Health and Development: HIV/AIDS and the Double Appropriation of Human Security Discourse by Practitioners of Female Circumcision and Development NGOs in Cameroon

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Health and Development: HIV/AIDS and the Double Appropriation of Human Security Discourse by Practitioners of Female Circumcision and Development NGOs in Cameroon
  Health and development HIV/AIDS and the double appropriation of human security discourse by practitioners of female circumcision and development NGOs in Cameroon Ngambouk Vitalis Pemunta CENTRAL EUROPEAN UNIVERSITY  ABSTRACT   The aim of this paper is to demonstrate ethnographically that within the new institutional context of the HIV/AIDS pandemic, development NGOs intervening in the fight against female circumcision by using the language of human security have instead produced a backlash marked by resistance and contestation. I argue that the issue of health security underpins the agenda of both the state and transnational stakeholders who use the ‘modernist’ language of security to reinforce their collective positions towards practitioners of ritual female circumcision. The advent of the HIV/AIDS pandemic reinvigorated debates about human security which contributed to the framing of practices such as ritual bodily ‘mutilation’ in a human security context. The health security (‘harmful health effect’) paradigm that dominates anti-mutilation advocacy is a double-edged sword. While this framework reduces the complexity of ritual mutilation to health alone, some segments of circumcising communities among the Ejaghams of southwest Cameroon frame the issue of female circumcision in terms of ‘social security’. This exemplifies competing health and security views, ‘local’ and ‘scientific’ knowledge systems. Within the new medical and institutional context and the dynamics of the AIDS pandemic, a double appropriation of the concept of ‘security’ is evident by some segments of the Ejagham community, by the state, and by anti-mutilation advocates. This has limited the success of the anti-mutilation campaigns, especially as these ‘risk’ and ’health security’ concepts do not always reflect the people’s lived experiences, partly because of the activists’ ‘failure’ to domesticate these concepts. INTRODUCTION The past few decades have witnessed the rapid diffusion of technology and information into all parts of the world, bringing to the attention of scholars, national policy makers and international organisations a broad range of local cultural practices. Some of these practices, such as polygamy, sati  , 1  forced and early child marriage, sexual cleansing, wife sharing, wife inheritance, the deprivation of women and/or widows from property inheritance, male child preference, widowhood rites, honour killings and food taboos have often appeared incompatible with the health, well-being, human rights and health security of both women and children. But it was rather the ritual practice called ‘female circumcision’ (hereafter, FGM), that provoked the most intense and unending debate  worldwide. Also known as ‘female genital mutilation’ (FGM), the ritual is practised in most countries of Africa, in some Middle Eastern countries and among immigrant populations in Europe, North America and Australia. The global traffic of people, goods, ideas and services turned a ‘culturally specific rite of passage’ (Van Gennep 1966) 2  into an issue of great international humanitarian concern.      P    e    m    u    n    t    a ,     N    g    a    m     b    o    u     k     V     2     0     0     7 ,     ‘     H    e    a     l    t     h    a    n     d     d    e    v    e     l    o    p    m    e    n    t     ’ ,      J    o    u    r    n    a     l    o     f     H    u    m    a    n     S    e    c    u    r     i     t    y  ,    v    o     l .     3 ,    n    o .     1 ,    p    p .     4     5  –     6     1 .     T     h     i    s     i    s    a    p    e    e    r  -    r    e    v     i    e    w    e     d    a    r    t     i    c     l    e . © Copyright RMIT Publishing 2007, available online at  46  |  Journal of Human Security  , vol. 3, no. 1, 2007 © Copyright RMIT Publishing 2007, available online at The United Nations Organization (UN) and the United Nations Children’s Emergency Fund (UNICEF) jointly defined FGM as ‘all procedures involving the partial or total [amputation] of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reason’. The World Health Organization (WHO 1998) and UNICEF have gone even further, classifying genital mutilation into four categories. Type I is called excision of the prepuce, with or without excision of part of the clitoris. Type II is the excision of the clitoris with the total or partial excision of the labia minora. Type III includes the excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation). Type IV is unclassified and includes pricking, piercing, stretching, burning, scraping and any other procedure inclusive of the above. The