Medical disposals and problem solving: About high blood pressure in Morocco

Introduction

In basic healthcare facilities in Morocco, ¹ general practitioners transform patients’ problems into solvable problems, taking into account constraints related to medical standards, financial issues and the organization of care. To analyze these transformations, I rely on Berg’s (1992) ‘medical disposals’, defined as a set of actions perceived as sufficient responses (for example, a prescription, a referral or advice), implemented to transform a specific patient problem into a solvable problem (by a physician at a time and place). I also rely on STS approaches to standards and their application to bodies (e.g. Cambrosio et al., 2009; MacKenzie et al., 2013; Thévenot, 2009). My disease focus is hypertension, or high blood pressure.

Blood pressure is the pressure exerted by the blood upon the walls of the blood vessels, produced by the contraction of the heart muscle; hypertension is a condition in which the blood vessels have persistently raised pressure. It is a symptom, a risk factor, and a disease common in medical and social discourses (Sarrandon-Eck, 2007). Known in Morocco as ‘tension’, hypertension is not a cause of stigma. In the context of global health governmentality, changing meanings of diseases, and of the boundaries between the normal and the pathological (Brown et al., 2012; Greene, 2007), hypertension is increasingly targeted by international health policies, because it is associated with several health risks, in particular coronary heart disease and stroke. It also affects the brain, heart and kidneys (Pathak et al., 2015; WHO, 2014).

Hypertension accounts for 9.4 million deaths worldwide every year (WHO, 2014). It is responsible for at least 45% of deaths due to heart disease and 51% of deaths due to stroke. It is associated with poverty and low levels of education (Leng et al., 2015). In Morocco, its overall prevalence is 33.6% (30.2% for men, 37% for women). One patient in three has complications linked to the disease (Nejjari et al., 2013). It is one of the main reasons for consultation in basic health care facilities and is highlighted as responsible for 51% of deaths due to stroke, 45% of deaths due to coronary heart disease and 28% of chronic kidney disease cases. The prevention and control of the disease is a priority for the Ministry of Health (Ministère de la Santé, no date). A vertical program ² for the prevention and control of hypertension was created in 1996, with the aim of reducing mortality and premature deaths related to the disease and its complications. Located at the level of the Ministry of Health, in the capital city of Morocco, Rabat, the program with its three dimensions (intervention, monitoring and evaluation), is among others in charge of defining guidelines for the diagnosis, treatment and follow-up of patients, as well as recommendations for good practices; it is in charge of providing health facilities with treatments, devices for diagnosis, tools for patients’ education, files and documents for the gathering of statistics. Finally, it is in charge of making updates to the guidelines available to health providers through workshops, training sessions and seminars, and of collecting statistics related to the disease, with the aim, in theory, of responding adequately to needs in terms of medications. To achieve this, connection and communication between the Ministry of Health and the periphery has to be maintained, the flow of information in the two directions uninterrupted, data coming from the periphery leading to changes in the policies and vice versa.

A patient’s problem, Berg (1992) writes, is whatever a person and/or his environment perceives to be problem for which a doctor has to be consulted. This problem is solvable when the doctor is able to propose a disposal, a set of actions (p. 155). This does not imply that the problem is resolved, but only that the physicians knows what to do next. Thus, the physician transforms the patient’s problem into a solvable problem by reducing the array of possible actions to one disposal (p. 156). The term ‘transformation’ implies a process in which the patient’s problem is not only translated but also remolded (p. 155). In this perspective, the physician asks questions to reconstruct historical information and can request further exams. The type of questions he or she asks, the way he or she asks them, and his or her interpretation will shape the symptoms since, through questions, the physician selects information that corresponds to the transformation he or she has in mind. Likewise, the selected or omitted examination procedures prestructure the ‘pathological reality’ to be cured (p. 158). During the transformation process, information collected through questioning the patient and examination are shaped in light of each other.

Time is among the factors pervading the process. As Berg explains:

Duty rosters, office hours, deadlines for X-ray and laboratory requests, create a rigid structure of ‘interlocking timetables’ in which the unpredictable flow of patients has to be fitted. When time runs short during consulting hours, potentially time-consuming historical or examination cues are often (re)moulded in favour of a more timesaving transformation. The physician, for example, can interpret a patient’s complaints about recurrent ‘stomach aches’ as ‘due to stress’ instead of ‘requiring thorough examination’ (Berg, 1992: 160).

