s/he could be a carrier on the basis this sexual history or else be held liable for possible transmission.
• The AIDS crisis became newly fashionable, as celebrities, fashion designers, musicians, corporations, and others took up the cause of the epidemic in Africa. It became possible for wealthy white Westerners to appear in awareness advertising proclaiming, “I AM AFRICAN.” It became possible to imagine that using a red American Express charge card was an act of empathetic human kindness:

These are just big developments that spring to mind — I’m sure there are others and I invite commentary.

If every articulation of knowledge also entails the exercise of power, we here have a set of knowledge-power relations fraught with an exceedingly complex tangle of interests, motives, fears, desires, each of them imaged and elicited through sophisticated semiotic technologies (laws, television ads, fashion, hyperlinks). Knowledge of HIV-status might be positioned as a form of self-care for a community under siege, an ethical imperative that promotes both health and eroticism. At the same time, however, knowledge may come at the expense of increased surveillance. ‘Normalization’ of HIV testing — and the dictate that one know oneself as a subject of HIV (regardless of status) — has all the marks of what we have so fondly come to understand as ‘governmentality.’ Persons emplace themselves on a leveling grid (the postive/negative diagnostic) that subsequently structures their rights, their senses of self, their potential pleasures. Spectres of confinement and incarceration, prosecution and persecution, haunt this self-knowledge that is simultaneously state knowledge. Bodies appear both more robust (medicated) and more fragile (infected), and the lives of the marginalized are metonymized as the cause/consequence of policies that reinscribe their marginalization. Residents of Washington, D.C. are told that HIV testing is a ‘prevention strategy’ — but they are not also told that they will be guaranteed care and treatment in the event that they are sick.

No wonder that some see silence on HIV as a way of resisting, or of relaxing, the tangles of conduct and coercion (and, yes, care) that comprise positive publics. Some activists in San Francisco, for example, are calling for a moratorium on social marketing campaigns directed at gay men. And silence too is a semiotic technology, possibly even a persuasive one. Silence too may be a semiotic technology of a ruthlessly simple kind — especially in worlds where we are incited and seduced, over and over, and in manifold ways, to know ourselves through a virus.

This strikes me as a rather silly/heavy photo: Gwyneth Paltrow with face paint embracing the cause of AIDS in Africa. When I first encountered the “I AM AFRICAN” campaign, it was Brazilian supermodel Giselle making the statement. There is a news story about the campaign — designed to promote a charity that will pay for anti-retrovirals in poor countries — here. Yesterday, thumbing through GQ magazine, I saw Sting proclaiming “I AM AFRICAN,” with golden dust scattered across his face. It’s around.

Earlier on SM, I asked what kinds of persons and publics HIV (as a virus laden with meaning) summons. Here’s one: the sympathetic celebrity in ‘cross-cultural,’ possibly ‘cross-racial,’ drag. To me, this campaign echoes Kenneth Cole’s “We All Have AIDS” campaign for awareness. Some kind of shift has occured, we’re not in the 80s anymore, or even the 90s. People now *identify* with the virus, people who may or may not have it. Clearly the goal of these campaigns is to combat the stigma associated with HIV so that people might more readily get tested and seek treatment. These days, as one friend reported to me, people without HIV are even wearing “HIV+” t-shirts at international conferences. Is HIV fashionable? And what configuration of fashion/celebrity/global concern has yielded this image? What has made HIV safe for this sort of identification? What does it mean? A few more questions here: to what extent does this imagery hail a public that already has HIV in it? Is the infected public imagined to be elsewhere or is it imagined to be ‘here’? How are people with HIV addressed? To my mind these are important questions for thinking about HIV prevention because campaigns and images like this one exist in a field of messages that also includes calls to get tested and to use condoms, among other things.

In San Francisco’s legendary Castro neighborhood, year 25 of the epidemic was recognized by community organizers with a banner mounted on the side of a Bank of America building at the corner of 18th and Castro. (The same site became a make-shift memorial to Princess Diana when she died; it was also the site of a little noticed memorial to both Jacques Derrida and Rodney Dangerfield the week that they died.) Organizers created large papier mache flowers that drooped over the Castro for a week or so. But though the gay community was ‘officially’ remembering this tragic event in its history, no one I know in my clique of thirtysomething denizens of the gay ghetto actually talked about it. The flowers just hung there and then went away.

HIV/AIDS is in the public eye again, in part because of the 2006 international AIDS conference in Toronto, which just ended. Reports from the conference indicate that the big ‘Double Bill’ session, featuring two of the world’s most famous and powerful men — Bill Gates and Bill Clinton — was standing room only. News is hopeful: antiretroviral drugs have dramatically transformed the disease from a terminal syndrome to something like a manageable chronic illness. These drugs reduce fatality, they can reduce infection, and they are very expensive. Massive funding will be needed to get these medications to the people in poor places who badly need them, and these include parts of the United States. Controversy swirls around whether or not U.S. initiatives aimed at Africa are constrained by the moralistic and inefficacious imperatives of the Bush regime. The consensus appears to be that because the means to hasten an end to the epidemic are now available, there is now a collective moral burden to make these means available to those whose lives they could save.

Meanwhile, in the United States, recent developments in HIV, law, and public health may be of interest to social anthropologists, especially those who work at the interstices of government, public health, medical technologies, and kinship. Reasons are manifold (AIDS disproportionately affects marginalized people, policy sometimes depends on knowledge of sexual practices and social networks that ethnographic methods uniquely reveal, the epidemic of its very nature mobilizes complex inter-connected/sometimes fractious social relations of vastly different orders [between sex partners, between ‘North’ and ‘South’]). I am am presently trying to think through some aspects of HIV/AIDS from a social perspective. I am interested in how different kinds of persons and publics are summoned by HIV. An example:

This image is from a pervasive social marketing campaign in the United States. You can see it, and similar ads, on the sides of buses or trams, in subway stations, on billboards, all over major urban areas. This year, I noticed several of these advertisements in San Francisco that were timed to coincide with National HIV Testing day. Here is an abundantly happy couple: attractive, apparently quite in love. The ‘know’ — knowledge of HIV status — the campaign assures us, is ‘spreading,’ to my mind an unfortunate metaphor in the context of an epidemic. Who is hailed in this call to gain self-knowledge? What indeed does this couple know? What is implied about the relationship between them? What does the advertisement ask its viewers to do? What does it promise them?

In upcoming posts, I will hazard an analysis of some current U.S. HIV prevention strategies, paying attention especially to ways that they construct ‘the public’ and its good. Recent emphasis on individual HIV testing, combined with legal decisions that criminalize the transmission of HIV between persons (and that problematize the status of one’s self-knowledge in the context of HIV), raise vital questions about individual agency and community responsibility. A provocation: suppose the person who responds to the “Know HIV/AIDS // No HIV/AIDS campaign” tests positive for HIV. How will this advertisement and ones like it frame the experience, its meanings, its psychological effects, its social entailments?

In an era in which biomedical interpellation is a pervasive and over-riding fact of life, the means and meanings of medical testing bear ethnographic inspection and social reflection.