The characteristics of the participants are presented in Table 1. These socio-demographic data largely concord with those of the cohort of Pakistani patients followed-up at Avicenne, and of the IOM study, which described recent migrants from Pakistan being constituted of single young men from Punjab (2).
Table 1
Participants’ characteristics
Participant characteristics | | |
Participant gender | Male | 13 |
| Female | 0 |
Province of origin in Pakistan | Punjab | 13 |
| Other province | 0 |
Age (years) | Median (extremes) | 30 (23–56) |
Type of infections | HCV | 9 |
| HIV | 2 |
| HBV | 1 |
| Co-infections HCV-HIV | 1 |
Status | Single | 5 |
| Engaged, fiancée in Pakistan | 3 |
| Married, wife in Pakistan | 4 |
| Married, wife in France | 1 |
Period since arrival in France (years) | Median (extremes) | 5 (8 − 2) |
Fluent language | Urdu exclusively | 12 |
| Urdu and French | 0 |
| Urdu and English | 1 |
Figure 1: Conceptual framework, adapted from Sorensen et al (23) |
Most participants entered France undocumented and remained so until they applied for a temporary residence permit for healthcare. In some cases, participants had applied unsuccessfully for asylum, and were undocumented. Most were referred to the hospital by local South Asian doctors in the Seine-St-Denis departement, after presenting with symptoms.
Table 1 here : Participants’ characteristics
Life-course trajectories and hepatitis /HIV risk factors
Before migration: poverty and myths
The pre-migration context of participants was dominated by hardship during childhood and youth: most grew up in rural and poor farming families in Punjab province, attended primary school (some religious, other public); some were educated to matric standard age (16) and worked in parallel with their family on the farm; a few were from families owing farms or shops, although threats or assaults over land or cattle disputes precipitated their economic decline. Some participants had family members living with hepatitis C. Although many were aware that HCV and HIV were dangerous, they had little clue about their shared transmission routes. They were not knowledgeable at all about HBV. They unanimously thought that dirty water (and retained this belief even after treatment in France) was the main HCV transmission route, together with dust, and that hot chillies could reactivate the virus. Words used to describe hepatitis in Urdu were descriptive of symptoms and included “yerkaan”, whatever the type (A, B, C, D, E), meaning jaundice, as well as “kala yerkaan” (black jaundice), or references to a hot liver. The few participants who had been tested for hepatitis C before migration did so exclusively because of “yerkaan”, a visible symptom. Participants all believed “yerkaan” could not affect a child or young adult and that they could not carry the infection without any symptom.
They considered HIV more dangerous than HCV, and associated its transmission exclusively with female sex workers. They discovered, once in France, that unsafe injections could be a transmission route, especially for the 3 viruses. Many participants had received therapeutic injections, especially for fever and fatigue. Participants all highlighted the divide between the expensive health care provision in Pakistani private hospitals, where good doctors practice (‘only rich people get treated at hospitals’, participant 1), and the cheap but unreliable care in villages offered by so-called quack doctors (‘we don’t have any other option, we don’t have any other doctor’, participant 2).
Participants had occasionally also patronized street barbers who worked with razors without disposable blades. A number of participants additionally reported having witnessed or being involved in sexual activities between boys (starting around age 13 at single-sex school), relations which could continue subsequently into adulthood. Some had heard of child abuse (i.e. men abusing boys) and qualified it as being quite frequent. Mutual sex between male adolescents was discussed as a commonplace practice in the men’s rural communities and, if not typically spoken about openly, did not appear to necessarily represent a shameful or unwanted practice. MSM was viewed as separate from heterosexual marriage which all aspired to, and a gay identity strongly was refuted.
“An adolescent and a man, it is not a gay relationship, it is not a MSM; an adolescent is not a man” (FGD)
Injecting drug was also reported as being frequent in Pakistan, but no patient disclosed having engaged in it.
The journey: long and traumatic
The lure of migration initially tempted participants as an exciting opportunity to mitigate poverty and support their family, escape dangers, or simply undertake youthful adventure with friends. Most young men knew of enviable others in these small communities who had migrated to Europe and benefitted their household via remittances. Some leaving Pakistan did so upon official invitation from a relative or friend already settled in Europe (in these cases, mainly Italy), allowing legal entry with a tourist visa. A small minority travelled by plane but became undocumented upon expiration of their 3 months Schengen visa. The principal migration mode was via an ‘agent’ (trafficker), at substantial cost to the family, and with greater expectations of remittances. All our participants who took the land route via the Eastern Mediterranean route were affected by violence. Participants experienced pervasive and ongoing violence, psychological fear of being discovered by local police, of being arrested, detained, or fired on by army personnel, being held to ransom by smugglers, seeing their travel companions disappear, shot, wounded, or abandoned; physical exhaustion after walking for days, extreme temperatures, hunger, thirst, being cramped in small spaces for long periods of time, as well as sexual violence (rapes, harassment, or witnessing either). The journey to Europe could take months or sometimes years, with several being deported and re-trafficked across borders multiple times before reaching France. Many stayed in transit countries such as Iran, Turkey, or in other European countries such as Greece or Italy for months or years, living in multiple places or migrant camps, and taking small jobs where possible. One participant engaged in transactional sex with men in exchange for accommodation and work, whereas other participants reported having witnessed fellow countrymen en route engaging in transactional sex in exchange for work, food, or accommodation, or forced sex. Participants all shared razors and crockery during the land-journey, due to an extreme lack of privacy.
