Feelings and Expressions of Happiness; Human Ties and Happiness which encompassed four sub-themes—family bond, the company one keeps, the pandemic and social disengagement, and the nation, society and happiness; Satisfaction with Material Needs and Resources; Lifestyle and Health; Work and Play; Accomplishment and Appreciation; Nature Connectedness; Religious and Spiritual beliefs; and Happiness as a Personal responsibility—Role of Positive Personality Traits. These findings revealed our respondent's multidimensional conceptualization of happiness, and adds to the growing body of happiness literature from the South Asian context.The present study aimed at understanding the subjective perception of happiness in a sample of Indian participants from diverse socio-economic backgrounds. Using convenience sampling, individual interviews were conducted with 60 participants aged between 19 to 73 years (M Age = 40 years). This study employed reflexive thematic analysis to analyse the written transcripts. Nine themes were generated which captured the essence of happiness for Indians— Happiness is a complex, elusive and diverse concept because of the multitude of meanings that people attach to it  aged between 19 and 73 years  belonging to Delhi NCR and Bhopal. Detailed socio-demographic characteristics of the participants are presented in This study received ethical clearance from the Institutional Ethics Committee of Indian Institute of Technology Delhi. Data was collected through semi-structured interviews (both online via Zoom meeting and face-to-face in the community) between February to March 2021. To get a diversity of views, we approached people belonging to different age ranges and socio-economic backgrounds.Written or verbal consent (based on participant preference and their literacy status), and socio-demographic information were obtained prior to the interviews and the participants were informed that they were free to answer the interview questions either in Hindi or in English, and confidentiality and anonymity was assured. The interview schedule was also prepared in both languages. The interview questions broadly covered the meaning of happiness to the participants, their happiness facilitators and inhibitors, happy and unhappy moments of their life, their happy habits and suggestions to others for enhancing happiness. These were followed by probing questions where needed. The interviews were between 25 to 45 min. At the outset, the participants were informed that they were free to withdraw consent at any time during the interview. All the interviews were audio-recorded, and transcribed verbatim.We used NVivo 12 for data management and analysis. Using a social constructionist framework and focusing on the semantic level of the data, we employed reflexive thematic analysis , while for the latter, it was about having resources that could help in leading a comfortable and luxurious life (excerpt—2):Excerpt 1: I become unhappy when I reach home and there is no money. It is very upsetting when a person does not have any food to eat at the end of the day. He wonders that despite working hard the entire day and night, he still does not have sufficient food to eat at home…also, another source of unhappiness is when you are unable to pay the house rent…there are additional expenses associated with children's education too. If one does not have enough money to pay their fee…this causes a lot of unhappiness.—Participant 15, 30 years, Private employee, lower SES.Excerpt 2…I have always wanted to own an amazing car and my own house. My mother and I specifically want to live in a house with a balcony. So, when I have that and I come home to find other things which I wished for, then that will be a perfect happy day for me—Participant 42, 23 years, Student, Higher SES.Physical and mental wellbeing and lifestyle practices was also found to be a pressing theme in this study. Many participants recognized the role of health [both physical and mental] on happiness. As most of them admitted, other happiness-inducing factors such as money and material things are “secondary” in comparison to the health and wellness of oneself and one's family. For Participant 39, a 38-year-old female, good health was the pre-requisite for enjoying the little things of life:If your health is not good, how much ever good the situation is, you will not feel happy. So, if you're healthy, if you are feeling good then only you can enjoy the little things in life. If health is fine, everything is fine, and if health is not fine, nothing is fine.Interviewees stressed that the presence of any minor or major illnesses, or merely its anticipation was enough to exponentially reduce their level of happiness and induce extreme “stress”. Especially for people belonging to the lower economic strata, illness puts additional burden because they often lack sufficient resources to afford quality treatment and medical intervention:Recently my father was very unwell. It was very unhappy that time…I didn't know how I will be able to manage…I don't have enough money to afford the expenses…sometimes I doubt and worry if I will be able to take care of my family since I don't have money—Participant 13, 41 years, Private sector employee, LSE.Therefore, to avoid ailments, participants were motivated to adhere to a good and healthy lifestyle. This involves following a disciplined routine that entails “sleep[ing] well, eat[ing] well”, having a “healthy diet”, and regularly engaging in health and wellness enhancing activities such as “exercise”, “yoga”, “meditation”. Participants also acknowledged the importance of “time management” in striking a proper balance between various life commitments and in practicing health-promoting behaviors. While describing his version of a “happy day”, Participant 9, a 24-year-old, a private-sector employee, highlighted how planning a schedule and sticking to it made him happy:…[a] normal routine would be where I'm satisfied with all the things that I have planned. So, I plan things. Basically, I like to plan certain things like my normal routine. I love to plan. That so and so things I need to do. If that goes all well, then I'm happy…Broadly, this theme highlights the importance of both work and recreation in the lives of our participants.While they considered work to be a major facilitator of their happiness, it took on a different meaning for people belonging to the higher and lower income group. For people in the higher economic strata, work gave them happiness when their job was in alignment with their interests and passion. They also expressed the importance of a “conducive work environment” which reinforces their potential, where there is harmony and good relationship between co-workers along with the availability of opportunities for personal and professional growth:…my work… for me, it's really important that every day I learn something new there…So if I have done something or I've learned something new, I feel extremely satisfied and happy. Participant 39, 38 years, Doctor.People in the lower income bracket, on the other hand, primarily focused on the need to work diligently and to have a secure job to ensure a stable source of livelihood:A person should work hard for a secure job. When they will get paid for their work, have a regular source of income they will feel happy from within because then they will be able to afford things they want - Participant 11, 38 years, Private sector employee.If work was highlighted as important, so was play. Devoting time to “hobbies” or recreational activities such as “dancing, singing, painting”, “cooking”, “writing poetry”, “reading”, “gaming”, “traveling” or other artistic or creative endeavors enabled the respondents to “take a break” from the stress and monotony in their lives, and “refreshed” them by providing the necessary “me time”. Both work and play were seen as effective distractors during times of distress:Your hobbies will play an important role [in making you happy] …if I continuously watch TV, then my mood changes, I become happy…Some people say, okay I like playing games, some may say I prefer TV or internet surfing helps me be happy. So, it depends…person to person – Participant 25, 62 years old, Retired.This theme encapsulates the experience of happiness which stems from accomplishment and subsequent positive appraisal in the form of appreciation by others and self. Our participants advocated the importance of “hard work” in achieving one's goals and the importance of demonstrating resilience in the face of adversity. Participants saw the achievement of “little” or “big” goals as happiness, be it professionally or personally. Professionally, they derived happiness from achieving “work-related targets”, career growth or promotion, or through overcoming a challenge independently. While participants admitted the inability to achieve goals as a major source of distress and frustration, they worked consistently, often with more vigor, to reach their goals. “Seeking help”, “taking a pause”, becoming “self-aware of limitations”, “accepting mistakes”, “sharing” about the problem with loved ones and having a positive mindset helped them stay motivated in the face of failure in accomplishing their mission:When I am stuck with a problem and when I am really unhappy…if I talk with someone that would solve my problem, then I would definitely want to bring up a conversation with my family members or with my wife or someone, you know, [for] a solution for the problem—Participant 8, 33 years, Private sector employee.A source of happiness related to accomplishment was the appreciation received for it. Participants lauded the influence of “positive feedback” or “appreciation” in the form of material tokens or “praises”, on their level of happiness. These not only validated their effort but also motivated them to improve their personal and professional performance:When I started playing guitar, I somehow felt that I would not be able to do it because it damages hands a lot. I felt that this is very difficult, but I took it as a challenge. So, when I did it, when I finally started playing it, people around me started appreciating me a lot. They were surprised that I learned how to play the guitar so quickly. That gave me energy…it feels good that I can live up to my potential. I can overcome my barriers. I like it when people get surprised…I