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Science, Medicine, and Anthropology
Mis à jour : il y a 33 min 54 sec

Persistent pathogen: A conference report of anthropological research on tuberculosis by Emilio Dirlikov

20 Octobre 2014 - 9:15am

The 2013 World TB Day theme was “Stop TB in my lifetime,” calling attention to both the goal of virtually eliminating tuberculosis (TB) by 2050, as well as the Stop TB Partnership, established in 2000, through which global antituberculosis activities are coordinated. Despite this valiant slogan, tuberculosis control is at an important crossroads. In 2012, there were an estimated 8.6 million incident cases of TB, of which approximately three million went undiagnosed (World Health Organization 2013a). That year, 1.3 million deaths were caused by TB (World Health Organization 2013b). Beyond health, TB continues to stymie productivity and negatively impact economic development (Jamison et al. 2013). Challenges such as increasingly drug-resistant strains, co-infection with HIV, and unsustainable funding structures threaten the gains made towards the Millennium Development Goals (MDGs) targets set for 2015 (Dye et al. 2013).

Despite its epidemiological and economic significance, TB has garnered scant anthropological attention, although a few notable exceptions bear mention. Erin Koch has examined the implementation of the DOTS strategy in post-socialist Georgia (Koch 2006, 2011, 2013a, b). The physician-anthropologists of Partners in Health (PIH), such as Paul Farmer and Salmaan Keshavjee, have used anthropological insights from their work in places like Haiti, Peru, Tajikistan, and Russia to create and advocate for better treatment programs (Farmer 1997, 2001, Keshavjee et al. 2008, Keshavjee et al. 2011). Ian Harper’s work on control efforts in Nepal has come through long-term support of program implementation (Harper 2006, 2010). Recently, anthropological interest on TB in a diversity of contexts around the world has notably increased. This trend has been buoyed by several doctoral projects, as well as Master-level research.

In order to bring together this burgeoning group of anthropologists, Ian Harper (University of Edinburgh) and Helen MacDonald (University of Capetown) formed a panel entitled “Infectious disease and wealth: exploring the links between tuberculosis and the political economy,” for the 2014 United Kingdom Association for Social Anthropology (UK ASA) conference, held from June 19-22. Panelists were asked to move beyond a simple linkage between social inequality, poverty, and TB in order to address:

“To what extent do or can attempts to control tuberculosis address the issues of underlying poverty around which the disease flourishes? How has the focus on drug treatments overshadowed other ways of addressing the control of the disease and what are the implications of this? What role does anthropology have in thinking about the relations between culture and economy with regards to tuberculosis, and how might these insights be important for policy and practice in the control of the disease?”

Here, I reflect on the full day of presentations in order to synthesize insights and distill the major themes that emerged from the conference papers. I focus on four themes:

1) Emphasis on History;

2) Importance of the Local;

3) Impact of the Global; and

4) Opportunities for Collaborations.

These themes were cross-cutting, and many of the panelists touched upon elements of all four in their presentation.

 

Theme I: Emphasis on History

Tuberculosis lends itself to taking a longue durée perspective in order to understand the impact of this ancient scourge on the contemporary. As opposed to historians of science and medicine, who have produced histories of TB in various contexts (e.g., Condrau and Michael 2010, Johnston 1995, Bryder 1988), anthropologists require a different relationship with historical antecedents, conditioned by encounters made possible through fieldwork.

For example, Bharat Venkat (University of California Berkeley) moved between past and present, recounting the history of the pivotal 1950s Madras Study, which shifted the treatment paradigm away from the sanatorium to out-patient care, through an interview with Dr. Radhakrishna, one of the study’s key statisticians (Tuberculosis Chemotherapy Centre 1959, Ramakrishnan et al. 1961). Venkat argued that the logic of the study was an attempt to move from “the unknowable temporality of the cure to the predictable future of the cure rate.” Yet the enduring promise of the cure, like all promises, can be broken, as seen in uncomfortable and often dangerous situations, such as irrational treatment and patient non-compliance.