In contexts like Morocco, where most of the patients do not have access to health insurance, financial aspects need to be considered. Care is free of charge in basic health care facilities, but indirect costs (e.g., transportation) and shortages of supplies usually lead to unpredictable costs when seeking care in private facilities (for biological exams, echography, etc.), or when dealing with prescriptions issued but not available at the level of public health-care facilities.

Here, a standard is a frame of reference. It provides physicians with a basis for actions and, eventually, routines. The frame of reference serves as a container in which physicians pick different actions and articulate them according to the individual patient, time, organization of health facilities, and available functioning devices. Standards are common in the field of public health and biomedicine. For example, when defined as a threat to public health or an international security issue, diseases and biomedical practices are subject to regulation and enforcement by government agencies and other bureaucratic institutions (Cambrosio et al., 2009). In this perspective, standards set for diagnosis and treatment are accompanied by regulatory devices, including different types of graphic artifacts (Hull, 2012a, 2012b), distributed in order to guide and follow up on practices. If they are not ordinarily mandatory, as highlighted by Cambrosio et al., they at times achieve the status of official regulations to be followed, at least in principle, by all practitioners (Cambrosio et al., 2009).

Yet, scholars in STS have shown that the process of standard-setting faces challenges when it comes to coping with things that are related to persons, their bodies and individual uses (Thévenot, 2009). ‘Forms of lives will tend to vary, resist, or disrupt the stable attribution required for standardization’ (MacKenzie et al., 2013: 703). Any attempt to attribute a fixed property to the biological multiplies dependencies between values, materials, humans and non-human agents (Thévenot, 2009). Standards generate forms of infrastructural liveliness, a diversified array of intermediaries (skilled personnel, types of equipment, material and conceptual entities) that intervene. Thus, they need formal material arrangements (MacKenzie et al., 2013). Yet, in emerging or resource-poor countries, the extraversion of disease categories – shaped by pharmaceutical research and marketing, public health priorities and health policies – lead to the importation of standards, while the material, institutional arrangements and continuity of practices among the diversified array of intermediaries is unstable or, sometimes, does not exist.

I argue that the frame of reference allows for the solving of patients’ problems through the production of an entity called high blood pressure. However, this ‘high blood pressure’ is not the one defined by standards, but rather an in-between high blood pressure. I show that the frame of reference consists of elements borrowed from different contexts, mainly the Global North. These elements, reflect Global North biologies and public health priorities. Yet, biologies vary according to context (Lock and Kaufert, 2001). Thus, pieces of the frame of reference need adjustment to the context. Investing in standards production for the regulation of practices is a costly endeavor (Thévenot, 2009). It is done in delimited collectives or equipped communities. The costs of such activities is so high, Thévenot highlights, that it can prevent experts from participating in standardization (2009). The Moroccan ministry of health can’t afford the process of adjusting the frame of reference to local biologies, practices, institutional and material arrangements. Thus, the entity produced through the transformation of the patient’s problem into a solvable problem is an in-between hypertension, an entity standing between the frame of reference (cognitive and social aspects) and the configuration of patients’ trajectories at this moment and place, that might generate stress and a raised blood pressure. Consequently, the patient’s problem, the one that led to the consultation of a physician, might or might not be the disease of the standards named ‘high blood pressure’. However, identifying the problem as hypertension allows doctors to know what to do next. In this context, the array of possibilities is not infinite, but limited and narrow due to constraints on both doctors and patients sides: lack of equipment, shortages in supplies (doctors) and financial issues (patients).

Methodology

I spent twelve months in Morocco for fieldwork. A research authorization was required and obtained from the Ministry of Health (Direction de l’épidémiologie et de la lutte contre les maladies). Research tools consisted of observations and in-depth interviews. I wanted as much as possible to ‘be with people’ in the health care facilities studied. I started by sitting inside waiting rooms and observing interactions between patients, experiencing in my body the active process of waiting (Tantchou, in press), listening to their worries, disputes, and comments about the provision of care. Then, I introduced myself to the doctor. I was sick myself during fieldwork, so I had the opportunity to experience the process of seeking care, the cognitive and social aspects (time, shortages in supplies) of the transformation of a patient problem into a solvable problem process.

I followed and observed doctors during their daily activities, including consultations, lunch and filling out of papers. I also observed how measures of blood pressure were performed. I paid attention to patients’ posture, measurement devices, the way they were adjusted and calibrated (Mol and Law, 1994) to fulfill their purposes efficiently or according to the frame of reference. I listened to issues raised by doctors, patients, blood pressure numbers, and to how issues were addressed. I paid particular attention to encounters during which a hypertension diagnosis was confirmed. I observed patients’ attitudes and responses to the diagnosis, listening to their questions and the doctors’ answers, and took note of the patients’ overall attitudes during medical encounters. I also managed to be part of a national training program organized by the cardiovascular disease service of the Ministry of Public Health. This allowed me to note updates to the frame of reference, and attempt to trace their implementation by doctors.

