HIV, AIDS and THE PUBLIC HEALTH SECTOR IN MOROCCO (2)
Prof. Dr. Abdessamad Dialmy
University of Rabat, MoroccoI-4 Financing and performances
In order to achieve these projects, funds received from the Global Fund for the 1st year (March 2003-March 2004) of the first phase (2003-2005) was $2 271 408, 00 (Ministère de la Santé 2004). Actual expenses amounted to $1 355 258, 08. The committed but not yet remitted funds are $702 741, 44 (up to May 10, 2004). These expenses concern the social communication campaign ($391 888, 89), the bio-medical equipment and reagents ($310 852, 56), and condoms ($58 000, 00). Funds saved on the ARV and condoms totaled $208 685, 00: ARV ($118 701, 67) and condoms ($89 983, 33).
For the whole of the first phase comprising two years, March 2003 to April 2005, the grant of the World Fund rose to $3 909 772, 00. Of this sum, $3 289 060, 14 have been used effectively. The used sum was distributed between the DELM/PNLS ($2 062 243) and the six under beneficiaries: ALCS ($458 126), OPALS ($259 250), AMSED ($301 591), LM-LMST ($65 050) , AMJCS ($36 900), Secretariat of State for Youth ($106 900).
The performances of the first phase can be divided in four sections (Ministère de la santé 2005 : 42).
At the level of the prevention of the HIV infection among vulnerable groups:
- 400 peer educators have been recruited concerning HIV prevention close to the vulnerable groups (410 were foreseen). But there has been no evaluation of their functioning or effectiveness.
- 3748 sex workers and female workers received an education from the peers concerning HIV-AIDS (3400 were foreseen).
- The percentage of sexual workers that acknowledge using condoms with their last client has not been measured although this has been foreseen. Yet a survey on the street prostitution has been achieved by the ALCS in 2003 in the setting of the first phase. This survey showed that a percentage of 37% of sexual workers use the condom systematically. However, the objective of the PSN regarding this topic during the first phase is to bring 50% of the sexual workers to use condom systematically. One could suppose that this study is not mentioned by the PNLS because its performance is unsuccessful. But it is also possible that not mentioning the result of this study means that the study is not perceived by the PNLS as representative and objective.
At the level of implementation of a program of social communication targeted on youngsters and women:
- 1563 educators were recruited concerning HIV prevention close to youngsters and women (foreseen: 1969).
- 332 600 young girls of 15 to 24 years age category and women sensitized for the prevention of the HIV (300 400 foreseen).
- 61 500 young girls of 15 to 24 years and women educated for the prevention of the HIV (84 800 foreseen).
- the percentage of youngsters of 15 to 24 years that know how to prevent the HIV has not been measured. It would be measured in June 2005 (according to the report).
- 5 142 000 condoms have been distributed at the level of intervention regions (foreseen 4 000 000).
At the level of the promotion of the counseling and the voluntary HIV test:
- 37 centers of counseling and HIV testing are henceforth functional (foreseen 35).
- 1 3 067 people were counseled and tested for HIV anonymously and confidentially (11 200 foreseen).
At the level of the tri-therapy treatment:
- 1 489 AIDS patients receives an association of ARV (foreseen 1500)
- 45% of people having an advanced HIV infection receive an association of ARV (foreseen 37%).
In general, these official results are positive. They led the Global Fund to grant a second slice for the 2nd phase. The approval of the 2nd slice confirms the recognition by the Global Fund of the expanded efforts for the implementation of the program. These efforts continue to make Morocco a model for MENA region. This recognition resulted in the choice of Morocco as host country of the 8th board meeting of Global Fund to hold at Marrakech from December 12-16 2005.
This second session will present some aspects of the IEC national campaigns but will especially analyze the popular reticence and resistance toward HIV test and the use of condom. It will conclude by a brief overview on the structural vulnerability in Morocco.
