PHARMACEUTICALS HAVE BECOME readily available in most corners of the world. In many developing countries, a wide range of drugs intended for use by practitioners is accessible over the counter to clients familiar enough with them to request them by name. The number of medicines known to the general public is increasing steadily as a result of interactions with practitioners (trained and otherwise), paraprofessionals (community health workers, and so on), chemist shop attendants, medicine vendors, and exposure to medicine catalogs. With the increase in information about medicines has come misinformation and unrealistic expectations. This has compromised public health by contributing to practices that lead to drug resistance, delays in the consultation of doctors, and a false sense of security that has fostered behavior recognized as risky. A central research focus of medical anthropologists who study pharmaceutical practice is how medicines are appropriated from expert systems of medicine for self-treatment based on interpretations of their properties and impressions of their usefulness.1,2 In some cases, popular interpretations of medicine interface with cultural ideas about how the body functions, how illness is caused, how sickness can be prevented from occurring or becoming serious, and how sickness may be managed if not cured. In other cases, empirical observations of the efficacy of medicines to cure popular conditions are generalized to other complaints based on cultural associations. In still other cases, it is reasoned that if a medicine can cure a condition, it can prevent it from developing. Over the years, I have documented a wide range of self-medication practices in developed and less developed countries. I have observed Indian women taking chloroquine as an abortifacient because of its bitter taste and Filipino women reading through the local version of the PDR (PIMS) to identify drugs that are contraindicated during pregnancy for the same purpose. I have documented the use of antitubercular drugs as vitamins for the lungs to prevent acute respiratory illness from becoming worse and the use of antibiotics to dry up diarrhea. In this issue of the journal, Dr. Ilya Abellanosa and I document the use of antibiotics as a prophylactic for sexually transmitted diseases, a practice I have encountered in countries ranging from India to Nigeria, from the Philippines and Thailand to Mexico. How widespread is this practice of using antibiotics as a prophylactic against STD? Who engages in this behavior? When and how are these medicines used? Does the prophylactic use of antibiotics preclude the use of condoms as a primary form of STD prevention when risk is not deemed to be great, constitute a second line of defense by those who do not have the power to negotiate condom use, or comprise a supplemental or complementary form of STD protection? Data available on the prevalence of prophylactic antibiotic use to prevent STD in the popular health sectors of developed and less developed countries are virtually nonexistent. A few clinicbased studies report self-treatment of STD with antibiotics by patients before clinic attendance. What the reports do not describe is when the patients began taking antibiotics—immediately before or after sex, when early symptoms occurred, or only when acute symptoms manifested. Data presented in our article suggest that in the Philippines, use of antibiotics to prevent STD is fairly common among commercial sex workers (CSW) in Cebu City for a composite of the three reasons identified above. One of our key findings is that unregistered, freelance CSW, the group least likely to frequent doctors and the most powerless to negotiate condom use with customers, is the group most likely to use antibiotics as a prophylactic to prevent STD. What about the general public and clients of CSW? Do they use antibiotics before or after sexual relations they deem potentially risky? Unpublished data from the Philippines and Thailand suggest that they do. Let me briefly highlight some of these data and raise research questions worth considering in future studies. In 1989, I conducted a small ethnographic study of the STD prevention behavior of 20 sexually active traveling salesmen and delivery van drivers who stayed overnight at a hotel frequented by CSW in a large town on the island of Mindoro, Philippines. After an initial interview with this convenience sample, I reinterviewed each man the night after he engaged in sex with a CSW. During the initial interview, 70% of the men reported using antibiotics in the past to prevent STD, and 80% reported “using condoms with CSW.” Morning-after interviews revealed differences in condom and antibiotic use depending on the marital status of the man and his familiarity with the CSW. Six of nine men “short-timing” a CSW used a condom during their one and only act of intercourse. All three married men in this group took or planned to take a prophylactic antibiotic. Of those three men who short-timed CSWs and did not use a condom, two stated that they knew the woman and trusted her to inform them if she was ill. Two of the three men reported that they had or planned to take an antibiotic in the next 24 hours. Interviews with the 11 men who spent the entire night with a CSW engaging