Interviews with general practitioners (GPs) were recorded and transcribed verbatim. I wanted to have a broad view of the network of basic health care facilities, the appropriation of the frame of reference and the ways specific doctors manage to solve issues related to discontinuities among intermediaries and shortages of material arrangements to enforce the frame of reference. To achieve this, I visited all of the basic health-care facilities in Rabat. I interviewed 28 doctors in charge of hypertension in 28 health centers (of the 29 functioning). I also had the opportunity to meet with nephrologists, cardiologists and private general practitioners, and to investigate the ambulatory monitoring of blood pressure (AMBP) at the level of the university hospital. Finally, through my involvement in a community organization, I was associated with focus group discussions organized with women to explore their perceptions of public health-care facilities. Here, I use data from basic health care facilities (observation and in-depth interviews), supplemented with data coming from interviews with specialists and focus group discussions with women.

The article is organized in three sections, it starts by giving details about the frame of reference that allows for the solving of patients’ problems through the production of an entity called high blood pressure. Then, I follow the ideal trajectory of a patient from their home to a basic health care facility and, once in the facility, from the first encounter with the doctor (for a specific problem) to the transformation of the problem into hypertension. During this journey, I highlight issues related to the above-mentioned constraints: medical standards, financial issues with the organization of the health system, and the process of care.

The frame of reference

The frame of reference is a guideline with ten recommendations, an algorithm summarizing the steps of the transformation process and their articulation with each other (Figure 1). The recommendations relate to the measure of blood pressure, treatments, dietetic rules, etc. In the following paragraphs, I give an overview of these recommendations, starting when the patient enters the doctor’s office and continuing until the problem is transformed into hypertension. In other words, I concentrate on the diagnosis process. As measuring accurately is at the core of the process, I give insight into requirements for accuracy.

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Figure 1.

Schematic of the frame of reference.

The first recommendation says the measure of blood pressure is done with a sphygmomanometer or a homologated electronic device on a patient at rest, using the appropriate arm cuff and with repeated measures. The patient’s problem is transformed into high blood pressure after several measures performed during separate consultations. High blood pressure is defined as repeatedly elevated blood pressure equal or exceeding 140/90 mmHg, systolic pressure above 140, and diastolic pressure above 90. The conditions under which measures should be taken to ensure their accuracy are specified. Calibration is among these conditions: It is recommended to check for accuracy and have sphygmomanometers calibrated by an accredited laboratory at least once per year, and manual devices at least once per 6 months. This corresponds to what can be read in the literature (Turner et al., 2006, Turner et al., 2007).

Blood pressure fluctuates, depending on individuals, physical activity, workplace, emotional state, bodily functions, and internal and external environment. For example, bowel and bladder distention, pregnancy and menstruation cause blood pressure to rise, as do smoking, the ingestion of alcohol, caffeine and meals. Some individuals have increased blood pressure while they are at their place of work. Feelings of anger and happiness are associated with increases in blood pressure. That is why it is recommended that patients should rest for at least five minutes in a quiet, comfortable, uncrowded room with a pleasing temperature before measurement, in order to allow physical and emotional stresses to settle (Campbell et al., 1994c). Patients are advised to empty their bladder and avoid coffee, cigarettes or any adrenergic stimulant intake before the measures.

The frame of reference gives requirements for accuracy. These requirements concern the devices used, the processes of measuring, focusing on patients’ posture and the adjustment of devices to the variability of bodies. Concerning the instrument, the frame of reference says that, no matter what type of instrument the provider uses, the arm cuff should be adapted to the patient’s arm size. There are four categories of cuffs, according to arms’ circumference. Regarding posture, it is written that the measure should be done while the patient is seated or lying down. The arm cuff is wrapped around the upper arm, just above the elbow, on top of the brachial artery. The arm should rest at the same level as the heart, to have the arm cuff near the heart. A picture (Figure 2) of a measurement of blood pressure appears in the frame of reference as a model. At least two measures, one to two minutes apart, should be performed. The mean of the two is taken as blood pressure numbers. Two additional measures might be performed, if the preceding are variable. On the first visit, it is important to measure on the two arms. In case of difference, the arm with the higher number is considered. Finally, one measure should be taken while the patient is standing.