Life in France: precarious and clandestine
A sense of temporal and spatial distance prevailed among Pakistani communities in Seine-St-Denis: none of the recently arrived participants in Seine-St-Denis mixed with older longer-settled generations of Pakistanis in France, who have settled in other areas. Almost without exception, participants shared small rooms with other recently-arrived men, also from Punjab province in Pakistan. Such living arrangements are common among South Asian migrants in Europe. Except for two, all participants had unstable precarious lives and worked in short-term contracted jobs. They mostly worked as painters on building projects, or electricians. Low-paid labour and complex dependencies on their ‘bosses’ mean that many Pakistani migrants in Europe work many hours daily, for six or seven days a week, for months on end, without respite or holidays (Nobil 2016, 10). Those who worked together and cohabited inevitably formed stronger ties—taking turns to shop and cook Pakistani food, share bills and chores. They admitted at times sharing toothbrushes and razors to shave their face, armpits and genital areas, customary shaving practices for Muslims. Once diagnosed with hepatitis and/or HIV and advised, participants became cautious about not sharing their personal belongings such as razors, toothbrushes. Most were not ashamed and disclosed their hepatitis status, and their roommates were sympathetic to them, since hepatitis and symptoms such as jaundice are understood to be a national issue. Significantly, none of the three participants living with HIV disclosed their status. HIV is highly stigmatized in Pakistan, associated with a scenario where homosexuality has been criminalized in Pakistani law since colonial times, and ‘pathologically high levels of discrimination and contempt towards sex workers, injecting drug users and transgendered hijrae’ exist (24). Notwithstanding, Pakistan has a high prevalence of hidden MSM, and HIV/hepatitis amongst MSM (25).
On presentation at the hospital, the majority of participants were either undocumented or relying on a residence permit for healthcare with short validity (six to twelve months).
Due to suspicion over being arrested, language barriers, and the imperative will to work, they barely had any leisure time. Most were single. A few disclosed having girlfriends (non-Pakistanis). Others, longer-settled, went to sex-workers (mostly engaging in unprotected intercourse). A few did say not engaging at all in sexual activity. Participants reported to have ‘heard about’ men engaging in same-sex within their community in France (Pakistanis with Pakistanis, or with Arabs), and one specifically knew some friends who had done so. Some were pragmatic:
“If there are no women, a man may have sex with another man, just to fulfill his needs” (participant 1)
Drug users seemed uncommon in the community, even though few participants mentioned having heard of Paistani using/selling heroin in Seine-St-Denis, but none declared having ever used some. By contrast, barbers seemed to be a significant potential area for transmission risk in France, especially in the community or proxy-community (where many Sri Lankan and Bangladeshi barbers run small shops). Areas such as Strasbourg-St-Denis in Paris (hosting a large North Indian community) and La Courneuve were, during the FGD, cited as places where barbers may not be ‘safe’. These data are supported by some ethnographic observations of barbers who used the same blade for consecutive customers. One participant mentioned having received dental care from an informal Indian dentist in a workers’ hostel. These findings bear unexpectedly on implications for the transnational mobility of informal and unregulated healthcare practices between South Asia and France.
Individual and social factors influencing behaviours
We interrogated here individual and social factors influencing behaviours in light of the Sorensen model (Fig. 1).
Transnational societal norms and taboos
Even while living in France, there was an overall sense of fear of the authorities, and sense of shame or outright denial when discussing behaviours that contravened Pakistani societal norms. For example, the majority of our participants admitted MSM practices being fairly common between Pakistanis, in Pakistan or abroad, but that these practices were ‘invisibilised’ through not being discussed, leading to contradictory statements in our interviews. One participant insisted ‘It doesn’t happen in Pakistan, it’s against Islam’. Even ‘Talking about MSM’ was considered taboo outside of very private, personal, male friendships:
“In Pakistan, you won’t say something like that – man [having sex] with man- you can say openly here, but not there in Pakistan” (participant 3)
The few who spoke without stigma about MSM activities were younger, and seemed less likely to judge, whereas older participants were judgmental and adamantly affirmed the illegal, morally prohibited (haram) nature of MSM activities. Moreover, hierarchy was very much respected, even in France, and some intimate topics were unspoken of, taboo, between generations.
