Prioritizing Risk

I worked with Annika Launiala and Marka-Liisa Hinkasalo’s article “Malaria, Danger and Risk Perception among the Yao in Rural Malawi.” I will discuss how these anthropologists are looking at the Yao community in Lungwena, Malawi and the medical anthropological perspective on their work analyzing risk perception. Describing pregnancy in Lungwena with medical anthropology means that one can assess various cultural and socioeconomic factors to reduce risks with pregnancy. The primary author, Annika Launiala, uses this perspective to look at risks to pregnancy holistically. Launiala’s study is a reminder that health is a culturally relative entity. Therefore, when trying to organize health care or aid it is vital that it addresses root issues of power. In practical use however, malaria in pregnancy as a global health issue stems from systemic problems regarding poverty and biopower.

Malaria in pregnancy:

The primary author, Launiala, initially aimed to focus on community perceptions of malaria risks during pregnancy. In actuality, however, the article mainly discusses perceptions of sociocultural risks being greater than perceptions of biological risks. The only time malaria as a health problem is really discussed is as such: an example of a biological risk. Launiala discusses gender dynamics when it comes to pregnancy and cultural perceptions of risk among this community. She also discusses how the community prioritized biological and sociocultural risks, like infidelity versus contracting an STI. As the author mentions, different biological risks defer to sociocultural risks because they are already part of everyday life. Biological risks like malaria can be dealt with to incur no social or biological adverse consequences The principle author ultimately concludes that malaria in pregnancy is not a major concern for the Yao because there are greater social and cultural risks than malaria. Even if a disease does not present much of a biological risk, like a curable STI,  it still has the power to generate huge social risk by raising questions of fidelity. This makes women vulnerable not because they are ill but because they may lose their financial support should their husbands chose to divorce them. Ultimately the danger with malaria in pregnancy is not the disease itself. The danger is the need for preventative care that accounts for “local vulnerabilities and perceived threats” rather than focusing on just curing malaria. Global health looks at straightforward cures for preventative care rather than holistic approaches that consider social and cultural effects on treatment. This article explores that topic using malaria in pregnancy as an example. While there are efforts to cure malaria and malaria in pregnancy, these efforts focus on the disease aspect. However, they do not deal with the cultural aspects of pregnancy. According the Launiala, dealing with malaria in pregnancy has been focused on treatment and prevention in specific cultural context.

Pregnancy as illness:

The principle author studied perceptions of risk of malaria relative to other risk factors. The population Launiala worked with was mainly Yao by ethnicity in the city of Lungwena, Malawi. Launiala states that “The purpose [of the study] was to gain a comprehensive understanding of the sociocultual context of managing pregnancy and malaria.” The author described how people perceived cultural relationships to the vulnerability of pregnant women. These relationships included those with witchcraft, infidelity from both partners, gender dynamics, diseases other than malaria, and poverty. Topics that were discussed in depth were perceptions of the severity of STIs and HIV/AIDS in particular. The author then discussed the effect of poverty in accessing treatment and sexual interactions. Launiala’s data supports that pregnancy induced certain behaviors from women who did not want to incite malevolent spirits or nearby witches. It also invoked cultural knowledge about certain marital behaviors. Infidelity from either partner is culturally believed to complicate or ultimately harm a pregnancy. However, the author points out that extramarital relationships on the husband’s part are common in Malawi but it is ultimately the woman’s responsibility to protect herself from sexually transmitted diseases. 

Medical anthropological perspective and WHO focus:

I thought this article was fairly well rounded from a medical anthropology perspective. Launiala already wrote it from one. She is focusing on a community and their relationship to a health problem. However, she looks at it from cultural as well as biomedical perspectives. She also doesn’t look at just access to biomedical treatment but attitudes towards risk management and societal factors to sickness. For anthropologists and care providers, the key to treating malaria in pregnancy seems to be treating changing its priority of risk relative to other diseases as well as giving pregnant women the agency to prioritize their health. According to the author, the WHO focuses on providing treatment for malaria and not much else. WHO’s focus, as well as other NGOs focus on providing treatment and prevention. While this is necessary, the author also stresses the need for anthropologists and all social scientists “to go beyond simplified measures of knowledge, attitudes and practices and incorporate sociocultural context, recognition of illness, perceived severity and susceptibility, perceived benefits, risks and capacity for action, and availability and accessibility” (414). Indeed, the WHO report focuses on malaria prevention throughout a population and in children under 5 years old. Even here, the data seems to focus on access to antimalarials and sleeping under an insecticide treated net (ITN). Though malaria is one of the most prioritized disease causes worldwide, there is no data in the WHO World Health Statistics regarding malaria risks in pregnancy. However, the WHO report does talk about poverty affecting areas that are geographically already prone to malaria. The WHO’s suggestion for dealing with this issue is by pushing international funding for these areas to increase awareness and provide access to health care. It addresses issues with healthcare that stem from economic access, but makes no mention of sociocultural perceptions of malaria. However, the report is also aware that funding should not be conflated with access:

“With very low levels of funding, countries cannot ensure universal access to even a very limited set of health services. On the other hand, higher levels of funding might not translate into better service coverage or improved health outcomes if the resources are not used efficiently or equitably.” (World Health Statistics Report 2012, 42)