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Figure 2.

Model image of the taking of blood pressure.

The person measuring blood pressure can affect the reading through the ‘alerting reaction’, or the ‘white coat phenomenon’. Those are increases in blood pressure occurring when patients encounter a physician. The former occurs when the patient is not familiar with the physician and wanes after several visits. The latter is provoked by the physician and is persistent over time (Campbell et al., 1994c). For these reasons, it is important to measure accurately, and to establish the persistency of raised blood pressure. That is the reason why measures have to be repeated. The frame of reference says that at least three successive consultations are needed, with at least two measures per consultation in a period of three to six months. The numbers considered should be the last two measures.

What moves the patient from house to health-care facility?

As mentioned, Berg (1992) defines a patient’s problem as whatever a person and/or his environment perceives to be a problem for which a doctor has to be consulted. Related to hypertension, the problems reported by patients are ‘headaches’, ‘dizziness’, ‘heart beating too fast’, ‘difficulty breathing’ or ‘feeling breathless’, ‘hear buzzing’ and ‘trouble seeing’. Once the decision to consult a doctor is made, going from one’s home to a basic health care facility is not easy for many patients. The body is at stake, feeling stress inside because of the ‘problem’, while experiencing constraints and pressures on the outside; this can last from the feeling of the first symptoms to the moment the patient enters the doctor’s office, and sometimes long after. According to the Ministry of Health, the mean distance to reach a health care facility is 21.9 km, with huge differences according to location: 13.8 km in urban and 38.5 km in rural areas. On average, it takes 35 minutes for those living in urban areas to reach a health-care facility, and 77 minutes for those living in rural areas. Overall, 41% of patients are over an hour’s travel from the nearest health care facility. The travel time is even greater when hospital care is involved. Rural dwellers spend at least 90 minutes to reach a hospital; urban residents take 53 minutes (Ministère de la Santé, 2007: 97).

Upon reaching the health care facility, the patient goes to the registration desk. According to their complaints, they are given a colored ticket with a number, the numérou, and asked to sit in the waiting room. Each color corresponds to a specific category of ill-health (general acute, children, new born/pregnant women and chronic diseases), manage by one to three doctors, occupying a specific consultations’ room. Patients have to sit near the consultation rooms corresponding with the color of their numérou. In this way, they can be sure nobody will jump the queue when their turn comes. Doctors do not open or close the door to patients. They sit behind their desk and expect them to enter the office, following each other, according to their numérou. When a patient’s number is called, they enter the office of the doctor who will be in charge of transforming their problem.

When entering the doctor’s office (Figures 3 and 4), the patient sees a man, a woman, or two people sitting behind a desk covered and full of papers, registers, files and boxes – I have elsewhere (Tantchou, 2018) analyzed the reconfiguration brought by these graphic artifacts (Hull, 2012a, 2012b.) into care practices. The patient can also see a blood pressure measurement device. They will be asked to sit on a chair in front of the doctor. Now, the dialogue that leads to the transformation of the patient’s problem starts. As mentioned above, the physician makes a patient’s problem solvable by proposing a limited set of actions perceived to be a sufficient answer (at this time and place). This does not necessarily imply that the patient’s problem is relieved, as Berg has highlighted, but only that the physician knows what to do next. Thus, the term transformation implies a process in which the patient’s problem is translated and remoulded (Berg, 1992).

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Figures 3 and 4.

The doctor’s office and desk.

It is important to note that the dialogue is only a moment in the process. The process does not start when the patient sits in front of the doctor and the latter asks the first question. ‘When you enter the doctor’s office, you are to some degree consulted’, a health provider commented elsewhere (Tantchou, 2018). The array of possible actions is already reduced when the patient is asked to sit, because doctors pay attention to specific and observable risk factors. The measurement of blood pressure is considered a part of the systematic medical examination of every patient (Ministère de la Santé –Service des Maladies Cardiovasculaires, 2016). However, the shaping of the contour of cardiovascular risks renders specific categories of populations visible and amenable to diagnosis and intervention (Brown et al., 2012). These are pregnant women, people over 60 years old, people over 40 years old with one or more of: obesity, tobacco use, renal diseases, hypercholesterolemia and diabetes. Those details are checked while the patient enters the doctor’s office; they will be confirmed (or not) through questions. If measuring blood pressure is part of the systematic examination of every patient, for the above categories of people, it is in theory obligatory. To start the process, a device has to be available.