“Elders won’t talk about their ‘girlfriend’ to younger ones” (FGD).
Jokes around women were permitted (between same aged men), normalised in a male-dominant model of society, whereas disclosing MSM experiences could risk their families discovering it.
“About [sex with] women they [Pakistani friends] make jokes but about men they are very cautious, they don’t say because they know that this will go to Pakistan and it will be a big mess. (participant 4)
Participants were cautious to not shame their family by revealing non-conformist sexual practices, notwithstanding the geographical distance: most of them awaited their family in Pakistan to choose a wife, but reported transnational sexual and romantic relationships, including adultery, as being common. The public admission of non-marital sex this implies is deeply shameful.
Overall, there were strong pressures for prosocial behaviours such as respect for generational hierarchies, familial and cultural norms. These meant socially prohibited and transgressive behaviours in participant’s private lives were hidden. Yet Islam remained prevalent mostly as a moral discourse, rather than a strict set of rules to follow, while seeming to shape behaviours and attitudes.
Community and family ties
Our participants were very much embedded within Pakistani migrant communities in France. They mixed largely with other Pakistanis from Punjab who were recently arrived, due to, inter alia: their common language (Punjabi), pre-existing networks which provided access to employment and shared accommodation, and their shared ethnic/regional commonalities (reflecting the transnational adaptation of regional hostilities and ethnic loyalties in Pakistan, in the French context). While these communal bonds of friendships and sociality operate in their favour, they also potentially lead to hepatitis and HIV transmission: via the sharing of personal belongings (razors, syringes); via community-born risks (barbers, informal medical care); or via MSM practices between friends. These communities also offered forms of identification and support regarding their obligations to their community in Pakistan, which allowed them to leave their country, but under certain conditions such as sending remittances. Family ties are of enormous importance and this debt ties them, as with many first-generation migrants or refugees to Europe to their families transnationally. Yet in Pakistan, migration constitutes a habitus amongst young men. Ahmad frames the desire to migrate as a condition of masculinity amongst young Pakistanis (26).
In terms of sexuality, he introduces the notion of “melancholia” in desexualized “dead bodies” working “invisibly” in order to send remittances informing Western representations of undocumented migrants (27). Invisible sexualities apply too to our migrant sample whose sexual desires are effaced or hidden because their families might discover they have sex lives and chastise them; because of culturally-shaped personal beliefs about taboos, and morally reprehensible behaviours (28); because of a habitus of secrecy in a country with post-colonial history of Islamic state nationalism becoming increasingly right wing and conservative (29); and because of the extreme restrictions and hard labour conditions migrants and refugees face in Europe (30), combined with the hidden shame of their diagnosis.
Nonetheless, agency should not be underestimated and we note the importance of not reproducing Orientalist tropes about the oppression of Islam. The interviewees all hoped that the study would help their local community in France. This has implications in terms of health promotion: certainly behavioural interventions need to tackle social and culturally-specific mediators (31).
Poor mental health status
The overarching perception of participants’ mental status was of pervading anxiety used in its lay meaning, to refer to poor sleeping quality, rumination, no hope in the future, and fears), deriving from multiple sources: HIV status which could not be disclosed; hepatitis C hypothetic survival in the body, and its potential for reactivation; infertility due to HIV or hepatitis, and transmission risks to a future spouse; the risk of becoming re-infected when back in Pakistan; being undocumented in France; being unemployed; working extremely long hours; feeling isolated from their family; feeling disillusioned; having no secure future in France. Their primary duty was to send remittances to family, and being sick or unable to work due to illness was a significant source of anxiety. Many of their reasons for anxiety, especially those related to hepatitis, were not based in fact. Despite reassurances from physicians, they continued to believe in unsubstantiated causes e.g. hot food with chillies, dirty water and environments. In addition, many suffered from traumatic reviviscences of their migration journey. None of our participants reported they drank alcohol, when asked by their physician. However, several reported having used alcohol before being diagnosed. There was a sense of enduring despair regarding their unstable status in France, a sense of desperation about their health conditions, and hope the French health system might provide them good healthcare and treatment. Above all, their priority was to work and earn money.
Paper and legal status issues were central for most participants, and produced much mental tension. Most navigated between rounds of asylum and residence permit for medical care applications, and had undocumented status. Poor mental health was a mediating factor affecting, for instance, self-efficacy in adopting non-risky behaviours. Mental health needs to be taken into account when designing health promotion and prevention interventions.