II-1 IEC activities
During the period 1991-1994, the following didactic materials were produced (InfoSida 1993):
- AIDS Posters 26.000
- AIDS Info-Bulletin 30 000
- Stop AIDS Auto-tights 10 000
- Stop AIDS Adhesive 40 000
- Big Public AIDS Leaflets 369 000
- STD Leaflets 167 000
- AIDS Pins 5 000
- AIDS Short sleeve shirts 10 000
- Blood transfusion Leaflets 220 000
- AIDS Game 10 000
- Streamers 15
- Leaflets for travelers 20 000
- TV Spotlight 1
- Song on AIDS in schools 1
- Press Book 250
While television is the first information medium, these data show that only one TV Spotlight was produced on AIDS between 1991 and 1994. Unfortunately, this television spots, which was sponsored by the Ministry of Health in 1993 depicting two men playing dice, lead some people to believe, “playing dice could cause AIDS” (Chajai 2002 : 91). Coming second is the radio. Newspapers and magazines reached only 10.1% while posters reached fewer women (2.9%). According to some nurses (Dialmy 1997), STOP AIDS poster is not well understood by people. People who do not read believe that it is about cars and about campaigns against accidents. So in a society where the illiteracy rate is still high, direct contact is more effective. For this reason, a lot of nurses were sent as mobile teams to popular markets, to gather people thanks to public crier in the countryside and shanty towns. Bars and mosques were also targeted as adequate places to transmit oral preventive messages. But the dominant perspective of the nurses suggests the use of audio-visual media. Some nurses assert that with or without the belief in Islam, sex workers, STIs and HIV exist, so it is necessary to talk about them and about condom both on TV and radio.
On the other hand, education aiming at the prevention of STIs-HIV in the school manual Feminine Education is shy and contains some mistakes. To mention only an example, one affirms that STIs can be transmitted sexually, either by pollution, that is to say the common use of toilets or using unclean napkins without making clear what is transferable by pollution. The manual concludes with the following recommendation: "that the person infected by AIDS should hurry in seeking medication because the more it is done quickly, the more the chances of recovery are bigger" (Ministère de l’Education Nationale 1993: 11)! In fact, this manual has little impact and is unable to change the schooled youngsters' representations of STIs-HIV. These representations remain close to the commonsensical dominant social representations (Dialmy et Manhart 1997: 47-67), that is to say, distant enough from the biomedical knowledge. A spontaneous epidemiology and a plain etiology still make of the STIs-HIV-AIDS a social construction made at a time of scientific elementary scraps, of judgments of values, of explanations being a matter for a pre-modern medicine and magic-religious beliefs. The spontaneous epidemiology develops xenophobia, social discrimination and misogyny while the plain etiology implies four spheres of factors in the explanation of the STIs-AIDS, the cold, the debauchery, the occult, and body proximity (Dialmy 2001).
The social construction of STIs-AIDS in Morocco reflects also the dominant social misogyny. Spontaneously, the Moroccan profane man tends to affirm that women are more likely to be infected by HIV-AIDS than men. The unconscious symbolic association established between women's cold and dirt lead to considerations of women as more vulnerable and as the source of all STDs. There is one shortcoming in the extensively patriarchal social constructions: the Moroccan man occults the sexual relationship power in which women are often victims of the sero-positivity (or of the disease) of men.
To fight those social representations, the ministry of Health launched in June 2004 a national social communication campaign on struggle against AIDS and used various media to reach a very large audience. This campaign utilizes the TV, radio, press and posters. It is financed by the program of support of the Global Fund. On February 3, 2005, the third phase of this campaign began and aims especially to fight against the stigmatization and the discrimination of people living with HIV. In order to meet that objective, four posters have been made as well as televised and radio spotlights in Arabic, the Moroccan national language, and in the different Berber dialects.
The question that arises here is this: how can we measure the impact of this social communication campaign on the social representations of HIV/AIDS described above? The answer to this question requires a specific and independent investigation.
II-2 Reticence vis-à-vis HIV Testing
The first Center of Information and Anonymous Free Testing (CIDAG) was set up by the ALCS in 1992 in partnership with the Ministry of Health. According to the ALCS and the OPALS, the CIDAGs train today a big number of consultants who are permitted to know their serological statute anonymously and freely and to absolutely respect ethical rules. The CIDAGS also orient the HIV+ people toward suitable medical services.
These CIDAGs exist today in the cities of Agadir, Azrou, Beni Mellal, Casablanca, El Kelaa, Essouira, Fez, Guelmim, Khenifra, Marrakech, Meknes, Oulad Teima, Rabat, Settat, Tangier, Taroudant, Taza and Tetouan. Because the existing CIDAGs do not cover all the national territory, mobile CIDAG of the ALCS furrowed all the country during the 2003 summer campaign. Those mobile CDAGs achieved 807 HIV tests in three months. Other mobile CIDAGs occurred in February 2005 at Layoune (with 101 HIV tests), in Tiznit in April 2005 (with 146 HIV tests), in the region Sous Massa Draa (with 508 HIV tests), at Meknes (with 400 HIV tests).