In the doctor’s office, measuring blood pressure

Measures: Space, posture, and multiple bodies

In the preceding section, we left the patient in the doctor’s office. Salutations had taken place, and the doctor announced that blood pressure had to be measured. The frame of reference says the measure should be done on the arm; it is not stated whether the arm should be bare or not. However, patients’ attitude shows that they expect the measure to be done on bare arms: When told that blood pressure has to be measured, they systematically start to fold the sleeve of their left arm.

In Morocco, most of the patients I encountered in health facilities were wearing djellaba, a long dress with long sleeves. ‘Their obsession is with catching cold’, wrote a doctor (Jamaï, 2016). This is also to protect their body, ‘to have smooth skin’, reported a nurse. Those I met in doctors’ offices were wearing many layers of clothes. For example, women were wearing a pajama, the first piece, closer to the skin, then a long dress, with long sleeves on the pajama, the djellaba, and, finally, a coat in winter. ‘I once decided to ask the patients the question of why two or three pants’, wrote Dr Souad Jamaï.

One of them told me that for him it was time-saving to keep his pajamas under the pants. Another told me that it was convenient to travel, he did not need a suitcase, it was enough to change the order of layering layers of clothes. Another, who was too thin, kept his underpants even in hot weather, as it gave him a fuller look. A self-respecting Moroccan does not want to be skinny. It seems that being fat is a sign of good health. Difficult to change mentalities. (Jamaï, 2016: 174, author’s translation)

With these pieces of clothing, I observed, as did Dr. Jamaï, that ‘when patients are told to undress, most often they only remove their djellaba and think that it is quite sufficient … I often have to negotiate so that the patient agrees to undress’ (Jamaï, 2016: 174), Usually, in basic health care facilities, doctors do not ask patients to undress. They are concerned about time: If everybody has to get undressed and dressed in the consultation office, consultations will be longer and waiting time will be extended. From their perspective, measuring blood pressure over a sleeve or a rolled-up sleeve saves time. They also highlight lack of facilities that would guarantee privacy. Elsewhere, I have specifically analyzed waiting spaces and what happens around doctors’ doors (Tantchou, 2020). I note that doctors’ office doors are quite frequently open because of nurses requesting advice, friends passing by, angry patients wanting to be received in emergencies, visitors from pharmaceutical firms, etc. Thus, it is impossible to make sure that nobody will enter the office while the doctor is examining a patient or while he or she is getting undressed or dressed.

For all these reasons, women will just try to push up the layers of clothes. As the clothes fold while the patient is pushing them to the shoulder, they enlarge, and sometimes, because of a large-sized arm, the cloth cannot go beyond the middle of the upper arm. Doctors have to force it up to have the arm cuff wrapped just a little below the elbow and press on the ‘start’ button of the electronic device, or press the inflation bulb to pump the air into the cuff for manual devices. When the cloth cannot go beyond the elbow, doctors usually ask patients, women in particular, to unfold one or two sleeves, depending on their thickness, to allow the cuff to move up and be wrapped around the upper arm or approach the upper arm.

Studies have found that readings taken over the sleeve of a shirt, blouse, or light sweater are not statistically different from those taken on bare arms or with rolled-up sleeves (e.g. Ma et al., 2008; Thien et al., 2015 ). In an outpatient clinic, blood pressure can be measured reliably with one layer of clothing underneath the cuff. This saves time and is supposed to be more comfortable for patients (Thien et al., 2015). It may be preferable because of hygiene concerns, patient privacy and religious beliefs (Rukiye et al., 2010). Discussing some of these results, McKay (2008) has called attention to the fact that differences in patients and in the technology used by manufacturers may limit the generalizability of results. At some clothing thicknesses or combinations of thickness and material, the pulse will not be sufficiently transmitted to the cuff. At present, this combination of factors is unknown. Until more is known about interactions between devices and clothing, he notes, the best advice is to prepare the patient in advance (e.g., avoiding consumption of caffeine and food, emptying their bladder) so that clothing removal will not be an issue. For, if the patient is not prepared for the blood pressure measurement in advance, the reading taken may not be of much clinical use.