In my presentation, I examined what I term the “price of free” in China—that is, the price of TB diagnosis and treatment despite current government programs that provide these services free of charge. Though the high costs patients reported could be interpreted as a major failure of the national program, I contextualized present control practices into a history of TB as the social disease. I argued that Chinese government policies instituted since 2000, such as the TB double free program and welfare reforms more generally, signal the emergence of a truly nationalized problem of tuberculosis in China, in terms of both scale and conceptual underpinnings.

 

Theme II: Importance of the Local

Tuberculosis continues to be a disease associated with poverty, as borne out by statistics. At the global level, TB is disproportionately found in low– and middle-income countries (LMICs). At the national level, TB proliferates along the fault lines of society, appearing primarily in disenfranchised communities, such as the poor, homeless, prisoners, minorities, immigrants, and indigenous groups (Lönnroth et al. 2010). In line with anthropology’s commitment to document social suffering and the experiences of the subaltern, panelists provided insightful accounts of at risk groups and patient perspectives that might be missed by other disciplines.

Drawing from research conducted in Mumbai, Ramila Bisht (Jawaharlal Nehru University) examined the risk of TB faced by healthcare workers. While media reports highlight doctors’ risk, she reveals that lower level healthcare workers, such as nurses, maintenance staff, and NGO outreach workers, are often more at risk, chancing exposure to TB out of fear of losing their jobs. Bisht advocates accounting for the health system as a whole in addressing the vulnerable situations all health workers who interact with TB patient find themselves confronting.

Working from Bilaspur district of Chhattisgarh state in central India, Helen MacDonald (University of Capetown) investigated the revealing and concealing power of numbers. She juxtaposed the deluge of statistics used in public health reports and media reports to more experiential understandings held by doctors at Jan Swasthya Sahyog, a non-profit organisation that treats TB patients. These doctors produced new metrics, which included body weight among other socioeconomic measures, in order to increase patient adherence and lower default rate. Such expanded metrics fit within a unique form of “care” and “empathy” not captured by state statistics.

Carina Truyts (University of Capetown) broadened the scope to consider the lived experience of TB patients in the suburbs of Cape Flats, South Africa. Her focus on the everyday was accompanied by a theoretical and methodological attention to the violence suffered by patients. This included the use of photographs and drawings made by patients in order to capture the unspoken or unsayable and avoid the potential violence of submitting patients to straight-forward interviews. Truyts concludes that the daily hardships experience by TB patients were compounded by structural inequalities that perpetuated cycles of violence.

Panelists faced the challenge of addressing macro processes that impact the TB epidemic while also attending to individual practices that facilitate transmission and activation of disease. In attempting to overcome this divide, Oriana Bras (Universidade de Lisboa) explored the social dimensions of TB in Rio de Janeiro at three distinct levels: structural, collective, and individual. Drawing on ethnographic examples, she illustrated that attention at each of these levels renders different problems and solutions. Combined, they offer a more robust, holistic approach to breaking the pathways through which the bacteria promulgates.

 

Theme III: Impact of the Global

In 1993, WHO Director-General Hiroshi Nakajima declared a “Global TB Emergency,” reviving attention to a disease that had largely fallen off the global agenda (Nakajima 1993). Since then, new antituberculosis organizations have proliferated, many of which work on a global scale. Several panelists positioned their research to investigate such organizations and accompanying global processes.

Presenting via Skype, Nora Engel (Maastricht University) outlined the difficulties of introducing newly developed TB diagnostics at points-of-care, with particular reference to India. She argued that although developers focus on the simplicity of diagnostic tests in order to maximize their applicability, paradoxically, this simplicity mutes the complexity of the situation at the primary health level. Engel proposes a greater inclusion of local expertise in the development and implementation of new technologies.

