Word Count (abstract): 102
Word Count (paper): 3,807

Acknowledgement: D Holmes and P O’Byrne would like to thank the Canadian Institutes of Health Research (CIHR), the Institute of Gender & Health, and the Institute of Infection and Immunity, for their support.

Introduction

Unprecedented growth in health care expenditures has become a common attribute in Western countries. Such pressure on society’s available resources gives rise to questions about the sustainability of health care and the ability of the public sector to continue funding it at present levels (WHO, 2005). Furthermore, an equally important explosion in the availability of innovative health care technologies that offer the potential to enhance health outcomes has developed within this environment of fiscal restraint. As a result, the provision of ‘closer-to-patient’ services has increased in most industrialized nations. The adaptation of existing health technologies and the emergence of new communications and information technologies, have contributed to this important change in health care systems (McKeever & Coyte, 2002). Some innovative, user-friendly, and often miniaturized technologies are reshaping the contours of the health care landscape by redefining the interrelationship of bodies, places, and health care provision (McKeever & Coyte, 2002). Other than the usual popular arsenal of devices such as vaccines, condoms, posters, and safer sex pamphlets, innovative technologies (especially artistically imaginative ones) are rarely accounted for in the domain of sexually transmitted infections (STI) prevention programs. However, we believe that within the current health care environment, STI prevention logic should be reassessed and redirected to target diverse aggregates of the population using state-of-the-art aesthetic-oriented approaches. STI prevention initiatives must move beyond the static context of sexual health clinics by changing message delivery tactics. For example, inert technologies such as posters and pamphlets could be accompanied by more fluid arts-based technologies to foster dynamic exchanges between public health authorities and targeted populations. In the 21^st century, health care comprises more than traditional health care settings, such as hospitals and clinics. Currently, health care is sought, delivered and received in a wide variety of settings within the community (Winch, Creedy, & Chaboyer, 2002) and is mediated by providers of new care and health care technologies (Coyte, & McKeever, 2001). These various configurations of people, places and technologies are as diverse as the underlying health needs of different groups of individuals in health care settings including the institutional and social settings in which people live, work, attend school, and play (Armstrong, 1995; 1983; Holmes & Gastaldo, 2002). This paper wishes to present a creative prevention strategy that was developed in Canada. In 2005, the government of Quebec (a Canadian province) initiated an intervention known as the M3S Squad to address STIs among men having sex with men (MSM). This new technology was a creative combination of man and machine that was introduced in a gay bar located in a large metropolitan area, and will subsequently be presented in venues such as bars, after-hours clubs, and raves. Our intention is to apply Donna Haraway’s work (1999) on cyborgs to address the technological features and perceived impact of this new prevention tool, while reflecting on the aesthetic impact/composition of the M3S Squad body-machine apparatus.

STIs: Contextualizing the Issue

Over the last five years there has been an increase in reportable STIs in industrialized countries (CDC, 2003) that has resulted in strategies to reduce STI rates and thus prevent the associated negative health sequelae caused by these infections (Health Canada, 1998; CDC, 2000), such as, gonorrhea and chlamydia infections increasing the likelihood of HIV acquisition, or syphilis, which causes neurological and cardiac damage, inevitably leading to death if the infection is not treated early enough. In addition, for HIV, such preventative measures are currently the only approach because no cure is available (Cox, Beauchemin, & Allard, 2004).

According to recent STI reports (Health Canada, 2004) from which all of the following STI rates were retrieved, the incidence of chlamydia, (as calculated on a 100 000 population size), has increased over the last three years from 178.9 (178.9/100 000) in 2002 to 208.0 for 2004. The 2002 incidence rate for gonorrhea was 22.9. This incidence climbed to 27.9 in 2004. In addition to these two STI, the incidence of syphilis has also shown an increase. While this rate is not high compared to the two previously noted STI, it is more alarming because while there was a 0.5 new infection rate per 100 000 individuals between 1996 and 2000, this rate steadily increased from 1.5 to 2.7 between 2001 and 2003, and has a projected rate of 3.8 for 2004. Lastly, regarding HIV, between the mid to late 1990s MSM HIV rates dropped from 75% to 37% of all newly diagnosed HIV infections. However, over the last four years this percentage has increased to 44.4% (Health Canada, 2004). This statistic illustrates that even though MSM are still a relatively smaller proportion of new HIV infections, they still constitute the largest at-risk group and that the number of new infections within this population is increasing. Furthermore, current HIV statistics illustrate that MSM have the highest HIV infection incidence rate (Health Canada, 2003) and that the circuit party subculture and the bar scene (two future presentation sites for the M3S Squad) could be associated with a significant proportion of these new infections (2001).