get a boost and I crave for that… I want people to appreciate me even more… This makes me very happy—Participant 3, 20 years, Student.Besides, in the case of some of our participants, an “absence of [anticipated] appreciation” gave rise to feelings of unhappiness. In such situations, they adopted the strategy of self-appreciation to derive happiness. Self-appreciation can be in the form of “self-care” by “treating oneself” or by simply feeling “content”, “confident”, and “reassuring” themselves of their worth. Participant 7, 31 years, explained how he incentivized and celebrated his wins by himself:I give a treat to myself… like going out for a movie or getting something which I wanted for a long time but was postponing it like a gift, a cool tech…a mobile or something which I was postponing.This theme pertains to the role of religion and spirituality in helping our participants lead a happy life:I feel happy when I worship my Guru… if for any reason, I fail to worship my Guru, I will be extremely unhappy. The more I devote myself to my Guru, the happier I will be, this is what I believe…thinking about Guru makes me happy…and that helps me navigate through tough life situations – Participant 45, 42 years, Businesswoman.bhajans” (or religious songs) as a way of advancing their spiritual and religious beliefs. These practices not only helped them stay connected to (their) ancestors but also guided them toward a good life—by teaching them how to be a “nice person” who is considerate to the feelings of others:Many of them reported routine engagement in activities such as “prayers”, “reading religious texts”, singing “I think it just makes me keep connected to myself as well as the ancestry…we've always been taught of being proud of who we are, where we come from, and there's a certain level of duty that we also owe toward our ancestors as well as [other] human beings. And I think being connected to spirituality makes me a better person—Participant 24, 27 years, Private sector employee.Interviewees pervasively associated their religious and spiritual practices with “faith”. Faith was construed as a multifaceted construct that instills “positivity” and “hope” for a bright future, motivates one to face and overcome challenges and provides opportunities for introspection and self-discovery. They recalled feelings of “positivity” and “peace” when practicing faith and emphasized the need to be grateful to God for whatever life offers, including the hardships. For instance, for Participant 44, a 46-year-old homemaker, spending even half an hour inside the temple adjacent to her house provided her with a sense of positivity and respite from household problems and tensions. She described her feelings while visiting the temple as:I mean it feels like there's only God, and nothing beyond God for me. I have worked at home all my life but the level of satisfaction and peace that I get there [in a temple], is unmatched. Even if I spend half hour, I feel like I am in another world altogether. No matter how many problems are there at home, how much tension is there, if I go to the temple, I get immense positivity. This feeling is impossible to explain and I can never get it from anywhere else.This theme reflects the influence of nature on happiness. Participants viewed nature as an effective escape from several “negative” elements in their life. Apart from popularly acknowledging “scenic beauty”, interviewees noted that being around nature offered a calm and relaxing environment that helped them reflect and contemplate on the good things in life. Observing the various elements of nature such as sunlight, green plants and trees, animals, and birds were accredited to inducing a sense of positivity, freshness, and energy. For instance, speaking of the happiness that she derived from nurturing and witnessing the growth of plants, Participant-51 remarked:It feels like heaven… You can find happiness in plants and trees. It feels like they talk to you. It feels so good when you water them. They grow faster when you crease them and nurture them with love—Participant 51, 70 years, Retired.Speaking more generally of the positive impact of nature, another participant emphasized that being around nature acted as a respite from the negative things happening around her, allowed her to think positively and made her happy:…there are many negative things that happen around you every day, it is common for everyone, but when I am around nature, I'm able to get those negativities out of my mind… And I am able to think positive…I'll be happy that… I have the nature in front of me—Participant 41, 19, Student.This theme embodies the idea that finding joy and happiness is a personal responsibility. While external factors can certainly dictate the level of happiness or cause unhappiness, rather than expecting society and its members to make them happy, respondents emphasized that an individual should take command and try to find happiness in their lives—Don't let your emotions be dependent on somebody else or don't let somebody dictate the way you're supposed to enjoy yourself. You are in charge of your emotions and if you want to be happy, you're the only person who can make yourself [happy]. If you let your surroundings dictate your emotions to you, then I don't think you can ever be as happy as you want to be, whereas [if] you are in charge of whatever emotion you want to feel, then nothing can stop you from having a happy day or achieving the happiness that you desire—Participant 1, 22 years, Student.This can be done through “positive thinking” or by having a “positive perspective” in life, “being satisfied with the available resources” and “having realistic wishes”, “building emotional capacity” to face adversities and the like. Interviewees stressed that certain personal qualities or personality traits can help an individual stay happy. According to them, a happy person will be “optimistic”, “extraverted”, “have high self-esteem”, “self-motivated”, be “self-aware”, have “moral consciousness”, be “determined”, “kind”, “empathic”, and have “humor”, “patience” and tolerance. Participants also recurrently stressed the importance of “living in the present moment” for one's happiness:A person will be happy if he lives in the present moment. Present moment is good for any individual. In a day, all 24 h are not bad, only few moments are bad…everything is in the present. Future makes a person scared and gives a lot of suffering. It is not healthy to think about the future. People who are positive are happy, and only the present moment is positive—Participant 43, 54 years, Businessman.Feelings and Expressions of Happiness; Human Ties and Happiness encompassing four sub-themes- family bond, the company one keeps, the pandemic and social disengagement, and the nation, society and happiness; Satisfaction with Material Needs and Resources; Lifestyle and Health; Work and Play; Accomplishment and Appreciation; Nature Connectedness; Religious and Spiritual beliefs; and Happiness as a Personal responsibility—The Role of Positive Personality Traits.The present study was a qualitative inquiry into the conceptualization of happiness in the Indian context. We identified nine themes that captures the essence of happiness—Our findings revealed that happiness was subjectively associated with felt emotions of peacefulness, calmness and contentment, that have been characterized as “low arousal emotions” in the literature Lim, . While wConsistent with a large body of happiness research conducted both in the east (e.g.,: Datu and Valdez, Such buffer also came from friends, acquaintances and colleagues who provided motivation and positive environment for personal growth. Our findings revealed the importance that individuals attach to surrounding themselves with good and positive company that further elevates their mood and helps them stay happy. Existing quantitative findings evidences a strong positive association between friendship and happiness (Demir et al., While human interaction was crucial for happiness, social disengagement due to the Covid-19 lockdown was identified as a subjective barrier, especially for people belonging to the middle or upper economic strata. Indeed, studies have shown that isolation and quarantine due to Covid-19 and constant worry about the wellbeing of self and family are linked to increased depression and anxiety symptoms (Grover et al., Moving on, the present analysis also showed that happiness was not narrowly confined to one's immediate surrounding, but extended to other members of society and the nation. For instance, the socio-politico-economic situation of the country regulated one's level of happiness. Consistent with the previous literature (see Veenhoven, Our findings also showed the significance that was attached to having sufficient resources for meeting basic life needs. Research on the association between money and happiness has been conflicting (Mogilner, pahla sukh nirogi kaya which means the first and foremost happiness in life is a healthy body (Modi, However, our participants also agreed that the presence of abundance of resources are of no use if they or their loved ones are not healthy—physically and mentally. In fact, a popular saying in the Indian context is dy Modi, . In the dy Modi, .While having a stable job was an important determinant of happiness for individuals with relatively low income, working productively in a conducive and supportive environment, which aligns with one's interests, and reinforces professional development, was more critical for the higher-income group. Pursuing one's hobbies and engaging in recreational activities was a happiness booster for most of our respondents regardless of their socio-economic background, as evidenced in the existing literature (Lu and Argyle, Another theme was the influence of appreciation in inducing happiness. This finding aligns with research which shows that in the workplace, verbal or tangible appreciation reinforces thriving and vigor, job productivity and satisfaction Fisher, . SimilarBeing affiliated with nature was also a catalyst of happiness. A sizable amount of research has elaborated on our finding of nature's contribution to increasing happiness and improving mental health (Kumar et al., Lastly, happiness was emphasized as a personal responsibility. For our participants, some behavioral, attitudinal