in several “rounds” of intercourse raised an important methodological issue related to the frequency of intercourse and general questions about condom use. When first asked whether they had used condoms with their partners the night before, eight men responded that they had. Follow-up questions revealed that three had not used a condom during all “rounds” of intercourse. None of the five men who used a condom during all rounds of sex was familiar with his partner, and of the two men who planned to take an antibiotic within the next 24 hours, one was married and the other was a pharmaceutical representative. Of those six men who did not use condoms during any or all rounds of sex, three had taken or planned to take an antibiotic. Of the three men who did not plan to take an antibiotic, two were familiar with the CSW in question. What do these data suggest beyond the fact that 30% of the sample of 20 men used or planned to use antibiotics before or after sex with a CSW? Among this group, prophylactic antibiotics were taken for the first and the third reasons identified above. Notably, five of the six men who planned on taking an antibiotic reported being able to identify a woman who had an STD by some sign or symptom (e.g., skin rash, body temperature, smell). They spoke of antibiotics as immediate protection as well as “just-in-case” insurance. Ideas varied as to whether an STD could be latent, asymptomatic, or both. At the time of the above study, I was conducting research on tuberculosis. It was unsettling to learn that among men in Mindoro, one of the drugs of choice as a prophylactic for STD was rifampicin, a drug essential to tuberculosis short course therapy. Discussion of this use of rifampicin at a meeting of the International Network of Clinical Epidemiology brought me in touch with Dr. Manop Kanato, a medical anthropologist from Khon Kaen University in Thailand. In 1993, Kanato and his team conducted a study in four field sites in different regions of Thailand (northeast, north, east, and south) in which they interviewed six categories of people (construction workers, factory workers, fishermen, tricycle drivers, male students, and CSW) with histories of STD recently treated at a government clinic. Taken as a group (n=524), roughly half of all the males interviewed had taken prophylactic antibiotics, and, among these, almost all had used rifampicin. Curiously, however, although 70% of CSW had taken prophylactic antibiotics to protect them against STD, none used rifampicin. Kanato's ethnographic observations of antibiotic prophylaxis are insightful on two counts. First, he found that men interpreted the red urine side effect of taking rifampicin in a positive light. They thought this was evidence that impurities and residues of illness that build up in the body from past sexual encounters were being removed by the antibiotic. Notable here was the notion that the antibiotic would protect them against illness transmitted during the current sexual encounter and the idea that antibiotics reduce vulnerability to STD, which is cumulative. Taking antibiotics before sex made one strong and less vulnerable, whereas taking them after sex was effective in killing the still-weak germ. Abellanosa and I documented a complementary rationality among some CSW in Cebu. When questioned about what they do to reduce their chances of getting an STD, some mentioned taking vitamins. Vitamins were seen by various CSW as improving resistance as well as removing impurities and sickness from the body. Filipino reasoning was not, however, as developed as that reported in Thailand. So why did Thai CSW not take rifampicin? Kanato speculates that this may have something to do with the side effect of red urine, which symbolically is associated with menstruation and the removal of impure, dangerous substances from the body. In Thailand, sexual contact with menstrual blood is linked to a category of local illness described as similar to leprosy (kud tang) that is manifest in the shrinking and deterioration of bodily appendages—in this case, the penis. Thai women take medicine called Ya Lang Tai when they experience urinary tract disorders to remove impurities from their kidneys, and it is feasible that they view menstruation and urinary purification in related ways. In any case, Thai CSW use a variety of antibiotics other than rifampicin as prophylactics against STD; these do not produce red urine. Kanato's finding that people treat what they perceive to be latent illness or illness residue with antibiotics opens up new lines of inquiry related to cultural notions of asymptomatic STD, a difficult concept to convey in health education. In Cebu City, Abellanosa and I documented mixed ideas from CSW about asymptomatic illness and illness latency after treatment at an STD clinic. Several CSW questioned whether STD could be asymptomatic. They blamed Cebu City's busy STD clinic for faulty laboratory procedures and record keeping when the presence of STD was confirmed, but they experienced no bodily sensations out of the ordinary. Other CSW generalized the message of the doctors beyond their intent. To prevent illnesses from becoming manifest and to improve their chances of getting a negative weekly test result, they routinely took antibiotics. Findings