Somatosphere

Organized by Sarah Willen and Elizabeth Carpenter-Song, the June issue of Culture, Medicine and Psychiatry (vol. 37, issue 2) is a special issue entitled “Cultural Competence in Action: Multidisciplinary Perspectives on Four Case Studies.”  Rather than engaging in the usual critique of medical “cultural competence” programs  (which aim to teach clinicians about culture, health disparities, and difference), this issue analyzes pedagogical strategies used in various clinical/educational settings, while illuminating the challenges these programs pose and the ways in which “cultural competence” takes local form. The issue features four original ethnographic papers, each of which is paired with a reflective companion essay written by a clinician-educator involved in the particular program (Antonio Bullon, Mansoor Malik, Roxana Llerena-Quinn, and Laurence Kirmayer). The programs include a course for psychiatry residents, a research/training collaborative that links a Historically Black University and an Ivy League University, a continuing medical education course, and a Canadian-based annual summer program for an international cohort of clinicians and researchers. The titles and abstracts of the ethnographic papers are pasted below. In addition, following the four paired papers are three commentaries by clinical educators and researchers: Michael Knipper, Robert Drake, and Mary-Jo DelVecchio Good.

Confronting a “Big Huge Gaping Wound”: Emotion and Anxiety in a Cultural Sensitivity Course for Psychiatry Residents (Sarah Willen)      Abstract: In his seminal volume From Anxiety to Method in the Behavioral Sciences, George Devereux suggests that any therapeutic or scientific engagement with another human being inevitably will be shaped by one’s own expectations, assumptions, and reactions. If left unacknowledged, such unspoken and unconscious influences have the capacity to torpedo the interaction; if subjected to critical reflection, however, they can yield insights of great interpretive value and practical significance. Taking these reflections on counter-transference as point of departure, this article explores how a range of unacknowledged assumptions can torpedo good faith efforts to engender “cultural sensitivity” in a required course for American psychiatry residents. The course examined in this paper has been taught for seven successive years by a pair of attending psychiatrists at a longstanding New England residency training program. Despite the instructors’ good intentions and ongoing experimentation with content and format, the course has failed repeatedly to meet either residents’ expectations or, as the instructors bravely acknowledged, their own. The paper draws upon a year-long ethnographic study, conducted in the late 2000s during the most recent iteration of the course, which involved observation of course sessions, a series of interviews with course instructors, and pre- and post-course interviews with the majority of participating residents. By examining the dynamics of the course from the perspectives of both clinician-instructors and resident-students, the paper illuminates how classroom-based engagement with the clinical implications of culture and difference can run awry when the emotional potency of these issues is not adequately taken into account.

Behind the Scenes of a Research and Training Collaboration: Power, Privilege, and the Hidden Transcript of Race (Elizabeth Carpenter-Song and Rob Whitley)
Abstract: This paper examines a federally funded research and training collaboration between an Ivy League psychiatric research center and a historically Black university and medical center. This collaboration focuses on issues of psychiatric recovery and rehabilitation among African Americans. In addition, this multidisciplinary collaboration aims to build the research capacity at both institutions and to contribute to the tradition of research in culture and mental health within the medical social sciences and cultural psychiatry. This article provides a window into the complex, often messy, dynamics of a collaboration that cross cuts institutional, disciplinary, and demographic boundaries. Taking an auto-ethnographic approach, we intend to illustrate how collaborative relationships unfold and are constructed through ongoing reciprocal flows of knowledge and experience. Central to this aim is a consideration of how issues of power, privilege, and the hidden transcript of race shape the nature of our research and training efforts.

Patrolling Your Blind Spots: Introspection and Public Catharsis in a Medical School Faculty Development Course to Reduce Unconscious Bias in Medicine (Seth Donal Hannah and Elizabeth Carpenter-Song)
Abstract: Cultural competence education has been criticized for excessively focusing on the culture of patients while ignoring how the culture of medical institutions and individual providers contribute to health disparities. Many educators are now focusing on the role of bias in medical encounters and searching for strategies to reduce its negative impact on patients. These bias-reduction efforts have often been met with resistance from those who are offended by the notion that “they” are part of the problem. This article examines a faculty development course offered to medical school faculty that seeks to reduce bias in a way that avoids this problem. Informed by recent social–psychological research on bias, the course focuses on forms of bias that operate below the level of conscious awareness. With a pedagogical strategy promoting self-awareness and introspection, instructors encourage participants to discover their own unconscious biases in the hopes that they will become less biased in the future. By focusing on hidden forms of bias that everyone shares, they hope to create a “safe-space” where individuals can discuss shameful past experiences without fear of blame or criticism. Drawing on participant-observation in all course sessions and eight in-depth interviews, this article examines the experiences and reactions of instructors and participants to this type of approach. We “lift the hood” and closely examine the philosophy and strategy of course founders, the motivations of the participants, and the experience of and reaction to the specific pedagogical techniques employed. We find that their safe-space strategy was moderately successful, largely due to the voluntary structure of the course, which ensured ample interest among participants, and their carefully designed interactive exercises featuring intimate small group discussions. However, this success comes at the expense of considering the multidimensional sources of bias. The specific focus on introspection implies that prior ignorance, not active malice, is responsible for biased actions. In this way, the individual perpetrators of bias escape blame for their actions while the underlying causes of their behavior go unexplored or unaccounted for.

A Diversity of Voices: The McGill ‘Working with Culture’ Seminars (Jaswant Guzder and Cécile Rousseau)
Abstract: The Working with Culture seminar is offered as a course during the month long Annual McGill Summer Program for Social and Transcultural Psychiatry, attended by local and international participants each May since 1994. The article outlines some of the premises and pedagogical approaches of this clinically oriented biweekly seminar series with discussions and didactic teaching on cultural dimensions of mental health care. The course readings, seminar topics and invited speakers focus mainly on therapist client encounters constructed by the multiple voices with dimensions of psychiatric, social, historical, legal, ethical, political, systemic and intra-psychic domains. The dual leadership emphasizes the gaps and complementarity amongst voices, and it invites and supports a destabilizing decentering process and the creation of solidarities amongst participants. Applying a bio-psychosocial case study method, each 3-h seminar engages the participants in a critical dialogue on apprehending the enmeshment of social suffering with psychiatric disorders whilst examining the usefulness and the limits of cultural formulation models. The seminar working group and teaching approach acknowledges cultural hybridity as a dynamic process marked by continuous therapist attunement to uncertainty or ‘not knowing’ which implies a dethroning of an expert position.

Body and Society 19(2-3) is a special issue entitled “Habit”, edited by Tony Bennett, Francis Dodsworth, Greg Noble, Mary Poovey and Megan Watkins. It features nine original articles and two commentaries. In the introduction, the editors discuss the renewed interest in “habit,” particularly with respect to body/society and processes of governance. “We argue that habit has typically constituted a point of leverage for regulatory practices that seek to effect some realignment of the relations between different components of personhood – will, character, memory and instinct, for example – in order to bring about a specific end. In reviewing its functioning in this regard across a range of modern disciplines – philosophy, psychology, sociology – we explore the tensions between its use and interpretation in different lineages: in particular, the Cartesian–Kantian/Ravaisson–Bergson–Deleuze lineages.” These concerns are variably taken up by the original articles that follow:

“The Question of Habit in Theology and Philosophy: From Hexis to Plasticity” (Clare Carlisle)
“Habit and the Limits of the Autonomous Subject” (Simon Lumsden)
“Habit, the Criminal Body and the Body Politic in England, c. 1700–1800″ (Francis Martin Dodsworth)
“Habit: Time, Freedom, Governance” (Tony Bennett)
“Habit and Habitus” (Nick Crossley)
“Cosmopolitan Habits: The Capacities and Habitats of Intercultural Conviviality” (Greg Noble)
“Habit and Affect: Revitalizing a Forgotten History” (Lisa Blackman)
“Habit Today: Ravaisson, Bergson, Deleuze and Us” (Elizabeth Grosz)
“Habit as a Force of Life in Durkheim and Bergson” (Melanie White)

Biosocieties 8(2) features a lecture by Margaret Lock examining scientific research on biomarkers for early detection and prevention of Alzheimer Disorder. Lock argues that the discovery of these biomarkers can be misleading, as they do not signify that one will necessarily get a form of dementia. Thus, it may be overly ambitious for scientists to claim the utility of biomarkers for making individual predictions.

Kirsten Bell emphasizes the challenges presented by molecular technologies used for tertiary cancer prevention. Using a semiotic approach, Bell explores the various meanings and effects of biomarkers for patients, both those “at risk” and those living with risk.

Neurofeedback (a biofeedback system aimed to help people adapt to their brainwaves) is the topic of Jonna Brinninkmeijer’s article, which examines interactions among practitioners, clients, and computers through which a new kind of self emerges.

In exploring the range of definitions of placebo, placebo effect, and similar terms, Susan Huculak discusses how the lack of agreement on these concepts highlights debates about mind/body dualism (and, relatedly, passive/active patient role, in/efficacy of placebo, etc.).

Christopher Groves and Richard Tutton discuss the role of expectations in personal genomic susceptibility testing (PGST), particularly how expectations can increase regulation. Attempting to stall or influence new regulations, some PGST companies use expectations as they work towards standardization that might further legitimize their practices.

Finally, David Reubi’s article focuses on the role of taxation in international anti-smoking initiatives in the global South to shed new light on the relationship of economics and global health.

American Anthropologist (vol. 115, issue 2), features six main research articles. Perhaps most relevant to Somatosphere is an article by Merav Shohet concerning the Vietnamese ethic of hy sinh (sacrifice), which is inculcated in children via socialization practices. The article explores “how participants linguistic and corporeal practices in routine interactions with children relate to their engagement with ancestors.” Shohet further argues that hy sinh reinforce asymmetrical relations within and beyond the family, thereby perpetuating the local sociomoral order.

In addition, book reviews relevant to science and medicine include:
Drug War Zone: Frontline Dispatches from the Streets of El Paso and Juárez, by Howard Campbell (review by Gilbert Quintero)
Trade of the Tricks: Inside the Magician’s Craft, by Graham M. Jones (review by Susan Terrio)
Fewer Men, More Babies: Sex, Family, and Fertility in Haiti, by Timothy T. Schwartz (review by Mindie Lazarus-Black)

Ethos 41(2) includes five original articles. Among them, Benjamin Koen’s article (“‘My Heart Opens and My Spirit Flies’: Musical Exemplars of Psychological Flexibility in Health and Healing”) explores the analytic utility of “psychological flexibility” for understanding cultural and clinical contexts of health and healing. Drawing on psychological anthropology and medical ethnomusicology, and based on his research in Tajik Badakhshan, Koen examines how aspects of local musical forms are one of several forms (among them: poetry, prayer, environment) that prime “psychological flexibility” and lend insight into healing processes. In addition, Avi Shoshana’s article (“Role Play and ‘As If’ Self in Everyday Life”) explores the “long-term influences of role-playing dynamics” at a Boarding School for Gifted Disadvantaged in Israel, a state-run school that aims to socially integrate Jewish immigrants from Islamic nations into Israeli society. Through analyses of government protocols and in-depth interviews, Shoshana examines how graduates of the school experience their “giftedness” and sense of self. Emphasizing the self concept, he shows how “the connection… between psychology, national culture, and political orders has critical implications for psychological anthropology.”

Psychosomatic Medicine 75(5) includes studies of the relation between socioeconomic status and inflammation among adolescents (Pietras and Goodman); the association of positive and negative emotions with pain perception (Finan et al.); psychosocial influences on atherosclerosis in women (Zimmerman-Viehoff, et al.); and the relation among social integration, emotional support, and mortality risk (Barger).

This issue of Science as Culture 22(2) focuses on energy transitions, energy policy, and energy justice, with an introduction by Clark A. Miller, Alastair Iles & Christopher F. Jones, and articles by David Hess, Sheila Jasanoff & Sang-Hyun Kim, among others.

It is somewhat predictable that at weekend-long workshop medical anthropologists and STS scholars would, first, talk a lot about bodies and, second, discuss the politics of their knowledge production.  What is not predictable is what happens when the workshop also includes a few cultural anthropologists, philosophers, and medical doctors; and allows a much longer-than-usual amount of time for paper presentations.

I can tell you what happens. Curious and provocative conversations, challenges to taken-for-granted ways of theorizing the world, and productive conversations that begin a collective process of re-drawing the borders around what might count as “medical anthropology.”

This is what happened at the “Medicine on the Edge” workshop held at UC Santa Cruz (UCSC) in the beginning of May, hosted by UCSC medical anthropologists Matthew Wolf-Meyer and Nancy Chen. While the workshop organizers may have been envisioning ways that medicine is “creeping out of the laboratory and clinic” into everyday life (as they stated in the workshop description), what the workshop became, I would say, is something that could be called “Medicine and Science, Unpredicted.”

Prediction and predictability are, of course, historically specific constructs, as Ian Hacking (1990) and others, such as Mary Poovey (1998) have taught us; concepts that organize time and space into the present and the future in ways that make us believe we are “modern.” Although as good scholars we know that We Have Never Been Modern (Latour 1993), when it comes to the processes and practices of our own knowledge production, turning away from the ruse is a challenge. For example, we may critique the use of population-level health statistics on one hand and rely on those very statistics on the other hand; we are in and of the worlds that we study. What “Medicine and Science, Unpredicted” allowed us were moments and spaces in which we could collectively consider not only how medicine is “creeping out of the laboratory and the clinic” but also how our own knowledge production processes are always a part of the world we are critiquing.  Our “situatedness” matters (Haraway 1999).

Part of this turn to unpredictability was achieved through an unconventional design; the workshop format demonstrated that the structuring of our knowledge production matters. First, only junior faculty presented work. Second, they were given 30 minutes for their presentation rather than a standard 15 minutes. Third, panels of senior faculty provided impromptu commentary. Finally, there were numerous times and spaces for conversation—extended lunches and dinners and lengthy Q&A sessions. Organizing the workshop in these ways allowed all of the participants to engage with the papers, as well as continue conversations started during the Q&A. In these extended spaces of conversation, numerous exciting themes emerged. In this series of posts I want to highlight three: comparison and commensurability, storying bodies, and knowledge production. These themes seem particularly relevant to the workshop-long concern of how medical anthropology’s predilection to ask certain kinds of questions—such as what constitutes a body?, how are bodies and citizenship claims related?, and how do bodies become gendered, racialized, and classed?—is increasingly meaningful for topics that don’t, at first glance, seem medical. In subsequent posts I will elaborate on each of these themes. In the rest of this post, I will begin what I hope can be an online conversation about themes that began at the workshop.

***

Bodies are not only material; they are also stories, and storied. They are mediated and mediatized. This is, of course, not news. In her on-the-spot commentary, Galen Joseph, however, noticed that in all the papers presented—even ones that initially seemed to be incomparable—the bodies and their stories were wrangling with issues of comparison and commensurability, of making sense of oneself through the story of someone else. That process of learning can be classroom-based and explicit, as in the case of Joe Hankin’s ethnographic work with Japanese Buraku activists and Indian Dalits. Both groups struggle to commensurate the social stigma of the Buraku, on the one hand, with the extreme physical violence experienced and enacted by the Dalits, on the other. It is the UN-based category of “discrimination based on descent and labor” that encourages them to seek this discursive calibration. But the process of learning to tell one’s story can also involve the (seeming) unlikely coupling of physical violence/torture and care. This was most stunning in the case of Angela Garcia’s current research with individuals and families in Mexico City who are desperate to care for drug-addicted family members. In the context of Mexico’s war on drugs, the unregulated—and extremely violent—residential treatment centers called annexos often felt safer than the streets. Through techniques of care that involved what Garcia described as “torture”—often at the hands of peers—the (mostly) men learned to narrate themselves in particular ways. These storied bodies, seeking a protected political status on the one hand, and medical care on the other, exist in an economically and politically fraught world in which knowledge of how to story one’s own body is always in dialog with the storied body of another.

These stories, these bodies, these interactions of comparison and commensurability exist in national or international contexts, but not only in these places. They exist, as Charles Briggs reminded the workshop participants, in a global situation of post-colonial medicine, in which stories and their telling do not simply play out against the backdrop of a static and finished colonial past. Rather, the stories are always historical. They continue legacies of creating geographic, economic, and political distance and proximity, and legacies of politicized sympathy. Often, statistical narratives of risk are put to this task. In the case of T.S. Harvey’s work with indigenous people living around two lakes with blue/green algae in Guatemala, stories of risk produce certain populations as risky and other populations as the much-needed controllers of risk. Seth Holmes, a medical anthropologist and a physician, drew on Lauren Berlant’s (2007) theory of “slow death” to describe how statistical stories about migrant laborers render the repetitive motion of their exhausted joints and backs invisible.

These papers pushed us to not to take “the body” for granted, to examine bodies in and of contemporary capitalist practice. What bodies are, how they are composed and how they decompose in labor, and how they are interrelated to form the world in which we live, were critical components of all the ethnographic work presented at the workshop.

But, what of knowledge production, unpredictability, and “the edge”? Certainly, this workshop demonstrated that the categories of medicine and science are increasingly part of many peoples’ everyday lives.  Thus, where is medicine’s edge? The workshop participants couldn’t decide on any one edge; instead we settled on unfinished and jagged edges, organized unpredictably in spaces and times that are always deeply historical. The edges of medicine and how they teach one to story the body might be quite different in each of the ethnographic sites I have described: Mexico City’s contemporary annexos, Japanese Buraku and Indian Dalit stories of the body’s suffering, indigenous Guatemalans lake-water practices, and Oaxacan migrant laborers’ back and joint pain.

One body has thus far been conspicuously absent from this post:  the body of the ethnographer. The next post, on knowledge production, will address this perpetually challenging issue.

 

Celina Callahan-Kapoor is a PhD Candidate in Anthropology at the University of California, Santa Cruz. Her research focuses on how chronic illnesses are reshaping everyday life and, in the process, informing individual, regional, and national identity in two historically distinctive border regions of the United States. Her primary fieldsite is McAllen, TX on the U.S./Mexico border and her comparative site is St. Albans, VT on the U.S./Canda border.

References

Berlant, Lauren. 2007  Slow Death (Sovereignty, Obesity, Lateral Agency). Critical Inquiry 33:754-780.

Hacking, Ian. 1990  The Taming of Chance. University of Cambridge.

Haraway, Donna J. 1999  Situated Knowledges: The Science Question in Feminism and the Privilege of Partial Perspective. In The Science Studies Reader. Mario Biagioli, ed. Routledge.

Latour, Bruno 1993  We Have Never Been Modern. Catherine Porter, transl. Harvard University Press.

Poovey, Mary. 1998  A History of the Modern Fact: Problems of Knowledge in the Sciences of Wealth and Society. University of Chicago Press.

It’s not often that we make book announcements on Somatosphere, but some books invite attention straight out of the gate.  One such book is Roger Cooter‘s (with Claudia Stein) Writing History in the Age of Biomedicine, published just this week by Yale University Press.  The book is a tremendous resource for those working along the vanishing coastlines of history, the human sciences, and the bio sciences.

From the press:

“A collection of ten essays paired with substantial prefaces, this book chronicles and contextualizes Roger Cooter’s contributions to the history of medicine. Through an analysis of his own work, Cooter critically examines the politics of conceptual and methodological shifts in historiography. In particular, he examines the “double bind” of postmodernism and biological or neurological modeling that, together, threaten academic history. To counteract this trend, suggests Cooter, historians must begin actively locating themselves in the problems they consider.

The essays and commentaries constitute a kind of contour map of history’s recent trends and trajectories—its points of passage to the present—and lead both to a critical account of the discipline’s historiography and to an examination of the role of intellectual frameworks and epistemic virtues in the writing of history.”

The latest issue of Transcultural Psychiatry is devoted to “Cultures of the Internet” – also the title of the 2011 McGill Advanced Study Institute (ASI) in Cultural Psychiatry at which many of the papers were originally presented.  In our introductory essay to the issue, Laurence Kirmayer, Sadeq Rahimi and I examine some of the issues which the Internet and other new media raise for cultural psychiatry.  In addition to giving some context for the papers in the issue, we review the social science and clinical literatures in four thematic areas:

 ”(a) how the Internet is transforming human functioning, personhood, and identity through the engagement with electronic media; (b) how electronic networking gives rise to new groups and forms of community, with shifting notions of public and private, local and distant; (c) the emergence of new pathologies of the Internet, e.g., Internet addiction, group suicide, cyberbullying, and disruptions of neurodevelopment; and finally, (d) the use of the Internet in mental health care, for example, by consumer advocacy and support groups, as well as for the delivery of health information, web-based consultation, treatment intervention, and mental health promotion,” (Kirmayer, Raikhel and Rahimi 2013).

Here’s the TOC along with abstracts:

 

Cultures of the Internet: Identity, community and mental health

Laurence J. Kirmayer, Eugene Raikhel, and Sadeq Rahimi

The Internet and World Wide Web have woven together humanity in new ways, creating global communities, new forms of identity and pathology, and new modes of intervention. This issue of Transcultural Psychiatry presents selected papers from the annual McGill Advanced Study Institute (ASI) in Cultural Psychiatry on ‘‘Cultures of the Internet’’ which took place in Montreal, April 26–29, 2011.…In addition to some of the ASI papers, this issue includes other recent contributions to the journal on related themes. In this introductory essay, we set out some of the broad implications of the Internet and related new media and information communication technologies (ICT) for cultural psychiatry.