violent nature of the ritual procedures and their incompatibility with basic human rights are clearly articulated by the extensive literature on FGM—which, unfortunately, does not take on board local notions of ‘health security’ and ‘risk’. This calls for a re-evaluation of those objections and their eventual contextualisation. THE NOTION OF HEALTH SECURITY IN RITUAL FGM  Among the various perspectives used in studying the ritual practice of FGM are the feminist and human rights approaches. By interpreting ritual mutilation as a patriarchal control mechanism over women, their bodies and their sexuality, scholars using this framework highlight the issue of health security. Daly (1978) for instance, categorises FGM with other ‘Sado rituals’ such as carcinogenic hormone therapy and psychosurgery. This objection emphasises the violent and painful aspects of women’s genitalia being mutilated ( Walker 1992, Rahman and Toubia 2000, Hosken 1995). But it is rather  women themselves who carry out these procedures, and patriarchy is not a monolithic entity. These studies further dissociate ritual mutilation from its cultural anchors, which has led to resistance and contestation by those that these activists and writers set out to ‘save’. While the human rights position highlights the notion of security and justice, it further suggests that FGM practices are monolithic and that practising societies are static, which is not the case. Dellenborg (2004) for instance, argues that local meanings are neither monolithic nor static but rather contested, constantly negotiated and renegotiated by various social groups and actors in Casamance, Senegal. In the same light, Grande (2004) takes issue with the decontextualisation of FGM practices in the human rights debates. She opts for a    holistic critical approach in understanding FGM and similar body modification practices such as breast implants and male circumcision in the West so as to avoid ethnocentrism. Fotheringham (2004) launches a clarion call to emphasise local needs. She sees the fragmentation of the anti-FGM advocacy as an outcome of unresolved culture clash and the failure to balance both local and international interests in ending FGM practices. I will use ethnographic data to demonstrate that the notion of human security underpinning the human rights approach has been doubly appropriated, i.e. by two parties using different interpretations. This is the case among some segments of the Ejaghams and anti-FGM advocacy groups especially within the institutional context set in motion by the HIV/AIDS pandemic. This double appropriation has led to contestation and resistance calling for the need to re-evaluate and domesticate the very concept of health security that underpins anti-FGM activism. But before I turn to that issue, let me briefly set the social context for this study.  Ngambouk V Pemunta, ‘Health and development’ | 47 © Copyright RMIT Publishing 2007, available online at BACKGROUND My ethnographic research among Ejagham clans in Southwest Cameroon sought to analyse what transformations the changing medical and institutional context of the HIV/AIDS scourge has triggered in the institution of Moninkim, an exclusively female secret society and traditional dance group charged with socialisation. Until the turn of the last century, FGM was the precondition for membership into this group. Against the functionalist contention that ‘tradition’ resists change unless it is modified by institutional modernisation, my research shows how the advent of the HIV/AIDS pandemic set up institutional dynamics that triggered a new debate between advocates and opponents of ritual female mutilation, causing certain segments of the local communities to reconsider and modify the modalities and functions of the practice. The ritual as practised among the three Ejagham clans occurs in four main categories. One type of mutilation was conducted at birth or at puberty and was predominantly found among the Ekwe and Obang clans. In the three clans, however, another category served as a cure against infertility. A third category is a status-granting ritual, which confers membership into the Moninkim cult. This entailed mutilation as a prelude at either infancy or at maturity and subsequent confinement thereafter when the girl came of age. The Keaka and Ekwe practised this category of the ritual. The fourth category is a purely symbolic representation of ritual circumcision without actual physical cutting of the genitalia—mere confinement and fattening as a form of substitutive rite that confers the title of Moninkim. Women that underwent this ritual were referred to as ‘social Moninkim’ to differentiate it from the other type of Moninkim. It concerns  women who, because of their socio-economic status, either bought their titles and membership or were co-opted into the group because of their ability to dance the Nkim dance. ‘Social Moninkim’ status was traditionally granted only among the Obang, but the practice has