Considering Cyborgs in the Public Health Domain

For some authors, there has been an acknowledgement that the age of the human has given way to that of the posthuman (Gray, Mentor, & Figueroa-Sarriera, 1995). This does not mean that humankind has been wiped out, but rather that humanity as a concept has been succeeded by its evolutionary heir (Hayles, 1995). Beyond the human looms the cyborg, a concept first coined and popularized by Clynes and Kline (1960), which refers to an artificially enhanced human being who could be created to survive in extraterrestrial milieus. For left-wing thinkers, technology moves toward dehumanization by accelerating the economy and society into ever less human dimensions where ‘the hands and eye of the individual worker are thrown on the junk heap by their inability to compete with the speed of microelectronic interfaces’ (Mansfield, 2000, p.158). As a consequence, technology is often conceptualized as being anti-humanistic, if not simply, anti-human.

According to feminist theorist Donna Haraway (1999), the cyborg is a metaphor for deconstructing the dyad of nature/culture. Her cyborg theory demonstrates how the quest to separate these two concepts is becoming increasingly difficult. She utilizes this blurring of borders to renew the manner by which one engages in the political field. According to Haraway (1999), the term cyb/org is a portmanteau of cybernetic organism and is extensively used to designate a life form which is a combination of organic and mechanical parts, an amalgamation of human, animal, and/or vegetal features. The objective of creating such organisms is to enhance or expand the abilities of a life form (human or otherwise) by using technology or a mixture of attributes (human, animal, vegetal).

Haraway’s prominent work, A Manifesto for Cyborgs (1999), defines the cyborg as a hybrid of machine and organism, a creature of social reality as well as of fiction. Haraway’s (1999) theory introduces a distinctly postmodern radicalism into the tradition of socialist and feminist critiques of science and technology within late capitalism and patriarchal society (Grassie, 1996). In the Cyborg Manifesto, she takes aim at the ideological infrastructure of the actual (post-positivistic) scientific paradigm and challenges the three sacred boundaries of modernity: animal/human, machine/life, and physical/non-physical. Within this definition, the possibility exists that cybernetic organisms could constitute extra tools for those involved in prevention programs in the domain of public health. The ability of clinicians and academics to promote safer sex practices could thus be expanded by the fusion of human bodies and technological devices.

For centuries, advances in technology have changed the way in which human beings live. Technological devices force us to step away from cherished assumptions that have lulled and comforted humanity since we first became self aware by requiring new responses to old dynamics, as they are experienced in new environments, such as virtual, work, and leisure contexts. The fusion of a living organism (such as men or women) with a machine is one such advance. Cyborgs do exist. According to Hayles (1995), more than 10% of the current U.S. population is estimated to be cyborgs in the technical sense. This percentage includes people with electronic pace-makers, artificial joints, drug implant systems, implanted corneal lenses, and artificial skin. A much higher percentage are engaged in occupations/leisures that turn them into metaphoric cyborgs including, the computer keyboarder joined in a cybernectic circuit with the screen, the neurosurgeon guided by fibre optic microscopy, and the teenage game player in the videogame arcade.

Scott Bukatman (1990) has named this condition ‘terminal indentity’ (p. 201) and calls it an ‘unmistakably doubled articulation’ that signals the end of traditional concepts related to subjectivity. Anyone with an artificial organ, limb or supplement (a pacemaker), anyone reprogrammed to defend against diseases (immunized) or drugged to think/behave/feel better (pharmacotherapy) is technically a cyborg (Gray, Mentor, & Figueroa-Sarriera, 1995).