 

Digital media, the developing brain and the interpretive plasticity of neuroplasticity

Suparna Choudhury and Kelly A. McKinney

 The use and misuse of digital technologies among adolescents has been the focus of fiery debates among parents, educators, policy-makers and in the media. Recently, these debates have become shaped by emerging data from cognitive neuroscience on the development of the adolescent brain and cognition. “Neuroplasticity” has functioned as a powerful metaphor in arguments both for and against the pervasiveness of digital media cultures that increasingly characterize teenage life. In this paper, we propose that the debates concerning adolescents are the meeting point of two major social anxieties both of which are characterized by the threat of “abnormal” (social) behaviour: existing moral panics about adolescent behaviour in general and the growing alarm about intense, addictive, and widespread media consumption in modern societies. Neuroscience supports these fears but the same kinds of evidence are used to challenge these fears and reframe them in positive terms. Here, we analyze discourses about digital media, the Internet, and the adolescent brain in the scientific and lay literature. We argue that while the evidential basis is thin and ambiguous, it has immense social influence. We conclude by suggesting how we might move beyond the poles of neuro-alarmism and neuro-enthusiasm. By analyzing the neurological adolescent in the digital age as a socially extended mind, firstly, in the sense that adolescent cognition is distributed across the brain, body, and digital media tools and secondly, by viewing adolescent cognition as enabled and transformed by the institution of neuroscience, we aim to displace the normative terms of current debates.

 

 Marketing the “radical”: Symbolic communication and persuasive technologies in jihadist websites

Kamaldeep Bhui and Yasmin Ibrahim

 This paper reviews the persuasion techniques employed by jihadist websites with particular reference to the patterns of rhetoric, image, and symbolism manifested in text, videos, and interactive formats. Beyond symbolic communication, the online media needs to be also understood through its persuasive tendencies as a medium which elicits social response through its design architecture. This double articulation of new media technologies, as a medium for information and as a form of persuasive technology, has provided new means to market the radical. The marketing techniques of jihadist websites through multimedia formats have consequences for the formation of identities, both collective and individual. As a marketing tool it combines established forms of rhetoric and propaganda with new ways to reach audiences through both popular culture and religious ideologies. The paper analyses the implications for further research and counterterrorism strategies.

 

A formal anthropological view of motivation models of problematic MMO play: Achievement, social, and immersion factors in the context of culture

Jeffrey G. Snodgrass, H. J. Francois Dengah II, Michael G. Lacy, and Jesse Fagan

 Yee (2006) found three motivational factors—achievement, social, and immersion—underlying play in massively multiplayer online role-playing games (“MMORPGs” or “MMOs” for short). Subsequent work has suggested that these factors foster problematic or addictive forms of play in online worlds. In the current study, we used an online survey of respondents (N = 252), constructed and also interpreted in reference to ethnography and interviews, to examine problematic play in the World of Warcraft (WoW; Blizzard Entertainment, 2004–2013). We relied on tools from psychological anthropology to reconceptualize each of Yee’s three motivational factors in order to test for the possible role of culture in problematic MMO play: (a) For achievement, we examined how “cultural consonance” with normative understandings of success might structure problematic forms of play; (b) for social, we analyzed the possibility that developing overvalued virtual relationships that are cutoff from offline social interactions might further exacerbate problematic play; and (c) in relation to immersion, we examined how “dissociative” blurring of actual- and virtual-world identities and experiences might contribute to problematic patterns. Our results confirmed that compared to Yee’s original motivational factors, these culturally sensitive measures better predict problematic forms of play, pointing to the important role of sociocultural factors in structuring online play.

 

Prevalence and risk factors of problematic Internet use: A cross-national comparison of Japanese and Chinese university students

Chun Yan Yang, Takeshi Sato, Niwako Yamawaki, and Masakazu Miyata

 The aim of the present study was to compare risk factors for problematic Internet use (PIU) among Japanese and Chinese university students. A sample of 267 Japanese and 236 Chinese first year university students responded to questionnaires on the severity of PIU, depression, self-image/image of others, and perceived parental child-rearing styles. The results indicated that Japanese participants were more likely to demonstrate PIU than their Chinese counterparts. Compared to Chinese students, Japanese students reported more negative self-image, lower parental care, greater overcontrol, and higher depression scores. The PIU group had a higher depression score compared to the normal Internet use group. Compared with the non-PIU group, the PIU group consisted of more male and Japanese participants. Further, they tended to have more negative self-images, saw their mothers to be less caring, and perceived their mothers and fathers as more overcontrolling. PIU is strongly associated with depression, negative self-image, and parental relations. Finally, mediation analysis revealed that such national differences in PIU between Japanese and Chinese were clarified in depression and perceived mother’s care. This cross-national study indicated that depression and perceived mother’s care were both significant risk factors that were associated with the national difference in PIU between Japanese and Chinese participants.

 

Internet suicide in Japan: A qualitative content analysis of a suicide bulletin board

Ai Ikunaga, Sanjay R. Nath, and Kenneth A. Skinner

Netto shinju, or Internet group suicide, is a contemporary form of Japanese suicide where strangers connect on the Internet and make plans to commit suicide together. In the past decade, numerous incidents have occurred whereby young Japanese make contact on the Internet, exchange tips on suicide methods, and make plans to meet offline for group/individual suicide. A systematic qualitative content/thematic analysis of online communications posted on a popular Japanese suicide bulletin board yielded a textured, thematic understanding of this phenomenon. Themes identified reflected Shneidman’s theory of suicide but with an emphasis on interpersonal concerns that are embedded in Japanese culture.

 

Internet suicide: Communities of affirmation and the lethality of communication

Ronald Niezen

As a tool of instant information dissemination and social networking, the Internet has made possible the formation and affirmation of public identities based on personality traits that are usually characterized by clinicians as pathological. The wide variety of online communities of affirmation reveals new conditions for permissiveness and inclusiveness in expressions of these socially marginal and clinically pathologized identities. Much the same kind of discourse common to these online communities is evident in some suicide forums. Web sites with suicide as their central raison d’être, taken together, encompass a wide range of ideas and commitments, including many that provide collective affirmation outside of (and often with hostility toward) professional intervention. The paradox of a potentially life-affirming effect of such forums runs counter to a stark dualism between online therapy versus “prochoice” forums and, by extension, to simple models of the influence of ideas on the lethality of suicide. Different forums either intensify or mitigate self-destructive tendencies in ways that are significant for understanding the place of communication in the occurrence of suicide and for therapeutic practice.

 

Factors influencing mental health providers’ intention to use telepsychotherapy in First Nations communities

Johana Monthuy-Blanc, Stéphane Bouchard, Christophe Maïano, and Monique Séguin

Telemental health is the use of information and communications technologies and broadband networks to deliver mental health services and support wellness. Although numerous studies have demonstrated the efficiency and utility of telemental health, certain barriers may impede its implementation, including the attitudes of mental health service providers. The current study draws on the technology acceptance model (TAM) to understand the role of mental health service providers’ attitudes and perceptions of telemental health (psychotherapy delivered via videoconferencing) on their intention to use this technology with their patients. A sample of 205 broadly defined mental health service providers working on 32 First Nations reserves in the province of Quebec completed the questionnaire adapted to assess TAM for telepsychotherapy. Confirmatory factor analysis and structural equation modeling provided evidence for the factor validity and reliability of the TAM in this sample. The key predictor of the intention to use telepsychotherapy was not mental health providers’ attitude toward telepsychotherapy, nor how much they expected this service to be complicated to use, but essentially how useful they expect it to be for their First Nations patients. If telemental health via videoconferencing is to be implemented in First Nations communities, it is essential to thoroughly demonstrate its utility to mental health providers. Perceived usefulness will have a positive impact on attitudes toward this technology, and perceived ease of use will positively influence perceived usefulness. Cultural issues specific to the populations receiving telemental health services may be more efficiently addressed from the angle of perceived usefulness.

 

Bad Souls: Madness and Responsibility in Modern Greece

Elizabeth Anne Davis

Duke University Press, 2012

344pp., US $25.95 paperback

 

Psychiatric care seems to be ever marred by the problematic and contingent relationships it fosters. Patient and physician, nurse and therapist, administration and action snag on the ideals and shortcomings of each other’s missions. In Elizabeth Anne Davis’ haunting ethnography, Bad Souls: Madness and Responsibility in Modern Greece, these snags complicate treatment and treatment seeking while Greece struggles to reform their psychiatric system to meet the needs of a diverse patient population. An ethnography of “kinds of subjects” (4), Bad Souls grapples with the moralistic underpinnings of taking care of mentally ill subjects and the moral and ethical parameters of patienthood under reform era ideology. With a nod to ancient Greek philosophy of the psyche, Davis explores Greece’s psychiatric establishment, through an outpatient behavioral health focused association and a university hospital psychiatric clinic in the Thrace prefecture, as it takes up the more Platonic based theory of the psyche as integrated into the conscious, and therefore responsible, self. All too often, however, treatment frames patients in the Homeric sense; psyche is not more than a shadow that survives the death of the body here. As psychiatry goes, and Davis illustrates, this problematization of the psyche can have devastating consequences when treatment is provided on the implicit condition that there is no wall separating madness from sanity; madness is simply sanity behaving poorly.

Drawing from Foucault’s work on the genealogy of ethics (12) the patients and clinicians in Thrace demonstrate what Davis terms a “fundamental asymmetry in therapeutic relationships”(13) wherein the patient is framed by morality, symptomology and responsibility, with the three perilously overlapping. Divided into three parts, Bad Souls takes into consideration conflicting personal and political responsibilities as they shape the meaning of being mentally ill in Modern Greece.

Part 1 looks at deceptive practices, blind deceits that are generated by the ethical expectations of patients in relation to their illness. Driven by the patients’ needs of ownership of diagnostic language and certification for state support and care, clinicians in Thrace navigate not just the dishonesty that arises naturally from such a situation but the “peculiar intimacy” (4) that comes from such therapeutic relationships that are built upon needs and authorization, with therapists negotiating “a shaky ground between guidance and coercion”(14). These complex negotiations of character the mentally ill and their therapists must manage in order to carry out and receive psychiatric care demonstrate where ethical tensions come into being when either party communicates poorly thereby breaking character. Davis describes the “self-presentation” the patients must develop to fill their role in the therapeutic relationship and the diagnosis the therapist must generate to complete the dyad as “distancing maneuvers” that create the autonomous yet congruent positions in the therapeutic relationship (72).

Part 2 takes into consideration the “local cultures of deception”(121) that are linked to the cultural minorities of the Thrace prefecture, framing diagnosis as dependent more upon cultural knowledge than of the more broadly accepted standards of diagnosis. The need to perform the role of qualifying patient (one eligible for state support) gives way to forms of deceit that bridge the gap between accepted “rights culture” (126) of the reformed psychiatric system and the peculiarities of the minority cultures, making salient the ethical tensions that arise between access and provision of care. Among the pathologies the minority cultures displayed there was Muslim conservatism, disallowing women patients from open and honest communication with the clinician and the often-constant presence of a husband, hesitant and shameful Turkish patients who require all the more prodding to open up and other forms of minorities that, presenting conversion symptoms of mental distresses, tended towards a more “somatic rubric” in clinical encounters (127). This “reordering of body and language”, left conversion disorders on the “surface of the body” (138), unable to penetrate down to the soft, morally implicated Self in the interior.  These practices of deception, whether agentic or not, found their way into the communities’ clinical profiles; deviant social behavior, chronic suicidality and incessant delusion all can be said to characterize not just discrete diagnostic categories but cultural minority markers as well. Much like the “rhetorical terrain of madness (τρελλα)”(173) Davis found deep within the social milieu of a Pontian settlement, mental illness lends itself to a theory of interpretation, of deciphering, of discerning. Little can be implicated from clinical symptomology alone; in Davis’ view, diagnosis takes a kind of acrobatics of cultural sensitivity attuned towards the diverse ethnologic landscape of the Thrace prefecture.

Part 3 questions the humanitarian concerns of reform era Greece, which leave many of the most severely mentally ill without the support  reform had aimed to establish. Reform discourse theoretically moved patients from the long-term institutional stays in psychiatric hospitals and psychiatric wards of general hospitals to the community for community-based care and support from family members and other caregivers with short term inpatient stays reserved for severe cases. This reform, Davis notes, acts “as both a paradigm and an allegory of modernization”(26). Modernization had the intent of reestablishing patient dignity and autonomy but ironically does some backtracking in this territory, providing more opportunities for patients to fail themselves and their state-caregiver. Kleandis, a patient Davis illustrates in part 3, tested the weakness of the system as his diagnosis of obsessive-compulsive disorder (OCD), a neurotic disorder that is typically thought of as well-managed through out-patient care and very amenable to therapy, resisted countless attempts at rehabilitation he had undergone over the years. Kleandis’ OCD was severely disruptive and the psychiatric system he was subject to was not designed to treat neurotics long-term, causing Kleandis to rotate throughout different stages of the system like an aimless pin-ball. Reform language stressing the importance of both community-based care and sufficient provisions for the most-helpless  resulted in a contestation of worlds where patients like Kleandis are never situated on one side of the agent/agentless binary and so never fall into a care routine that is efficacious enough for recovery. His failure to find himself in situ of this “care and control”(194) of the system makes the almost “pathological sense of responsibility”(235) OCD generates all the more tragically ironic. Unable to take clinical responsibility for his illness, Kleandis fell into therapeutic suspension, prostrate under the burden of full responsibility for his life.

To conclude psychiatric care in modern Greece is a negotiated practice of making responsibilities known and provided for.  “Here, psychiatrist and patient negotiated their responsibilities in different, perhaps incommensurable registers”(9).  These registers imbricate upon the already established modes of recognition and responsibility that patient and practitioner are commissioned with understanding and wielding to their advantage. In this sense, the psychiatric reform in Greece holds responsible its citizens for their care, regardless of mental capacity but not without consideration of diagnosis, which seems to frame as much as set free psychiatric patients.  The patients’ “exile to a liberal landscape where they had either to take responsibility for themselves or to craft pathological modes of dependency”(6) was indeed indicative of this hold reform held over some of Greece’s most vulnerable citizens. Though some could benefit from the liberal models of care espoused by the reform, emphasizing self-control and accountability, “these therapeutic techniques required an ontological freedom that eluding many patients, addressing them in vain as autonomous subjects who could choose to become responsible”(18). To become a psychiatric patient in modern Greece, therefore, is to become a powerful and crafty player in one’s own treatment, rendering helplessness and complete illness incompatible with the accepted modes of care and assumed ‘goods’ of autonomy and personal freedom. This means that ““wild” madness” is no longer a viable role for even the most severe of cases (19), thus placing mental illness closer to a pathology of character and will than of genes. The therapists and clinicians working under this command know this model is faulty but at least one that enables a mobilization of modernity and democratization. Still, some patients are lost somewhere between autonomy and dependency, unable to fully actualize either character to the tune of the state’s expectations as set forth by therapeutic goals. Patients and therapists meet somewhere near this stop-gap, engaging not just diagnostics and therapy but the shared humanity of the divide between sickness and health. To Davis, this is “a story about collaboration between patients and therapists, and the impasses of their collaboration”(15).  This collaboration is the salvaging of a nation-state’s broken account of psychiatric illness, an account that reveals the strengths and weaknesses of psychiatric care in modern Greece and the wider discourse on human dignity.

 

Erica Rockhold will be beginning her masters in anthropology at Northern Arizona University this fall.

The Kashmir valley experienced a painful, unsuccessful armed movement for national self-determination against Indian rule from 1989-2002. [1]  While a ceasefire was declared in 2002, Kashmir’s political future continues to be mired in uncertainty, caught between the national interests of Pakistan and India.   Despite the end of the armed struggle, the vast majority of Kashmiris aspire to the yet-unfulfilled promise of self-determination (azaadi). The Indian state responded to the movement for self-determination, not as an indigenous struggle for political autonomy, but rather, as cross-border terrorism.[2]  As such, the significant militarization of Kashmir has been, and continues to be, justified on the grounds of protecting the Indian nation-state’s territorial integrity.  The Indian state’s repressive response to Muslim “terrorists” in Kashmir has been further buttressed by a continuing global “war on terror,” leading Kashmiri activists and political figures to, in turn, reevaluate their strategies of protest away from an armed movement to mass street protests.

 In this post, I reflect on the multiple temporalities that characterize militarized everyday life in Kashmir, including how these affected my own ethnographic field experience.  In the process, I think through two rather different kinds of public “events” to understand how militarization is conceptualized and temporalized.  Finally, I introduce another temporality—that of ethnographic writing—which I suggest has the potential to hold these events in tension, while also deviating from them in important ways.

 

1.     Catastrophic time

This spring has been unusually difficult for Kashmiris.  This is saying a lot, for a people living in an uninterrupted state of emergency since 1989, in one of the most militarized places on earth. One of the challenges I have faced as an anthropologist working in Kashmir is how to write about the mundane in a context where catastrophic events occurred frequently and unexpectedly.  Beth Povinelli writes that “catastrophic” events are those which “seem… to necessitate ethical reflection and political and civic engagement” (2011: 13-14).  Meanwhile, medical anthropologists have also emphasized the significance of the “everyday” or what I call mundane time.

One such catastrophic event occurred this past February.  On a Saturday morning, Kashmiris awoke to the news that Afzal Guru, a 43-year old Kashmiri man convicted of “aiding and abetting” an armed attack on the Indian parliament in December 2001, was secretly executed in a jail in Delhi.  Guru had spent the last twelve years in solitary confinement, in the company of Sartre and other French existentialists. In 2005, the Indian Supreme Court judgment which gave Guru three life sentences and a double death sentence, arguing that although there was only circumstantial evidence against him, “the collective conscience of the society will only be satisfied if…capital punishment is awarded to the offender” (Appeal 373-375 of 2004).  Despite serious doubts cast on the veracity of the case built against Guru by legal experts and commentators, the execution went ahead.

While Indian TV channels and newspapers accompanied the news story with a lurid graphic of a noose around Guru’s neck, Kashmiri protestors held up photos of Guru looking peaceful and pensive, with a kaffiya wrapped around his head.  The images below exemplify the existence of two Afzals, materialized through their rather different physical appearances.

Fig 1: News of Afzal Guru’s hanging broadcast on an Indian national English-language channel.

Fig 2: The image of Afzal Guru widely circulated in Kashmiri newspapers and blogs.

Guru himself may not have been surprised by this bifurcation.  In a 2006 interview, he was asked how he wanted to be remembered.  He said, “As Afzal, as Mohammad Afzal.  I am Afzal for Kashmiris, and I am Afzal for Indians as well, but the two groups have an entirely conflicting perception of my being.” For Kashmiris, the execution and its aftermath made explicit the alienation between India and Kashmir in an intimate, profoundly personal way, as the Indian state refused to return Guru’s body to his family.  As Mirza Waheed, a Kashmiri writer put it, the decision to bury Afzal Guru in Tihar jail exemplified how even a “Kashmiri corpse can be seditious.”   Perhaps unsurprisingly for anthropologists, Guru’s death did not signal the end of his life: rather, the Indian state’s refusal to return his body produced new forms of political action.

After the news of Guru’s hanging, mass protests broke out in Kashmir.  In response, the Indian military imposed curfew for days.  Local newspapers and cable TV networks were blocked, and 185 out of 252 ATMs in the valley were put out of commission.  Despite the restrictions on movement (curfew in Kashmir implies restriction on movement as well as time), a group of Kashmiris erected a tombstone for Guru over an empty grave in Mazar-e-Shuhada, the main Martyr’s Graveyard. The Urdu epitaph read, “The martyr of the nation, Mohammad Afzal Guru…whose mortal remains are lying in the custody of the Government of India.  The nation awaits its return.”  Meanwhile, most Indians digested the event as a triumph of justice.  I tried, but was unable to read many of the comments on major Indian news sites; their celebratory, high-pitched tone was unbearable, even though I was 7000 miles away and outside the crisis-time.

 

2.     Mundane time

Some weeks later, a seemingly different news story from Kashmir caught my attention.  This time, media outlets reported that counterfeit versions of the antibiotic Amoxicillin Trihydrate were supplied en masse to several hospitals in the capital, Srinagar.  Laboratory tests of the pills, Maximizen 625 and Curesef, which are supposed to contain 500 mgs of Amoxicillin each, showed no traces of the antibiotic.  According to some accounts, over 200,000 pills had been distributed to hospitals in Kashmir the previous year and had possibly attributed to the deaths of hundreds.

A number of professional medical organizations and political parties called for a statewide shutdown (bandh) on May 6 to protest the sale of spurious drugs.  One of Kashmir’s leading political figures linked the government’s supply of spurious drugs as a “conspiracy [by the Indian government] to carry out genocide” against Kashmiri civilians.  Unlike the protests after Guru’s death, however, the protests against spurious drugs were halfhearted.  Newspapers reported that despite calls for a shutdown, only one of Srinagar’s main marketplaces remained closed; the rest of the city functioned “normally.”  As the story unfolded, it became increasingly focused on systemic corruption and governmental neglect.  Government documents revealed that the Drug and Food Control Organisation (equivalent to the US FDA) took more than three years to test samples of medicines.