Ian Harper (University of Edinburgh) examined the modalities of financing mechanisms introduced by the Global Fund to fight AIDS, TB, and Malaria (Global Fund), focused on programs conducted in Nepal since 2002. He explained how under the Global Fund, new metrics have shifted the focus from program impact to program targets. While such metrics are designed to promote program efficiency and transparency, on the ground, the new modality for gathering data is not always productive and may create conflict within established local bureaucracies.

Justin Dixon (Durham University) presented the case of a long-term clinical trial of a new TB vaccine being carried out in South Africa. While the new vaccine has recently been shown to confer no added protection over the current vaccine, BCG, through the trial close to 3,000 underserved children were provided healthcare services. Dixon highlighted the relational and ethical predicaments of conducting clinical trials, especially in considering the legacy of inequality and structure of power that gives rise to TB.

Curiously, the geographic focus of presented papers may further reflect a destabilization of the old centers of “the global” by drawing attention to the growing significance of the BRICS countries (i.e., Brazil, Russia, India, China, and South Africa). BRICS are important for TB global control for at least three reasons. First, all five countries are part of the 22 designated high-burden countries (HBCs), and combined account for 46% of incident cases of TB, and 40% of global mortality (Creswell et al. 2014). Controlling TB in these countries thus impacts global progress. Second, individually, BRICS countries have historically championed innovative health programs, at times going against established norms and global paradigms. While challenges to health remain (Marten et al. 2014, Rao et al. 2014, McKee et al. 2014), novel strategies and technologies developed in these countries could be used elsewhere. Finally, since July 2011, BRICS’ Health Ministers have produced five joint communiques and one declaration on shared health challenges, and propose areas of collaboration. The January 11th 2013 meeting of the Ministers galvanized a commitment to combat TB, with a focus on multidrug-resistant (MDR) forms, demonstrating high-level political commitment (BRICS Health Ministers 2013). Anthropological research conducted in BRICS countries, such as the panelists’ working in Brazil, India, China, and South Africa, sheds light on the shifting importance of these countries for global TB control.

 

Theme IV: Opportunities for Collaborations

“How can anthropology be useful to overcoming inequalities [that give rise to TB] and to identify new intervention strategies to eradicate TB?,” asked Elisa Vasconi (L’Università di Siena). She posited: “the role of anthropology should go beyond the study of local knowledge and practice to stand to be a tool of political critique and transformative action.” Using long-term ethnographic fieldwork conducted in Ghana’s rural Western Region, Vasconi explored an innovative TB control program that made use of traditional medical practitioners for service delivery. Yet, which practitioners were employed, how they were trained, and issues that emerged in diagnosis and treatment present challenges to the success of control efforts. Ethnographic research, such as Vasconi’s, reveals these difficulties, providing insights that could be addressed through policy reform.

Vasconi was not alone in her search for the broader applicability of anthropological research. Indeed, most of the panelists conducted research through affiliations with antituberculosis health organizations, ranging from the global scale (i.e., Harper with the Global Fund, Engel with the Gates Foundation, Dixon with an international pharmaceutical company, and I worked with WHO and Family Health International 360), local hospitals (i.e., Bisht in Mumbai and Bras in Rio de Janeiro), and local NGOs (i.e., MacDonald in Bilaspur district, Bisht in Mumbai, and Truyst in Cape Flats). In effect, panelists shared a commitment to going beyond isolated anthropological investigations in order to collaborate with public health experts and policy makers towards improved programs and patient outcomes.

Harper’s work highlights the value of productive collaboration beyond the academy. Previously, he managed a TB control project in Nepal for three and a half years, and has also worked with NGOs in India for two years supporting community health programmes. More recently, in 2008, he worked in the Nepal National Tuberculosis Programme assisting with the implementation of the Global Fund program. Harper’s dedication to both anthropological research and programmatic support exemplifies the importance of establishing productive collaborations across multiple disciplines and sectors.