These numbers, as well as those showed in the setting of the performances of the support program of Global Fund, must not conceal the reticence of the Moroccan population toward the HIV test. An indirect evidence is that the majority of the 453 seropositive people participated in the Service of the Infectious Diseases of the Ibn Rochd hospital in 2003 learned about their serological statute at random, either at the time of a medical visit or at the time of donating blood. According to a social worker of the ALCS, the 20 000 seropositive people are unaware of their statute or did not dare to take the test. The seropositivity is therefore often unconscious, unknown, what clears on a brutal passage in the state of illness. Reasons to this situation are numerous. First of all, CDAG are often not known, or if they are, they are sometimes far from the people and, therefore, geographically inaccessible. Then, for those that did not transgress norms, the HIV risk is not perceived. They do not feel concerned, perceiving themselves as normal individuals. There is also the desire for ignorance, to delay most possibly the moment of the conscious entrance in precarious state of HIV+. Finally, in a society where each still lives under the (mortal) look of others, it is difficult to keep confidentiality. To take the test means taking the risk of being stigmatized, marginalized, and excluded. The belated HIV test, when it is not the consequence of a total ignorance (of HIV infection and its transmission modes), is a way to win time against social death.
Another fact surrounding the HIV test is consent. People arrested for prostitution or homosexuality are submitted to forced and involuntary HIV test during their detention. These practices, which seem to be on the increase, are carried out by the police, with the complicity of some physicians of the Ministry of Health (ALCS 2004). Such HIV tests are done at the police station. Sources from the regional hospital of Tetuan affirmed to the ALCS that a physician and a male nurse have been called to the police station where they were asked to administer HIV tests on homosexuals arrested at Tetuan. This practice is completely illegal: no HIV test can be done without the knowledge of the individual and without his/her consent, as stipulated in the instructions of the Ministry of Health. In these instructions confidentiality is also mentioned as an inalienable right of the individual.
This fact shows how “the struggle against AIDS, disease transmissible through blood and sexual contacts, re-tie surreptitiously with social hygiene, associated with the sanitary police and the moralization of mores” (Thiaudière: 2002: 4). In fact, has the struggle against AIDS in Morocco ever overlap with social hygiene, the sanitary police and the moralization of mores? When “incidents” occur, associations like ALCS and OPALS-Maroc promote the citizen and defend the individual liberties, including those of homosexuals and prostitutes. But the conflict between the NGOs, the Ministry of Health and the police has never occurred : on the one hand, the nursing implied in this affair acted without the downstream of the Ministry of Health and its agreement, on the other hand, the NGOs ever claimed the right to homosexuality or prostitution.
II-3 Resistance to the Use of Condom
The condom is precisely an object of multidimensional resistance. Associated with sexual activity outside marriage, a supposedly immoral, dirty, and dangerous activity, the condom inherits all the negative features of this "bad sexuality". Consequently, we find the condom trebly condemned by popular opinion, by the jurist (traditional), and to some extent by the health system itself (Dialmy 2003).
For the popular opinion, extensively dominated by a patriarchal perspective, the condom is rejected because it hinders an easy and fast excitation and because it risks compromising the man in his virility. It may also prevent a complete enjoyment. The condom is also rejected because it is expensive and compromising at the time of its purchase (being tied to bad sexuality). Individuals accuse the condom of being fragile and permeable and sow doubts and distrust in couple (both conjugal and non-conjugal). The condom is often unavailable at the time of an unforeseen and circumstantial intercourse. Also, in many cases, in spite of the consciousness of risk, the condom is not used just to prove one’s courage, for example.