Several news articles also reported how the scandal tapped into widespread fears surrounding biomedical technologies, particularly pills, in Kashmir.  As one government employee explained to a journalist, “One trusts nothing in Kashmir these days.  If a committee of senior doctors by the government can purchase fake drugs, what stops retail drug shops from selling spurious medicines?” I had encountered such suspicion first hand while observing interactions between mental health experts and patients.  I learned that despite complaints by medical professionals that Kashmiri patients were irrationally desirous of pills, there was intense circumspection and doubt surrounding their consumption.

For example, patients often questioned the efficacy of pills based on the fact that although “branded” and “generic” drugs reportedly had the same active ingredients, there was a significant price difference between them.  “How can one drug cost 15 rupees and the other drug cost 150 rupees, and they be the same thing?” one of my interlocutors asked rhetorically.  In general, if they could afford them, patients preferred foreign pharmaceutical brands over their Indian counterparts.  However, doubts over pills were not limited to their material or ontological form.  Patients also identified pills as permeable objects, transmitting the nefarious intentions of corrupt medical practitioners.  In this sense, biomedicine was not viewed as a neutral or universal form of knowledge, but rather, was shaped—and corrupted—by its social and economic context; in this case, Kashmir’s endemic corruption (Schaffer 2005).

 

3.  The longue durée

It feels odd to draw a connection between these two events—the event of Afzal Guru’s execution and the report of spurious drugs—because it invariably invites a comparison.  Yet in the process of ethnographic writing, we are forced to choose between such events all the time.  It is perhaps worthwhile to ask: what makes an event significant, in the sense that it makes it into public consciousness and calls for ethical reflection or action? Which events are presented as self-evidently significant, and which remain under the surface?

Guru’s hanging represents a moment of shared, public mourning, a(nother) notable rupture in the history of Kashmiri-Indian relations, and one likely to be remembered by Kashmiris for generations to come. By contrast, the report of spurious drugs produced an active response only from health professionals, despite considerable efforts to mark it as a kind of public health “crisis.”  I suggest that part of what made Guru’s death visible and urgent was that his death localized the cumulative suffering of Kashmiris in a singular body—and in a specific temporal moment.  The knowledge of spurious drugs, on the other hand, dispersed suffering across different bodies—old and young, male and female, rich and poor.  While Guru’s death provided specific knowledge about Kashmir’s suffering, the effect of spurious pills was diffuse and general.

These two moments also reveal something about the limits of our own heuristics of “catastrophic” vs. “mundane” violence, categories that are not entirely satisfying for Kashmiris either.  While Kashmiris (like anthropologists) struggle to make space for everyday suffering in a context where spectacular forms of injustice are plenty, the fact is that, both events cohere within a single framework.

Many Kashmiris told me that the conflict is a disease (bemari).  In this sense, while Guru’s death represented an important moment of localization, there were many other everyday moments where Kashmiri patients refused such a logic of containment.  In the psychiatric clinic where I conducted fieldwork, the vast majority of Kashmiri patients I spoke with refused to specify their suffering, in that they did not present symptoms specific to trauma even though they had been through a ‘traumatic’ event, such as witnessing the death of a loved one in unnatural circumstances.  Patients who suffered from a range of diseases, from depression to diabetes, all shared a common symptom, that of kamzori or bodily weakness.  While other symptoms would often be treatable through the consumption of pills, complaints of weakness did not respond to medication.

Similarly, rather than locate their suffering within a specific catastrophic event, patients preferred to speak of their daily struggles of life under occupation: how they worried about the safety of their children when they went to school, how it was impossible to be healthy in Kashmir, and how their quality of life or livelihoods had suffered because of frequent strikes and shutdowns.  My questions about how the post-1989 period was different from the pre-conflict days also exceeded the timeframe of militarization I imposed: “This occupation is nothing new,” many said, “We have been colonized for 400 years,” referring to previous colonizations of Kashmir by Mughal, Afghan, Sikh, and Hindu rulers.

 

4.     Ethnographic time

What does it mean to do fieldwork in these intersecting temporalities? In practical terms, it meant navigating security checkpoints, unruly traffic, and gun-wielding soldiers on the streets, accounting for days of unexpected protests, strikes, or curfews, and attending to not one but two simultaneous calendars, the “official” calendar of the Indian state agencies, and a “protest” calendar published weekly by a Kashmiri separatist political organization.

My research, which examines trauma-related psychiatric and humanitarian interventions in Kashmir, was profoundly shaped by this unsteady, and at times, dual reality.  During my fieldwork, in June 2010, major street protests erupted after reports of a fake “encounter”[3] killing by the Indian army surfaced.  As the numbers of civilian casualties mounted, more protests took place to commemorate the dead, fueling a cycle of violence that lasted till October.  The international and national Indian press was awash with images reminiscent of Palestine, of kaffiya-wearing youth hurling stones at an Indian paramilitary force that responded with gunfire and teargas.  When the protests gradually dissipated, 124 protesters—most of them young—had been killed and the months of strikes and curfews had paralyzed social and economic life in Kashmir once again.[4]

At the time, I told myself that the first-hand experience of curfew was important to what I was writing, and in a way, encapsulated what Kashmiris had been going through for the past twenty years.  In my field journal, I carefully chronicled my feelings of imprisonment—I felt I truly understood the meaning of “cabin fever”—since there were days when I wasn’t allowed to leave the house at all.  At the same time, as a non-Kashmiri, I was fully shielded from the dangers and tribulations of the streets.  I never felt personally threatened during my time in Srinagar, and in any case, I had the luxury of hopping on a plane to Delhi at any given time. I was not living in a different place, but I was in a different time, fieldwork time, temporary time.

I felt a sense of immediacy, often corroborated by Kashmiri interlocutors who used 2010 as a badge of my authenticity: “You were there,” they would say, “so you know.”  Yet the strange sense of accomplishment I derived from my presence was always tempered with the acknowledgement that the writing process would take me far away and leave me behind.[5]

As much as “catastrophic” events such as Guru’s death drew me back in, there were people and narratives that pulled me away.  I became interested in those events that existed below the surface and seemed a necessary part of how Kashmiris experienced and understood suffering in the longue durée.  It is a suffering that becomes almost invisible, yet still palpable, although in a less-localized yet equally significant way.  In accounting for these different histories and temporalities, ethnographers will do well to remember that ethnographic time is itself not unified.  It has its own strange temporality.  To paraphrase Marilyn Strathern, it is produced by alternating between the time of “being there” (present) and “being here” (absent).  In this sense, rather than think of ethnographic time as encompassing these other temporalities, I’d like to think that we are bobbing along besides them.

 

Saiba Varma received her PhD in anthropology from Cornell University and is currently a postdoctoral fellow at the Thompson Writing Program at Duke University.  Her research examines psychiatric and psychological humanitarian interventions in the Kashmir valley.

 

References

Miyazaki, Hirokazu. 2007 Between Arbitrage and Speculation: An Economy of Belief and Doubt.  Economy and Society 36(3): 397-416.

Povinelli, Elizabeth. 2011 Economies of Abandonment: Social Belonging and Endurance in Late Liberalism.  Duke University Press.

Redfield, Peter. 2013 Life in Crisis: the Ethical Journal of Doctors without Borders.  University of California Press.

Schaffer, Teresita C. 2005 Kashmir: The Economics of Peace Building. A Report of the CSIS South Asia Program with the Kashmir Study Group.  The Center for Strategic and International Studies.

[1] I use the shorthand “Kashmir” to refer to a geographical region within the Indian state of Jammu and Kashmir, otherwise known as the “Kashmir valley.”  This region is controlled by India, but portions of Kashmir are also controlled by Pakistan (Pakistan occupied Kashmir or Azad Kashmir) and China.

[2] Many young Kashmiri men crossed over the border to Pakistan in the late 1980s and early 1990s to receive military training.  However, while Indian military officials estimate the number of active militants in Kashmir to be in the hundreds, over 600,000 Indian troops maintain a presence in the valley.

[3] An encounter is a euphemism used in South Asia to describe extrajudicial killings in which the victims are described as suspected gangsters or terrorists.   A fake encounter refers to death in custody or cases where unarmed victims are framed.

[4] This was not the first time that mass protests had broken out in the post-ceasefire period in Kashmir; there were also major protests during the summers of 2008 and 2009.  However, the protests of 2010 and the brutal response led to an unparalleled outpouring of grief, concern, and outrage on the part of Kashmiris, but also many Indian commentators.  For the first time, there was the acknowledgement on mainstream Indian channels that something was deeply wrong in the government’s policies on Kashmir.

[5] Hiro Miyazaki (2007) argues that the fear of being “left behind”—or the temporal lag that characterizes scholarly production—is what propels anthropologists to study new, so-called cutting-edge subjects.

The Society for Medical Anthropology welcomes nominations for the Eileen Basker Memorial Prize, awarded annually for a significant contribution to anthropological scholarship on gender and health by a scholar (or scholars) from any discipline or nation for a specific book, article, film, or exceptional PhD thesis produced within the preceding three years. The Prize is awarded to the work judged to be the most courageous, significant, and potentially influential contribution to this area of scholarship. Winners receive a $1000 cash award and are recognized at the SMA business meeting during the AAA.

The Prize was founded by Virginia R. Dominguez in collaboration with the Society for Medical Anthropology in 1987 following the death of Israeli-American critical medical anthropologist and feminist, Eileen Basker, in October 1986.

Nominations are invited from one or more individuals in the form of a letter indicating the impact of the designated work on the field. Self-nomination is not permitted. Publishers of nominated books are expected to supply three copies of the relevant work to the Prize Committee.

The deadline for receipt of materials is July 1. Inquiries and nomination materials should be sent to the chair of the Basker Prize Committee:

Sarah Willen – sarah.willen@uconn.edu

Department of Anthropology

University of Connecticut

Beach Hall 438

Storrs, CT 06269-1176

 

For more information about the prize, see http://www.medanthro.net/about/sma-awards/ileen-basker-memorial-prize/.

Dear all,

We would like to cordially invite you to attend the public co-lectures that will be part of the international summer school “Well-being at the margins: Seeking health in stratified landscapes of medicine and healing” at Freie Universität Berlin:

22 July 2013

9.30 am – Introduction by Hansjörg Dilger (Freie Universität Berlin) & Anita Hardon (University of Amsterdam)

10.00 am – “Engaging care, citizenship and sovereignty: dialectices of theory and ethnography” by Miriam Ticktin (New School for Social Research, New York) & Vinh-Kim Nguyen (Université de Montreal, Collège d’Etudes Mondiales, Paris, University of Amsterdam)

 

23 July 2013

9.00 am – “Somatic modes of attention: embodying inequality and structural violence” by Heide Castañeda (University of South Florida) & David Napier (University College London)

 

25 July 2013

9.00 am – “Syndemics, insecurity and access to health care in Zimbabwe and Nepal” by Lenore Manderson (Monash University) & Ian Harper (University of Edinburgh)

 

26 July 2013

9.00 am – “Ethical choices and challenges in the anthropology of health” by Sylvie Fainzang (Cermes3/Inserm, Paris) & Peter Redfield (University of North Carolina at Chapel Hill)

 

For more information, please see the poster below.

Summer School Berlin_Well-being at the margins_July 2013

 

Best regards on behalf of the organizing team,

Dominik Mattes

(Freie Universität Berlin)

The Alcohol, Drug, and Tobacco Study Group (ADTSG) of the Society for Medical Anthropology requests submissions for the best graduate student paper in the anthropology of alcohol, drugs, pharmaceuticals, tobacco or similar substances. Qualifying submissions will be judged by a committee of ADTSG members. The author of the winning paper will receive a cash award of $100 and her or his name will be announced in Anthropology News and at the Society for Medical Anthropology awards ceremony at the American Anthropological Association Annual Meeting in November. Submissions from all anthropological sub-disciplines are encouraged.

 

QUALIFYING CRITERIA

• No more than 9,000 words
• Must be based on original fieldwork and data
• Must have been written in the past 12 months
• Primary or first author must be a graduate student at time of submission
• May be unpublished or submitted for publication at the time of submission

 

JUDGEMENT CRITERIA

• Originality of fieldwork and data
• Richness of substantive or evidentiary materials
• Clarity of anthropological methods
• Linkage of work to social science literature
• Effective use of theory and data
• Organization, quality of writing, and coherence of argument

 

SUBMISSION PROCESS

• Please do not include your name or any identifying information in the paper itself
• Papers must be double spaced and in PDF format (please include page numbers)
• References should be formatted in the American Anthropologist style
• Please submit an electronic copy to Tazin Karim, chair of ADTSG at karimtaz@msu.edu
• Submissions must be received by 5:00PM EST, September 1, 2013 for full consideration

 

Questions may be directed to Tazin Karim at the above email address. We look forward to your submissions!

Here is the second part.

American Ethnologist

Feminine power or feminine weakness? North Indian girls’ struggles with aspirations, agency, and psychosomatic illness (Jocelyn Marrow)

In Hindi-speaking northeastern India, mothers whose daughters are afflicted with a psychosomatic illness referred to locally as “the teeth have clenched” employ standard tropes pertaining to Indian femininity to negotiate their daughters’ agency against the backdrop of new aspirations. An inquiry into two cases I encountered during fieldwork in Varanasi psychiatric clinics in 2001–04 demonstrates how girls’ symptomatic bodies mediated social concerns pertaining to the challenges that women’s education and work in public spaces present to non-elite middle-class domestic orders. While these illnesses may have been born of previous traumas or household conflicts, and sometimes were acknowledged as such, mothers’ and daughters’ own concerns about the illnesses focused on what they indicated about the daughters’ potential for social and academic success. In particular, mothers regarded their daughters as possessing either too much or too little “power” or “strength,” and these attributions attached to their anxieties and hopes for their daughters’ futures. In the drama of clenched teeth, disordered bodies, disruptive behavior, and possible futures were folded into the same metaphors of agency.

Cultural Anthropology

Left Behind: Security, Salvation, and the Subject of Prevention (Kevin Lewis O’Neill)

In North Carolina, a faith-based 501(c)(3) nonprofit organization facilitates a child sponsorship program that connects North American evangelical Christians with at-risk children in one of postwar Guatemala City’s most violent neighborhoods: La Paloma. Pitched in the name of gang prevention, child sponsors help create a context in which these Guatemalan kids might choose God over gangs. Based on fieldwork in North Carolina and in Guatemala, with both sponsors and the sponsored, this article explores how child sponsorship makes the work of gang prevention dependent on the work of self-cultivation. It is an ethnographic approach attuned to what this article understands as the subject of prevention, that is, the individual imagined and acted upon by the imperative to prevent. This includes at-risk youths, in all their racialized otherness, but also (and increasingly so) North American evangelicals who self-consciously craft their subjectivities through their participation in gang prevention. The subject of prevention’s observable outcome is a kind of segregation with its own spatial logic. The practice of evangelical gang prevention ultimately produces an observable kind of inequality that says something about the surgically selective nature of Central American security today. Some Guatemalan youth connect with North Americans. Others get left behind.

Post/Socialist Affect: Ruination and Reconstruction of the Nation in Urban Vietnam (Christina Schwenkel)

This article explores the engineering of affect in socialist urban design and subsequent changes in the affective register of a rapidly growing city in late socialist Vietnam. The setting is the north central city of Vinh, destroyed by aerial bombing during the American War and rebuilt with assistance from East Germany. A primary focus of urban reconstruction was Quang Trung public housing that provided modern, European-style apartments and facilities for more than eight thousand residents left homeless from the war. Drawing from interviews, images, poems, and archival materials that document urban reconstruction, the article foregrounds the complex historical, ideological, social, and gendered meanings and sentiments attached to a particular construction material: bricks. It argues that bricks have figured prominently in radical and recurring urban transformations in Vinh, both in the creation and the destruction of urban spaces and architectural forms. As utopic objects of desire, bricks gave shape to an engaged politics of hope and belief in future betterment, as construction technologies once reserved for the elite were made available to the masses. In Quang Trung public housing, bricks harnessed political passions and utopian sentiments that over time, as Vinh’s urban identity shifted from a model socialist city to a regional center of commercial trade and industry, came to signify unfulfilled promises of the socialist state and dystopic ruins that today stand in the way of capitalist redevelopment.

Tokyo’s Commuter Train Suicides And The Society Of Emergence (Michael Fisch)

This article considers the treatment of commuter train suicides in Tokyo’s commuter train network in an effort to think critically about the lived experience mediated by theories of emergence materialized through “smart” infrastructures. In so doing, it embarks from the question of how the commuter train network thinks the disorder of the commuter suicide in relation to how the network has been restructured in recent decades to handle irregularity as regular. This restructuring, I demonstrate, works to corporealize the network in accordance with an understanding of the body as a paradigm of decentralized complex emergence, which is a concept with roots in cybernetics and artificial life but which has also been adopted in recent political theory to rationalize social, economic, and environmental instability. Materialized in the commuter train network, this concept asks us to think the system as a kind of machinic life that, while generating the potential for new forms of value creation, potentially encourages the experience of commuter suicides as a necessary and recursive process of metabolic renewal within a totalizing system.

 

Social Science & Medicine

‘Faking til you make it’: Social capital accumulation of individuals on low incomes living in contrasting socio-economic neighbourhoods and its implications for health and wellbeing (Kathryn Browne-Yung, Anna Ziersch, Fran Baum)

People on low-income living in low socio-economic neighbourhoods have poorer health in comparison with those living in advantaged neighbourhoods. To explore neighbourhood effects on health and social capital creation, the experiences of low-income people living in contrasting socio-economic neighbourhoods were compared, in order to examine how low-income status and differing levels of neighbourhood resources contributed to perceived health and wellbeing. Quantitative and qualitative data were analysed: survey data from 601 individuals living in contrasting socio-economic areas and in-depth interviews with a new sample of 24 individuals on low-incomes. The study was guided by Bourdieu’s theory of practice, which examines how social inequalities are created and reproduced through the relationship between individuals’ varying resources of economic, social and cultural capital. This included an examination of individual life histories, cultural distinction and how social positions are reproduced. Participants’ accounts of their early life experience showed how parental socio-economic position and socially patterned events taking place across the life course, created different opportunities for social network creation, choice of neighbourhood and levels of resources available throughout life, all of which can influence health and wellbeing. A definition of poverty by whether an individual or household has sufficient income at a particular point in time was an inadequate measure of disadvantage. This static measure of ‘low income’ as a category disguised a number of different ways in which disadvantage was experienced or, conversely, how life course events could mitigate the impact of low-income. This study found that the resources necessary to create social capital such as cultural capital and the ability to socially network, differed according to the socio-economic status of the neighbourhood, and that living in an advantaged area does not automatically guarantee access to potentially beneficial social networks.

Misrecognition of need: Women’s experiences of and explanations for undergoing cesarean delivery (Kristin P. Tully, Helen L. Ball)

 International rates of operative delivery are consistently higher than the World Health Organization determined is appropriate. This suggests that factors other than clinical indications contribute to cesarean section. Data presented here are from interviews with 115 mothers on the postnatal ward of a hospital in Northeast England during February 2006 to March 2009 after the women underwent either unscheduled or scheduled cesarean childbirth. Using thematic content analysis, we found women’s accounts of their experiences largely portrayed cesarean section as everything that they had wanted to avoid, but necessary given their situations. Contrary to popular suggestion, the data did not indicate impersonalized medical practice, or that cesareans were being performed ‘on request.’ The categorization of cesareans into ‘emergency’ and ‘elective’ did not reflect maternal experiences. Rather, many unscheduled cesareans were conducted without indications of fetal distress and most scheduled cesareans were not booked because of ‘choice.’ The authoritative knowledge that influenced maternal perceptions of the need to undergo operative delivery included moving forward from ‘prolonged’ labor and scheduling cesarean as a prophylactic to avoid anticipated psychological or physical harm. In spontaneously defending themselves against stigma from the ‘too posh to push’ label that is currently common in the media, women portrayed debate on the appropriateness of cesarean childbirth as a social critique instead of a health issue. The findings suggest the ‘need’ for some cesareans is due to misrecognition of indications by all involved. The factors underlying many cesareans may actually be modifiable, but informed choice and healthful outcomes are impeded by lack of awareness regarding the benefits of labor on the fetal transition to extrauterine life, the maternal desire for predictability in their parturition and recovery experiences, and possibly lack of sufficient experience for providers in a variety of vaginal delivery scenarios (non-progressive labor, breech presentation, and/or after previous cesarean).

 

Sociology of Health & Illness

The end of life and the family: hospice patients’ views on dying as relational (Alex Broom, Emma Kirby)

The end of life is a highly emotive and critical period in the life course and families often play a central role during this time. Despite significant sociological work on dying as a relational experience, there has been little exploration of the significance of contemporary family structures and relations. In this article, drawing on the accounts of twenty hospice in-patients, we explore how the end of life (in this case within an in-patient unit) is mediated by family dynamics and expectations. Participants’ accounts reveal a range of interpersonal experiences, including: pressures and strains on families and patients; differentiation in family responses to and involvement in the dying process; and tensions between individual and family preferences/desires. We argue that family dynamics strongly influence individual experiences near death and that the focus on individual preferences and the management of disease in palliative care contexts must be augmented with sophisticated and nuanced understandings of the family context. We suggest that sociological conceptual explanations of shifts in social and family life, such as individualisation and ontological security, may also help us better understand the ways families approach and respond to the dying process.