When measuring blood pressure, patients sit on the chair and stretch their arms. They do not always rest on the back of the chair, but bend toward the front to rest their elbows on the doctor’s desk. I also observed patients resting on the back of the chair and stretching their arms. Not supported, the arm stays stretched and suspended between the chair where they sit and the doctor’s desk, until the measure is completed. There are doctors’ offices equipped with one bed. But the bed is piled with papers and boxes, making it impossible for use by patients. The bed would have allowed patients to lie down and have their arms resting on the bed during the process. Studies have shown that the position of both the patient and his arm during measurement influence the blood pressure (Campbell et al., 1994a, 1994c; Eser et al., 2007). In a trio of publications on errors in the assessment of blood pressure, Campbell and colleagues highlighted the patient factor as well as the measuring technique. Among the factors related to the measuring techniques, they emphasized patient position, patient arm position, and patient arm support. Studies have also found 2- to 4-mmHg changes in blood pressure between sitting and lying position, and demonstrated that being seated without back support and even small changes in arm position can affect readings (Campbell et al., 1994a, 1994c; Eser et al., 2007). Blood pressure changes according to the position of the antecubital above or below heart level. It increases when the arm is supported and decreases when it is held vertically. Diastolic and systolic blood pressure can increase in some subjects when their arm is not supported (Campbell and McKay, unpublished observations). Hypertensive patients and those being treated with beta-blockers may have exaggerated increases in blood pressure when their arm is unsupported (Campbell et al., 1994a).

Measures are performed on one arm, even on the first visit. Doctors with manual devices occasionally measure on two arms. The electronic devices provided by the Ministry of Health measure the pressure three times and give a mean. When, depending on the age of the patient, the numbers are at least 140/90 the doctor says: ‘tension tala’, in Darija (Moroccan colloquial language), meaning that the blood pressure is high. However, according to some doctors, a blood pressure reading up to 160/100 is mmHg is still acceptable. The cacophony and debates related to divergent thresholds has been highlighted (Denolle, 2018; Greene, 2007). If there seems to be a consensus around the dividing line between normotension and hypertension, the thresholds might change depending on the general state, age, and existence of co-morbidities for patients. The evaluation of this depends on the ‘feeling’ of doctors, as dealt with elsewhere (Tantchou, 2017). If he considered that for this patient at this moment, the dividing line between normotension and hypertension is crossed, the persistency of raised blood pressure has to be evaluated.

Checking persistency

Checking persistency allows for the elimination of other sources of stress in social or personal life, or generated by the medical encounter as possible explanations of the raised blood pressure. For this purpose, the patient will be asked to measure their blood pressure at ‘home’, at least twice per day, and mark the numbers as well as the date and time on a sheet of paper (Figure 5). They will do this for three days or one week, depending on the doctor’s ‘feeling’, and then return to the health facility with the numbers.

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Figure 5.

Example of home blood pressure readings.

Asking a patient to measure their blood pressure at home supposes that they have access to a personal device, theirs or a family member’s. None of the patients I met in basic health care facilities during fieldwork had a personal device. One patient I met at the university hospital told me that he actually had one but didn’t use it for himself. He loaned it to family members in need because, from his perspective, it was another source of stress. Having his blood pressure measured in the doctor’s office was enough. He didn’t want to medicalize his daily life or have it disturbed because of a need to keep track of numbers. He knew that his raised blood pressure was due to professional stress, and thus he changed his professional status, incurring a loss in salary, but that was fine because he was feeling better.

Knowing that ownership of personal devices is not common, when asking patients to measure their blood pressure at ‘home’, doctors usually advise them to go to a pharmacy, or to come back to the health facility. There are constraints related to the two alternatives. Regarding the case where people have to travel to a health-care facility, the major constraint is waiting time. They are not ‘chronics’ yet, or individuals with specific ‘problems’ that have to be solved, who will receive a numérou and wait for consultation to see their problem transformed or referred for follow-up. Nevertheless, they have to sit and wait as if they belonged to the two preceding categories (as for their first encounter with the doctor for this specific problem). This is a source of dissatisfaction for patients.

Doctors and patients agreed that measuring blood pressure is not a doctor’s duty; a nurse can perform the task. If facilities were equipped and organized efficiently, doctors commented, blood pressure, weight and sometimes temperature should be among the numbers taken after identity was checked and a numérou assigned. Taking such readings is not a medical but a paramedical procedure. Nevertheless, lack of equipment, shortage of human resources, and poor organization moved the measure from nurses’ roles and space to doctors’ offices, they remarked. It has become one of the doctors’ duties, for which patients should wait, as they do for a consultation – and not just any doctor, but those in charge of ‘chronics’ (because, when available, sphygmomanometers are kept in their offices). The doctors complained about having spent eight years studying medicine to measure blood pressure at the end.

Concerning the second alternative (measuring blood pressure in a pharmacy), doctors do not agree. Some advise patients to go to pharmacies to avoid the wait. Others raise issues related to the calibration of the device.