progressively appeared today among the Ekwe and the Keaka—a remarkable sign of changing times, probably partly as a result, I argue, of the aging of the initial initiates, formal education, anti-mutilation sentiments and anti-HIV/AIDS campaigns. In the sections that follow, I will first define the concept of health security in this context and describe the theoretical framework and research methodology informing my research. Second, I will examine the preoccupation with security shown by NGOs, and how this preoccupation leaves them open to accusations of acting as ‘agents and representatives of state power’. Third, I will discuss the relationship between HIV/AIDS and FGM in the context of the Ejagham people’s multiple and ambivalent attitudes toward FGM.In this paper I show that the transnationalisation of FGM, a ‘local rite of passage’, has led to imposition, competition and debates between international forces and the state. The prioritisation of security by these actors has fuelled resistance among certain segments of the Ejagham population while urging others to abandon violent ritual mutilation. Within the present AIDS context this group presents the ritual mutilation as a ‘native’ antidote against the pandemic. I adopt a comprehensive approach to the concept of human security which ‘links [it] with the state of the global economy, development and globalization’ (  Oberleitner 2005, p. 188  ) . I further adopt Thomas’ (2000) conceptualisation of human security as ‘a condition of existence in which basic material needs are met and in which human dignity, including meaningful participation in the life of the community, can be met’ (Thomas 2000, Preface). I conceptualise health security as a sub-component of human security, which Vohlonen et al. (2004, p. 199) define as ‘funding and service elements of a social security system that either  48  |  Journal of Human Security  , vol. 3, no. 1, 2007 © Copyright RMIT Publishing 2007, available online at protect against or alleviate the consequences of trauma, illness, or accident’. I will demonstrate that by framing the issue of FGM in terms of health security, transnational actors are building a common platform for themselves. Further, the internationalisation of the campaign against FGM led them to oblige states within whose boundaries FGM is practised to enact legislation calling for abolition rather than mere harm reduction.  As the WHO (1998) argues, harm reduction must counteract ‘the perpetuation of this heinous practice’. The issue of security has therefore taken centre stage in development discourse because transnational actors place it on the agenda of the state. Despite this, some states subscribe to and simultaneously distance themselves from such international norms as they are yet to formally criminalise ritual mutilation. By using imposition in the absence of legal recourse specifically criminalising FGM, some states like Cameroon have abandoned their commitments to transnational stakeholders at the local, national and international levels. The governments continue to be influenced by multiple external actors, primarily NGOs, whose agenda tend to be hampered by bureaucratisation, fragmentation and a maze of regulations. Local resistance to the anti-FGM messages capitalises on the way in which those messages rely on the risk concept, as reflected in the ‘harmful effect model’ that underpins and dominates most campaigns. The terms ‘human rights violation’ and ‘harmful health effects’ are used here in connection with the notion of risk to human security. Agencies working towards human security include mainly the state, as well as local, regional and transnational NGOs intervening against the practice of FGM. The state as an agency of ‘disciplinary power practices’ (Foucault 1977) exercises its power over the population by its adoption of modern biomedical health concepts. These concepts present the practice of FGM as risky and incompatible with the health and wellbeing of initiants and practitioners alike.  At the same time, the state pursues its own interests and agenda that might prevent it from taking action (Skocpol 1985, p. 116) against practising communities, usually minority groups. Such agenda include the protection of minority rights and the need to uphold state sovereignty. On the other hand, transnational stakeholders are independent ‘units of action’ at both the level of the state and in the international system. They are ‘collectivities with their own members who have private interests’ (Ness & Brechin 1988, pp. 269–270  ) . They include but are not limited to international organisations, such as the WHO and the United Nations Population Fund (UNPF), affiliates of the UN, national and international medical associations, human right groups and women’s health advocates. Following recommendations from the WHO they oppose the medicalisation of FGM on ethical grounds, thereby leaving practising communities  with only one option: eradication. These transnational stakeholders