Inter-embodiment and the experience of genetic testing for familial hypercholesterolaemia (Nicholas Jenkins, Julia Lawton, Margaret Douglas, Nina Hallowell)

In this article we explore the concept of inter-embodiment and its potential for advancing sociological research into illness biography and genetic identity. Inter-embodiment theory views embodied knowledge as produced through relations between bodies, as opposed to originating from within the body or as the product of relations between disembodied selves. Drawing on a qualitative study in which we interviewed 38 individuals about their experiences of discovering they had high cholesterol and undergoing genetic testing for familial hypercholesterolaemia (FH), we discuss how their narratives may be understood from an inter-embodiment perspective. The participants frequently talked at length about their family histories of high cholesterol and cardiovascular disease. Through these accounts, we develop the concept of the family corpus in order to highlight the role body networks play in shaping lay constructions of genetic identity and a familial disease biography. The notion of a family corpus, we argue, is useful in understanding why genetic testing for FH was experienced as either biographical re-enforcement or as biographical disruption. We conclude by discussing the implications of our findings for future sociological research into illness biography and genetic identity.

Learning to doctor: tinkering with visibility in residency training (Iris Wallenburg, Antoinette Bont, Maas-Jan Heineman, Fedde Scheele, Pauline Meurs)

Medical doctors in teaching hospitals aim to serve the two central goals of patient care and medical training. Whereas patient care asks for experience, expertise and close supervision, medical training requires space to practise and the ‘invisibility’ of medical residents. Yet current reforms in postgraduate medical training point to an increasing emphasis on the measurable visibility of residents. Drawing on an ethnographic study of gynaecology training in The Netherlands, this article demonstrates that in daily clinical routines multiple practices of residents’ visibility (visibilities) coexist. The article lists four visibilities: staging residents, negotiating supervision, playing the invisibility game and filming surgical operations. The article shows how attending physicians and medical residents tinker with these visibilities in daily clinical work to provide good care while enacting learning space, highlighting the increasing importance of visualising technologies in clinical work. Moreover, the article contributes to traditional sociological accounts on medical education, shifting the focus from medical education as a social institution to the practices of medical training itself. Such a focus on practice helps to gain an understanding of how the current reform challenges clinicians’ educational activities.

In search of the cancer candidate: can lay epidemiology help? (Sara Macdonald, Graham Watt, Una Macleod

First published in 1991, the ideas embedded in ‘Lay epidemiology and the prevention paradox’ offered a novel and rational explanation for the lay public’s failure to fully engage with the lifestyle messages offered by health educators. During the course of a large ethnographic study in South Wales, Davison and colleagues described the emergence of what they termed the coronary candidate. Candidacy provides a ‘cultural mechanism’ that facilitates the estimation of risk for coronary heart disease. The model has rarely been applied to other major illnesses. This article presents findings from a study that sought to explore the lay epidemiology model, candidacy and cancer. In a series of in-depth individual interviews, members of the lay public discussed their ideas about cancer, and what emerged was an explanatory hierarchy to account for cancer events. Yet the random and unpredictable nature of cancer was emphasised as well as a general reluctance to accept the idea of cancer candidacy.

The effort to control time in the ‘new’ general practice (Sara MacBride-Stewart)

Since the 1980s and 1990s doctors in the UK have reported a lack of time; this has been reproduced in the reorganisation of work through various contracts and regulatory mechanisms. I draw on interviews with 32 General Practitioners (GPs) in Wales about their everyday work, focusing on accounts about the limited nature of their time. I use Adams’ analysis of the rationalisation of work time through the processes of commodification, compression, and colonisation, to explore tensions between traditional and new ways of doctoring. While it was possible to find evidence of traditional ways of managing time that shaped the activities of doctors and controlled those activities, the doctors were not passive participants in the rationalisation of work time. Rather they actively modified its processes using notions of professionalism that are aligned to traditional doctoring, and which offer new ways of doing and being a professional.

 

Subjectivity

The affective labour of autism neuroscience: Entangling emotions, thoughts and feelings in a scientific research practice (Des Fitzgerald)

This article extends discussions on the role of emotion in scientific lives by showing how the emotional commitments of researchers (here, psychologists and neuroscientists) can play a specifically constitutive or generative role. Autism research is an area where the tricky intertwinements of subjects, thoughts, interactions and bodies can be remarkably explicit: the article uses this case to show how researchers’ emotions can actually mediate transactions between intellectual/scientific problems and more material/bodily concerns. The article argues that autism research shows the on-going presence of affect in scientific subjectivities; in particular, it shows how scientific subjects sometimes constitute intellectual projects through a sensitivity to their own bodies and emotions. Gathering these concerns together, the article extends recent discussions of body work and emotion work by Natasha Myers and Wilson, and also draws on the ‘emotional’ aspects of Whitehead’s process philosophy.

Biopolitics, trauma and the public fetus: An analysis of preconception care (Katie Gentile)

In 2006, the US Center for Disease Control rolled out guidelines for ‘preconception care,’ institutionalizing the use of the public fetus as a fetish object in relation to which the cultural body can disavow and contain the post 9/11 contagion of annihilation anxiety. Integrating Bergson’s ideas of duration with cultural and psychoanalytic theories of time and subjectivity, this article will examine these guidelines and the ways in which they become alluring as forms of traumatic repetition instilling hypervigilance as normality. The preconception care guidelines are a perfect example of Clarke’s ideas of biomedicalization, as women’s bodies emerge through practices of self and biomedical surveillance and risk management strategies in relation to the future fetus. This future orientation functions not only to disavow, displace and contain vulnerability, but also creates a future in order to attempt to go on being in the face of trauma and humiliation.

Inventing the female self in Greenwich Village, 1900–1930: Mabel Dodge’s encounter with science and spirituality (Carla Christina Hustak)

Through the case study of Mabel Dodge, the mystic of Greenwich Village, this article shows how new forms of knowledge and free love converged in a turn to interrogating the female self. Mabel Dodge’s practice of subjectivity is an early twentieth-century example of what Michel Foucault called the ‘hermeneutics of the subject’, a form of spirituality grounded in the pursuit of the ‘truth’ of the self. Dodge’s efforts to grasp her ‘secret concentrated essence’ reveal an early twentieth-century invention of a new feminist spirituality at the crossroads of occultism, social reform, and sciences of psychology and biology.

Recognising life – A study in the atheist micro-bio-politics of drugs (Morten Nissen)

The author attempts a micro-bio-politics of drugs, starting from an excerpt of an interview with a couple of young drug users in a Copenhagen social youth work facility that pushes harm reduction in 1996. The article is guided by Derrida’s idea of ‘drugs as the religion of atheist poets’ – that the contemporary discursive pragmatics of more or less pharmaceutical life practices still include forms of transcendence – and by the wish to fertilize the field of bio-politics with the indexical inter-subjectivity of the concept of ideology, as derived from an anti-essentialist reading of Hegelian–Marxist traditions. The analysis unfolds as an ideology critique that reconstructs, and seeks ways to overcome, particular forms of recognition that are identifiable in the data and in the field of drug practices, and how these form part of the constitution of singular collectives and participants – in these life practices, but also in the research practice that engaged with them through the interview.

Exploring embodied perspectives of change within a psychiatric context: Some preliminary remarks from a psychiatrist (Sebastian von Peter)

Psychiatric discourses and practices largely focus on the mind when explaining why people change. Agency is thought to emerge out of rational introspection, insight and self-reflexivity, rendering them to key targets of psychotherapeutic interventions. In this essay, an everyday psychiatric situation will be presented in order to illustrate that agency cannot merely be located in the depth of the human mind, but might also arise from a pre-reflective, internalized corporeality. Such a mode of subjectivity is shown to direct ways how to move and position a body, both incorporating a mindful rationality and its embodied foundation. Over the course of this discussion, agency is explained as resulting out of a sort of distributed effect, simultaneously allowing for the analysis of cognitive, embodied and environmental factors that produce change in a symmetrical way. To conclude, initial thoughts will be presented to alter both the clinicians and academic approach towards agency, assigning the embodied self a more substantial role in navigating a person’s behaviour.

Hi all, here’s the first part of the journal roundup for this month. Enjoy.

 

Science, Technology, & Human Values

Theorizing the Bioeconomy: Biovalue, Biocapital, Bioeconomics or . . . What? (Kean Birch and David Tyfield)

In the policy discourses of the Organization for Economic Cooperation and Development (OECD) and European Commission (EC), modern biotechnology and the life sciences are represented as an emerging “bioeconomy” in which the latent value underpinning biological materials and products offers the opportunity for sustainable economic growth. This articulation of modern biotechnology and economic development is an emerging scholarly field producing numerous “bio-concepts.” Over the last decade or so, there have been a number of attempts to theorize this relationship between biotechnologies and their capitalization. This article highlights some of the underlying ambiguities in these conceptualizations, especially in the fetishization of everything “bio.” We offer an alternative view of the bioeconomy by rethinking the theoretical importance of several key economic and financial processes.

 

 Selective Ignorance and Agricultural Research (Kevin C. Elliott)

Scholars working in science and technology studies have recently argued that we could learn much about the nature of scientific knowledge by paying closer attention to scientific ignorance. Building on the work of Robert Proctor, this article shows how ignorance can stem from a wide range of selective research choices that incline researchers toward partial, limited understandings of complex phenomena. A recent report produced by the International Assessment of Agricultural Knowledge, Science, and Technology for Development serves as the article’s central case study. After arguing that the forms of selective ignorance illustrated in cases like this one are both socially important and difficult to address, I suggest several strategies for responding to them in a socially responsible manner.

 

Drinking Wastewater: Public Trust in Potable Reuse (Kerri Jean Ormerod and Christopher A. Scott)

In the coming decades, highly treated wastewater, known as reclaimed water, is slated to be a major element of municipal water supplies. In particular, planners propose supplementing drinking water with reclaimed water as a sustainable solution to the growing challenge of urban water scarcity. Public opposition is currently considered the primary barrier to implementing successful potable water reuse projects; nonetheless, public responses to reclaimed water are not well understood. Based on a survey of over 250 residents of Tucson, Arizona, this article assesses the relationship between trust in the professional institutions responsible for municipal water development and willingness to drink reclaimed water. Results demonstrate that public acceptance of potable reuse is contingent on trust in the authorities who influence design of sociotechnical systems for water supply and reuse—including water and wastewater utilities, regulators, consultants, academics, and elected local officials. Findings emphasize the highly interdependent social and political factors that inform personal decisions to support or reject potable reuse. The authors suggest that achieving greater acceptance of potable reuse will require bringing local and regional water policy in line with public values, as well as finding ways to incorporate these values into the planning process.

 

Values Levers: Building Ethics into Design (Katie Shilton)

As information systems transform our world, computer scientists design affordances that influence the uses and impacts of these technological objects. This article describes how the practices of design affect the social values materialized in emerging technologies, and explores how design practices can encourage ethical reflection and action. The article presents an ethnography of a laboratory that engineered software for mobile phones to track users’ locations, habits, and behaviors. This technical work raised a number of ethical challenges, particularly around questions of data use and surveillance. The ethnography suggests that particular activities within laboratories can help engineers agree on social values as important to design. It characterizes these activities as values levers: practices that open new conversations about social values and encourage consensus around those values as design criteria. Laboratory leaders and advocates can enable and strengthen these levers to encourage ethical reflection and action as an explicit part of design practice.

 

Making Predictions: Computing Populations (Christine Holmberg, Christine Bischof, and Susanne Bauer)

Statistics constitute the social universe of which they are gathered. The foundation necessary to develop quantified knowledge about society is the population. If quantified knowledge changes society, the question arises on how individuals become to be represented as population. The population has to be extracted from individuals in a process that we call “populationisation.” This encompasses the development of the individual into a segment of a population through the compilation of individual data into population data and its analysis. To describe the process of populationisation, we follow a statistical risk assessment tool, the German Diabetes Risk Score, from its inception in a cohort study to its entry into the public sphere of German society. The population is extracted from individuals that function as research subjects through an identification number. Preprocessed information is entered into a dynamic database that enables its rearrangement according to main aggregates. Through populationisation, a signified is enacted that can be sliced up and that is equal in all its parts. Now predictions can be computed and fed back to society as tools of moral judgment. The acting individual and “society” are—numerically and literally!—entangled in the production and enactment of risk knowledge.

 

Displacement of Agency: The Enactment of Patients’ Agency in and beyond Haemodialysis Practices (Wen-yuan Lin)

How might the agency of the subaltern be conceptualized within the intersection of multiple worlds? Actor-network theory’s (ANT) translation framework for understanding agency portraying this as entrepreneur and talking of a world in the making is arguably “imperialist,” “managerial,” and “monolithic.” Draws from the enactment turn of ANT and insights into the politics of representation, this article elaborates an alternative framework which focuses on displacement. By examining the case of dialysis patients, the article explores the displacing practices that follow the disruption of routines in dialysis. Patients have to go through a process of problematization, distribution, hybridization, and restabilization, in order to sustain the coexistence of their alternative practices with dialysis. Unlike entrepreneurs in the translation model who transform the world by interesting others, enduring trials, and becoming spokespersons for all, those patients who manage to displace and sustain the coexistence of multiple worlds avoid interesting, still less confronting, the hegemonic actors and claiming representation for themselves. This article suggests the displacement of agency as a generic alternative.

 

Health

Constructing the moral body: Self-care among older adults with multiple chronic conditions (Laura Hurd Clarke and Erica V. Bennett)

Older adults are increasingly living with and managing multiple chronic conditions. The self-management of illness occurs in a social and political context in which the responsibility for health has shifted from the State to the individual, who is expected to be an active consumer of health care. Although there has been extensive investigation of the management of single chronic conditions, the realities of living with multiple morbidities have largely been ignored, particularly among older adults. Addressing this gap, our study entailed in-depth interviews with 35 older Canadian adults, aged 73 to 91, who had between three and 14 chronic conditions. Self-care emerged as a primary means by which our participants managed their illnesses. Specifically, all of our participants were engaged in some form of self-care in order to cope with often debilitating physical symptoms and functional losses. They also utilized self-care because they had reached the limits of available medical treatment options. Finally, our participants argued that self-care was a moral responsibility that was underscored by gendered motivations. Whereas the men tended to emphasize the importance of self-care for the achievement of masculine ideals of control and invulnerability, the women suggested that self-care allowed them to maintain feminine norms of selflessness and sensitivity to the needs of others. In this way, self-care enabled the men and women to reframe their aging, chronically ill bodies as moral, socially valued bodies. We discuss our findings in relation to the extant research and theorizing pertaining to self-care, gender, and healthism

 

Bodies completed: On the physical rehabilitation of lower limb amputees (Michal Hoffman)

This ethnographic study, based on empirical work carried out in an Israeli rehabilitation hospital, discusses the physical rehabilitation of lower limb amputees, during which body normalcy is re-constructed. Throughout the process, physiotherapists serve as social agents who teach pragmatic and discursive practices to manage the body as well as the prosthesis in the re-cultivation of body techniques. The findings, portraying four spheres of meaning, show that the mere use of prosthesis is insufficient since it stigmatizes the body as absent a limb. To avoid such stigmatization, the staff teach compensatory and discursive skills which enable incorporation of the prosthesis in body techniques while referring to it as a biological leg. Constructed as a ‘social organ’, the device is gradually transformed from an extension to an integral part of the body. Disability and its remedies, thereby concealed, facilitate able-bodied performance. Paradoxically, the prosthesis, though meant to benefit patients, induces pain and discomfort, a fact that challenges the acceptance of its conventionality as a medical aid for amputees. Yet, physical rehabilitation by means of prosthetics remains one of the many medical practices in Israel that ensure a disability-free society, together with the promotion of rights to accessibility and anti-discrimination regulation. The study contributes to the theoretical debate regarding the relationship between the biological and the social in disability studies. The findings indicate the need to encompass the cultural and the corporeal when exploring disability. The ethnography of disability, I suggest, should be viewed as a juncture of socio-cultural perceptions of the body, embedded in its own corporeal constraints.

 

Parallel vigilance: Parents’ dual focus following diagnosis of Type 1 diabetes mellitus in their young child (Selaine Niedel, Michael Traynor, Martin McKee, and Margaret Grey)

There is consensus that enabling patient self-care and expertise leads to better management of chronic illness. Clinicians are being encouraged to manage clinical encounters in ways that promote these outcomes rather than perpetuate hierarchical relationships. This article describes one part of a larger study of 55 outpatient consultations conducted within 14 months of the diagnosis of Type 1 diabetes mellitus in young children. Participants were parents and the specialist doctors, nurses, dieticians and social workers who oversee the child’s secondary care. Consultations were audio-recorded and transcribed. Our analysis draws on aspects of conversation analysis (CA) to investigate how parents’ talk enacts a growing confidence in the management of their child’s disease in the face of questioning from professionals. Analysis reveals how this talk distinguishes a duality of focus that combines the normal watchfulness exhibited by all parents as they protect their children, with an additional intense, parallel watchfulness for signs of potentially serious manifestations of diabetes. We term this phenomenon parallel vigilance and illustrate its development using five representative extracts from consultations. The concept of parallel vigilance extends the chronic illness literature and informs our understanding of a process that contributes to parents’ developing expertise and provides new and important insights into the way in which parents conceptualize and implement their evolving role in the care of their child. Moreover, parallel vigilance serves as an enabler of parental contributions to the specialist consultation.

 

From fatness to badness: The modern morality of obesity (Ingeborg Grønning, Graham Scambler, and Aksel Tjora)

Obesity (or being overweight) is now considered a by-product of membership of developed societies. Moreover, it is considered a growing ‘global’ health problem. This article reports on a small qualitative study of adults who fell into one or other of these categories in Norway in 2010, and who have been faced with decisions about lifestyle versus surgical remedies. This decision making is contextualized and the principal criteria examined. Embodiment, bodywork, self- and social identity, stigma, deviance and issues around the idea of personal responsibility and public health emerge as key themes. The concluding paragraphs commend incorporation of a macro- or social structural perspective to the conceptualization and investigation of obesity.

 

In pursuit of leanness: The management of appearance, affect and masculinities within a men’s weight loss forum (Eleanor Bennett and Brendan Gough)

In a somatic society which promotes visible, idealized forms of embodiment, men are increasingly being interpellated as image-conscious body-subjects. Some research suggests that men negotiate appearance issues in complex and varied ways, partly because image concerns are conventionally feminized. However, little research has considered how overweight men construct body projects in the context of weight loss, or how men talk to each other about weight management efforts. Since sources of information and support for overweight men are now provided online, including dedicated weight loss discussion forums, our analysis focuses on one such forum, linked to a popular male-targeted magazine. We conducted a thematic analysis of selected extracts from seven threads on the forum. Our analysis suggests a widespread focus on appearance, as well as the use of emotion categories when describing difficult bodily experiences. Invariably, however, such talk was carefully constructed and constrained by hegemonic masculinities founded on discipline, work-orientation, pragmatism and self-reliance. The findings are discussed in relation to magazine masculinities and aesthetics, as well as literature on male embodiment.

 

Bodies of knowledge: Nature, holism and women’s plural health practices (Carla Meurk, Alex Broom, Jon Adams, and David Sibbritt)

The proliferation of complementary and alternative medicine (CAM), and women’s high level of engagement with these practices, has presented sociology with a range of questions regarding gender, embodiment and identity work in the context of contemporary medical pluralism. The current study, drawing on 60 qualitative interviews with women from the Australian Longitudinal Study on Women’s Health (ALSWH), examines how a group of Australian women negotiate CAM and biomedicine in a range of health and illness contexts. Selected from the mid-aged cohort of this national study, here we explore their accounts of engagement with CAM and biomedicine, unpacking their logics underpinning, and rhetorical practices surrounding, their therapeutic engagement. The results provide significant insight into: the importance of ideas about nature, holism and strengthening; perceptions of the harshness and softness of medicines for women’s bodies; and, the relative importance of scientific proof vis-a-vis individual subjectivities. Ultimately, their accounts illustrate gendered and embodied strategies of strategic integration, and importantly, border crossing. We conclude that while women’s engagement with CAM and biomedicine may be indeed be gendered in character, we suggest a rethinking of gender-based resistance (to biomedicine) or gender-alignment (to CAM) arguments; the notion of women as designers would more adequately capture the landscapes of contemporary medical pluralism.

 

 

Social Theory and Health

Social inequalities in health: Notes in the margins (Gareth Williams)

This essay makes notes in the margins of the vast corpus of work now encompassed by what is termed ‘social inequalities in health’, the best of which provides important evidence about what health inequalities are, how they come about and what might be done about them. However, much of this work still does not properly connect with either wider public debates about political economy or those focussed points of attention and concern which can be found in people’s responses to the conditions in which inequality is experienced. The consequence of this is the production of policies to address health inequalities, which ignore the politics of those policies and further undermine those people already pushed to the margins by economic and political developments.

 

The interactions of disability and impairment (Edmund Coleman-Fountain and Janice McLaughlin)

Theoretical work on disability is going through an expansive period, built on the growing recognition of disability studies as a discipline and out of the political and analytical push to bring disability into a prominent position within accounts of the intersecting social categories that shape people’s lives. A current debate within critical disability studies is whether that study should include impairment and embodiment within its focus. This article argues it should and does so by drawing from symbolic interactionism and embodiment literatures in order to explore how differences in what bodies can do – defined as impairments – come to play a role in how people make sense of themselves through social interaction. We argue that these everyday interactions and the stories we tell within them and about them are important spaces and narratives through which impairment and disability are produced. Interactions and stories are significant both in how they are shaped by wider social norms, collective stories and institutional processes, and also how they at times can provide points of resistance and challenges to such norms, stories and institutions. Therefore, the significance of impairment and interaction is the role they play in both informing self-identity and also broader dynamics of power and inequality.