and personality traits can aid the process of keeping oneself happy. The qualities listed by them included positive and optimistic thinking, building strong relationships, kindness, being empathetic, altruistic, self-motivated and self-aware, having realistic wishes, having a strong sense of moral consciousness and emotional capacity (Hafen et al., Broadly, happiness was seen as a multidimensional construct with inside-out and outside-in dimensions. The Inside-out aspect was characterized by traits such as optimism, empathy, altruism, spirituality that complemented the individual's innate experience of calmness, peace, contentment, symbolizing happiness. The outside-in, on the other hand, comprised elements external to the individual that enhanced happiness. In our study, these involved meaningful social bonds, professional and personal growth, receiving admiration, good health and naturalistic environment. Happiness was viewed as the harmonious interplay of these elements. As revealed in this study, the facilitating factors interact with one another at the face of adversities to restore happiness. Therefore, an individual's recovery from illness is supplemented with feelings of hope and optimism instilled by supportive family, friends and religious and spiritual faith.Our conception captures the essence of dominant happiness theories such as PERMA (Positive emotions, Engagement, Relationship, Meaning, Accomplishment, Seligman, Although to the best of our knowledge, the present study is the first to illuminate the happiness perspective of Indians, the study findings must be considered in the backdrop of its limitations. Since we collected data only from a north Indian and a central Indian state, there is an absence of perspective from the other parts of India. Future studies may be conducted using a more diverse sample including participants across different Indian states.The present qualitative exploration aimed at understanding the meaning of happiness to Indians. Reflexive thematic analysis, using an inductive approach resulted in the generation of nine themes and four sub-themes which revealed their multifaceted conceptualization of happiness. Apart from filling an important gap in the literature, i.e., representing the happiness perspective of Indians, the present findings also have implications for future intervention studies as well as for various stakeholders such as policy makers, counselors, educators and employers.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by IIT Delhi Institute Ethics Committee. The patients/participants provided their written informed consent to participate in this study.KS conceptualized the study. GS collected data. KS, SB, and GS were involved in data analysis. All authors worked on the first and final version of the manuscript.This research was part of a project that was funded by the Happiness Ministry, Madhya Pradesh Government [Grant number: RP03926]. SB is a UGC-SRF and would like to thank UGC for sponsoring her doctoral fellowship.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Bronisława Brandla Fejgin was a Polish-born Jewish female physician. Among Fejgin’s numerous articles in the field of microbiology, her later work was almost entirely devoted to phage research. Although not equally famous as the phage pioneers from Western Europe, F.W. Twort and F. d’Herelle, Fejgin’s contribution to phage research deserves proper recognition. Her studies on phages resulted in the publication of numerous original scientific reports. These articles, published mostly in French, constitute an important source of information and expertise on early attempts towards therapeutic use of phages in humans. The interwar period marks the most intense years in Bronisława Fejgin’s research activity, brutally interrupted by her death in the Warsaw Ghetto in 1943. Her microbiology contributions have not been analyzed so far. Thus, the aim of this article is to fill the existing gap in the history of microbiology and phage therapy. Frederick William Twort and Felix d’Herelle are considered to be the discoverers of phages and fathers of phage therapy . HoweverThere has been no scientific analysis of her works conducted in the literature. Thus, the aim of this study was to perform such an analysis supplemented with some reliable biographical information.We collected all of Fejgin’s available publications in Polish as well as an international database and bibliography encyclopedia . Then, we selected the most important contributions within 17 articles, 16 in French and one in Polish, among which she was the first author of 15 articles. They were further analyzed in detail, paying attention to scientific relevance, evidence of international cooperation and accuracy in drawing hypotheses.Bronisława Fejgin was born in Warsaw into a Jewish family on November 13th, 1883 . Her lifThe first article co-authored by Bronisława Fejgin was published as early as 1913, when she was still a medical student. As a result of cooperation with D. M. Bertrand, she focused on bacterial microflora and its role in uterine infections. The authors isolated and described in detail a bacteria-producing green pigment which was responsible for infections in female patients . The autPelargonium zonatum following inoculation of a bacterial strain isolated from human cervix carcinoma [Proteus culture [Proteus described in the aforementioned article from 1924 was appreciated decades later by Coetzee and Sacks in Nature [Although we want to emphasize Fejgin’s contribution to phage research, her earliest work clearly went beyond interest in phages. She focused on microbiology and serology without a clear distinction towards phages. In fact, she did not even mention them in several of her articles. For instance, she described a plant tumor that had grown on arcinoma . Today,  culture . Lysogen culture . Notablyn Nature .The first known article of Bronisława Fejgin focusing on phages dates to 1923. Together with Janusz Supniewski, a Polish physician, pharmacologist, chemist and a Ph.D. student of Prof. Ludwik Hirszfeld, they devoted this work to “d’Herelle phenomenon”, as exactly provided in the title . Once shBacillus (today: Shigella dysenteriae), a pathogen responsible for dysentery in humans and animals. She obtained phages against these pathogens directly from d’Herelle. The author noticed that bacteria that acquired resistance to lytic agents differed in terms of biochemical and serological properties from the susceptible cultures , but most importantly, she discovered that the toxicity of resistant bacteria was reduced. Subcutaneously injected rabbits did not show signs typical for dysentery in the following hours. Noticeably, this phenomenon is being extensively investigated in recent literature, nearly a century after the publication of Fejgin’s article. Furthermore, it serves as a main argument against phage resistance developing in bacteria during phage treatment [At the onset of her publishing activity, in the mid-1920s, a series of Fejgin’s articles was published by the French journal Societe de Biologie. We learn from this source about Fejgin’s cooperation with Felix d’Herelle [reatment ,22,23.Interestingly, in her earliest work, Fejgin used the term “bacteriophage” only once when she described a phage received from d’Herelle. She was more willing to use the term “lytic agent” to describe the force leading to bacterial lysis. One explanation for this could be the fact that d’Herelle and his conception of phages were initially met with great opposition from Bordet, who was a director of the Pasteur Institute in Brussels, and his followers . HoweverOne of Fejgin’s first observations toward phages was made with J. Supniewski, a Polish pharmacologist and chemist. Fejgin and Supniewski discovered that the lytic agent lysed only living bacteria and was capable of withstanding the prolonged action of ether and then retaining its vital properties intact, a feature that had not been observed in any other living structure. These revelations were published by the abovementioned Societe de Biologie in 1923 as the third article in a series . Both auBacillus causing diphtheria (today: Corynebacterium diphtheriae). The bacterial strain was obtained from the State Institute of Hygiene in Warsaw. Notably, the abovementioned article is probably one of the first reports suggesting toxic properties of unpurified phage lysates following bacterial lysis. Fejgin noted that filtered broth containing bacterial debris remained after bacteriophage lysis exhibited toxic properties to rabbits with clearly visible symptoms of intoxication. She continued her research on this phenomenon in the subsequent years. In an article from 1936 [Shigella phage lysates obtained in different conditions . Only the latter one with the highest number of lysed bacterial cells  turned out to be lethal for intravenously injected rabbits. Interestingly, control samples deprived of bacteria through filtration in which bacterial lysis did not occur (due to phage absence) were not toxic to tested animals.In a short article from 1925 , Fejgin rom 1936 , she testhe idea is that, by preadapting the phage to a bacterial host, the phage will experience the ways in which the host evolves resistance, and will evolve reciprocally” [Staphylococcus were resistant to phages, a fact that, according to her, was reported for the first time. Notably, this finding was cited by numerous authors in the subsequent years [Shigella dysenteriae and phage HX19. In her own words, these secondary cultures appearing after bacteriophage lysis “represent the most exciting side of the bacteriophagy phenomenon” [Analysis of Fejgin’s literature reveals that the previously mentioned article from 1923  was not rocally” . Fejgin nt years ,34, inclnt years . It was nt years  or “visint years . In the nomenon” .In general, the 1930s are marked by Fejgin’s more detailed articles in which her knowledge of and experience with bacteriophages is noticeably greater. As already mentioned, in 1931, Fejgin published an article on marine microbes . It cannEscherichia coli, and a lytic one causing “bacteriophagy”, as described by d’Herelle [In 1935, Fejgin and Epstein focused on an epidemic of dysentery that took place in Poland in the city of Krzemieniec (today’s Ukraine). Although careful in making final judgments, she was aware of the potential