from a second study carried out by Kanato and his team in 1995 may be noted briefly in light of shifting patterns of sexual behavior in Thailand and the three patterns of prophylactic antibiotic use identified above. In Thailand, data suggest a decrease in brothel frequency and an increase in condom use. Other reports suggest increases in sexual exchanges with “pick-up” girls met at food stalls and bars who engage in sex for enjoyment, the chance of becoming girlfriends or minor wives, or for opportunistic sex work. These reports suggest that condom use in such sexual encounters is much lower than that with CSWs working in brothels. Kanato examined antibiotic use (but unfortunately not condom use) among 85 sexually active high school boys and 104 men interviewed at an STD clinic by type of sexual partner. Approximately 50% of both groups had taken prophylactic antibiotics before or after their most recent sexual encounter with a CSW. Among 19 students and 10 men who had sex with pick-up girls, 90% also had taken antibiotics. Approximately 10% of both groups also noted that they had taken antibiotics before sex with girl friends. Two sets of questions arise from these data associated with local perceptions of STD risk and prevention. First, are pick-up girls viewed as at lower risk for AIDS so that condoms are seen as less essential? If rates of antibiotic use before or after sex with these girls are high, does this mean that pick-up girls are seen as a viable source of STD but not of AIDS infection? Do these girls take antibiotics themselves in lieu of insisting that some categories of men use condoms or when they are unable to convince a man to use a condom? Is antibiotic use common among students who view their sexual exchange networks as relatively safe and insulated from AIDS but not from STD? How do changes in popular perceptions of the commonality of STD affect antibiotic use? In 1996, Dr. Pimpawan Boonmongkon and I encountered a general impression in the Chang Rai region of northern Thailand that STD are much less common now because of AIDS. Although some people related this to increased condom use, others noted that AIDS had replaced these illnesses. A few informants reported that taking antibiotics was an old practice, a practice suited to a past era. Kanato's last finding that 10% of his sample used prophylactic antibiotics before sex with a girlfriend begs closer consideration. A question worth raising is whether antibiotics were taken to protect the man or whether his behavior constitutes some exercise of male responsibility, however misguided. We know little about how men who engage in risky sex attempt to reduce their chances of infecting wives or girlfriends. Ethnographic research conducted by Kanato in Thailand and by me in the Philippines has found that men maintain several ideas about the prevention of STD. These include observing a waiting period from the time they have had risky sex to the time they engage in sex with their partners, consuming specific foods and drinks to hasten symptoms so they may avoid sexual contact until they “know” they are safe, and taking antibiotics to reduce risk. In the Mindoro study discussed above, it appeared more common for married men than for unmarried men to take prophylactic antibiotics whether or not they had used condoms. The convenience sample used in the study was too small to make any generalizations, but it raises an important hypothesis worth testing: Married men (and men in long-term relationships) engaging in extramarital sex are more likely to use antibiotics than other men. The extent to which their behavior may be considered an exercise of male responsibility remains to be seen. In need of investigation is whether such men primarily are trying to protect their wives from disease or are trying to prevent them from learning about their extramarital affairs through illness. Self-administration of antibiotics as a prophylaxis for STD must be investigated in all countries in which they are readily available to the public. What is needed is not just rates of prevalence among specific groups but a sense of how the practice of taking prophylactic antibiotics is related to the local perceptions of risk, power relations that impact on condom use and negotiation, and ideas about the efficacy of medicines. What also is needed is situational analysis attentive to perceptions of physical risk and social risk (risk to social relationships) that influence preventive health actions. Such research must attend to sensitive gender issues—men's attempts to exercise responsibility after engaging in risky sex and women's use of antibiotics as a last ditch attempt to protect themselves after men have refused to use condoms (that is, to protect them). The issues raised in this editorial offer challenges to those involved in STD education, challenges that require a closer working relationship between health social scientists, epidemiologists, health educators, and clinicians. It is time we pay more attention to popular health culture and the practices engaged in by populations to reduce the risk for STD and to manage reproductive tract infections. Self-medication is a good place to begin.
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Mark Nichter (1996) studied this question.