 

Going through the back door: Chronically ill academics’ experiences as ‘unexpected workers’ (Sharon-Dale Stone, Valorie A Crooks and Michelle Owen)

Framed around the notion that chronically ill academics are unexpected workers in an able-bodied work environment, we draw on 35 interviews with Canadian academics with multiple sclerosis (MS) to explore their experiences of seeking accommodation. This analysis draws on and extends Goffman’s (1959, 1963) theoretical concepts of ‘frontstage’ and ‘backstage’ performances and ‘stigma’ to show that getting accommodation needs met is not a straightforward process for many academics with MS. We find that seeking accommodations is highly dependent on whether or not one has disclosed having MS to others, and what institutional supports exist to assist disabled faculty members. We draw on the metaphor of ‘going through the back door’ to make sense of this finding. This analysis advances understanding of how chronically ill employees within a particular organizational culture do (or do not) get their needs accommodated, thereby adding to knowledge on chronic illness and disability accommodation in the workplace. It also sheds new light onto how the backdoor metaphor can be applied to understanding lived experiences of disability and chronic illness.

 

Understanding the experience of dementia: Utilising the theoretical insights of ‘status passage’ (Edward Tolhurst and Paul Kingston)

This paper critically evaluates status passage as a social theory which might enhance the research and understanding of the experience of dementia. Status passage is introduced with consideration of the theory as presented by Barney Glaser and Anselm Strauss (1971). Their theory suggests that individuals move from different stages, or statuses, throughout the life course: a long-term health condition, such as dementia, is considered such a life status. The particular value of status passage is asserted via comparison with other conceptual models of long-term illness, in particular Michael Bury’s ‘biographical disruption’. The paper proceeds to consider how the different key dimensions of Glaser and Strauss’s theory, Reversibility, Temporality, Awareness Context, Shape, Desirability, Circumstantiality and Multiple Status Passages, might apply to the empirical study of dementia. This paper concludes that status passage provides valuable theoretical resources that can enhance research across the spectrum of social scientific epistemological orientations. By encouraging theoretically guided empirical study, the utilisation of status passage could thus enhance the research of dementia, as well as contribute to a more cogent sociology of dementia.

 

Money, commodification and complementary health care: Theorising personalised medicine within depersonalised systems of exchange (Stuart McClean and Ronnie Moore)

Across the United Kingdom and other Western nations, complementary health care has become big business, with pressure to commercialise and technologise its goods and services. Economic liberalisation and the democratisation of health care have encouraged the increased commodification of complementary health services. This article focuses particularly on more personalised forms of complementary health care, such as folk healing, but equally highlights the importance of a whole health-care systems analysis when thinking about commodification and marketisation. We develop an exploratory synthesis of recent empirical data in the United Kingdom, in which we theorise the significance of money for complementary healthcare and folk healing. Four mutual themes and questions emerge and are presented here, with a discussion of their contribution to wider theoretical debates about money, the community, and social and health-care systems.

 

Re-moralising medicine: The bioethical thought collective and the regulation of the body in British medical research (David Reubi)

The way in which the scientific and medical use of the human body is problematised and governed in the United Kingdom was radically reconfigured over the last 30 years, changing from a logic of rule articulated around ‘supply’ and ‘solidarity’ to one construed around ‘ethics’. Drawing on the work of Ludwik Fleck and others, this article argues that one of the reasons for this reconfiguration was the existence and influence of a network of philosophers, doctors and lawyers who sought, from the 1960s onwards, to re-moralise medicine: the bioethical thought collective. The article first describes the collective’s membership and organisation, focusing in particular on the form of the interdisciplinary expert committee. It also describes some of the knowledge and practices that make up the community’s thought style, such as its moral concern about modern medicine and the notions of respect for persons and informed consent. The article then shows how these organisational forms, knowledge and practices that characterise the collective have shaped the government of human tissue research over the last 15 years. By highlighting the important role played by expert networks and knowledge, the article makes an original contribution to the sociology of the ethical government of biomedical science.

 

 

Philosophy, Ethics, and Humanities in Medicine

Cardiovascular medicine at face value: a qualitative pilot study on clinical axiology (Adalberto de Hoyos, Rodrigo Nava-Diosdado, Jorge Mendez, Sergio Ricco, Ana Serrano, Carmen Flores Cisneros, Carlos Macías-Ojeda, Héctor Cisneros, David Bialostozky, Nelly Altamirano-Bustamante, Myriam M Altamirano-Bustamante)

Introduction: Cardiology is characterized by its state-of-the-art biomedical technology and the predominance of Evidence-Based Medicine. This predominance makes it difficult for healthcare professionals to deal with the ethical dilemmas that emerge in this subspecialty. This paper is a first endeavor to empirically investigate the axiological foundations of the healthcare professionals in a cardiology hospital. Our pilot study selected, as the target population, cardiology personnel not only because of their difficult ethical deliberations but also because of the stringent conditions in which they have to make them. Therefore, there is an urgent need to reconsider clinical ethics and Value-Based Medicine. This study proposes a qualitative analysis of the values and the virtues of healthcare professionals in a cardiology hospital in order to establish how the former impact upon the medical and ethical decisions made by the latter. Results: We point out the need for strengthening the roles of healthcare personnel as educators and guidance counselors in order to meet the ends of medicine, as well as the need for an ethical discernment that is compatible with our results, namely, that the ethical values developed by healthcare professionals stem from their life history as well as their professional education. Conclusion: We establish the kind of actions, communication skills and empathy that are required to build a stronger patient-healthcare professional relationship, which at the same time improves prognosis, treatment efficiency and therapeutic adhesion.

 

“Advice to the medical students in my service”: the rediscovery of a golden book by Jean Hamburger, father of nephrology and of medical humanities (Piccoli Barbara)

Jean Hamburger (1909–1992) is considered the founder of the concept of medical intensive care (réanimation médicale) and the first to propose the name Nephrology for the branch of medicine dealing with kidney diseases. One of the first kidney grafts in the world (with short-term success), in 1953, and the first dialysis session in France, in 1955, were performed under his guidance. His achievements as a writer were at least comparable: Hamburger was awarded several important literary prizes, including prix Femina, prix Balzac and the Cino del Duca prize (1979), awarded, among others, to Jorge Luis Borges and Konrad Lorenz.      Here we would like to offer a selected reading of a “golden” book, “Conseils aux étudiants en medicine de mon service” (“Advice to the Medical Students in my Service”), the first book dedicated to patient-physician relationship in Nephrology, written when dialysis and transplantation were becoming clinical options (1963). The themes include: the central role of the patient, who should be known by name, profession, life style, and not by disease; the importance of the setting of the care; the need for truth-telling and for leaving hope; the role of research not only in the progression of science, but also in the daily clinical practice.

 

Should trainee doctors use the developing world to gain clinical experience? The annual Varsity Medical Debate – London, Friday 20th January, 2012 (Barnabas J Gilbert, Calum Miller, Fenella Corrick, Robert A Watson)

The 2012 Varsity Medical Debate between Oxford University and Cambridge University provided a stage for representatives from these famous institutions to debate the motion “This house believes that trainee doctors should be able to use the developing world to gain clinical experience.” This article brings together many of the arguments put forward during the debate, centring around three major points of contention: the potential intrinsic wrong of ‘using’ patients in developing countries; the effects on the elective participant; and the effects on the host community. The article goes on to critically appraise overseas elective programmes, offering a number of solutions that would help optimise their effectiveness in the developing world.

 

 

International Journal of Social Psychiatry

Perceptions of boundaries and cultural influences in Qatar (Suhaila Ghuloum, Abdulbari Bener, Michael Lamport Commons, Patrice Marie Miller, F. Tuna Burgut, and Dinesh Bhugra)

Background: Boundary issues, which regularly arise in therapy, can present dilemmas for most clinicians. There has been substantial literature on boundary excursions in clinician–patient relationships, however, very little empirical research exists and is documented. As mental health researchers, we need to investigate a wide range of sensitive topics to enhance our understanding of the many issues that arise in the psychotherapeutic frame.
Aims: We set out to empirically explore perceptions of what may constitute a boundary violation among the mental health staff in the State of Qatar and their views on the subject.
Results: A total of 50 participants (24 psychiatrists, 2 doctorate level psychologists, 24 psychiatric nurses) responded with a response rate of 80%. Participants rated each possible boundary violation according to its degree of harm and professional unacceptability. Three distinct groupings of boundary violations were obtained: (1) core, consisting of the most serious violations; (2) disclosure and greeting behaviour, involving disclosure of information about the therapist and greeting behaviour; and (3) separation of therapist and client lives, involving encounters between therapists and clients outside of therapy.
Conclusions: It is important to ascertain these dilemmas so that these theoretical models can be integrated in clinical practice.

 

Coercion in psychiatric care: Can paternalism justify coercion? (Mi Kyung Seo, Seung Hyun Kim, and MinKyu Rhee)

Background: It has long been debated whether coercion can be justified as paternalism in the field of mental health and it is still a continuing issue of controversy today.
Aims: This study analyses whether coercive intervention in mental health can be justified by the basic assumptions of paternalists: the assumption of incompetence, the assumption of dangerousness and the assumption of impairment.
Method: This study involved 248 patients: 158 (63.7%) were diagnosed with schizophrenia and 90 (36.3%) were diagnosed with mood disorder. In this study, experiences of coercion were divided into legal status, subjective (perceived coercion) and objective experiences (experienced coercion).
Results: The assumption of incompetence was justified in all three categories of coercion whereas the assumption of dangerousness was not justified in any. The assumption of impairment was not justified in legal status and perceived coercion, but provided a partial explanation to serve as a basis for justifying experienced coercive measures.
Conclusions: It can be noted that mental health experts who support paternalism without question must reconsider their previous methods. Above all, the reason why the assumption of dangerousness was not justified in any of the categories of coercion was because coercive intervention used to prevent harm to oneself and others must be very carefully carried out.

 

Exposure to suicide and suicidality in Korea: Differential effects across men and women? (Min-Ah Lee, Seokho Kim, and Eun-Jung Shim)

Background: Little is known about whether exposure to suicide within close social networks is associated with the suicidality in exposed individuals, and potential gender differences regarding this association.
Aims: This study examines the effect of exposure to suicide on the suicidality in exposed individuals.
Methods: The data were drawn from the 2009 Korean General Social Survey, a nationally representative interview survey. Suicidality was measured by the suicidality module in the Mini International Neuropsychiatric Interview (MINI), with exposure to suicide being determined by asking about the experience of a failed or completed suicide attempt by a closely related person.
Results: Exposure to the suicide of someone close was significantly associated with higher suicidality in exposed individuals. While the effect of a failed attempt became non-significant after controlling for psychological factors, that of exposure to a completed act of suicide remained significant. A subsample analysis by gender indicated a significant gender difference: with control for demographic and psychological factors, exposure to a completed suicide had a significant effect on the suicidality of females only. The effect of exposure to a failed attempt became non-significant both in males and females after controlling for other factors.
Conclusions: Findings suggest the necessity of screening for prior exposure to suicide in suicide risk assessment and the need for gender-tailored suicide-prevention strategies.

 

Some aspects of social exclusion: Do they influence suicide mortality? (Andriy Yur’yev, Peeter Värnik, Merike Sisask, Lauri Leppik, Kaur Lumiste, and Airi Värnik)

Background: The current study is aimed to assess the relationship between the ‘economic/employment’ and ‘social/welfare’ dimensions of social exclusion and suicide mortality in Europe.
Methods: Suicide rates for 26 countries were obtained from the WHO. Data on social expenditure were obtained from the OECD database. Employment rates and GDP were obtained from the Total Economy Database. Questions about citizens’ attitudes towards different aspects of social exclusion were taken from the European Social Survey. Structural equation modelling was applied to research the theoretical structure of the variables.
Results: All variables are statistically significant in male and female models except of the relationships between ‘economic/employment’ and ‘social/welfare’ dimensions and female suicides; and the relationship between ‘employment rates’ and ‘economic/employment’ dimension. Suicide mortality rates among both males and females are influenced negatively by ‘economic/employment’ and ‘social/welfare’ dimensions. Among females, the influence of ‘social/welfare’ dimension is stronger compared to the ‘economic/employment’ dimension. The remaining influence of GDP is positive in both models.
Conclusions: Both ‘economic/employment’ and ‘social/welfare’ dimensions of social exclusion significantly influence suicide mortality among males. The influence of ‘economic/employment’ and ‘social/welfare’ dimensions of social exclusion on female suicide mortality is controversial. Social exclusion might be considered as a risk factor for suicide mortality in Europe.

 

Financial satisfaction and its relationship to depressive symptoms in middle-aged and older adults: Results from the FIN-D2D survey (Nina Rautio, Hannu Kautiainen, Hannu Koponen, Pekka Mäntyselkä, Markku Timonen, Leo Niskanen, Timo Saaristo, Heikki Oksa, Markku Peltonen, Hannu Puolijoki, Mauno Vanhala, and Sirkka Keinänen-Kiukaanniemi)

Background: Studies using traditional measures of socio-economic position, such as education, income and occupation, have found inequalities in depressive symptoms, but less is known about the association between financial satisfaction and depressive symptoms.
Aims: To examine the association of depressive symptoms with financial satisfaction in Finnish adults in a population-based cross-sectional FIN-D2D survey.
Methods: Four thousand, five hundred randomly selected individuals aged 45–74 years were invited to the study. Participation rate for health examinations was 64%. Complete information on depressive symptoms and financial satisfaction was available for 2,819 individuals. Financial satisfaction was asked using a questionnaire. Depressive symptoms were measured by Beck Depression Inventory (≥ 10) and/or use of antidepressants.
Results: Altogether 11.6% of individuals who were satisfied with their financial situation had depressive symptoms. Corresponding figures for individuals who were somewhat satisfied or dissatisfied were 20.6% and 42.6%, respectively. Individuals who were less satisfied with their financial situation were more likely to suffer from depressive symptoms even after adjusting for gender, age, marital status, number of chronic diseases, smoking, binge drinking, physical activity, education and household income.
Conclusions: Instead of more traditional measures of socio-economic position, financial dissatisfaction seems to be associated with depressive symptoms in Finnish adults.

 

Education and employment levels among Jamaican patients newly diagnosed with schizophrenia and bipolar disorder (Bertilee Burgess, Desdemona Curtis-Downes, and Roger C. Gibson)

Background: Comparisons between persons with bipolar disorder and those with schizophrenia are not well researched in the Caribbean.
Aims: To compare the educational and occupational attainments in Jamaicans diagnosed with these two disorders.
Methods: Data on diagnosis, educational level, type of employment and other basic socio-demographic variables were collected from Jamaican hospital patients who were newly diagnosed with schizophrenia or bipolar disorder. Fisher’s exact and χ2 tests, as well as binary logistic regression, were used to explore how these characteristics varied according to diagnosis. Statistical significance was taken at p < .05.
Results: Schizophrenia was associated with significantly lower educational attainment than bipolar disorder (p = .022 for educational level attained; p = .026 for completion of secondary school). The majority (87.1%) of the 93 patients included in the analysis had no specific marketable job skills. However, the proportion of persons with bipolar disorder who had such skills was three times the corresponding proportion of persons with schizophrenia.
Conclusions: The low educational achievement among persons with schizophrenia makes education a potentially important area for interventions targeted at this group. Because gross deficiencies in job skills were common to both patient groups, improvement in job skill levels is an important goal for persons with either of these disorders.

 

Temperament and its relation to social functioning in schizophrenia (Michelle K. Jetha, Joel O. Goldberg, and Louis A. Schmidt)

Background: We previously noted increased shyness in stable community outpatients with schizophrenia compared to healthy controls and that shyness may be a risk factor for social functioning impairment in this population (Goldberg & Schmidt, 2001).
Aims: We attempted to replicate and extend these findings by comparing the use of a brief trait measure of shyness and sociability (SS; Cheek, 1983; Cheek & Buss, 1981) with the longer Temperament and Character Inventory (TCI; Cloninger, Przybeck, Svrakic, & Wetzel, 1994) used traditionally in work to measure personality dimensions in this population.
Methods: A group of stable outpatients with schizophrenia (n = 41) and healthy controls (n = 41) matched on age and gender were compared on the SS and TCI measures. Patients were assessed on clinical symptoms using the Positive and Negative Symptom Scale (PANSS) and on social functioning measures using a Quality of Life Scale (QLS).
Results: Patients reported significantly higher shyness, retrospective inhibition and harm avoidance, and lower novelty seeking, self-directedness and cooperativeness than healthy adults, replicating previous findings. Shyness and sociability were related to conceptually linked dimensional sub-scales of the TCI and were predictive of social functioning in the patient group. Importantly, scores on these measures were unrelated to symptom profiles and explained additional variance in social functioning beyond clinical symptoms.
Conclusions: These findings suggest that individual differences in trait shyness and sociability may influence social functioning in stable outpatients with schizophrenia. The results also support the use of the brief trait measures of shyness and sociability in this population.

 

A recovery journey for people with personality disorder (Heather Castillo, Shulamit Ramon, and Nicola Morant)

Background: The study investigates the process of recovery for people diagnosed with personality disorder, a client group that suffers significant social exclusion known to impact on demand for health and other public services. It aims to examine efforts that attempt to reverse this social exclusion as an aspect of the recovery process.
Aim and Method: The following study aims to (1) explore what recovery means to people with personality disorder; (2) develop a conceptual model of recovery in personality disorder; and (3) evaluate the contribution of the setting (The Haven) to recovery practice. The study uses a Participatory Action Research (PAR) design. Data was collected from 66 participants by focus groups and individual interviews.
Findings: A map based on thematic analysis of data collected during the study is proposed of the recovery journey for people with this diagnosis, shown as a pyramid that represents a hierarchy of progress, from building trust through stages of recovery to social inclusion.
Conclusion: The findings offer contributions to knowledge in terms of the service design and propose a new model of recovery in personality disorder. This is defined as a journey of small steps highlighting recovery as a process rather than a goal, leading to the emergence of the new concept of transitional recovery

 

Influence of dependent personality status on the outcome and health service costs of health anxiety (Helen Tyrer, Peter Tyrer, and Barbara Barrett)

Objective: To assess the effect of dependent personality disturbance as an influence on the cost and clinical outcome of health anxiety.
Method: In the course of a randomized trial of treatments for patients with high health anxiety over 12 months, we also recorded dependent personality status by two methods: the Personality Assessment Schedule (an observer-rated instrument) and the self-rated Dependent Personality Questionnaire (DPQ), the latter being administered at baseline, six months and 12 months. The two main hypotheses tested were that patients with dependent personality features would have a worse outcome and attract greater health service costs.
Results: Forty-nine patients took part in the trial; all had baseline dependent personality data, 44 provided health service costs, and 38 had observer-rated personality assessments. At baseline patients with any personality disorder had higher clinical ratings for health anxiety, and dependent personality disturbance, mainly in the form of personality difficulty, was associated with a worse outcome than those without dependent personalities after correction for baseline differences. The DPQ at a score of 15 successfully identified all patients with dependent personality disorder in both ICD and DSM classifications and showed a significant but relatively modest reduction in scores of 1.5 (13%) during the course of the 12-month trial. Costs in those separated by personality status showed those with dependent personality incurred 45% more health service costs than those without these personality characteristics (p = .10). No patient with dependent personality disorder dropped out of treatment compared with 6 out of 38 (16%) of those with no dependence.
Conclusions: The DPQ is probably a reliable instrument for assessing dependent personality characteristics without the need for interview and its scores, unlike many ratings of personality, are stable over time. The findings may have been influenced by different responses to those treated in the trial with cognitive behaviour therapy compared with control treatment.

 

The Schedule for Evaluating Persistent Symptoms (SEPS): A new method of recording medically unexplained symptoms (Helen Tyrer, Leila Ali, Faye Cooper, Paula Seivewright, Paul Bassett, and Peter Tyrer)

Background: Medically unexplained symptoms are difficult to measure and in most cases the diagnosis is made either from independent data such as consultants’ opinions or medical outcomes, or by proxy measures such as numbers of symptoms or consultations. A valid self-rated measure would be of value in assessing this highly prevalent condition.
Aims: To describe a new scale of nine items, the Schedule for Evaluation of Persistent Symptoms (SEPS), its properties, its internal consistency, its distribution in a sample of 470 medical patients, its relationship to social functioning and health anxiety (hypochondriasis), and its construct validity by comparing its results with an independent diagnostic examination of each patient’s notes two years subsequent to assessment.
Method: A prevalence study was carried out in 405 consenting medical patients in primary care, cardiology, respiratory medicine, gastroenterology and endocrine clinics, in which the SEPS scale, the Health Anxiety Inventory (HAI) and the Social Functioning Questionnaire (SFQ) were each completed.
Results: The mean score on the SEPS scale in 470 patients was 13.4. Exploratory factor analysis revealed two main factors, one concerned focus on symptoms and the other on their attribution. Examination of all data showed a cut-off point of 14 as indicating the presence of pathological medically unexplained symptoms (MUS). Agreement between the consultants’ diagnosis and pathological MUS scores was fairly good with a score of 14 or more on the SEPS showing sensitivity of 0.65 and negative predictive accuracy of 0.90.
Conclusion: It is concluded that the SEPS scale has potential value in screening patients with suspected medically unexplained symptoms.