I don’t advise patients to go to pharmacies, a specialist said, because devices are not calibrated. The numbers are not accurate. That can generate unnecessary stress. When they say to a patient, ‘you have 140/90’, while with a calibrated device he will have a normal blood pressure, he will spend the night thinking about the numbers, false numbers. That’s not good.

His colleague added:

If the aim is to erase white coat blood pressure, it fails, because in pharmacy, people usually wear white coats.

Another issue relates to what is being measured. The colleague continued:

What’s fundamental here is that what is expected is not only a measure, but the measure of blood pressure in the normal life of an individual. Entering a pharmacy is not normal life; we mean, at home, in the morning, in the afternoon, in the evening, three times a day – three times. What really matters is that it should be done in the patient’s normal daily life environment, not the pressure with which he enters my office or the pharmacy.

Consequently, what is at stake here is having ‘normal life numbers’. However, when a patient identifies a problem for which he seeks care, he is not in ‘normal life’ anymore. To get closer to ‘normal life numbers’, a device at home or an ambulatory blood pressure monitoring (ABPM) is required.

The ABPM is a device attached to the patient that records blood pressure every 15 minutes. The device is initially connected to the computer to create a new computer file where data related to a specific patient will be recorded. Then, it is attached to the patient, who will carry it for 24 hours. Back at the health facility, the device will be detached and connected to the computer, which will give pictures as well as numbers describing the patient’s heart activity during the 24 hours. The ABPM appears in the frame of reference as a step needed to confirm the persistency of blood pressure, which supposes that it should theoretically be available in health care facilities.

We have to move to ambulatory blood pressure monitoring. The Ministry accepted the idea of buying measuring devices and will open a call for bids soon; the first attempt did not work. Then we will have to think about how we can have this work, because if we give the devices to patients, we have to make sure that they bring them back! We will organize that. (specialist).

Nevertheless, the ABPM was not available at the level of primary health care facilities when I was doing fieldwork, and it was far from becoming available. Most of the health facilities were not equipped with computers on the one part, and a tracking system to follow the device in case the patient does not hand it back (one major subject of concern at the level of the ministry of health, according to a specialist) was not available. Thus, physicians at the level of basic health care facilities do not prescribe ABPM.

Patients informed through internet searches or friends having a family members with hypertension request ABPM. In these cases, they will go to a private clinic, pay (20€) for the procedure (attaching the ABPM to their body) and make a deposit (150€), in case they do not return the device. Those are huge amount of money for patients consulting at basic health care facilities where everything is free of charge. All the doctors I met agreed on the fact that their patients lack resources. They are poor, ignorant and lack discipline, many of the interviewees commented. ‘They are so deprived’, a general practitioner highlighted, ‘that if they don’t have their treatment, the complete treatment here, they will not buy it in a pharmacy. They are dependent on the free-of-charge care provided at the level of public health care facilities with its constraints, frequent shortages, and long delay to have an appointment with a specialist or for specific exams’.

Thus, to have access to ABPM, described in the frame of reference as a step necessary to confirm a diagnosis or provide a diagnosis corresponding to the internal real bodily experience (Tantchou, 2020), one has to pay. Otherwise, the doctor will solve the patient’s problem as high blood pressure. The transformation process that should have lasted at least three months has shrunk, and is subsumed in two or three consultations during one or two weeks. According to a nephrologist, the shrinkage of the procedure from at least three months to one or two weeks means that many patients are diagnosed with high blood pressure and put under medication when they do not really suffer from the disease: ‘At least one out of two patients diagnosed are not really high blood pressure patients. That is too much’.

Once the patient’s problem is transformed into high blood pressure, two set of actions are possible: putting the patient on medication or prescribing hygienic and dietetic rules. The latter mainly consist of reducing the ‘three white poisons’ (sugar, salt, and white bread), reducing fats, and adding vegetables, fruits and exercise. Doctors complain about patients being unable to follow the rules, arguing about their lack of discipline and ignorance. Patients complain about not being able to afford the changes. A woman summarized this point as follow: ‘We don’t even have the money to afford daily food, how can you ask somebody who can only meet the expense of a cup of tea and bread to change eating habits?’ Facing this issue, a doctor noted, ‘You prescribe hygienic dietetic rules, they don’t respect them, and they will come here with high numbers. What do you do? You put them on medication’. Yet during one of the training sessions I attended, a point was made that

putting patients on medication is not an emergency. Doctors should not be in a hurry. Once the treatment is started, nobody will have sufficient boldness to doubt it. As such, it is important to be sure, when starting the treatment, that you are doing the right thing. Before starting a treatment, the first question is: Is the high blood pressure true? (specialist).