Among female sex workers, the majority acknowledges not being able to impose the condom on the customer for fear of losing him (Dialmy 2000). They prefer to ignore the probability that the customer could be sick or that they themselves may be sick. For them, the use of the condom serves first to protect the customer. Meanwhile, they consider themselves as already dead. Their soul is dead, they say. The customer's power and supremacy shows that “masculine domination” finds here a privileged field to express itself completely and also to ruin the woman's personality completely. This relation of domination between the customer and the female sexual worker shows how “the possibility to protect an individual is limited ... when there exists a big imbalance in the relationship” (Spencer 1992: 35-37). Female sex workers, admitting their own lack of control, “conduct” themselves with an almost mystical abandonment into God’s hands. Resigned and fatalistic, they are convinced that whatever happens to them and what can still happen to them depends on external social or supernatural strengths. Female sex worker does not have any “internal orientation of control” (Spira and Bajos 1992) and consequently cannot adopt any preventive measures. This attitude refers to a specific religiosity made of total passivity in front of the divine will. But for the sexual worker, this fatalistic attitude is beneficial. It makes her not to feel guilty, which in some sense is relaxing.
Some quantitative data, achieved by the ALCS after an investigation on street prostitution (n = 315), confirm the non-systematic and non-general utilization of the condom. “If 99% of female sex workers know the condom, only 37.6% of them reported using it with all customers. 57.9% reported that they accept intercourse without condom if the condom is not available at the moment of the intercourse. For 80.1%, the condom is perceived as a factor that makes the client move away” (ALCS 2003).
Another factor that were discouraging the use of condom among female sex workers is the police behavior as it is reported by Schuette : “up until a few years ago, if a police officer discovered a teenage girl with a condom in her purse she could be fined and apprehended. The police assume that the girl is a prostitute, based solely upon her possession of a condom. The Moroccan AIDS NGO ACLS organized two or three seminars for judges, lawyers and police on prostitution to begin addressing cultural issues such as the possession of a condom. ACLS director (Amina Chajai) reports that the situation has improved since these seminars (Schuette 2003).
Coming to the Moslem jurist (Dialmy 2000), sexual activity outside marriage is religiously illicit and it is unconceivable to think about its protection from the risks of infection by the use of condom. Recommending protection through the condom implies encouraging sex outside marriage institution. The jurists refuse here to use ijtihad, that is, the creation of new and adapted laws in the AIDS context. The sanitary protection of the non-institutional sexuality is not conceived. According to these traditional jurists, the real protection consists of the mutual conjugal fidelity and in premarital abstinence. Consequently, protection of sexuality outside marriage raises a legal problem because of the legal rejection of the use of condom outside marriage (Dialmy 2000: 207-210).
At the level of physicians and practitioners, the attitude towards prevention is ambiguous. Nurses are divided over non-discrimination, negative discrimination, and positive discrimination (Dialmy 1997: 52). Those who are for non-discrimination mean that there is difference between the STI patients and other patients. These nurses say that they do not have the right to judge a patient of immorality. On the other hand, the nurses that express a negative discrimination do not hesitate to condemn the immorality of the infected individual, her/his unconsciousness and her/his ignorance. For these, the STIs that should be avoidable are sought-after through a risky and illegal sexual behavior. Their condemnation is sometimes expressed in the name of Islam, with sex-related diseases being a kind of punishment for fornication. Other nurses consider the STI patients as an object of mercy and express a positive discrimination. Thus, they hold that STI patients should be a priority and require an educative management. For the majority of the nurses, STIs consultation is an ideal moment to immediately transmit the educational and preventive message. For them, it is necessary to exploit the fear of the sick and his/her disarray, his/her incentive to spread messages of prevention and education (sanitary and sexual). During the treatment, these nursing-counselors recommend in principle abstinence, faithfulness or the use of condom. However, nurses prioritize these instructions: the advice of the condom comes after the one of morality. Worse, the advice for the condom use is offered only in 9% of medical consultations (Ministère de la Santé 1997: 11). One notes, therefore, that recommending the use of the condom and change in sexual behavior implies two contradictory instructions: to counsel on condoms is associated with secularism and a civil sexuality while to counsel on moralization is associated with re-islamisation.