 

Quality of life and social determinants of anxiolytics and hypnotics use in women in Poland: A population-based study (Pawel Zagozdzon, Emilia Kolarzyk, and Jerzy T. Marcinkowski)

Background: The majority of studies show a substantially higher consumption of anxiolytics and antidepressants among women than among men and in the age bracket above 45 years.
Aims: To analyse association between the use of hypnotics/anxiolytics, and various characteristics of Polish women, including health-related quality of life.
Method: One thousand, five hundred and sixty (1,560) women aged 45–60 years completed a questionnaire dealing with the use of hypnotics/anxiolytics, demographic characteristics, environmental and work stress exposure, and self-reported quality of life (SF-36 form).
Results: The following variables were revealed as the predictors of hypnotic/anxiolytic use on univariate analysis: age; social pension; stress at work and environmental stress; hormone replacement therapy; headache; palpitations; mood swings or increased muscular tension; anger; duration of symptoms longer than one week; consulting a specialist; and low physical and mental health-related quality of life. The significant protective factors included: vocational and tertiary education; job satisfaction; and home as place of rest. The independent predictors of anxiolytic/hypnotic use included consulting a specialist and symptoms lasting more than one week, while job satisfaction and home as place of rest were the independent protective factors.
Conclusions: The use of hypnotic/anxiolytic medication is strongly associated with environmental and psychosocial characteristics of women between 40 and 65 years of age.

 

 

Psychosomatic Medicine

The Effect of Violent and Nonviolent Video Games on Heart Rate Variability, Sleep, and Emotions in Adolescents With Different Violent Gaming Habits (Malena Ivarsson, Martin Anderson, Torbjörn Åkerstedt, and Frank Lindblad)

Objective: To study cardiac, sleep-related, and emotional reactions to playing violent (VG) versus nonviolent video games (NVG) in adolescents with different gaming habits. Methods: Thirty boys (aged 13–16 years, standard deviation = 0.9), half of them low-exposed (≤1 h/d) and half high-exposed (≥3 h/d) to violent games, played a VG/NVG for 2 hours during two different evenings in their homes. Heart rate (HR) and HR variability were registered from before start until next morning. A questionnaire about emotional reactions was administered after gaming sessions and a sleep diary on the following mornings. Results: During sleep, there were significant interaction effects between group and gaming condition for HR (means [standard errors] for low-exposed: NVG 63.8 [2.2] and VG 67.7 [2.4]; for high-exposed: NVG 65.5 [1.9] and VG 62.7 [1.9]; F(1,28) = 9.22, p = .005). There was also a significant interaction for sleep quality (low-exposed: NVG 4.3 [0.2] and VG 3.7 [0.3]); high-exposed: NVG 4.4 [0.2] and VG 4.4 [0.2]; F(1,28) = 3.51, p = .036, one sided), and sadness after playing (low-exposed: NVG 1.0 [0.0] and VG 1.4 [0.2]; high-exposed: NVG 1.2 [0.1] and VG 1.1 [0.1]; (F(1,27) = 6.29, p = .009, one sided). Conclusions: Different combinations of the extent of (low versus high) previous VG and experimental exposure to a VG or an NVG are associated with different reaction patterns—physiologically, emotionally, and sleep related. Desensitizing effects or selection bias stand out as possible explanations.

 

The Effect of a Primary Sexual Reward Manipulation on Cortisol Responses to Psychosocial Stress in Men (J. David Creswell, Laura E. Pacilio, Thomas F. Denson, and Maureen Satyshur)

Objective: Although previous research provides evidence for the role of rewarding activities in reducing hypothalamic-pituitary-adrenal axis responses to stress, no studies have tested whether rewards can buffer cortisol responses in humans undergoing social stressors. Method: This study experimentally investigated whether viewing appetitive rewarding pictures reduces cortisol responses to an acute stress challenge. Fifty-four heterosexual men were randomly assigned to view either mildly erotic (reward) or neutral images (control) of mixed-sex couples before completing the Trier Social Stress Test (TSST). Results: Participants in the reward condition had significantly lower area-under-the-curve cortisol reactivity to the TSST (mean [M] = 363.46) in comparison with participants in the control group (M = 807.06; F(1,46) = 4.84, p = .033, η2 = 0.095). Reward participants also had improved cognitive performance on the math portion of the TSST (M = 20.74) in comparison with control participants (M = 13.82; F(44) = 5.44, p = .024, η2 = 0.11). The stress-buffering effects of reward were specific to hypothalamic-pituitary-adrenal axis reactivity: the reward and control groups did not differ on psychological perceptions of anticipatory or poststress perceptions, heart rate, or blood pressure responses. Conclusions: This research provides the first evidence linking the experience of reward with reduced stress reactivity in humans and suggests a potential novel reward pathway for coping under stress.

 

Association of Elevated Blood Pressure With Low Distress and Good Quality of Life: Results From the Nationwide Representative German Health Interview and Examination Survey for Children and Adolescents (Angela Berendes, Thomas Meyer, Martin Hulpke-Wette, and Christoph Herrmann-Lingen)

Objective: Quality of life is often impaired in patients with known hypertension, but it is less or not at all reduced in people unaware of their elevated blood pressure. Some studies have even shown less self-rated distress in adults with elevated blood pressure. In this substudy of the nationwide German Health Interview and Examination Survey for Children and Adolescents (KIGGS), we addressed the question whether, also in adolescents, hypertensive blood pressure is linked to levels of distress and quality of life. Methods: Study participants aged 11 to 17 years (N = 7688) received standardized measurements of blood pressure, quality of life (using the Children’s Quality of Life Questionnaire), and distress (Strengths and Difficulties Questionnaire). Results: Elevated blood pressure was twice as frequent as expected, with 10.7% (n = 825) above published age-, sex- and height-adjusted 95th percentiles. Hypertensive participants were more likely to be obese and to report on adverse health behaviors, but they showed better academic success than did normotensive participants. Elevated blood pressure was significantly and positively associated with higher self- and parent-rated quality of life (for both, p ≤ .006), less hyperactivity (for both, p < .005), and lower parent-rated emotional (p < .001), conduct (p = .021), and overall problems (p = .001). Multiple regression analyses confirmed these findings. Conclusions: Our observation linking elevated blood pressure to better well-being and low distress can partly be explained by the absence of confounding physical comorbidity and the unawareness of being hypertensive. It also corresponds to earlier research suggesting a bidirectional relationship with repressed emotions leading to elevated blood pressure and, furthermore, elevated blood pressure serving as a potential stress buffer.

 

Sense of Coherence, Depressive Symptoms, Cardiovascular Diseases, and All-Cause Mortality (Ari Haukkala, Hanna Konttinen, Elviira Lehto, Antti Uutela, Ichiro Kawachi, and Tiina Laatikainen)

Objective: There is increasing interest in whether positive and negative psychological constructs are bipolar opposites of the same phenomenon. We examine whether a positive construct—sense of coherence (SOC)—has independent predictive power over and above depressive symptoms for cardiovascular disease (CVD) and all-cause mortality. Methods: Participants included 3850 men and 4083 women aged 25 to 74 years who had participated in risk factor surveys conducted in 1992 or 1997. Antonovsky’s 13-item SOC scale was used to measure SOC, and had a correlation of −0.60 with the Beck Depression Inventory. Results: During a mean follow-up time of 14.2 years, there were 670 deaths and 487 nonfatal and fatal CVD events. Higher SOC scores were associated with a lower risk of all-cause mortality (relative risk [RR] = 0.90, 95% confidence interval [CI] = 0.84–0.97 per unit), especially among men, but this association became nonsignificant after adjustment for depressive symptoms (RR = 0.99, 95% CI = 0.90–1.08). Among participants without a history of CVD, higher SOC scores were related to a lower risk for CVD (RR = 0.90, 95% CI = 0.83–0.98), but this association disappeared after adjustment for cardiovascular risk factors. Depressive symptoms remained significant predictors of CVD among women in a model including also SOC (RR = 1.24, 95% CI = 1.06–1.46). Conclusions: SOC was related to all-cause mortality among men; the association with CVD events was modest. Measures for SOC and depressive symptoms were significantly correlated, which might result in overlap in their associations with adverse disease and mortality outcomes.

 

Last month Matthew Dalstrom linked to web content on abortion and patent laws. The divide between public and private, and questions such as: Is what’s private really always political? inspire this month’s short web roundup.
The Open Access movement has a vocal political agenda. In academic publishing, and also in anthropology as an academic field, one argument is that what is researched, often with public funds, cannot be hidden behind pay walls once published. Ryan Anderson of Anthropology in Public not only has the fitting blog title, but is also really interested in open access in and about anthropology. He has conducted a series of interviews for Savage Minds with Jason Baird Jackson, Tom Boellstorff, and Keith Hart on the topic. Already from 2011 and 2012, these interviews are now available for download at Ryan’s academia account. The Open Access Now Initiative shares thoughts on the AAA’s decision to go open access.

If anthropology is in the public eye, what is its image? Surely there are many concepts and perceptions of what anthropologists do (inspiring groups such This Is Anthropology!). But what about the bad press? Anthropology has a bad reputation argue guest columnists Ty Matejowsky and Beatriz M. Reyes-Foster in the Orlando Sentinel. They want anthropologists to reclaim their public “brand” and not have it defined by “others”. Sarah Kendzior talks more about anthropology’s public engagement in another interview over at Anthropology in Public.

Is there anything more public yet private at the same time as social media? How tools may contribute to work on development, and what role anthropology plays, is at the center of a debate in the Guardian. Also on the topic of blogging for and about international development: Tobias Denskus and Andrea S. Papan’s reflections. The public activity of blogging would appear to give a voice to those usually unheard: but does it? I’d be interested in hearing more about an anthropology of empowerment through social media, especially in the context of expensive technologies and access. Feel free to leave a comment below. If you are working on issues of digital media and anthropology, there is also currently a call for papers on the Ethnography Matters Blog.

Public vs. private: Ethnology and anthropology also play roles in the closed environments of corporations. Working in this field is Steve Portigal, who gives an interview on Ethnography Matters on the issue of interviewing users (and his book).
Finally, we all move between and beyond spheres of privacy and the public eye, and sometimes we break the (official or inofficial) rules of what behaviors belong to which sphere. Krystal D’Costa has written a short but fascinating piece on crying in the workspace. Her conclusion: While the workplace might be too restricted a place to let it all out, “neutral” public spheres like sidewalks or the subway are legitimate spaces to be both private and public. Do you find her division accurate? Please share your ideas on private and public spaces in the comments.

At the end of 2009, linguists around the world collected words to characterize the first decade of the new millennium.  “Aporkalypse” appeared at the top of their list, describing a swine-inspired end of days ushered in by the threat of bird flu. Though playful, this term points to a growing recognition that animals –and their diseases –have determining effects on human existence. Recent estimates suggest that over seventy percent of emerging and re-emerging infectious diseases are zoonotic –or have their origins in animals. As self-proclaimed “virus hunter” Nathan Wolfe warns, we are living at the dawn of a new pandemic age, where “human infection by an animal virus may wipe out millions, or hundreds of millions, of people throughout the planet – permanently changing the face of humanity.” Conjuring images of mass destruction at the hands (or wings) of animals, pandemic prophecies bring our entanglements with other species into threatening relief.

Pandemic flu threats have been particularly visible in Vietnam, where highly pathogenic avian influenza –bird flu –is decimating poultry populations and causing alarming human fatality rates. Here, bird flu outbreaks correspond to shifting contours of people-poultry interaction.  Economic growth and rising income levels resulting from Doi Moi economic renovation policies have expanded poultry production and consumption since the early 1990s.  Backyard farms once populated by a handful of free-range birds are now sites of overcrowded flocks confined to diminishing spaces.  From these farms, ducks and chickens travel on the bicycles, boats, and motorbikes of independent farmers and traders themselves, or in the trucks of transporters connected to wholesale distributors.  The heightened movement of poultry across Vietnamese landscapes has opened up new and dangerous disease ecologies –particularly in urban wet markets where live animals from across the country engage in all manner of biological exchange. These trends translate to increased opportunities for viral transfer and reassortment between species.

 

Poultry transport, central Vietnam.

Household duck farm, Mekong Delta, southern Vietnam.

Vietnam was among the first countries to report outbreaks of bird flu in 2003, and has since suffered some of the heaviest losses to the disease. The country tops the list of reported poultry outbreaks and ranks third worldwide in terms of human fatalities. Compounding these casualties, the status of poultry production as a chief industry in Vietnam means that avian flu also threatens national economic health. In the first year of outbreaks alone, Vietnam lost one percent of its GDP as a direct result of avian flu. The scale of human, animal, and economic losses has made the country a locus for multinational interventions against the disease. To date, Vietnam has received the highest per capita amount of foreign avian flu aid of any country. Further, in contrast with pandemic flu strategies in places like the US, which focus on developing vaccines, drugs, and surveillance mechanisms for humans, Vietnam’s bird flu strategies target humans and animals simultaneously. An early official statement declared, “The Joint Vietnam Government-UN program was established to support an integrated … well-coordinated response to … controlling avian influenza in animals and responding to the threat of a possible human pandemic.” Bringing animals into the fold of human health in unprecedented ways, the Vietnam provides an ideal site for investigating zoonotic governance beyond species distinctions.

My ethnographic study of bird flu management in Vietnam examines the intersections of humans and animals in contemporary global health. Between 2009-10, I traced a series of bird flu interventions from their development in policy arenas in the capital, Hanoi, through to their application among chicken farmers in a province in the northern Red River delta, and among duck farmers in a province in the southern Mekong delta. I looked specifically at strategies that took place at the “human-animal interface” –that is, strategies that altered existing relationships and interactions between people and poultry.

In my book manuscript, provisionally entitled, Bird Flu: The Circulation of Life and Death in a Postspecies World, I draw from this research to build a framework for analyzing health from a postspecies perspective. Bringing medical anthropology into conversation with a longstanding disciplinary interest in human-animal relationships, I foreground poultry in the processes through which human life is understood and safeguarded. This approach projects biopolitics across species to consider the role that poultry play in shaping human health and vitality in Vietnam: from the discipline of individual bodies, to the administration of populations, to the control of social relations. In doing so it illustrates animals’ essential role in the apprehension and regulation of human life and raises new questions about how to live with other species in contemporary pandemic contexts.

Providing the first long-term ethnographic study of avian flu management in the poultry sector, I examine how bird flu interventions manifest in both scientific arenas and poultry producing communities. Tracing interventions from policy to practice, I illustrate the various forms of expertise that intersect and collide as health workers engage with poultry producers. I situate this work in a consideration of the role of poultry in Vietnamese rural ideologies and cultural practices, adding historical and moral considerations to political economic analyses of disease emergence and spread. Taken together, this research seeks to offer a nuanced, ethnographically grounded discussion of the ways that species co-constitute one another in a variety of social and institutional settings over time. Not only do these interspecies relationships affect zoonotic management practices, but they also shape the ways in which species coexist in everyday life.

I trace the primary avian flu strategies in Vietnam to illustrate how these health efforts seek to prevent a human pandemic through calculated interventions at the interface of people, poultry, and pathogens. I suggest that inasmuch as these interventions operate on distinct forms of reasoning and practice, they posit heterogeneous, ambivalent, and conflicting species divisions. For instance, in targeting the influenza virus, mass poultry vaccinations molecularize people/poultry relations –inoculating poultry to prohibit viral transfer to humans. On the other hand, risk-mapping interventions spatialize interspecies relationships, surveilling and graphing contact zones among people and poultry. Going further, behavior change campaigns discipline interspecies relationships by cultivating responsibilities among people living with poultry. And finally, biosecurity interventions standardize interspecies relationships, establishing spatial and temporal divisions between people and poultry in farming communities.

Household chicken vaccination, northern Vietnam.

Duck weigh-in, southern Vietnam.

Yet, in tracing the implementation of these strategies in rural communities, my project reveals how avian flu control strategies encounter existing relationships between species, which express alternative ways of ordering and valuing human and nonhuman lives. In this national context, poultry figure into a variety of biological, social, cultural, ecological, and economic relationships with humans and other organisms. These relationships express multiple concerns, including, among others: personal profit, ritual performance, social advancement, agricultural production, and moral conduct. The dynamic role of poultry in Vietnamese society therefore confronts instrumental global health strategies that would relegate ducks and chickens to purely biological or economic interactions with humans and other creatures. In short, bird flu management confronts a complex environment where poultry play a dominant, yet changing, part in local lifeworlds.

Chicken slaughter, northern Vietnam.

Diverse ideas and practices circulate in Vietnamese bird flu management, which has important consequences for the definition of bird flu risks and their appropriate management. From a health perspective, hierarchies of knowledge and expertise between veterinary and human health sciences have posed challenges in determining whose lives merit protection and optimization, and whose lives require intervention and control. For instance, while human health officials may favor safeguarding human life by culling thousands of poultry during an outbreak, veterinary officials (and farmers) may point to a lack of disease symptoms in flocks, and the economic import of poultry, as reasons for avoiding mass slaughter. Moreover, from an agricultural perspective, disagreements about how to develop Vietnam’s livestock economy in light of zoonoses augment these debates. Namely, in questions over how to increase the productivity and safety of livestock production without marginalizing the small farmers who continue to dominate the industry. These small examples point to the fact that differential ideas about the place of poultry in human biosocial life engender ambivalence in influenza management strategies.

Cockfight festival, Hanoi

Moving from policymaking arenas to everyday practice compounds the complexity and ambiguity of bird flu management. Poultry farmers in contemporary Vietnam inherit a hard-won history of independence from outside intervention, particularly in the context of agricultural production. In poultry producing communities, practical experience and phenomenological knowledge outweigh what farmers consider to be the overly theoretical orientation of veterinary “experts.” Poultry health, then, seldom falls under the purview of state agents and global consultants, but rather remains the right and responsibility of farmers themselves. Further, inasmuch as multinational actors increasingly participate in these interventions, new modes of political subjectivities emerging in Vietnam, wherein farmers both incorporate and resist global health discourses and strategies in their everyday interactions with animals. In the daily implementation of bird flu interventions, then poultry play an important role in shaping knowledge hierarchies and relationships between authorities and citizens in the country.

Taken together, these local trends signal contingent modes of governing humans and animals in global health orders. The bird flu interventions I document encounter, entrench, and transform existing ideas about human’s biological links with, and moral responsibilities toward, other species. In contrast to recent work celebrating multispecies entanglements and flourishings, then, this research suggests that human exceptionalism still matters, particularly in zoonotic situations where people’s vulnerability to animals sparks intense panic and dread. Rather than eschew notions of human mastery over nature, I show instead how actors mobilize and reconsider these notions as a means to cope with pandemic threats. The tenuous, shifting human/animal distinctions in bird flu management thus demonstrate efforts to capture and control the increasingly uncontrollable, the chaos of agentive viruses, migrating fowl, unstable ecologies, and transgressive people-poultry interactions.

In sum, my research reveals how poultry’s multifaceted role in Vietnamese society comes to complicate global health strategies, which seek to secure health through rationalized and calculated interventions on interspecies relationships. Ethnographic attention to these relationships reveals an unavoidable interdependence of people and poultry for biological existence, economic wellbeing, social networking, and ethical self-fashioning. At times people and poultry threaten each other’s lives; at other times they sustain them; and still at other times they infuse them with meaning and value. These rich and multifaceted interspecies relationships call into question the utility of a “One World, One Health” order, which implies by its very name a singular way of apprehending health and vitality, and a singular way of living, or coexisting, across species.

 

Natalie Porter is a postdoctoral fellow in the BioProperty Program at the Institute for Science, Innovation and Society, University of Oxford.  Her work examines intersections of pandemics, biomedicine, and multispecies relations. Focusing on avian flu, Natalie’s research combines analyses of laboratory practice with observations of poultry farmers and global health workers in Vietnam, Europe, and the United States. She is currently conducting ethnographic fieldwork on the exchange of viruses and transgenic animals in global pandemic flu research.

"Book tower"

For the latest “Top of the heap” we have lists from A. Jamie Saris of the Department of Anthropology at the National University of Ireland, Maynooth and Elizabeth A. Wilson of Emory University’s Department of Women’s, Gender and Sexuality Studies.

 

A. Jamie Saris

C. Jason Throop, Suffering and Sentiment: Exploring the Vicissitudes of Experience and Pain in Yap (University of California Press, 2010).

Angela Garcia, The Pastoral Clinic: Addiction and Dispossession along the Rio Grande (University of California Press, 2010).

Natasha Dow Schüll. Addiction by Design: Machine Gambling in Las Vegas (Princeton University Press, 2012).

 I have been thinking a lot about addiction of late and the whys and wherefores of suffering and subjectivity.  Meanwhile, consumption and pleasure have also been on my mind. These three recent ethnographies read together spark off one another very well. They come from very different theoretical angles in quite different settings, but they come across quite similar issues — understandings of choice and will, of memory and pain, of morality, and an imaginative inquiry into what the subject of all those processes might be.  I would love to teach a class with just these three texts and some supporting articles as, it seems to me, in running the thick description of real people caught up in these (very often unhappy) webs of meaning against one another, there is some profound insight into how humans and human networks are produced and, of course, sometimes degraded.