 

Conclusion: Towards the Anthropologies of Tuberculosis

What lessons can we, as anthropologists, take away from research and discussions about TB?

As seen, TB provides fertile ground for anthropological exploration. Here, I have highlighted themes that emerged from the presented papers, such as: the importance of history in anthropological research; a focus on local diversity and the experience of those affected by the disease; attention to global processes; and areas where anthropologists can work collaboratively with health organizations and beyond.

Emilio Dirlikov is a PhD Candidate in McGill University’s Department of Anthropology and Social Studies of Medicine. He is currently finalizing his dissertation, for which he spent two years conducting field research on tuberculosis control in China.

 

References

BRICS Health Ministers. BRICS Health Ministers’ Communique 2013 [cited Jul 17, 2014. Available from http://www.brics.utoronto.ca/docs/130111-health.html.

Bryder, Linda. 1988. Below the magic mountain: a social history of tuberculosis in twentieth-century Britain. Oxford: Oxford University Press.

Condrau, Flurin, and Worboys Michael. 2010. Tuberculosis then and now: perspectives on the history of an infectious disease. Montreal: McGill-Queen’s University Press.

Creswell, J, S Sahu, K. S. Sachdeva, L. Ditiu, D. Barreira, A. Mariandyshev, C. Mingting, and Y. Pillay. 2014. “Tuberculosis in BRICS: challenges and opportunities for leadership within the post-2015 agenda.” Bulletin of the World Health Organization no. 92 (6):459-60.

Dye, C., P. Glaziou, K. Floyd, and M. Raviglione. 2013. “Prospects for tuberculosis elimination.” Annu Rev Public Health no. 34:271-286.

Farmer, Paul. 1997. “Social scientists and the new tuberculosis.” Social Science and Medicine no. 44 (3):347-58.

Farmer, Paul. 2001. Infections and inequalities: the modern plagues. Berkeley, Calif.: University of California Press.

Harper, Ian. 2006. “Anthropology, DOTS and understanding tuberculosis control in Nepal.” Journal of Biosocial Science no. 38 (1):57-67.

Harper, Ian. 2010. “Extreme condition, extreme measures? Compliance, drug resistance, and the control of tuberculosis.” Anthropology & Medicine Anthropology & Medicine no. 17 (2):201-214.

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Johnston, William. 1995. The modern epidemic: a history of tuberculosis in Japan. Cambridge, Mass.: Harvard University Press.

Keshavjee, Salmaan, Irina Y. Gelmanova, Paul Farmer, Sergey P.. Mishustin, Aivar K. Strelis, Yevgeny G. Andreev, Alexander D. Pasechnikov, Sidney Atwood, Joia S. Mukherjee, Michael L. Rich, Jennifer J. Furin, Edward A. Nardell, Jim Y. Kim, and Sonya S. Shin. 2008. “Treatment of extensively drug-resistant tuberculosis in Tomsk, Russia: a retrospective cohort study.” Lancet no. 372 (9647):1403-9.

Keshavjee, Salmaan, Mark Harrington, Gregg Gonsalves, Lucy Chesire, and Paul Farmer. 2011. “Time for zero deaths from tuberculosis.” Lancet no. 378 (9801):1449-50.

Koch, Erin. 2006. “Valuing Life, Weighing Death – Beyond suspicion: Evidence, (un)certainty, and tuberculosis in Georgian prisons.” American ethnologist. no. 33 (1):50.

Koch, Erin. 2011. “Local Microbiologies of Tuberculosis: Insights from the Republic of Georgia.” Medical Anthropology no. 30 (1):81-101.

Koch, Erin. Free market tuberculosis managing epidemics in post-Soviet Georgia. Vanderbilt University Press 2013a.

Koch, Erin. 2013b. “Tuberculosis Is a Threshold: the Making of a Social Disease in Post-Soviet Georgia.” Medical Anthropology no. 32 (4):309-24.