This practical ambiguousness comes from the medico-sanitary official vision. This one recommends (and distribute) the condom as a protective tool against STD-HIV but it (implicitly) recommends it as a vulgar instrument to use in a vulgar sexual relationship to escape a vulgar disease. For the health system, the condom is a necessary evil. It is a necessary bad thing for avoiding risks of a bad sexuality. The condom is said to be used for preventive ends without the adherence to the secular morals that is its main component and, which founded it (Dialmy 1997). For this secular morality, the condom is part of a permissive sex education process that recognizes the right to sexual activity for members of the two sexes even outside marriage. In recommending the condom for saving public sexual health, one indirectly recognizes the individual right to sexual health and to sexuality. However the public health system, confined by political and religious considerations, cannot assume this secular founding morals of the condom. It is, therefore, satisfied with adopting the condom as a technique devoid of sense and culture. Indeed, it can only recommend it as a tool without values because it is in a weak position in relation to the religious power. The sexual health policy is supposed to be “islamically correct” whatever the political orientation of the ministry of health and of the government. In Morocco, any political force could be non Moslem. Let's recall here that the Moroccan Islamic State’s reaction was unfavorable to chapters 4 and 7 of the program of action of the ICPD at Cairo in 1994. For Moroccan officials, all notions relating to sexuality and sexual health must be dealt with in conformity with a principle believed to be immutable in the Islamic law (the Shari’a which is also conceived as indisputable), the subordination of sex to marriage and to the heterosexuality. No right to sexual activity outside heterosexual marriage is islamically recognized. Consequently, there is an official silence on sexual pleasure in itself. For the health decision-makers, the most important function of the condom is to maintain a low prevalence of HIV infection. In doing so, the ministry of health seems to ignore that the recognition of the right to sex is a major condition to individual and collective sexual health. Such ethics is not assumed by public decision-makers of public sexual health who are mainly concerned with reaching a "religious" agreement on public sexual health programs. This goal is not difficult to achieve given the lack of a fundamental secular conviction among the majority of public decision-makers and of physicians in the public sector (Dialmy 2002). Those in nursing define medicine as a set of techniques that do not carry universal human values. This reduction of medicine to a technique leads some physicians to claim its moralization in the sense of its Islamization. Consequently, a sexuality that is supposed to be correctly regulated by Islam has also to be treated by an Islamized medicine and public health.
As one sees it, the adopted logic of prevention does not refer to an individual judged free and responsible to himself, but to a subject of God (or of the King, the commander of believers) who must remain Moslem and must respect the Moslem sexual morals.
II-4 A necessary struggle against structural vulnerability
“Where overall social and economic conditions are poor, there is a greater chance of HIV spreading” (Jenkins and Robalino 2003: 42). That is the case in Morocco where the poverty level is increasing, developing to 19% in 1998/1999. The World Bank estimates that 10 million Moroccans live below the threshold of poverty. According to the national figures, Morocco had 5.3 million poor people between 1992 and 1999. In effect, out of five Moroccans one is poor. Poverty is more common among women, children (most of whom are engaged in trading or are living in street), the illiterate and the rural inhabitants. Rural Moroccans are worse off, representing 60% of all the poor. “This situation resulted in high levels of internal migration, with increasing numbers of young men and women searching for jobs in urban areas. While the national unemployment rate is 22 percent, the rate is 35.5 percent among youths 15 to 24 years old” (Jenkins and Robalino 2003: 43).
Measures of larger social and economic factors, such as the Human Development Index, literacy rates by gender, unemployment, expenditures on health and, as a measure of women’s health, maternal mortality, give an indication of the relative state of development in a country. In Morocco, the Human Development Index is 126. Some indicators of Development are as follows: Male literacy (62 %), Female literacy (34 %), Unemployment (22%), GDP spent on health (3,6%), Maternal mortality (230), Urban (52%). These structural factors, besides a poor and dysfunctional health care system (inadequate STIs treatment) increase overall vulnerability in Morocco.
These structural factors lead to a practical tolerance of sexual liberalism that could be observed in spite of the existence of repressive laws, which forbid all shapes of non-marital relation. Sexual liberalism is observable in the impunity of urban sexual harassment and in the rise of male and female prostitution. Indeed, the field of sexuality knows a fast evolution characterized by the emergence of anarchical sexual behaviors and practices. In a context of economical precariousness, these anarchical sexual behaviors are not informed nor chosen, they are undergone in a way that increases the HIV risk.
 But in societies where Islam isn’t the state religion like in the countries of Europe, Moslem jurists consent to legitimize the use of condom to preserve public health. It provides proof that it is possible to create new laws ( ijtihad ) even where laws and texts exist already. That is to say that the question becomes political when Islam is the main source of legitimization of the political power.
 ICPD : International Conference on Population and Development.
 227 according to the last declarations of the Moroccan Ministry of Health in 2004.