 

A. Jamie Saris is Senior Lecturer in the Department of Anthropology, NUI Maynooth. He has been working for more than fifteen years in medical and psychological anthropology in Ireland, North America, and parts of Africa, where he has researched and published on such diverse issues as the social life of mental hospitals, the experience of major mental illness, colonialism and its aftermath, poverty and structural violence, drug use and abuse, and HIV risk and treatment.  He is also the Co-Chair of the Combat Diseases of Poverty Consortium (www.cdpc.ie) and he was formerly the Deputy Director of NIRSA (National Institute of Regional and Spatial Analysis), a multi-disciplinary research centre of excellence examining space and society.

 

 

Elizabeth A. Wilson

 R.D. Laing and Aaron Esterson, Sanity, madness and the family (Penguin, 1964).

I first read this as an undergraduate.  It remains a formative book for me intellectually and politically.  I have re-read it recently for class, and was delighted to find that it still feels powerful.  As a visual accompaniment try: Asylum (Director: Paul Robinson 1972).  It is a really excellent film of life in one of the houses set up in London in the early 1970s by practicing anti-psychiatrists. Crazy and brave.

 

Peter Kramer, Listening to Prozac (Penguin, 1993).

Still a sharp, thoughtful account of Prozac, even after all these years.  Essential reading for anyone interested in the contemporary psychocultural landscapes of the US.  And, in my opinion, this is a more feminist book than many of the other more obviously critical/political texts on antidepressants.

 

Ken Corbett, Boyhoods: Rethinking masculinities (Yale University Press, 2009).

Based on Corbett’s clinical experience with the analysis of boys, this is a book that makes me happy because it shows how academic theories of gender and sexuality can still be shaped, twisted, enlivened by contemporary psychoanalytic practice.

 

Sigmund Freud, Beyond the pleasure principle. In James Strachey, ed., trans., The standard edition of the complete psychological works of Sigmund Freud Vol. 18, 7–64. (Hogarth Press, 1920)

Because too much Freud is never enough.

 

Todd Meyers, The clinic and elsewhere: Addiction, adolescents, and the afterlife of therapy (University of Washington Press, 2013).

Meyers and I are stable-mates in the wonderful In Vivo series at the University of Washington Press (Editors: Robert Mitchel and Phillip Thurtle).  His book further confirms my view that I am in excellent company in this series: it is a beautifully written ethnography of adolescents in and out of drug rehab in Baltimore.

 

Adam Frank, Transferential poetics, from Poe to Warhol (Fordham University Press, forthcoming).

I’ve just read the first chapter of this manuscript, forthcoming from Fordham.  It is a virtuoso composition of Stein with Klein with Tomkins. I’m dying to read the whole book.

 

Yotam Ottolenghi and Sami Tamimi, Jerusalem: A cookbook (Ebury Press, 2012).

A cookbook; because I am finishing up a project on the gut.  These are amazingly good recipes from Ottolenghi and Tamimi’s home town.  Treat yourself.

 

Elizabeth A. Wilson is Professor of Women’s, Gender, and Sexuality Studies at Emory University. She is the author of Psychosomatic: Feminism and the Neurological Body (Duke University Press 2004); Affect and Artificial Intelligence (University of Washington Press 2010). She is finishing a project (Gut Feminism) on feminist theory, depression, the gut and psychopharmaceuticals.

This month’s Web Roundup is dedicated to the role that legislation and the courts have in promoting or restricting access to medical care. In particular, I will focus briefly on the passage of anti-abortion legislation in the US and a few recent court cases that are testing the limits pharmaceutical patents. While not overtly theoretical in nature, I have found these events to be particularly useful for discussing critical medical anthropology in undergraduate courses.

 

Abortion Rights

The abortion debate is an issue that never seems to totally go away. According to the Guttmacher Institute, a pro-abortion rights non-profit organization, 93 provisions addressing reproductive heath have passed at least one legislative body in the US since the beginning of the year. Of particular note is the Arkansas bill that limits abortion at twelve weeks and the North Dakota bill that bans most abortions as early as six weeks, both of which violate the Supreme Court standing that abortions can occur up to the point where the fetus is viable outside of the womb. In a second measure, North Dakota has also banned abortions sought for genetic abnormalities such as Down syndrome, making it the first state in the country to do so [KOAA].  The Center for Reproduction Rights has vowed to fight the legislation, however as of April 15, they were already in court fighting another law that bans medication to induce abortion [Jamestown Sun].

Anti-abortion advocates also scored a victory in Virginia with the Board of Health’s passage of new abortion clinic regulations. With these new regulations, abortion clinics now have to abide to the same building codes as surgical units and will be mandated to comply with standards related to specific hallway and door measurements, ventilation systems, and front entrance coverings.  According to the NARAL Pro-Choice Virginia Deputy Director, “the overall goal of these restrictions is to limit access to safe, legal abortions” [MSNBC].

 

Patent Laws

On a different front, there have been several legal challenges to pharmaceutical companies who tinker with the composition of their pharmaceuticals to make a new version of an older drug, a process called “evergreening”.  The practice has been contested both abroad and in the US. In India, the Cancer Patients Aid Association won a case in the Indian Supreme Court claiming that Novartis’s reformulation of its cancer drug Gleevec was not different enough to drastically improve its efficacy, a precondition for a new patent in India. The ruling paved the way for Indian generic companies to continue manufacturing the generic version of the drug that costs patients approximately 68,000 USD less per year [New York Times]. As one of the largest producers of generic medications, the ruling enables Indian pharmaceutical producers to sell the medication to developing nations around the world.

Within the US, the issue of generics has also been in the news with the recent Supreme Court case, Federal Trade Commission (FTC) v. Watson Pharmaceuticals et al. At the center of the issue is whether Solvay, the maker of AndroGel, a prescription testosterone gel, can pay generic manufactures 45 million per year not to make a generic version of their drug. The case came out a of a two year litigation battle between Solvay and generic manufactures who claimed that Solvay’s patent expired years ago and the changes made to the product were not enough to justify a new patent. A settlement was eventually reached in the case, where Solvay agreed to pay generic manufactures 45 million per year not to produce the product, successfully protecting their 400 million annual market. Consumer advocates, hospitals, and medical providers call this practice “pay to delay” and claim that it unfairly undermines competition and forces patients to pay more for pharmaceuticals. The FTC agreed and argued that the practice violates the nation’s anti-trust laws. A ruling is expected later in the year [NPR].

Finally, on April 15, the Supreme Court heard a case on whether human genes can be patented. The case centers around the company, Myriad Genetics, which has patents on two parts of the human genes that are used to detect breast cancer, BRCA 1 and BRCA 2. Through its patent the company has exclusive rights on the test that can be used to detect mutations in the genes that lead to ovarian and breast cancer. The American Civil Liberties Union claims that since the genes are part of nature, they cannot be patented and that Myriad Genetics’s monopoly over the test makes it too expensive for some women. On the other hand, the company claims that without the protection of patents, companies would be less likely to do this type of research. [NBCNEWS]

Each one of these events highlights the tension between patients, lawmakers, and corporations. Moreover, they illustrate the role courts may have in advocating for patients’ access to family planning (in whatever form it takes), affordable pharmaceuticals, and their own genetic material.

 

Further Readings:

In TIME Magazine last month Steven Brill wrote an amazing article about medical billing and the ever-growing cost of healthcare. Bitter Pill: Why Medical Bills Are Killing Us

A study by the National Voices Project found that there are disparities in mental health access for children. National Voices Project 

The Association for Social Sciences and Humanities in HIV conference in Paris presents an ideal opportunity to establish an open assemblage of early career researchers and scholars connected through a shared engagement in HIV/AIDS. By coming together and forming this collective, we hope to institute a space in which to provoke and facilitate dialogue and collaboration amongst early career scholars across various disciplines and institutions worldwide. We aim to develop and nurture an inclusive space in which to share research experiences and knowledge emerging from our individual and collective projects to the benefit of all involved and, equally importantly, the multiple intellectual worlds we inhabit. Moreover, our network intends to engage with and encourage dialogue surrounding the various issues young scholars face in their transition from student to professional.

Two launch events for the proposed collective will take place at the ASSHH conference in Paris being held from the 7th to the 10th of July. We hope that you will join us for one or both of the events to join in the conversation and to offer your voice to this newly forming collective.

1. Sunday the 7th of July: There will be a roundtable event to introduce the networks, to share ideas and discuss emerging themes in our work and to begin to set an agenda for collective and international discussion.
2. Monday the 8th of July: There will be a cocktail party for early career scholars to meet informally, discuss ideas and forge connections. Attendance at the Sunday event is not a prerequisite for participation at the event, which will focus on building networks of support and knowledge sharing more broadly.

Please sign up below to express your interest in joining the network and participating in the Paris events. If you cannot attend the Paris conference, but are still interested in joining the collective, we would still appreciate a response from you to indicate your interest in joining our mailing list and participating in future network events.

The early careers scholars events at ASSHH are being jointly organised by the Interdisciplinary Network on HIV and Innovation (UK), the Network of Young Scholars on Social Sciences and HIV/AIDS (France), and the Transcriptions Forum.

• The Interdisciplinary Network on HIV and Innovation (United Kingdom) was established in 2008 as part of the HIV Project led by Marsha Rosengarten at Goldsmiths College, University of London.  As a collective we encourage interdisciplinarity and collaboration in order to open up debate across disciplines and engage the complex problematic of HIV/AIDS in its various guises using theory such as Science and Technology Studies (STS) and an imaginative approach to novel research methods.
• The Network of Young of Scholars on Social Sciences and HIV/AIDS (France) is an interdisciplinary network of approximately 80 members that was created in 2008 to advocate for collective activities and for the professionalization of young scholars. Its members organise seminars, conferences, thematic workshops and writing/publication workshops. The network is mainly supported by the French National Agency for AIDS research (ANRS) and the Young Scholars Network on Health & Society (Réseau Santé & Société), which also provides support for scientific activities.
• Transcriptions is a collaborative forum for critical enquiry on HIV/AIDS and global health: experiment, ethics, and practice. The site, hosted by Somatosphere, is designed as a space for scholars and activists, policy makers and practitioners working at the intersections of the biosciences, social sciences, public health, and the humanities to engage in critical conversation and to take each other up on important issues that cross disciplinary divides – methodological, conceptual, and programmatic.

Please sign up here to express your interest in joining the network and participating in our Paris events:

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Following up on Melanie’s In the Journals… (1/2),  here is a short sampling of other recently published articles.

On “Early View” from Sociology of Health & Illness:

In an article entitled, “Undoing gender? The Case of Complementary and Alternative Medicine,” Joslyn Brenton and Sinikka Elliott show how middle-class Americans who use complementary and alternative medicine reproduce traditional gendered identities, and neoliberal tenets like the cultivation of personal control. Fadhila Mazanderani, Louise Locock, and John Powell have investigated what motivates people to share their experiences on the internet or in memoirs. Using literature about the commodification of illness narratives and data from a large collection of illness narratives gathered in the UK, they show how patients point to the “biographical value” of sharing their stories. Sociologist Jessica Powers Koski uses social movement theory in an analysis of eating disorder support groups in the Midwestern United States to argue that “framing and collective identity promote participation in eating disorder support groups while simultaneously constructing a collective eating disorder illness identity.” There is also an article about healthcare utilization among Gypsies/Travellers in England, and another about identity work in people with speech dysfluency (stutter/stammering).

The most current print issue of Sociology of Health & Illness features articles that have been available online for a few months, but I’ll highlight some that may be of interest. Neil Stephens, Jamie Lewis, and Paul Atkinson write about uncertainty in the regulatory frameworks that govern stem cell research, drawing on ethnographic data from the UK Stem Cell Bank and another British laboratory. Catriona Rooke writes about the increasing use of harm reduction approaches in English tobacco control strategy. Renata Kokanovic, Gillian Bendelow, and Brigid Philip discuss dissonance in lay accounts of Australians diagnosed with depression that vacillate between medicalized discourse of depression and emphasis on the social context of distress.

There are also two articles in the same issue about “good death”: Erica Borgstrom, Stephen Barclay, and Simon Cohn show how denial appears as a disease-like, treatable object to UK medical students confronting dying patients, and Hannah Frith, Jayne Raisborough, and Orly Klein examine the cultural labor of constructing deaths as good or bad, with reference to media coverage of the death of UK reality television star Jade Goody.

In the April issue of Psychosomatic Medicine, there is an article evaluating the association between miscarriage and exposure to stress during pregnancy caused by rocket-attack alarm sirens in southern Israel.

Finally, the Journal of Ethnobiology and Ethnomedicine announced that it will run editorials in which ethnobiologists reflect on their first fieldwork experiences, though none have been published yet.  In March, that journal published a study that highlights the public health benefits of educating dairy farmers in Pakistan about the management of houseflies.

When Robert Lemelson, an anthropologist, filmmaker, and research professor at UCLA, recently visited the George Washington University to speak at a conference on how ethnographic films can help us understand torture, I had to request an interview. I confess—I have long been a fan of Lemelson’s films, which I have seen screened at meetings as large as those of the American Anthropological Association and the Society for Psychological Anthropology, and as small as the Culture, Life Course and Mental Health workshop at the University of Chicago.

Lemelson’s films have played at film festivals around the world. So, here are some tips for you.

Tip #1: Lemelson loves to screen his films to a wide variety of audiences, and if you invite him to screen his films for you, he may just agree to come and speak with your group.

Several of Lemelson’s films that I have seen are now part of a six-film series titled Afflictions: Culture and Mental Illness in Indonesia, which Lemelson produced and directed with Elemental Productions. This powerful series was nominated for Best Limited Documentary Series from the International Documentary Association Awards in 2010. The films have won numerous other awards, which can be viewed here.

Tip # 2: Rather than purchasing the film series yourself, it is ideal to request that it be purchased through your home institution’s library, which will make it available to your students (who will benefit from having access to the series), and faculty (who will enjoy using it as a teaching tool for various topics related to culture and global mental health). Or you can rent it on Amazon, etc.

The series consists of six, 20- to 45- minute ethnographic films on people diagnosed with severe mental illness in Indonesia. The series is based on material drawn from 12 years of person-centered research by Lemelson. In the spirit of psychological anthropology, the series follows six individuals of different ages and backgrounds across time to explore the relationship between culture, mental illness, and first-person experience. The films include (these titles hyperlink to trailers for each film): Memory of My Face, The Bird Dancer, Family Victim, Ritual Burdens, Shadows and Illuminations and Kites & Monsters.

As Lemelson and I settled in for his interview in the basement of the Red Cross building in Washington, DC, he told me that his commitments to the methods and theory of psychological anthropology, as well as his love for—and desire to experiment with—ethnographic film were the inspiration for this series. In general, Lemelson told me, he is committed to looking at anthropological concepts and their application to real-world problems. We must raise awareness of issues related to political economy, power, and gender, he claimed, because they are so important to solving global challenges.

Robert: I am trying to pioneer a kind of filmmaking that places people and their narratives at the forefront, or at least in an equal position with what is at stake theoretically for anthropology. As a psychological anthropologist, the subjects’ stories come first and telling those stories, informed by theory, is what the films are about. So stories are person-centered but they point to larger things.

Robert Lemelson and Nyoman Kereta and Family- the family highlighted in the film “Shadows and Illuminations”

What inspired the Afflictions Series?

These films tell the stories of the diagnosis, care and treatment of Indonesians suffering from mental “afflictions,” while analyzing the impact of cultural elements, such as kinship networks, symbol and ritual, stigma, gender, employment, politics, caregiving, and pharmaceutical and traditional treatments on the course of their illness.

The films were inspired by data presented in the DOSMED (Determinants of Outcome of Severe Mental Disorders) and IPSS (International Pilot Study of Schizophrenia) studies conducted by the World Health Organization. The IPSS was conducted in 1979 and investigated over 1200 young people with recent-onset functional psychosis in nine countries across the globe (China, Colombia, Czechoslovakia, Denmark, Nigeria, India, the USSR, the UK and the USA). The main finding of the IPSS was that people in the “developing countries” seemed to have better outcomes than people in the “developed countries.” Because the IPSS recruited people from psychiatric facilities, which may have been a confounding variable since help-seeking patterns can differ widely depending on social context, a second study (DOSMeD, 1992) was designed to correct this by recruiting people who were making their first contact with any helping agency and who had also received a diagnosis of schizophrenia.

This study recruited almost 1400 patients from 12 centers. At 2-year follow-up, the DOSMeD study confirmed the IPSS findings of a more favorable outcome in developing countries. Part of Lemelson’s dissertation research in the mid 1990’s was exploring the question of why people diagnosed with forms of severe mental illness in the developing world, in this case in Indonesia, had significantly better psychosocial outcomes than in the West. The Afflictions films have their origins in a number of his subjects from this research endeavor.

How did the findings of the DOSMeD and IPSS studies influence your own inquiry?

Robert: Well, these films – they all address issues related to better outcomes in the developing world for people with serious mental disorders. You can see it in the aggregate—all the films together. For example, what’s helpful for better outcome overall is social support. What’s disruptive is social isolation. People need valued roles—valued social roles. Labeling and attributions of illness also play important roles. For example, people can be psychotic but not viewed locally as mad. There is space for that in the Indonesian culture. You can see in the films how important non-stigmatizing labels may be and the important role of explanatory models. Take Gusti, for instance [a young woman from The Bird Dancer who experiences Tourette’s Syndrome]. Her family used local explanatory models that tend to stigmatize people like Gusti.

She is not really that ill, but because her family thinks she is bewitched and ancestrally cursed she has a terrible outcome- she is isolated, feared, scorned and rejected, all because of a negative, local explanatory model. You can see all of these things at work in the films—attribution, labeling, work routines, social support. Each film focuses on one or more of these critical factors integrally linked with differential outcome.

Pak Kereta, from “Shadows and Illuminations”

Lemelson’s attention to detail and his focus on issues pertaining to the outcomes data make these films a great tool for promoting student discussions pertaining to culture and global mental health. Topics they prompt for discussion, for example, include: how families’ attitudes and perceptions of afflicted family members shape the afflicted person’s sense of self in both positive and negative ways; the power of culture to protect and buffer people with psychiatric diagnoses, or exacerbate their condition; the nuanced stresses of everyday experiences of life with a serious psychiatric diagnosis (e.g., wanting to commit suicide to lessen the family burden of the costs of care); the importance of one’s cultural universe and for the explanation, expression and management of mental distress; and finally, the complex ways that pharmaceutical treatment can be effective or unsuccessful. These are issues at the heart of what it means to be human, as well as recent debates about the role of pharmaceuticals in global mental health, the role of religious institutions in care for people experiencing emotional distress, and the role of the family in sickness and in health.

Tip #3: The series also comes with a range of excellent supplemental study guides that my students and I have found to be very useful. They help me to flesh out my students’ understandings of the film with rich information about culture and context. These guides are available as free downloads from the same links that I used for the film trailers above.

But enough about me, what does Lemelson love about the films, and what advice does he have to offer those of us who are keen to make our own?

Robert: One thing I love about these films is that they were shot over an extended period—of years to over a decade. I have been filming in Indonesia for fifteen years, and we must have four to five thousand hours of raw film and video. I could do nothing else for the rest of my life besides edit what we have, which I have no plan of doing because there is a world out there waiting to be understood!

How did you get started?

Robert: It’s been a long road to get here and we shot for a long time. We have worked from 1997 (30 hours) and then I went back every year from 2000, except for the 2 years I was blacklisted [a notable hazard for ethnographers and filmmakers] for my political work on the film “40 Years of Silence” about the Indonesian mass killings of 1965. We sometimes did several shoots per year, but we waited till 2007 to do a complete output of a feature film. Well, we did put out a number of smaller films, but we saved a lot for this longitudinal perspective of people’s lives. A lot of times we didn’t even know how their story would become important until multiple visits had been made and we learned more of the details of people’s lives that you cannot really hide over time.

What is your advice to young anthropologists?

Robert: People shoot research footage for coding, logging, analyzing, and that’s fine. A lot of times, we don’t care what it looks like, but honestly for cinematic purposes it’s not valuable. So, I try to encourage people to film how I film when they are conducting their research, so that technically and artistically it’s of sufficiently decent quality to make a teaching film. A level above that is using your ethnographic video footage to produce an actual film, which will go out in the world beyond the class. In my ethnographic film classes, I want the students to understand film conventions—really basic fundamentals of cinema that enables them to transfer collected field data into teaching materials and beyond.

Do you think it’s possible to do that without, say, going to film school?

Robert: Well, film school helps, no doubt, but film school does not teach Anthropology! For simple projects, if you are smart enough, you can do it on your iPhone. They have HD cameras that 15 years ago would have been $100,000, and are now $100. This is the digital revolution—right now. But what is Youtube filled with? Videos of people with their cats, or whatever—sex. But if people approach film a little more methodically, we could have amazing teaching materials, like ten-minute pieces that you can screen in class. Ten years later the students may not remember what they read or the lecture you gave, but I bet they will remember that great film. The vast majority our students are not going to be anthropologists, so we want them to remember things of value that they can use to be better citizens. The digital revolution gives us this opportunity.

What is your perspective on bearing witness as a filmmaker?