role of phages in the course of the epidemic. The authors found active phage particles in the feces of 24 out of 25 convalescents and in 15 samples collected from 28 patients with an active disease. The authors concluded that phages, thanks to their ubiquity, constituted the most potent factor leading to bacterial variability . In the ’Herelle . Today, Science cited Fejgin’s observations on bacterial variability under the influence of its “lytic bacteriophage substance” [The Journal of Infectious Diseases [Bacillus dysenteriae, B. typhosus, B. proteus was cited in terms of serological properties of bacterial isolates but also in terms of “lytic principle” and its action towards Bacillus strains. Almost half of the above volume was written by Philip Hadley, who used Fejgin’s, Arkwright’s and Gratia’s findings to push his cyclogenic theory on bacterial variation which was dismissed by d’Herelle. Leaving aside the validity of his theory, there is no doubt that Fejgin’s work was cited, valued and acknowledged by the most prominent scientists of her times. Notably, Hardley mentions Fejgin together with d’Herelle in one sentence as authors who were able to obtain “a lytic principle” which would be called a phage particle these days.As already mentioned, articles published by Fejgin were extensively cited during her scientific activity and, to a lesser extent, in the following years. In addition to the aforementioned d’Herelle or Coetzee, who cited her work nearly 20 years after her tragic death , we founbstance” . Two yeaDiseases , Fejgin’Bronisława Fejgin played an important role in paving the way for the advancement of research on bacteriophages and for the future generations of phage scientists. Her numerous articles from the interwar period constitute evidence of the significance of Bronisława Fejgin’s achievements. Working on a phenomenon whose nature was not fully understood certainly did not make her work easier. Despite the obstacles, she made observations that, to this day, form basic knowledge for all scientists investigating bacteriophages. In retrospect, it must be admitted that her interpretations and descriptions were surprisingly accurate. Her unique scientific intuition rarely failed her and the conclusions she drew based on her own and others’ work were balanced, without being overly optimistic, and were always supported by scientific evidence. Last but not least, her articles constitute a valuable source of knowledge about the methodology and techniques used for the isolation, filtration and purification of phages as well as media used to culture bacterial hosts during the times she lived in. Berkefeld and Chamberland filters, Soxhlet extractor, Martin broth, Chapoteaut peptone, etc., complete the picture of her daily professional life and marked directions for future generations of scientists.After an in-depth analysis of Fejgin’s published work, we believe that she deserves no less attention than the phage pioneers, Twort and d’Herelle, as well as Ludwik Hirszfeld, whose work was mainly directed towards serology but, as the founder and first Director of the Institute of Immunology and Experimental Therapy, Polish Academy of Sciences in Wrocław (Poland), is inevitably associated with phage research and phage treatment of humans ,46. ConsOlga Amsterdamska, in her article from 1991, presents an interesting point of view that historians tend to forget about fruitful scientific activity during the pre-war period by considering it less significant compared to post-war advancements in genetics and biochemistry . As a reIn conclusion, the fact that the scientific work of Bronisława Fejgin is a forgotten element of scientific history is highly unjustifiable. We sincerely hope to change it with this publication and previous articles by giving due credit to her work and achievements.


Only a fraction of the estimated tenth or so of Senegalese who are chronically infected with hepatitis B virus (HBV) have been diagnosed. Of these, few have been assessed for their risk of progressing to potentially fatal liver disease (indicating need for treatment), and fewer still are taking antiviral drugs. A massive gap between those needing and getting treatment is widely acknowledged among experts. But given that HBV and its biomedical treatment options are largely invisible in bodies, health data, care practices, public messaging, or mass media, how can we observe, ethnographically, the effects of constraints on and inequalities in treatment? What are the stakes of access to drugs, when this access is not being sought out, claimed, or enacted? This article tackles these questions by examining how HBV is being enacted in Senegal, but not necessarily in relation to antiviral treatment. I first describe the emergence, over the past decade and a half, of an exclusionary topography of HBV diagnosis and treatment. I introduce the notion of “filtration” to describe the effects of this topography on the formation of potential “subjects of access.” The diagnostic therapies and expertise required to determine need for treatment are expensive, urban, and largely privatized. Moreover, knowledge about HBV and its possibilities of care circulates in narrow and sparsely distributed channels. Only a tiny minority of persons are effectively “filtered into” care, while issues of access remain largely outside of public debate. I then move onto small-scale efforts, led by rural primary health workers and community associations, to raise awareness of and expand screening for HBV. Those driving information and screening either do not reveal that effective drugs exist or locate these beyond the reach of most of their audiences or patients. Why then do they do it? I examine the logics and effects of their work to identify the forms of inclusion, care, efficacy, and explanation these open up. At the same time, I seek to discern the indirect effects of unequal access to knowledge and resources in the ambivalence, uncertainties, and contradictions that pervade these efforts to inform, diagnose, and advise. Quickly, she caught and corrected herself: “well, in any case, availability.”already out there, even if they are asymptomatic, as chronic HBV infection often is. They need only to be diagnosed. Identifying virus carriers requires a serological test for hepatitis B surface antigen (HBsAg). Not all carriers, however, are or will ever get sick from their infection. Current consensus is that only those at higher risk of developing severe, usually fatal cirrhosis and cancer should be treated. Identifying these treatment candidates requires further diagnostic testing and interpretation of viral activity, liver damage, and other indicators of risk.This slip states a seemingly obvious point: drugs “being there” is not the same as drugs getting to all those who need treatment. But how are we to identify those whose lives are marked by the gap between available drugs and their accessibility as HBV treatment? Public health discourse generally assumes that the potential subjects of HBV treatment are s. The experts convened to develop and review the WHO’s first treatment guidelines, published in March 2015, focused in particular on developing diagnostic pathways that bypassed the high-cost equipment and expertise—including HBV-DNA quantification , liver ultrasonography and specialist consultations—on which assessment protocols used in high-resource settings depend  and of equity .Population infection rates estimated from sample surveys suggest that the majority of the world’s HBV carriers are not diagnosed or linked into care, that is, effectively referred for treatment eligibility assessment followed by prescription and/or monitoring. Global advocacy for access to HBV treatment, which has emerged in and around the World Health Organization (WHO) and World Hepatitis Alliance (WHA) in the past decade, has focused on improving and demonstrating the feasibility of large-scale screening and assessment in resource-poor settings, where most HBV carriers live. Although drug prices and supply certainly remain a concern, the wide availability of generic antivirals for HBV (notably tenofovir disoproxil fumarate) has shifted attention to diagnosis depend . The WHOs depend . For pubFor ethnography, however, the scarcity of HBV diagnosis also poses a methodological problem, especially given the variable and delayed perceptibility of an infection that often remains asymptomatic or only vaguely symptomatic for most or all of carriers’ lives.Who are the potential subjects of HBV treatment, and how are they constituted as such? Where can we locate the gap between available treatment and its accessibility to those who have not or only partially been constituted as its subjects? How does this gap manifest around the limited and uneven presence of embodied and diagnostic knowledge as well as public communication and debate about HBV infections, pathology, and care?In Senegal, HBV screening is performed systematically and for free only to donated blood,Moreover, public talk about HBV and its treatment—as advocacy, health messaging, or news coverage—is sparse. “Awareness-raising” has been small in scale as well as episodic. Examples include media coverage of a few, high-profile conferences on hepatitis held in Dakar as well as of annual “World Hepatitis Day” events. There are also occasional hepatitis-themed features or episodes, many serving as publicity for “neo-traditional” healers, on radio, television or internet channels. There have been no mass campaigns to inform that HBV infection is very common among unvaccinated adults (more than one in ten for those born before 2005) and can lead to fatal disease. Nor is information widely available about how and where HBV infection can be diagnosed, assessed, and treated. A qualitative study in rural Senegal found that only a third of nonexperts had ever heard of “Hepatitis B” . This stnot necessarily as a condition for antiviral treatment. I focus on the practices that bring HBV into being an object of knowledge and care in three types of settings, which form the core sections of this article: urban specialized HBV care, where treatment eligibility assessment followed by prescription are offered; the screening and advice provided by primary healthcare workers in one rural district; and two sets of “grassroots” initiatives to create collective awareness about HBV.Given