alongside the state are independent units of analysis, occupying different power fields but interpenetrating each other in society through particular issues, such as through the discourse of health security. THEORETICAL FRAMEWORK AND RESEARCH METHODOLOGY In a bid to theoretically explain the complex interaction between various stakeholders involved in the FGM field, I combine Beck’s critical theory of ‘risk society’ (Beck & Ritter 1992), Foucault’s post- structuralist theory of ‘power and governmentality’ (Foucault 1994; Rose and Miller 1992) and theories of hegemony (Gramsci   1971; Guha   1999). They allow me to explicate the use of risk and governmentality by transnational stakeholders and the state as mechanisms for the reinforcement of their positions in a particular social field and to simultaneously situate resistance from below. The data reported here was extracted using a wide array of social science methods: free listening,  Ngambouk V Pemunta, ‘Health and development’ | 49 © Copyright RMIT Publishing 2007, available online at individual in-depth interviews, community interviews, and informal group discussion sessions, casual and participant observation between February and October 2006. A total of 173 respondents were interviewed. The extended case study method involved three Ejagham clans: principally the Ekwe Ejaghams but with an extension to their Keaka and Obang co-ethnics among whom the ritual initially had different trajectories and functions.This paper analyses the different, ambivalent positions of stakeholders in a complex, contested debate involving local, national, regional and international actors occupying different, interwoven power fields who are appropriating different notions of health security. On the one hand there is modernity versus tradition, ‘local’ versus ‘scientific’ knowledge. On the other, there is a dilemma between modernity and tradition. In other  words, the contestation and defence of ‘female genital cuttings’ has turned women’s bodies into a site of struggle between two hegemonic representations. ‘Modernity’ on the one hand, is represented by the Cameroonian state and its ‘ideological state apparatuses’ (Althusser 1971) of schools and NGOs. ‘Tradition’ on the other, is represented by some dominant segments of the local Ejagham population. NGOs as ‘agents of power’ and the issue of security Countries in which some ethnic groups practise FGM are called on by national and international NGOs to eradicate the ritual procedure of FGM. This is to happen through the enactment and subsequent enforcement of legislation based on the health security discourse. This discourse is framed in terms of the protection of women’s and children’s human rights and health through the ‘challenge of the growing shared risk of disaster, disease and disruptions’  (  Missiroli 2005  ). This is evident from the health concepts used in the anti-FGM campaigns and materials. Low income countries are mostly influenced through the linking of development aid with democratisation, good governance and the respect for human rights (‘donor democracy’). One of the implicit aims of such policies is to decrease the influx of refugees into wealthy donor countries. Some potential victims have been granted asylum on the basis of their risk of undergoing FGM should they return to their home countries (See for instance, Boyles and Preves 2000).Transnational stakeholders have invoked the notion of health risk and, by extension, the comprehensive concept of human security to justify their presence and dominance in FGM practising communities and countries for two main reasons. First of all, their aim to protect the human security of individuals, in this case women and children, enables transnational stakeholders to legitimately influence the authority of the state. Second, human security and state sovereignty are not incompatible when a ‘cautious approach to human security is used … [while] a broader understanding of the concept challenges state sovereignty more fundamentally’ (Oberleitner 2005, p. 193) .  However, most states—Cameroon and Egypt, for example—while publicly endorsing the international commitment to end FGM, at the same time distance themselves from that goal at home and assert their sovereignty. I suggest that NGOs and other transnational actors appropriate the concept of health risk and security also to reinforce their status and to promote their own self-interests. Such interests include the promotion of neo-liberal ideology and ‘third way’ welfare development (Kemshall 2002, p. 133). The preoccupation with health security in low income countries is a reaction to ‘tradition’ where ‘modernity’ is supposed to confront the high level of risk created by the neo-liberal paradigm. Kemshall (2002, p. 103), for instance, states that ‘risk is replacing need as the central principle of social policy formation and welfare delivery’. On her part, Joyce (2001) makes the claim that the
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