Modern surgical procedures, particularly those involved in transplanting or replacing body parts, have redefined the way in which individuals conceive their physical bodies. Cyborgs, as renewed physical bodies, thus enlarge human-only qualifications. Viewed from this perspective, we believe that the use of cyborgs in the domain of public health could constitute a new means to convey safer sex messages. They represent a method of mass communication that pushes prevention techniques beyond their present boundaries. We believe that the aesthetic nature of cyborgs can provide a powerful and creative method of conveying messages.

M3S Squad: Cyborgs at Play

In 2005, the Ministry of Health and Social Services of Quebec (Canada) launched an innovative prevention campaign to counter the rise of STIs among MSM. With the help of a communications firm, the Ministry of health released the M3S Squad; a group of four individuals clad from head to toe in tight, matte black clothes with wires encircling, entwining and physically connecting their bodies to computer equipment (one keyboard, a computer, and a liquid-crystal display (LCD) projector). The interaction of each squad member’s body with the technical attachments made the human and the machine components of this apparatus appear as one entity – a cyborg. Wires swirled around the waist (acting as a belt), in and out of the coat, and under the arms. The CPU was enclosed in a shiny, hard-cased backpack, the keyboard platform jutted out in front out of the performer at waist height, and the LCD projector was fixed to the top of the right shoulder. The combination of these mechanical and human components challenged the traditionally accepted form of the body, with its predetermined vertical and horizontal lines. Within the context of a downtown gay bar, the body disappeared, only to be resurrected as a cyborg. This entity permitted each member of the group to autonomously project STI related images, (key concepts and abbreviations) as safer sex messages. Although specific concepts that reflect the mandates of the Ministry of Health and Social Services of Quebec were selected and predetermined for these presentations, the independence of each squad member enabled them to freely interact with the environment and to project messages on all available surfaces (walls, windows, curtains, the street) as well as on the bodies of any individuals present (the dancers, mannequins, and comedians) in an apparently random fashion. However, observation of the crowd’s (and of our own) reactions suggested that possibly the ostensible randomness of projection (both of the location and of the message) was, in fact, a pre-determined and well thought-out aesthetic component of the man-body messaging machine. As the projections appropriated the surrounding environment, whether a smooth surface or the uneven shape of a bar patron, the gaze of the crowd shifted to watch for new visual presentations – while the same STI terms may have been displayed numerous times, their visual presentations were continually renewed as the letters, varying in colour, size, font, and direction were either flat (when projected on a wall), or bent (when cast onto the corner of two walls), or rippled (when illuminated on the body of a bar patron). In addition to the aesthetic utilization of the environment, the continual change of the projection surface left individuals wondering what target would be next. Would it be their bodies that would be appropriated as the next messaging surface? Would it be their bodies that would next be consumed by the visual representation of an STI – or the physical symptoms of infection?

However, within 10-15 minutes, the novelty factor of the performance began to dissipate and the individuals in the bar began to resume the conversations and activities that had ceased with the seamless integration of cyborgs into the bar. At this point, in a way that only the human component of the cyborg could have sensed, the second phase of the presentation commenced. In addition to the four darkly clad computerized bodies, four dancers (clothed only in white briefs) whose bodies had been heavily covered in white powder and then streaked with black powder streaks slashed across their bodies. Much like the cyborgs, these bodies no longer appeared completely human, but rather as visual representations of blemished purity. These white bodies immediately began thrusting, heaving, swaying, pushing, and lunging – expressing a graphic, dance-like representation of sexual movements. Through interaction, touching, and movement around and between each other, these four independent bodies transformed into one interdependent living screen that transfixed the gaze and attention of all observers. This use of nearly naked, toned bodies as vulnerable receptors aesthetically and artistically provided a powerful additional message to an already sexually charged environment. From an STI prevention perspective, it is important to note that the symbolism that was invoked when bodies, exemplifying modern conceptualizations of health (because of their muscled and nearly pure white appearance) were unexpectedly struck with images of the phrases “genital herpes”, “genital warts”, “gonorrhea”, or “chlamydia”. In a fleeting instant, these ‘clean’ bodies lost their purity, thus, the fusion of bodies with one another and with safer sex messaging transformed the erotic aspect of these dances into one of danger. The parallel idea that bar patrons observing this spectacle, (who were potentially in the process of trying to find and select their own erotic dance partners), might be undertaking steps to potentially have the language (DNA) of STIs inscribed into and onto their bodies was inescapable.