Robert: Writing is the central part of our field. Margaret Mead called it “a discipline of words”. Writing is not going to go away. Words are valued. But a lot of journal articles are read by maybe 25 people in the entire world, all specialists—films get to be seen by many. For example, one of our films, “40 Years of Silence,” has been viewed by upwards of 40,000 people on our Facebook page. Some people are so grateful and others issue death threats, but the materials are out there for them to see and think about in their own lives when they are able.

So, bearing witness is a step of solidarity?

Robert: Right, trying to tell a story that has some impact in a domain. We have some ethnographic pieces that have a little bit of history. In Afflictions, we are making statements about stigma and the role of culture in mental illness. For example, Ritual Burdens and Memory of My Face, in very different ways, show how culture plays a role in differential outcome. A lot of theory went into how we constructed that.

Ni Ketut Kasih and her family from “Ritual Burdens”

In Ritual Burdens, we were trying to tell a story about developmental and cohort effects—how significant loss and trauma in childhood plays a role in a setting where life is very stressful for women. When the main character—an elderly women who survived the tumult of WW2, Indonesian independence struggles, and the mass killings of 1965—undergoes the gender-based stress of ritual preparation and ceremony, she remembers her difficult childhood and has a psychotic episode. The main character was psychiatrically hospitalized, like, 40 times. In the US, she would be on the street—she would not be at home, with a loving family, being cared for, massaged. This would be very unlikely to happen. So the film makes a comparative point also—about social support and the role social support plays in better outcome.

Bambang the main character from “Memory of my Face”

Memory of My Face is a piece on globalization. Globalization penetrates this subject’s life- in the metaphors he thinks with, the illness categories he labels himself with, the mechanized work routines of sweat shop work for multinationals, and—most interestingly—the content and shape of his psychotic delusions and hallucinations.

More positive, still globalized factors, pointed to the protective effect of a caring religious (in this case, Sunni Muslim) community. Also, a lot of the people in the films are married and have kids, unlikely for people with serious mental illnesses in America. These are all examples of how culture can be protective—meaningful social roles, protective families, meaningful work, but also harmful when stigma is strong or social expectations are too great.

How do you watch these things happen in your films and not want to just fix it right there?

R: Well, I do, sometimes. I have to get involved. Take the example of Lisa [a young woman Lemelson’s team first met when she was six years old and followed through her teenage years in a recent film on human trafficking, Standing on the Edge of a Thorn]. She wanted to be a doctor, but was recently herself was in danger of being trafficked into the globalized sex trade in Indonesia’s urban areas. So, we—my Indonesian collaborators and I—promised Lisa that if she kept up her grades, she could go to college if she still wanted to go, and we would find a way to pay for it. It was really not expensive. And listen, I feel like I contribute to the world through my philanthropy. I do my part to be a good contributing citizen to the world with my foundations, but my “subjects” in these films are in many cases also my friends. And you help your friends out in whatever way you can.

Do you let people watch the films you make about them?

Robert: Yes, I always, when I am able, screen my films to my subjects and get their feedback. That is an important part of the editing process. Sometimes they think we nailed it, sometimes there are criticisms, but this has to be a collaborative process.

What’s next for him?

Robert Lemelson has recently been filming in Burma (now Myanmar). He is also working more on short-format films, and he is excited about the portability and affordability of current technologies.

What’s next for anthropology?

Robert: Anthropologists have a real educational and research mission. The fact we are being consulted by international aid organizations shows that there is a fundamental orientation to development, and in an applied anthropology way we have a lot to offer. So much of the focus of anthropology on inductive, grassroots knowledge—these are concepts that if you think with and apply to a real-world problem, there is so much to learn.

Further Reading (from most recent)

The Bird Dancer, a film on Neurospychiatric Disorders, has all ready been extensively reviewed by Greg Downey, in a lovely piece available here, called Not allowed to have a small heart: Tourette’s Syndrome.

Myers, N. 2011. Update: Schizophrenia across Cultures. Current Psychiatry Reports.

Luhrmann, T.M. 2007. Social Defeat and the Culture of Chronicity: Or, why schizophrenia does so well over there and so badly here. Culture, Medicine and Psychiatry.

Hopper, Kim J. and Wanderling, J. (2000). Revisiting the Developed versus Developing Country Distinction in Course and Outcome in Schizophrenia: Results from ISoS, the WHO Collaborative Project.

Good, Byron J. 1997. Studying Mental Illness in Context: Local, Global or Universal?

With daylight saving time come new articles this April!

The current issue of Medical Anthropology explores concepts of healing in diverse contexts. James B. Waldram opens the discussion with his investigation into the notion of efficacy within indigenous healing practices in Belize and Canada. He offers two approaches to define efficacy, each focussed on a different outcome: transformation and restoration.

Tsipy Ivry coins the term “kosher medicine” for the interaction between Israeli biomedicine and religion in the context of hormonal infertility treatment. She argues that collaboration in healing between medical doctors and rabbis only works as long as medical doctors do not display knowledge in rabbinic law nor challenge the rabbinic directives.

HIV/AIDS in displacement camps in Northern Uganda is associated with a diverse range of meanings, drawing from militarism, Christian missions, camp life to humanitarianism, argues Matthew Wilhelm Solomon. His fieldwork suggests that people with HIV/AIDS create new health identities at the intersections of being labeled and operating within biosocial and therapeutic spheres.

In Southern Ghana, healing is a pluralistic endeavour, write Kate R. Hampshire and Samuel Asiedu Owusu. The authors portray four healers, who “selectively adapt, adopt, and modify elements of biomedical, ‘local,’ and ‘exotic’ healing practices”. Thus, traditional healing is infused by modern technologies to increase reach and access to a growing healing market.

Finally, Tine Tjørnhøj-Thomsen and Helle Ploug Hansen describe a Danish cancer rehabilitation program through the study of ritualization.

Among the latest articles in Philosophy, Ethics and Humanities in Medicine is a commentary on physicians and the death penalty in the United States, by Joel B Zivot. The commentary is intriguing as Zivot describes physician involvement in the death penalty as a Catch-22: “If, according to the United States Supreme Court, the death penalty is not cruel per se, it needs no improvement. If the death penalty is cruel, then attempts to reduce cruelty by pharmacological adjustments are not necessarily humane, or worse, create an illusion of humanness as they are physician directed.”  I’d be interested in readers’ comments on this stance: the article itself does not have any comments yet.

Micol Ascoli and colleagues evaluate their Cultural Consultation Services project in mental healthcare in East London. The resulting narratives of cultures of care among health and social work professionals show that during the workday, professionals do not consider cultural influences on patient recovery and instead focus on organisational proficiency.

 

The April issue of the Journal of the History of Medicine and Allied Sciences includes four research articles discussing topics spanning from 1558 to the 1970s. In “Sex and the Capital City: The Political Framing of Syphilis and Prostitution in Early Republican Ankara,” Emine Ö. Evered and Kyle T. Evered argue that in the early Turkish Republic, public health professonials combined the fight against syphilis with policing of what they deemed inappropriate sexual practices and relations.

Andrew T. Simpson describes the establishment of modern paramedics and ambulance services in the United States in the 1960s and 1970s, and Stephen Woolworth examines the history of the Seattle school clinic (1914–21), a full-service medical program for poor and working class children.

I’d like to point out two open access articles in Social History of Medicine. The first one is by Roberta Bivins, arguing for a looking through a postcolonial lense at the investigation of post-war migration to Britain from (former) colonies.

The second open access article discusses the case of a disabled poor person starving in a workhouse in 1877 despite being “cared” for. Kim Price sees this man’s case as an example for systemic problems in the UK with workhouse care and contrasts it with community care during the Victorian period.

 

On the Social Science and Medicine website, you can already access articles in press or scheduled to be published up to June 2013. There you’ll find a plethora of articles. Some choices:

“ ‘We view that as contraceptive failure’: Containing the ‘multiplicity’ of contraception and abortion within Scottish reproductive healthcare ” by Siân M. Beynon-Jones.

“Metaphors and myths in pharmaceutical advertising” by Marjorie Delbaere.

“Addressing the unequal geographic distribution of specialist doctors in Indonesia: The role of the private sector and effectiveness of current regulations” by Andreasta Meliala et al.

“An impact evaluation of the Safe Motherhood Promotion Project in Bangladesh: Evidence from Japanese aid-funded technical cooperation” by Yusuke Kamiya and colleagues.

“Suicide in rural Haiti: Clinical and community perceptions of prevalence, etiology, and prevention” by Ashley K. Hagaman et al.

 

In the April issue of Social Studies of Science, Christopher J. Lawless discusses disputes around ‘low-template DNA’ methods, forms of forensic DNA profiling technologies; and Joanna Radin describes a case study of the International Biological Program in the United States in the 1960s and 1970s, arguing that “new access to technologies of cold storage, which would allow blood to be transported from the field to the lab and be stored for subsequent reanalysis, gave shape to this episode in Cold War human biology.”

When Robert Lemelson, an anthropologist, filmmaker, and research professor at UCLA, recently visited the George Washington University to speak at a conference on how ethnographic films can help us understand torture, I had to request an interview. I confess—I have long been a fan of Lemelson’s films, which I have seen screened at meetings as large as those of the American Anthropological Association and the Society for Psychological Anthropology, and as small as the Culture, Life Course and Mental Health workshop at the University of Chicago. Lemelson’s films have played at film festivals around the world.  So, here is a first tip for you.

 Tip #1: Lemelson loves to screen his films to a wide variety of audiences, and if you invite him to screen his films for you, he may just agree to come and speak with your group.

Several of Lemelson’s films that I have seen are now part of a six-film series titled Afflictions: Culture and Mental Illness in Indonesia, which Lemelson produced and directed with Elemental Productions.  This powerful series has recently won the Award of Excellence at the Accolades Film, Television, New Media and Videography Awards. The films have won numerous other awards, which can be viewed here.

Tip # 2:  Rather than purchasing the film series yourself, it is ideal to request that it be purchased through your home institution’s library, which will make it available to your students (who will benefit from having access to the series), and faculty (who will enjoy using it as a teaching tool for various topics related to culture and global mental health). Or you can rent it on Amazon, etc.

The series consists of six, 20- to 45- minute ethnographic films on people diagnosed with severe mental illness in Indonesia.  The series is based on material drawn from 12 years of person-centered research by Lemelson. In the spirit of psychological anthropology, the series follows six individuals of different ages and backgrounds across time to explore the relationship between culture, mental illness, and first-person experience. The films include (these titles hyperlink to trailers for each film): Memory of My Face, The Bird Dancer, Family Victim, Ritual Burdens, Shadows and Illuminations and Kites & Monsters.

As Lemelson and I settled in for his interview in the basement of the Red Cross building in Washington, DC, he told me that his commitments to the methods and theory of psychological anthropology, as well as his love for—and desire to experiment with—ethnographic film were the inspiration for this series. In general, Lemelson told me, he is committed to looking at anthropological concepts and their application to real-world problems.  We must raise awareness of issues related to political economy, power, and gender, he claimed, because they are so important to solving global challenges.

Robert: I am trying to pioneer a kind of filmmaking that places people and their narratives at the forefront, or at least in an equal position with what is at stake theoretically for anthropology.  As a psychological anthropologist, the subjects’ stories come first and telling those stories, informed by theory, is what the films are about.  So stories are person-centered but they point to larger things.

What Inspired the Afflictions Series?

 These films tell the stories of the diagnosis, care and treatment of Indonesians suffering from mental “afflictions,” while analyzing the impact of cultural elements, such as kinship networks, symbol and ritual, stigma, gender, employment, politics, caregiving, and pharmaceutical and traditional treatments on the course of their illness.

The films were inspired by data presented in the DOSMED (Determinants of Outcome of Severe Mental Disorders) and IPSS (International Pilot Study of Schizophrenia) studies conducted by the World Health Organization.  The IPSS was conducted in 1979 and investigated over 1200 young people with recent-onset functional psychosis in nine countries across the globe (China, Colombia, Czechoslovakia, Denmark, Nigeria, India, the USSR, the UK and the USA).  The main finding of the IPSS was that people in the “developing countries” seemed to have better outcomes than people in the “developed countries.”  Because the IPSS recruited people from psychiatric facilities, which may have been a confounding variable since help-seeking patterns can differ widely depending on social context, a second study (DOSMeD, 1992) was designed to correct this by recruiting people who were making their first contact with any helping agency and who had also received a diagnosis of schizophrenia. This study recruited almost 1400 patients from 12 centers.  At 2-year follow-up, the DOSMeD study confirmed the IPSS findings of a more favorable outcome in developing countries.  Part of Lemelson’s dissertation research in the mid 1990’s was exploring the question of why people diagnosed with forms of severe mental illness in the developing world, in this case in Indonesia, had significantly better psychosocial outcomes than in the West. The Afflictions films have their origins in a number of his subjects from this research endeavor.

How did the findings of the DOSMeD and IPSS studies influence your own inquiry?

Robert: Well, these films – they all address issues related to better outcomes in the developing world for people with serious mental disorders.  You can see it in the aggregate—all the films together. For example, what’s helpful for better outcome overall is social support. What’s disruptive is social isolation.  People need valued roles—valued social roles.  Labeling and attributions of illness also play important roles. For example, people can be psychotic but not viewed locally as mad.  There is space for that in the Indonesian culture.  You can see in the films how important non-stigmatizing labels may be and the important role of explanatory models. Take Gusti, for instance [a young woman from The Bird Dancer who experiences Tourette’s Syndrome].  Her family used local explanatory models that tend to stigmatize people like Gusti.  She is not really that ill, but because her family thinks she is bewitched and ancestrally cursed she has a terrible outcome- she is isolated, feared, scorned and rejected, all because of a negative, local explanatory model.  You can see all of these things at work in the films—attribution, labeling, work routines, social support.   Each film focuses on one or more of these critical factors integrally linked with differential outcome.

Lemelson’s attention to detail and his focus on issues pertaining to the outcomes data make these films a great tool for promoting student discussions pertaining to culture and global mental health.  Topics they prompt for discussion, for example, include: how families’ attitudes and perceptions of afflicted family members shape the afflicted person’s sense of self in both positive and negative ways; the power of culture to protect and buffer people with psychiatric diagnoses, or exacerbate their condition; the nuanced stresses of everyday experiences of life with a serious psychiatric diagnosis (e.g., wanting to commit suicide to lessen the family burden of the costs of care); the importance of one’s cultural universe and for the explanation, expression and management of mental distress; and finally, the complex ways that  pharmaceutical treatment can be effective or unsuccessful. These are issues at the heart of what it means to be human, as well as recent debates about the role of pharmaceuticals in global mental health, the role of religious institutions in care for people experiencing emotional distress, and the role of the family in sickness and in health.

Tip #3:  The series also comes with a range of excellent supplemental study guides that my students and I have found to be very useful. They help me to flesh out my students’ understandings of the film with rich information about culture and context.  These guides are available as free downloads from the same links that I used for the film trailers above.  

But enough about me, what does Lemelson love about the films, and what advice does he have to offer those of us who are keen to make our own? 

Robert:  One thing I love about these films is that they were shot over an extended period—of years to over a decade. I have been filming in Indonesia for fifteen years, and we must have four to five thousand hours of raw film and video. I could do nothing else for the rest of my life besides edit what we have, which I have no plan of doing because there is a world out there waiting to be understood!

How did you get started?

 

 Robert:  It’s been a long road to get here and we shot for a long time. We have worked from 1997 (30 hours) and then I went back every year from 2000, except for the 2 years I was blacklisted [a notable hazard for ethnographers and filmmakers] for my political work on the film “40 Years of Silence” about the Indonesian mass killings of 1965. We sometimes did several shoots per year, but we waited till 2007 to do a complete output of a feature film.  Well, we did put out a number of smaller films, but we saved a lot for this longitudinal perspective of people’s lives.  A lot of times we didn’t even know how their story would become important until multiple visits had been made and we learned more of the details of people’s lives that you cannot really hide over time.

What is your advice to young anthropologists?

R: People shoot research footage for coding, logging, analyzing, and that’s fine. A lot of times, we don’t care what it looks like, but honestly for cinematic purposes it’s not valuable. So, I try to encourage people to film how I film when they are conducting their research, so that technically and artistically it’s of sufficiently decent quality to make a teaching film. A level above that is using your ethnographic video footage to produce an actual film, which will go out in the world beyond the class. In my ethnographic film classes, I want the students to understand film conventions—really basic fundamentals of cinema that enables them to transfer collected field data into teaching materials and beyond.

Do you think it’s possible to do that without, say, going to film school?

R: Well, film school helps, no doubt, but film school does not teach Anthropology!  For simple projects, if you are smart enough, you can do it on your iPhone. They have HD cameras that 15 years ago would have been $100,000, and are now $100.  This is the digital revolution—right now.  But what is Youtube filled with?  Videos of people with their cats, or whatever—sex.  But if people approach film a little more methodically, we could have amazing teaching materials, like ten-minute pieces that you can screen in class. Ten years later the students may not remember what they read or the lecture you gave, but I bet they will remember that great film.  The vast majority our students are not going to be anthropologists, so we want them to remember things of value that they can use to be better citizens.   The digital revolution gives us this opportunity.

What is your perspective on bearing witness as a filmmaker?

R: Writing is the central part of our field.  Margaret Mead called it “a discipline of words”. Writing is not going to go away.  Words are valued. But a lot of journal articles are read by maybe 25 people in the entire world, all specialists—films get to be seen by many.  For example, one of our films, “40 Years of Silence,” has been viewed by upwards of 40,000 people on our Facebook page.  Some people are so grateful and others issue death threats, but the materials are out there for them to see and think about in their own lives when they are able.

So, bearing witness is a step of solidarity?

R: Right, trying to tell a story that has some impact in a domain. We have some ethnographic pieces that have a little bit of history.  In Afflictions, we are making statements about stigma and the role of culture in mental illness.  For example, Ritual Burdens and Memory of My Face, in very different ways, show how culture plays a role in differential outcome.  A lot of theory went into how we constructed that.

In Ritual Burdens, we were trying to tell a story about developmental and cohort effects—how significant loss and trauma in childhood plays a role in a setting where life is very stressful for women.  When the main character—an elderly women who survived the tumult of WW2, Indonesian independence struggles, and the mass killings of 1965—undergoes the gender-based stress of ritual preparation and ceremony, she remembers her difficult childhood and has a psychotic episode.  The main character was psychiatrically hospitalized, like, 40 times.  In the US, she would be on the street—she would not be at home, with a loving family, being cared for, massaged.  This would be very unlikely to happen.  So the film makes a comparative point also—about social support and the role social support plays in better outcome.

Memory of My Face is a piece on globalization. Globalization penetrates this subject’s life- in the metaphors he thinks with, the illness categories he labels himself with, the mechanized work routines of sweat shop work for multinationals, and—most interestingly—the content and shape of his psychotic delusions and hallucinations.  More positive, still globalized factors, pointed to the protective effect of a caring religious (in this case, Sunni Muslim) community. Also, a lot of the people in the films are married and have kids, unlikely for people with serious mental illnesses in America.  These are all examples of how culture can be protective—meaningful social roles, protective families, meaningful work, but also harmful when stigma is strong or social expectations are too great.

How do you watch these things happen in your films and not want to just fix it right there?

R: Well, I do, sometimes. I have to get involved.  Take the example of Lisa [a young woman Lemelson’s team first met when she was six years old and followed through her teenage years in a recent film on human trafficking, Standing on the Edge of a Thorn].  She wanted to be a doctor, but was recently herself was in danger of being trafficked into the globalized sex trade in Indonesia’s urban areas.  So, we—my Indonesian collaborators and I—promised Lisa that if she kept up her grades, she could go to college if she still wanted to go, and we would find a way to pay for it.  It was really not expensive.  And listen, I feel like I contribute to the world through my philanthropy.  I do my part to be a good contributing citizen to the world with my foundations, but my “subjects” in these films are in many cases also my friends.  And you help your friends out in whatever way you can.

Do you let people watch the films you make about them?

Robert:  Yes, I always, when I am able, screen my films to my subjects and get their feedback. That is an important part of the editing process.  Sometimes they think we nailed it, sometimes there are criticisms, but this has to be a collaborative process.

What’s next for him?

Robert Lemelson has recently been filming in Burma (now Myanmar).  He is also working more on short-format films, and he is excited about the portability and affordability of current technologies.

What’s next for anthropology?

Robert: Anthropologists have a real educational and research mission. The fact we are being consulted by international aid organizations shows that there is a fundamental orientation to development, and in an applied anthropology way we have a lot to offer. So much of the focus of anthropology on inductive, grassroots knowledge—these are concepts that if you think with and apply to a real-world problem, there is so much to learn.

 

Further Reading (from most recent)

The Bird Dancer, a film on Neurospychiatric Disorders, has all ready been extensively reviewed by Greg Downey, in a lovely piece available here, called Not allowed to have a small heart: Tourette’s Syndrome.

Myers, N. 2011. Update: Schizophrenia across Cultures. Current Psychiatry Reports.

Luhrmann, T.M. 2007. Social Defeat and the Culture of Chronicity: Or, why schizophrenia does so well over there and so badly here.  Culture, Medicine and Psychiatry.

Hopper, Kim J. and Wanderling, J. (2000).  Revisiting the Developed versus Developing Country Distinction in Course and Outcome in Schizophrenia: Results from ISoS, the WHO Collaborative Project.

Good, Byron J. 1997. Studying Mental Illness in Context: Local, Global or Universal?