Concptual analysis:

Biopower is at play here. The men in this society have disciplinary biopower in the sense that the patriarchal societal norms remove a woman’s ability to protect her body from STIs. According to Launiala, AIDS is considered a bigger threat in Malawi because AIDS has no cure. Yet regardless of this, condom use within a marriage is societally discouraged because its implications in female infidelity. For the sake of financial and community support, women were willing to put themselves at risk for the disease they considered the most severe and dangerous. Here, it is where the men of Lungwena have the power to constrain the agency of their wives, both over her body and her means of living. It is also interesting to remember that participants in this study also included malaria as one of the most dangerous diseases to contract in a biological sense. In fact, some respondents to the study said that all the discussed diseases in the study were just as dangerous to one another. However, intersections of societal risks and ability to cure a disease created higher perceptions of overall risks in diseases like HIV/AIDS and STI’s in general. Though malaria was certainly considered a dangerous disease, it was only considered a high risk disease if untreated. Then there was the notion of vulnerability in regards to witchcraft and extramarital relationships. It is believed that witchcraft or malevolent spirits can be dangerous for the mother and unborn child. It is also believed that infidelity from either side of the relationship can harm or terminate the pregnancy. These beliefs enforce a set of proper behavior needed to avoid danger from malevolent magic. Here, biopower is wielded in its regulatory model. By the cultural politics of Lungwena, men are not supposed to be having extramarital sex. This is for the interest of the wife and baby and out of expectations as a  husband to help produce children.  The women listed STIs and HIV/AIDS as most dangerous to a pregnant woman. It was interesting because the assessed these dangers bacsd on the ability to cure the disease, severity of the disease, and treatment. Malaria exposes the pregnant woman to biological risks that she can control by going to a clinic. However, when it comes to STIs and HIV/AIDS her agency is limited because challenging how she contracted these diseases is a social risk that is greater than the biological risks. She can get antimalarial drugs if she needs to with no social repercussions. She cannot divorce a husband because of financial needs. This is because it suggests infidelity on the mother’s side and could risk divorce. “Although it may not be a conscious choice made by women in Lungwena, this ethnography depicts how a pregnant woman ends up accepting immediate disease ans medical risks…rather than placing herself at social risk of being divorced by her husband, losing support, and even being cast out by her family and relatives because of  HIV- related stigma” (412)

Practical changes to risk:

I don’t know how much could change in this medical system without first making huge changes to political, financial, and health system infrastructure. According to the WHO report, Malawians pay very little out of pocket for their health care expenditures. Launiala’s data seems to echo this. The main cost is usually that of acquiring transportation. So while it’s good that the Yao don’t have to pay for necessary health costs that they couldn’t afford anyway but not all that helpful if they cannot access those resources when necessary. Part of medical anthropology is understanding how power affects the health and healthcare systems that affect communities. Here it is the effect of poverty on biopower. Women in this community need to get married and have children in order to cement social capital and to support themselves with husbands. However, because of prohibitive transport costs, most of these women cannot access emergency healthcare when necessary. Then there is further restriction of agency when it comes to protecting the health of the mother. Though there are cultural restrictions regarding infidelity, it is generally understood that it happens anyway, usually with the husband of a relationship. Therefore, women can’t even protect themselves from STIs in this community because their husbands cheat, contract the infections, and women are culturally expected to have sex with their husbands. However, to ask the husband to use protection isn’t even an option because it raises suspicions that the woman is the promiscuous party. Then it puts the women at risk of divorce, which in this community, carries too high a risk of financial ruin. All these factors need to be considered instead of just throwing money at these communities. Again, the problem here is not actually malaria, it is risks associated with pregnancy.

Solutions in agency:

The primary author, Launiala, initially aimed to focus on community perceptions of malaria risks during pregnancy. In actuality, however, the article mainly discusses perceptions of sociocultural risks being greater than perceptions of biological risks. While I thought this was a unique article to address malaria specifically in pregnant women, I didn’t think it was a very effective article explaining what it set out to do. From an anthropological standpoint, I don’t think there was anything very new about this article; many cultures practice cultural restrictions to protect pregnancy. People in many cultures go through pregnancy in extreme poverty. However, Launiala’s work was a good reminder of why holistic approaches to medical anthropology are necessary. What seems to be a specific problem in a community is actually one that reflects holes in systems of healthcare. Knowledge of cultural practices is absolutely necessary when dealing with global health issues. However, that knowledge cannot be used without also considering socioeconomic factors that are affecting a community. Giving communities financial aid to soothe economic problems will only help so far as communities have the social impetus to use it effectively.

- G James Keum

Works Cited

Global Heath Watch, comp. Global Health Watch 3: An Alternative World Health Report. London: Zed, 2011. Print.

Launiala, Annika, and Marja-Liisa Honksalo. "Malaria, Danger, and Risk Perceptions among the Yao in Rural Malawi." Medical Anthropology Quarterly 24.3 (2010): 399-420. Print.

WHO. World Health Statistics 2012. Rep. N.p.: WHO, 2012. Print.