The M3S squad could be described as an optical show of movement, lights, bodies, and images, in which the audience cannot remain as passive spectators, and must progress to becoming part of the spectacle. However, whether intentional or not, the context of the bar supplemented the aesthetic nature of this presentation. At the time of their entrance, daylight still provided light within the bar and individuals were entering the bar post-work. At this point, low volume, rapid tempo, music, as well as a setting sun that cast shadows across the room created the ambience. As the spectacle progressed, the sun set quickly, and the darkness was only interrupted by the dim bar lights and the discontinuous messaging from the M3S Squad cyborgs. Then, as quickly as it started, it ended; without any explanation, the white bodies faded into the background and the dark cyborgs were engulfed by the darkness. The movement of the dancers, the flashing of the lights, the projection of concepts and sentences onto bodies, walls, and the surrounding individuals transforms the entire milieu into total inclusiveness for the target audience. To someone who has never seen it, the spectacle could best be described as an experience where everyday reality collides with the imagination, where mundane life meets Alice in Wonderland.

For the spectators, it is almost mesmerizing and hypnotically surreal watching the performance; and yet, when a phrase such as ‘genital warts’ was projected on a member of the audience, it seemed to transform this key phrase into reality. This was not a poster. These were real, living, breathing, sexually active individuals. The attitude of the audience could no longer be ‘it’s not me; those are actors/ models in the commercials or posters’. The key phrase was physically connected to those who surrounded the researcher, and who was to say that this individual would not be the next target, the one to become a backdrop for an STI campaign? The connectedness that the crowd developed with the cyborgs and the dancers made the presentation a personal reality. At times, an individual who was targeted as the projection screen of a cyborg appeared to become uneasy and restless with the attention and the involvement of their body in the presentation, thereby displaying a personal response to the complete lack of control or choice in becoming a target. Thus, the experience, which varies between three and twenty minutes in length, was intended to be dynamic and spectacular and to emphasize the randomness of the process. No individual present could determine who or when someone would be chosen as the surface for these messages.

It has proven extremely difficult to reach, or to have an impact on, certain populations through conventional cognitively oriented safer-sex messaging (CDC, 2003). However, by engaging the aesthetic sensibilities of the target group, the M3S Squad enables the public health department to interact with these populations in their own (leisure) environments. Not only do the presentations take place in highly public entertainment oriented areas such as bars, movie theatres, dance clubs, arenas, and urban locales such as street parties and street performances, but they also actively engage the target audience and elicit some form of emotional response from them.

Mapping Bodies through Art and Technology: The Future of STI Prevention

At present public health departments and community agencies focus mainly upon the (re)creation of posters and pamphlets. Within the field of sexual health, finding a suitable poster for any environment is not difficult. Yet, while the amount of money being spent and the resources being allocated increases, the impact of these media do not. STI incidence rates are still increasing (CDC, 2000). We believe that a radical shift in the domain of prevention campaigns is long overdue. Could not even a small portion of the energy and time being devoted to the re-production of current (and obviously not thoroughly effective) technologies be redirected toward the development of experimental new ideas? Yes, there is the risk that this idea has the potential to be a waste of resources, but viewed from the perspective of the ever growing rates of STI infections it might be said that current strategies could also be classified as not completely sound. The acceptance of new ideas and strategies does not mean that posters/ pamphlets should be eliminated. The use of cybernetic technologies and other forms of artistic creativity could complement the already existing ones and might result in an improvement in the domain of STI prevention.

Viewed within a historical context, it is immediately apparent that many of the most powerful prevention technologies were developed by taking the risks not only of being wrong, but of being seen as ridiculous. This proposal may sound wonderful on paper, yet still be judged by many as completely impractical. It is important to remember the recent successes that have occurred: the initial HIV outbreak and its subsequent decrease through mass condom distribution and education campaigns, the decrease in infectious disease among intravenous drug users due to needle exchange and smoke inhalation exchange programs, and the inoculation of entire populations with the hepatitis B vaccine - although a seemingly extreme example, the utilization of the hepatitis B vaccine has proven to be the single most effective method of reducing the incidence and prevalence of an infectious disease.