this invisibility, how is it possible to engage with inequalities in access without assuming that its potential subjects are “already out there,” existing biologically by their (undiagnosed) viral infection and immune response? In this article, I propose to begin, empirically, by examining how HBV is being enacted in Senegal but This article is based on fieldwork I conducted in Senegal in 2019. My broader research project concerns how aetiological knowledge about liver cancer has been produced and deployed in West Africa from the 1950s to the present. Given that chronic HBV infection was shown to be a risk factor in the 1970s–1980s and that antiviral drugs are, since the late 1990s, recognized to prevent infection-induced liver damage (cancerous and cirrhotic), my research included an ethnographic focus on HBV care in Senegal.infirmier chef de poste, or ICP), 4 retired ICPs who had opened private clinics, and 10 midwives. A research assistant, Aissatou Diouf, was present during some interviews and participated in discussions. I also spoke with a range of other health actors at community, district and regional levels. Finally, I sought out and interviewed individuals who I heard had initiated HBV information and screening activities.The three core sections of the article draw, respectively, on interviews and conversations with HBV specialists and experts; primary healthcare (PHC) workers in the rural health district of Nioro; and laypersons active in HBV screening and communication. The first group comprises approximately 20 internists, gastroenterologists, infectious disease specialists, epidemiologists, and virologists, mostly based in the capital city of Dakar. This covers a significant portion of the persons actively involved in HBV research and care in Senegal. I also attended several meetings on HBV care and research as well as conducted an extensive review of published research, policy documents, and media coverage. In February-March and July 2019, I spent four nonconsecutive weeks in Nioro, which is located in south-central Senegal between the regional capital of Kaolack and the Gambian border. I selected it on the basis of anecdotal reports of high liver cancer incidence, as well as its association with peanut consumption and farming given the identification of aflatoxin, a common contaminant of peanuts, as a cofactor of liver cancer. I interviewed 25 primary healthcare workers, including 11 nurses who managed village-level health posts  and cited. Research authorization was also obtained in Senegal at national, regional, and district levels. Participants are systematically anonymized in this article, except for public figures who also agreed for interview content to be cited.Access to treatment has been a core focus of the anthropology of HIV/AIDS in Africa. From the late 1990s to the mid-2000s, antiretroviral drugs (ARVs) were available in limited quantity through private and personal channels, as well as in research trials and pilot treatment projects. Anthropologists revealed the effects, not only on bodies and survival, but also on social relations, political debate, and moral deliberation, of these uneven provisions and of the inequalities they generated. This body of work is rich in insights about the politicization of access and the subtle tensions and fault lines that treatment inclusion and exclusion can (re)produce. Such insights can guide the questions we pose about access to HBV care in Africa. Yet there are important differences in how HIV and HBV have been made visible as a threat to bodies, lives, and society, and as being treatable by antiviral drugs (even though some of the same molecules are used against both viruses). The prospect of ARV treatment increased and modified the visibility of HIV, for example through test uptake and disclosure of status. Yet ARVs entered into landscapes where HIV/AIDS had already been given a palpable presence through, for example, rumors of suspicious deaths , preventindirect effects of the limited visibility of HBV and of access inequalities on broader  provisions of HBV diagnosis, information, and care.Around what kinds of visibilities of HBV infection and care can we observe the effects of treatment (in)accessibility and its inequalities? There have been few qualitative or ethnographic studies of HBV in Africa (or elsewhere), with the exception of revealing but nonextensive studies in Côte d’Ivoire , Burkinanot in view of initiating trajectories into specialized assessment and treatment. Rather than dismissing testing without “linkage to care” as a therapeutic dead-end, as a public health perspective might, I propose to attend to these efforts as enactments of HBV with their own logics and effects. These open up unexpected forms of inclusion, care, efficacy, and explication that bypass inaccessible assessment and treatment. At the same time, these efforts are shaped by uneven distributions of information about HBV and other resources for care, and some of their actors are troubled by the restrictions on access to treatment they know or suspect lie beyond.I begin by mapping out the equipment, drugs, and expertise through which antiviral therapy is provided in Senegal. Yet I also attend to how the privatization of both specialized HBV care and communication limits the visibility of treatment beyond the narrow, urban, and exclusive circuits through which drugs and eligibility assessments can be accessed. In the following two sections, I turn to spaces where screening tests are performed, namely, in rural primary healthcare and through community action, but generally Most specialists trace the first expansion of HBV treatment in Senegal to a trial, “HEPADAK,” initiated in 2003. Subjects were provided with access to manufacturer-donated lamivudine.Trial researchers and the funder, a French public research agency, were committed to ensuring posttrial access to lamivudine. Negotiations with the Ministry of Health and National AIDS program allowed HBV patients to “dip into” donor-purchased stocks of HIV drugs, switching from lamivudine to tenofovir (both used for HIV) in 2010.Saafara Hépatites in late 2011. Speaking to the media, which gave wide coverage to PLNH-organized 2012 World Hepatitis Day events, Sall Diallo and Gueye denounced the “excessive,” “out-of-reach” and “horribly expensive” price of HBV drugs . However, the figures they gave were for pegylated interferon, which Gueye had been prescribed because of a coinfection with HBV , and which was sold only by the best-supplied private pharmacies for 159,000 CFA/280 USD per week (a full course lasting a minimum of 48 weeks). They did not mention tenofovir, which was available in generic form, nor the fact that some HBV patients were already obtaining these from the HIV program.The cost of HBV treatment was briefly but forcefully put in the spotlight in the Senegalese media in 2011–2012. Having focused on vaccination since 1998, the country’s pioneering National Hepatitis Program (PLNH), established by Aminata Sall Diallo, organized a high-profile pan-African meeting in Dakar to mark the first “World Hepatitis Day” in July 2011 . The conMeanwhile, around 2012, the PROLIFICA study, which was the first to evaluate the feasibility of large-scale test-and-treat strategies in Africa with a view to informing strategies and advocacy for expanded access, was launched in various sites . One of Hôpital Le Dantec. The rep explicitly framed this as a private initiative to fill an accessibility gap in partnership with the public sector and was able to negotiate a price of 15,000 CFA/26 USD per test (he hoped subsidization would reduce this). In the first months of 2019, however, testing had stopped due to a reagent stockout. I heard that the rep held a monopoly on the supply of kits specific to the donated apparatus and had been too busy with politics to renew the order. At one meeting I attended, this donation-supply arrangement was criticized not only for failing HBV patients, but also for bypassing public procurement rules.HBV-DNA testing capacity was set up in Dakar in 2013 or 2014. One machine was obtained by a military pharmacist, involved in research, who told me he had witnessed the “suffering” of patients from the high price and long wait associated with shipping samples for testing in France. So, he told me, he approached a PCR manufacturer and pleaded with them: “I’m passionate about hepatitis B, but [you] have to help us, give us the apparatus.” They did, but operating costs, he says, mean he needs to charge 25,000 CFA/44 USD per test in the semiprivate lab he runs. Around the same time, the Dakar Pasteur Institute, a research institution that also provides private diagnostic and vaccination services, began offering HBV-DNA tests for 35,000 CFA/62 USD. In late 2016, the regional rep of a major European diagnostics firm announced the donation of a molecular testing platform .In 2019, I heard many HBV experts in Senegal express doubts about the extent to which “gold standard” diagnostic assessment (such as used in high-resource settings) could be simplified and cost reduced. Many said they tried to “adapt,” but that, as one hospital specialist exclaimed: “there are norms!” Some specifically questioned the WHO’s “no-viral-load” criteria, which they thought would miss too many patients who needed treatment see also . InterviSaafara Hépatites from the news, a specialist or the hospital blood bank with which the association works. Gueye, who has parted ways with the PNLH, fields frequent calls from patients who have not been told where to get various tests, what they are for, or what the results mean. He tries to keep up to date on test prices, drug stocks, and equipment breakdowns. Specialists say their HBV caseloads are growing due to increase in referrals from blood banks as well as, more recently, from prenatal care providers. I asked one whether he thought the availability of medicines was drawing people into HBV care. “No,” he quickly answered, “I don’t think people know.”In 2017, public drug procurement specifically for HBV treatment became operational as a result of negotiations between HBV specialists (including the PNLH) and the national pharmacy. The availability of this “HBV” tenofovir and its subsidized price of 5,000 CFA/9 USD for a month’s supply was, as reported in a brief newspaper item, announced by the Minister of Health “on the