How can the ‘truthfulness’ of a condition be assessed when the necessary structures are continuously disarticulated and discontinuous? Yes, the device used and the frame of reference shows raised blood pressure. But, is the device accurate? Is the raised blood pressure persistent?

When the patient’s problem is transformed into high blood pressure, breakage of equipment and devices, shortages related to the provision of supplies, among other problems, reduce the possibilities, leaving the clinician with a limited choice: hygienic dietetic rules or medication. Hygienic dietetic rules are not followed, mainly because of lack of resources. Medication seems to be the major, even the only fix. Besides, it is one point of consensus between patients and physicians, because when a problem does not match any available disposal, there is always the possibility of giving medication, ‘at least for headaches’, as one doctor observed. But here, shortages are also frequent. Lack of medication, discontinuity in the continuum of care, and poor organization of the provision of care, contribute to nurturing people’s negative perceptions of public health care facilities (CESE, 2013). This also nurtures doctors’ negative perceptions of their patients, mainly the poorest, in front of whom they are powerless because of shortages and because they are unable to access health care in the private sector to give doctors a chance to move forward with the process of problem solving. In these circumstances, rather than assuming a problem related to the organization of care and the lack of resources, or their lack of power, these patients are regarded as ignorant and undisciplined (Tantchou, 2016).

During an interview, a doctor explained how he was sad to see that all the work he and his colleagues were doing was not being used to improve practices and the program. They were gathering a lot of statistics and would have appreciated it if they were analyzed in a longitudinal approach to provide an idea of successes and failure. This was both a matter of self-satisfaction and efficiency, as only such analyses would induce changes, even slight, into practices and lead to an adjustment of the program to the local context.

What this doctor was complaining about has been raised about vertical health programs – like the Moroccan program for the prevention and control of hypertension – in Africa. That is, they are disconnected from local health systems, and resemble bureaucracies caught within the routines of ministries of health. Usually, support (financial, technical) for these vertical programs comes from international organizations, used to problematize the South as requiring interventions (Brown et al., 2012). The efficiency of these interventions, targeting specific diseases like hypertension, without considering structural constraints related to health systems has been debated (McCoy et al., 2005; Mills, 1983; Mounier-Jack et al., 2017; Schneider et al., 2006). Taking HIV/AIDS policies as an example, it has been shown that bypassing health systems by creating vertical structures that drain resources from a ‘crumbling core’ may address short-term needs (Schneider et al., 2006), but also contribute to health systems’ fragmentation, the duplication of services because of decontextualized donors’ priorities, the dilution and distortion of limited human and financial resources, and weak coordination between levels of care (Barr et al., 2019). The ‘health systems strengthening’ approach has been perceived as one way to improve health outcomes and the efficiency of these programs. Yet, donors’ commitments, priorities, agendas and routines, make it difficult to impulse changes. Consequently, no matter constraints, bottlenecks and programs’ failure to meet the expected results, they must continue, until interrupted, redefined or reoriented by donors, according to their agendas and priorities for the South.

Conclusion

‘Medical practice does not adhere to universal rules and categories’ (Berg, 1992: 169). In medical problem-solving, physicians have a frame of reference that allows for judgement. In Morocco, this frame of reference consists of biomedical knowledge borrowed from other contexts. They provide a set of steps or actions and the articulation between them. However, the material arrangements and the continuity needed to allow physicians to act continuously according to the frame of reference are lacking. Cambrosio et al. (2009) write that taking blood pressure or transforming a patient’s problem into high blood pressure involves the establishment, regulation and maintenance of an increasing and diversified array of intermediaries (skilled personnel, types of equipment, material and conceptual entities). It also involves the production and maintenance of the specific arrangement that affords such activity (Cambrosio et al., 2009). The lack of production and maintenance of the specific arrangement that could afford the accurate measure of blood pressure and check its persistency does not allow high blood pressure to be enacted (Mol, 2002); the diagnostic process doesn’t allow for the production of numbers closely connected to the reality of the bodily experience.

High blood pressure is an entity that stretches, shrinks or mutates depending on relations that can or cannot be established with relevant practices, forms of life, humans and non-humans (Cambrosio et al., 2009). Consequently, like other informed entities, high blood pressure undergoes a process of ‘informational enrichment’ as it faces disarticulation in the array of intermediaries and arrangements. Discontinuities allow the enactment of a contextual form of biomedical entities, an in-between raised blood pressure, enriched with social issues and deprived of its technical components.