When the HIV epidemic began in the early 1980s, education through posters, television, radio, and community associations was essential and effective. It provided a quick and easy means of accessing multiple populations at various levels. However, over the last 25 years, all populations have begun to experience ‘prevention-fatigue’ (2003). This phenomenon occurs with any long-term activity (especially health related activities) that must be performed by an individual, and includes such behaviors as dieting, safer sexual practices, smoking cessation, and breastfeeding (Stockman et al., 2004).

As a response to this prevention fatigue, the M3S Squad provides a new presentation medium. Throughout the entire campaign the focus was broad rather than specific. The M3S squad targeted many STI rather than concentrating strictly on HIV. The squad did an excellent job of drawing the attention of the audience, of presenting a thorough overview of STI, and of not repeating facts that many individuals have been given repeatedly in the past. The M3S squad made everything much more personal and by actively involving the target audience made it the audience’s responsibility to educate themselves about the STI words they were seeing. Because the presentation was highly aesthetic, engaging and memorable, it was a highly effective means of opening the lines of communication between peers. Hopefully, the Government of Quebec will continue to produce more novel campaigns such as the M3S squad. Hopefully, this innovation will influence other public health departments to follow their lead and begin a journey of discovering bold new strategies for STI prevention campaigns. Such strategies should include the fusion of highly artistic and technological means.

Final Remarks

In today’s climate of fiscal restraint and burgeoning health care demands, an innovative strategy was born out of the age old and ever evolving relationship between art, human bodies and machines. As a response to the new outbreak of sexually transmitted disease, cyborgs physically carried a message of prevention into a milieu – transformed into a scene – where it is clearly needed but seldom heeded. At this time, because it is so new, there is no scientific evaluation regarding the efficiency of this innovative public health approach, but then, at every point in human history, there have been risks, whether great or small, which had to be undertaken before they could be adequately assessed. It is the risk takers who expand the boundaries of human possibility into greater dimensions while the rest of us judge their efforts from the comfortable position of hindsight. We believe that if even a small portion of the resources (time and money) now allocated for the re-production of current technologies were to be redirected toward the support of experimental new ideas, the result might be an improvement in the domain of STI prevention. This combination of aesthetics with STI prevention messaging based as it is on the understanding that STI transmission requires individuals to stroke, fondle, and caress one another may provide a unique and potentially effective innovation because it creates a dynamic and artistic representation of sexual practices and their consequences and thus evokes a visceral rather than intellectual response from on-lookers. Surely, if there is any chance at all of reaching individuals who are immune to the traditionally accepted prevention approaches, that chance should be taken. The alternative is stagnation, the results of which we already know.

Dr. Dave Holmes, Associate Professor
School of Nursing, Faculty of Health Sciences, University of Ottawa

Dr. Dave Holmes is Associate Professor at the University of Ottawa's School of Nursing and Nurse-Researcher at the University of Ottawa, Institute of Mental Health Research (Forensic Psychiatry Program) and at the Douglas Hospital Research Centre in Montreal (Psychosocial division). For several years, he has been a clinical nurse in forensic psychiatry (both in hospitals and in the community) as well as in public health. His research interests focus primarily on the issue of the power relationship between nurses and vulnerable clients. He is also interested in the control mechanisms used or deployed by nurses. Most of his work, comments, essays, analyses and research are based on the theoretical work of Michel Foucault.

Patrick O'Byrne, Lecturer School of Nursing, Faculty of Health Sciences, University of Ottawa

Patrick O’Byrne is Lecturer in the School of Nursing, Faculty of Health Sciences, University of Ottawa, Canada and CIHR Doctoral Fellow.

Dr. Peter C. Coyte, Professor Department of Health Policy, Faculty of Medicine, University of Toronto

Dr. Peter C. Coyte is a Professor of Health Economics and a CHSRF/CIHR Health Services Research Chair in the Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto. Dr. Coyte is a national and international expert in the areas of health economics, health services evaluation, and health policy and planning. His studies have included the measurement of regional variations in health service utilization, evaluations of the cost effective provision of health care services, and assessments of health service finance, organization, and delivery.

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