sidelines” of a ceremony for the reception of four donated ambulances . I did nnot a major topic of conversation. A couple of specialists admitted that it was still high “relative to incomes,” and that a handful of patients resented the shift from free to fee-paying drugs. Most, however, insisted that patients were “willing to pay” out of fear of getting liver cancer . By contrast, I heard many express concerns about the lack of “communication” or “awareness-raising” about HBV. Some criticized the PNLH in private for its failure to do mass awareness-raising and screening, as well as to decentralize HBV care (beyond Dakar). Gueye has, in recent years, been openly critical of the program and of Sall Diallo’s autocratic leadership: “there is only her,” he said on TV  about HBV and HBV care. In this topography, potential subjects of HBV treatment are constituted, or not, by being “filtered” into or out of narrow circuits of care.I propose filtration as an extension of Nguyen’s use of triage (2010) to describe the paradoxical effects of limited ARV provision, whereby humanitarian efforts to “save lives” sort out those who may live from those left to die. Triage describes the selective allocation of scarce technologies (diagnostic and therapeutic), which, in the case of HBV care, is underpinned by the combination of high cost, urban concentration, and privatization. Some services are offered in private clinics and labs, while even in public institutions, patients are expected to bear a large portion of the costs of tests  and drugs, a fact that specialists largely accept as the normal state of affairs. By introducing filtration, I also want to draw attention to the additional, or rather amplifying, effects of sparse and uneven distributions of information and knowledge about HBV, whose channels are also, in a way, privatized. Communication about HBV is, due to lack of funding for awareness-raising, training, or even patient orientation, concentrated around public figures such as Gueye and Sall Diallo, or left to the initiative of individual practitioners. It is therefore highly personalized and small in scale. The result is that neither scarcity nor its modes of rationing have become topics of public or professional debate.out of care and who have not been (fully) enacted as subjects of treatment (or even of HBV) are unlikely to demand access or to criticize its inequalities. In the following section, I examine how filtration is initiated at points of primary healthcare, in a rural area where HBV screening tests are expanding yet very few are referred for assessment and treatment.Filtration is a mediated process, in which potential subjects of treatment, their kin and clinicians, give advice and make decisions on the basis of incomplete and heterogeneous knowledge of the stakes of infection and the possibilities of care. In this mediation, obstacles such as cost, distance, and lack of knowledge are difficult to clearly delineate and may be impossible to disentangle. Some who may be able to arrange, even if at considerable sacrifice, to pay for lifesaving drugs are uninformed of their condition or of how it can be managed. Practitioners, some of whom are poorly informed about available treatment options, may selectively mete out such information to avoid futile, interrupted quests for care. What does seem clear is that filtration increases the likelihood that those to whom drugs are eventually prescribed—after having been successively filtered into care by screening, persuasive and well-informed referral and full assessment, as well as ability to pay and travel—will in fact be willing to pay for them. Meanwhile those who have been filtered “I like hepatitis B too much!” exclaims Dr. T. “I mean I like the follow-up of hepatitis B, not,” he clarifies, laughing, “the patient.” Dr. T. is not a doctor but the nurse who heads a rural health post (ICPs are commonly addressed as “doctor”) in the district of Nioro, which is near the Gambian border and whose main town is about an hour’s drive from the regional city of Kaolack. He is describing his plan to set up a system to register and monitor his HBV patients, as he did for diabetes and hypertension. He also describes previous HBV initiatives.In 2013–2014, during a community health education project for malaria, he “integrated”—a deliberate term of contrast with “vertical” disease-specific actions—hepatitis B  in a series of public events such as conferences and plays. As the demand for HBV screening increased, Dr. T., again as a “personal initiative,” procured a stock of rapid tests for his health post from the District Health Centre’s Laboratory. He also organized blood drives, primarily as an HIV-screening strategy—which the district mandated each post to develop—but with the knowledge donor blood would also be tested for HBV.ambivalence about the uncertain benefits, or the high costs, of additional consultations, testing and treatment. Instead of, or alongside, referrals, PHC workers nearly always provide advice for self-care, mainly through diet. I explore this dietary advice as a form of lateral care, a term of contrast with the public health model of a “continuum of care”—from screening through referral, further assessment, treatment, and/or monitoring, or palliative care—that supposes a linear trajectory organized around access to diagnostics and drugs. Nonreferral and dietary advice are lateral in the sense of eschewing options that PHC workers are either poorly informed about or know to be unaffordable to the majority of their patients. Yet they also manifest preventive logics anchored in situated understandings of available resources, social relations, emotional care, and liver cancer aetiology. In concluding this section, I reflect on how lateral care both responds to and reproduces inequalities in patients’ capacity to treat HBV.Among Nioro’s PHC workers, Dr. T. appears as exceptionally enterprising; the only one to report having organized information and screening events . Yet he was not the only one to be concerned about HBV. HBV screening is increasing in the district, as a result of occasional blood drives organized by youth or religious associations and its recent routinization in prenatal testing. The high proportion of positive results has made the infection visible as a public health problem to many PHC workers.The prospect of antiviral treatment figures ambiguously, alongside the therapeutic power of diet, in Dr. T’s advice to those who test positive:N.T.: … what do you tell people to convince them that it’s important to do the follow-up…?It depends, eh, it depends … on age … on sex too, it depends on the patients you have. Because there are people who are educated, who know something about it … but for others … you tell them clearly that there is a disease inside you, well, sometimes … it can manifest itself, but it can also not … we explain to them, the treatment how it goes, the diet you need to follow … Especially the diet, because sometimes there is a lack of means, with respect to the correct treatment…Dr. T: Well! […]N.T.: And you tell them that in some cases it’s possible to treat, that there are medicines…?well it’s a treatment, in quotation marks, who just followed a diet and were ok. Well, I don’t know if it was the test that wasn’t … well or not, but there are people who followed a diet and who came back with a negative test . And, well, those people, we consider them to be cured. There are also people who follow another treatment … an antiviral treatment, who do their viral loads to see the evolution of the disease. There are really advances concerning treatment!” (emphasis mine)Dr. T: Yes, of course, of course! Because there are people even if they haven’t had treatment … Although he seems to identify antivirals as the “correct treatment,” Dr. T. concedes that this option is not open to all chronic carriers. Conversely, he describes “diet” as effective, but also as a fallback for when “there is a lack of means.” What he is hinting at here, I think, is that he modulates how he communicates the stakes of HBV as part of sorting out candidates for referral for treatment, from the rest, for whom, playing on the uncertainty of HBV effects, he reassuringly insists that the virus may never “manifest” at all and that diet is therapeutic. Another ICP, Dr. P., is more forthcoming about how he tailors his advice:“You know, when you’re in front of a person, an intellectual, the way of communicating differs from [that] with an illiterate person … you can confuse a person. Us, we know the quality of the person in front of us … with illiterate people … they don’t get nuance, and when you explain certain things, it makes them scared, it terrorises them, they fear death … it’s very complicated!”some understand very well, and sometimes have the means to go get followed up” (emphasizes mine). Dr. D., a former ICP now in private practice, describes himself as the most energetic and successful HBV referrer in the district. He is adamant that persuasive referral depends on conveying just how high the stakes of infection and treatment are: “I tell [them] if you don’t treat, you will have cancer … I don’t mince my words [je ne lésine pas sur les mots]!”His tone here is admittedly patronizing, suggesting doubt in the intellectual as well as emotional capacity of the “uneducated” to handle the implications of HBV infection. But for Dr. P., as for Dr. T., differential ability to “understand” HBV seems to be tangled up with unequal ability to pay for follow-up care. As Dr. P. also put it: “persuasively referred. This information is not only complex but also, as Drs. P. and D. insist, emotionally charged. By juxtaposing ability to pay for treatment with capacity to understand and handle the stakes of HBV, Drs. T. and P. may be hinting that they judge the latter as a proxy for the former. Yet they may also be implying that informing patients who cannot afford treatment about the potentially fatal outcomes of infection and the availability of lifesaving drugs would create a situation of cognitive and emotional incomprehensibility. Selective referral may thus be a manifestation of ambivalence about initiating trajectories into further care amid widespread poverty and lack of communication about HBV.These three ICPs are the only PHC workers who told us that they refer at least some HBV positive persons to the regional hospital in Kaolack specifically to be assessed for antiviral treatment. They seem better informed than others: they know treatment is available, but also that it entails frequent travel to the city and expensive tests. Some of their patients may be able to afford this, and, indeed, it is notable that they practice in some of the district’s larger towns, serving populations among which some can be described as members of, or have close connections to, a religious, farming, or political elite. Though none of these ICPs explicitly stated that they referred some but not others, Drs. T. and P. are quite clear that they selectively provide the information by which patients can be only dietary advice, without referral, as did a few ICPs. Most midwives, however, described referral to the GP at the district health center in Nioro as standard practice. Yet they are unaware that treatment is available and about the steps required to obtain it. This may limit their motivation and ability to refer persuasively, since they cannot tell their patients why, exactly, they should consult the GP. Several stated they felt inadequately trained to deal with HBV infection.Ambivalence about referral can also be discerned in midwives’ response to HBV tests. The latter oversee the lion’s share of HBV screening at PHC level. A minority (2 of 11) reported providing Referral ambivalence, whether enacted as selective referral, nonreferral, or “half-hearted” referral, can be seen as a force of filtration that pushes the majority of HBV carriers away from trajectories into further care and the possibility of treatment. The poor training of health workers as well as the lack of public information about HBV has indeed been identified as a “barrier to linkage to care” in other African settings . Yet refany effect of dietary restrictions on the outcome of chronic HBV infection. They interpret the widespread “belief” in diet—which appears to cut widely across space and education levels  are projected against experiential knowledge of foodscapes, landscapes, and disease. Let us return to Dr. T.: he did seem to position diet as a lesser and cheaper alternative to antivirals, which he calls the “correct” treatment. Yet he went on to explain that the reason for very high rates of HBV infection in the region was “due to dietary habits, with the use of peanuts, we’ve noticed that people don’t use the good kernels, the good kernels are used for seed, and also for sale. So generally, the bad kernels are used … so naturally in the Saloum [the geographical region] there are many cases [of hepatitis].” By “bad kernels”, Dr. T. means those with signs of damage or mold, indicating they are likely to be contaminated by aflatoxin.Current biomedical evidence shows that chronic consumption of aflatoxins is, like chronic HBV infection, a risk factor for liver cancer and that both can act in synergy as cofactors . WithoutPeanuts saturate Nioro’s landscapes: fields fill the rolling hills; bigger towns are crowded with piles of pods, machines to shell them, warehouses to store them, and trucks to drive them away; the smell of simmering peanuts sauces and roasting kernels and the sounds of pressing and grinding waft along their streets, while piled plastic drums of unrefined peanut oil mark weekly markets; and regional cuisine is made up of a long list of peanut-based dishes. Primary healthcare workers “know” the interaction between peanuts (as fatty or as toxic) and HBV infection not through epidemiological data, but through a juxtaposition of intensities: positive test results and cases of liver cancer alongside the omnipresence of peanuts in the landscape and foodways. As midwife K.—who had hoped, like Dr. T., to organize a communication and screening event—puts it:mafe [a peanut-paste based dish], how many times to they cook mafe during the week? Ceere bi [millet couscous] they make it [with a peanut sauce], how many times? Mbaxalou saloum [a regional specialty made with peanut flour]… Their oil too, it’s made from peanuts. So their whole consumption is based on peanuts. It’s because of this that there is an excessive rate of positive antigens here. Liver cancer, yes, there’s a lot of it.Hepatitis is a problem … here … Because Saloum … peanuts, there are a lot here [she repeats this]. So people eat fatty food all the time. All they eat is peanuts. Lunch, dinner, all peanuts. Cooking … bad peanuts) can slow or halt the damaging effects of chronic infection. This view overlaps, even if it is not perfectly aligned, with biomedical evidence of synergistic relations between aflatoxin and HBV. As mentioned above, emphasizing the efficacy of diet is also a way of reassuring positive individuals, particularly pregnant women. Those who were most emphatic about diet are those, like Dr. T., who say they have seen it reverse antigen test results. Midwife W., who advises patients to avoid peanut paste and paracetamol and to reduce oil and butter, has also seen “women who come back with a negative HBs antigen after, after the diet [she repeats this],” as has Midwife K., who concluded: “so you see the value of educating them in relation, especially, to the diet they have to follow!”For many ICPs and midwives, this entanglement underpins the efficacy of dietary management of HBV. For some, a fat- and/or peanut-restricted diet  “or nothing” proposition. They may filter a few into further care through selective referral. But others who have been diagnosed as positive are not filtered out of care altogether, even if the dietary treatment offered has limited efficacy on biomedical terms . A few, like Dr. T., further recommend HBV positive individuals to self-monitor for a prickling sensation in the upper-right abdominal quadrant and sometimes prescribe liver enzyme tests to check for indicators of liver damage, or abdominal ultrasounds , for signs of cancer. These forms of self-care through diet and vigilance are opened up not just by “ignorance” and poor training, but also by the aetiological entanglements of liver disease with peanut-filled diets, the uncertainty and variability of HBV infection outcomes, and lack of access to further diagnostic assessment .Yet individuals are also filtered into, or out of, dietary self-care. Most midwives noted it was a challenge to get women to pay for prenatal testing. The price of the HBV test was fairly low, at 2,500 CFA/4.4 USD .within households  as a relatively cheap and abundant source of protein, calories, and taste. Furthermore, eating is a communal process with gendered and generational hierarchies, while meal preparation is time, labor, and fuel consuming. Even the more precise and potentially more useful advice to eat (rather than sell) only “good” peanuts may entail loss of much-needed income. Only those with privileged access to resources—as part of wealthier households and/or because of their position olds see —might beThey cannot. And, here in the Saloum, women aren’t really taken into consideration, not really […] So that they can decide absolutely nothing […] Men are the ones who make the decisions. So if you are a homemaker, in your home you say, I’m not going to eat […this or that] you risk having all the problems in the world !Another midwife reported a woman being brought in by her family because she refused to eat anything at all after testing positive for HBV. Indeed, for many, the only way of heeding the advice given, mostly, recall, to pregnant women, is to go without. Moreover, self-care turns responsibility for HBV management onto individuals and households , and awaThe Nioro district lab technician told us of HBV screening activities organized by a village association led by a “very dynamic youth.” Back in Dakar, I met with Saliou, a busy freelance consultant. There were two factors behind the initiative, he told me. First was his own sense of obligation to “do something” in his home village, to which he wanted to maintain his attachment and where expectations were high given he obtained a Ph.D. from a North American university and his father played an important role in national politics. Not wanting to go into politics, as village elders pressed him to, he opted to launch a “citizen action movement” which would work in various domains, including health. The second factor , was an intense, cumulative experience of deaths in the village due to what some labelled liver cancer. “There is not a single house[hold] in the village that hasn’t lost a young person [to the disease],” he told me. This triggered not only grief, but also pervasive fear (a “psychosis”) and divisive accusations of witchcraft. He recounted asking himself: “Will we let this disease destroy us? Let inaccurate beliefs dictate our actions?” By organizing conferences about HBV and offering screening tests, which began in 2017, the movement would thus recast the deaths as arising from HBV infection that was highly prevalent in the village and a cause of liver cancer.The purpose of raising HBV “awareness” in this village, which I will call Keur Laye, was, as in PHC settings, not primarily to launch trajectories toward further diagnostics and antiviral drugs. As in the health posts, those found positive in Keur Laye were reassured their diagnosis was not “synonymous with liver cancer” and were given dietary advice. In the first year, Saliou also paid for liver enzyme testing. But in addition to opening up this space of lateral  posttest care, HBV knowledge in Keur Laye was valued for establishing new causal explanations for a shared history of misfortune, thereby shifting attributions of responsibility in a collective “moral imagination” . In thisbanaliser] the disease.”Aissatou Diouf and I went to Keur Laye to meet with members of the movement. Gathered in a circle in a courtyard at dusk, they described how the repeated deaths of mostly young men, occurring after rapid weight loss and abdominal swelling, had affected this village of about a thousand inhabitants. As far as he could remember, said the eldest of the group, more than forty had died since 1976, others said one or two every year. Most of the victims were men, and all were young, in their twenties and thirties, so their deaths “really hurt.” Members of the movement were also young men. They spoke of the blood drive  as an “awakening.” Before was a time of ignorance, when recurring illness and death were attributed to possession or evil eye, and there was a lot of “fighting” (which I suspect is an understatement) in the village. With the blood screening, “many cases were revealed, that’s when we knew that it is hepatitis that brought this problem.” Or, as another put it: that all this time, it was “just hepatitis.” Back in Dakar, Saliou had told me (he was not in Keur Laye that evening) villagers had come to him after Gueye’s well-attended conference to say they felt “relieved of a pressure. The situation had been real tense because of the disease.” “The HBV initiatives had succeeded,” he suggested, because they had managed to “demystify, to render banal  about HBV more often, and with greater emphasis, than that for greater access to care. Much of his advocacy work, with other members of Saafara Hépatites (of which he is the nearly exclusive public face), focuses on screening and information. This includes World Hepatitis Day, conferences in villages and in prisons (which Gueye was doing in 2019 in collaboration with a prisoner welfare NGO), and newspaper and television interviews, in which Gueye emphasizes the scale of exposure in Senegal and the need to get tested.Ibrahima Gueye has called for greater state subsidization of HBV care, particularly of diagnostic tests, including, recently, free screening . Yet I nwithin, rather than against, a topography of unequal access to largely privatized HBV care. By informing people about the risk they face and what they can do about, more may decide to pay for care. He insists, for example, on the possibility of vaccination for those who test negative. This is a reason he gives for why even those who cannot afford specialized care should get tested. A course of three vaccine doses for adults is subsidized and costs 5,000 CFA/9 USD (infant HBV vaccination is free). The epidemiological logic of adult vaccination is debatable, given low rates of susceptibility in Senegal. Epidemiological data indicates that most adults who test negative for HBsAg antigen are already immune  the privatization of HBV care and resulting inequalities. “Personally,” Gueye told me, “I’m against free care [la gratuité]. Subsidization, sure, but there has to be a minimal price … there’s always someone who pays, who will pay tomorrow … people get used to it.” I heard specialists speak similarly about charging for antiviral drugs. right .Gueye’s emphasis on willingness to pay for exposure. He likes to illustrate this point by evoking an image familiar to many Senegalese adults of schoolchildren lined up to be vaccinated with a jet-gun. As the host of a 2012 talk show laughed, presumably at her own memory of this image, Gueye pressed on: “one single needle, five hundred people […] the reason I bring this up [is to emphasize that] hepatitis, it concerns us all, everyone is at risk” . To me, he said, “I show the scar on my arm. People see it and tell themselves they too might be affected.” Sall Diallo also points to widespread risk; “hepatitis concerns us all” was a slogan she circulated, along with the figure of an 85% exposure rate While Gueye’s “awareness-raising” individualizes responsibility for care, it also seeks to deindividualize and destigmatize responsibility for infection by insisting on the collective nature of Sall Diallo appears unworried about stigmatizing HBV; for example, she frequently and bluntly reminds audiences that sex is a mode of transmission. By contrast, Gueye treats sexual transmission as a delicate issue. He explained his strategy to me:I cannot be said that it does not exist. It can exist. But I bring it up last, starting upstream. When someone is positive, they cannot know when they were infected. The first possibility is that they were born with it. That’s to reassure […] for the majority here in Africa, that’s it. In any case, it lifts a weight. I summon the past first.Evoking uncertainty about infection source, early-life transmission, and serial childhood vaccination are, for Gueye, ways of conveying HBV as a neutral and widely shared exposure; a risk for which individuals cannot be held responsible. This is a strategy to counter stigma and the kinds of tensions he has witnessed around HBV diagnoses: for example, of men seeking to cast out their infected wives. His goal, he states, is “that the person does not feel responsible.” Gueye sees stigma as an obstacle to both  care-seeking and collective mobilization.Saafara Hépatites communicates to audiences that HBV circulates widely among them and that they should not be held responsible for their status, nor should they accuse each other of transmission or of causing swollen-stomach deaths. HBV knowledge is treated as having the power to reconstitute social relations around shared infection, risk, disease, and loss. In neither case has this emergent sense of HBV as a collective burden been explicitly linked to arguments for redistributing the costs of care through collective, public mechanisms. Yet the potential is there: reframing HBV as collective misfortune, in which some must bear the bodily effects of its variable outcomes but should not necessarily be made to bear the financial and logistical costs of mitigating these, may serve as a basis for making claims to free and public care as a right.The work of Keur Laye’s movement and of Gueye and say about what they do and why. There is more to be learned through observation of clinical and educational practices and by tracking their effects on patients and audiences, as well as on trajectories of testing and care (likely in combination with information-sharing and decision-making among kin networks). Yet my focus, via HBV actors, on the topography of specialized care and HBV communication, alongside screening and information efforts that largely fail to join up with this topography, opens up a vista onto uneven provisions of both HBV technologies and knowledge and a glimpse of interactions between them. This has allowed me to identify filtration—which arises from these interactions—as a mechanism that produces inequalities in access to care and, at the same time, renders these inequalities less visible and less open to contestation.Further research is needed to determine whether and how clinical interactions, as well as other modes of communication about HBV, may filter individuals in or out of care and thereby mediate access inequalities. My research has been limited to what actors involved in the provision of HBV information and care By attending to the indirect effects of access inequalities on enactments of HBV, I have sought to illuminate complex entanglements among HBV knowledge/communication, “means” (to pay for care), privatization, gendered and socioeconomic disparities, explanatory models of causation and efficacy, and assumptions about who can and should bear the costs of care. Access is not determined only by who knows about, or can pay for, what kind of care. “Filtration” describes this nonlinear, dynamic entanglement by which different sites and mechanisms of inequality are mutually enacted and constitute—or not—potential subjects of HBV care.public health issue. For one, there are few resources to detect and communicate the scale of infection at the national level and thus frame it as a collective problem. In addition, the distribution of scarce resources for care both assumes and reinforces private responses to (the risk of) infection and illness. Infected individuals are expected to pay, in part or in whole, for diagnostics, drugs, or “therapeutic” diets. The provision of most of these services, as well as communication about HBV, have been left to personal and/or commercial initiatives, with little or no public oversight. Even the nominally public but underfunded PNLH manifests as a highly personalized presence. This results in uneven and fragmented distributions of both HBV care and information about it, so that subjects of treatment are formed in spaces of privileged access that remain largely invisible and uncontested. Moreover, widespread emphasis on personal responsibility for exposure  and for care, including self-care, deflects attention from potential collective models of viral circulation and protection. There are sites of tentative conceptualizations of HBV as a shared problem that should be tackled collectively through public channels, but these have yet to give rise to vocal demands for access to treatment.To conclude, I want to highlight two themes amid this dense tangle: privatization and gender. HBV has been pointed to as a neglected issue in global health e.g.,  despite The privatization of HBV and its care partly overlaps with its gendering. As the PHC practitioners we interviewed point out, expectations that individuals can and should pay for HBV screening tests and that dietary restriction is an effective and accessible form of self-care, are both challenged by and reinforce gendered household dynamics. More research is needed on the gendered implications of focusing screening efforts on pregnant women, especially given widespread assumptions about the sexual transmission of HBV. Gueye, for example, has hinted that diagnoses of HBV often provoke suspicion, rejection, guilt, and confusion due to these (unfounded) assumptions. Yet epidemiologically validated emphasis on perinatal and early childhood HBV exposure as both frequent and risky (more likely to lead to cirrhosis and cancer) also draws attention to mothers as transmitters of an infection that tends to kill more men. How do HBV data and models shape understandings of gendered relations of care, pleasure, and harm? Similar questions can be asked of occult forms of swollen-belly death: in all the stories I heard, the accused were always—often jealous—women.partial expansions of access to diagnosis and drugs. Increasing the availability of screening tests, viral load testing or antivirals are likely to have unintended effects if not accompanied by a public strategy for their coordination, and the fair distribution of resources, including information, and costs. A focus on filtration, rather than on the proportion of treatable individuals getting treatment, provides a fuller and more nuanced view of what happens in the gap between the availability and accessibility of biomedical technologies.Points and processes of filtration—whether as orientation into lateral care , unpersuasive referrals or too-expensive, unexplained test prescriptions—arise from