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In the Journals, October 2014 – Part 1 by Francis Mckay

20 Octobre 2014 - 2:41am

Here’s the first half of this month’s roundup. Enjoy.

Social Science and Medicine

Intergenerational health consequences of in utero exposure to maternal stress: Evidence from the 1980 Kwangju uprising
Chulhee Lee

The evidence that demonstrates the negative effects of maternal psychological stress during pregnancy on a wide variety of offspring outcomes is growing. Animal studies suggest that negative influences of maternal stress during pregnancy persist across multiple generations, but the direct evidence to confirm that the effect is present among human populations is scarce. This study draws evidence on the intergenerational influences of maternal stress from the Kwangju uprising (May 18–27, 1980), arguably the bloodiest incident that occurred in South Korea since the end of the Korean War in 1953. The results of difference-in-difference estimations suggest that in utero exposure to the Kwangju uprising significantly diminished the offspring birth weight and length of gestation, and increased the risks of low birth weight and preterm birth. Exposure to stress during the second trimester of pregnancy exerted the strongest negative effect on grandchildren’s birth outcomes.

Perceived quality of an alternative to acute hospitalization: An analytical study at a community hospital in Hallingdal, Norway
Øystein Lappegard, Per Hjortdahl

There is growing international interest in the geography of health care provision, with health care providers searching for alternatives to acute hospitalization. In Norway, the government has recently legislated for municipal authorities to develop local health services for a selected group of patients, with a quality equal to or better than that provided by hospitals for emergency admissions. General practitioners in Hallingdal, a rural district in southern Norway, have for several years referred acutely somatically ill patients to a community hospital, Hallingdal sjukestugu (HSS). This article analyzes patients’ perceived quality of HSS to demonstrate factors applicable nationally and internationally to aid in the development of local alternatives to general hospitals. We used a mixed-methods approach with questionnaires, individual interviews and a focus group interview. Sixty patients who were taking part in a randomized, controlled study of acute admissions at HSS answered the questionnaire. Selected patients were interviewed about their experiences and a focus group interview was conducted with representatives of local authorities, administrative personnel and health professionals. Patients admitted to HSS reported statistically significant greater satisfaction with several care aspects than those admitted to the general hospital. Factors highlighted by the patients were the quiet and homelike atmosphere; a small facility which allowed them a good overall view of the unit; close ties to the local community and continuity in the patient–staff relationship. The focus group members identified some overarching factors: an interdisciplinary and holistic approach, local ownership, proximity to local general practices and close cooperation with the specialist health services at the hospital. Most of these factors can be viewed as general elements relevant to the development of local alternatives to acute hospitalization both nationally and internationally. This study indicates that perceived quality should be one of the main motivations for developing alternatives to general hospital admissions.

Dispensing emotions: Norwegian community nurses’ handling of diversity in a changing organizational context
Jonas Debesay, Ivan Harsløf, Bernd Rechel, Halvard Vike

Since the mid-1990s, public sector health care services in Norway have been restructured, in line with New Public Management ideas. This restructuring has coincided with demographic changes that have led to a more culturally diverse patient population. Both developments have created new challenges for community nurses in managing their work. This qualitative study applies the concept of “emotional labor” to examine nurses’ experiences in working with ethnic minority patients in the context of pressures arising from organizational reforms. The analysis sheds light on the nurses’ attempts to comply with system-induced efficiency considerations, while catering to the special situation of patients with language barriers and unfamiliar cultural traditions. The article demonstrates how efficiency requirements and time constraints either aggravate the nurses’ insecurity in dealing with minority patients or, in some cases, compel them to assume more work responsibilities so as to mitigate the effects of such constraints.

What must I do to succeed?: Narratives from the US premedical experience
Katherine Y. Lin, Renee R. Anspach, Brett Crawford, Sonali Parnami, Andrea Fuhrel-Forbis, Raymond G. De Vries

How does a lay person become a doctor? How is a physician made? These questions have been central to work of medical sociologists for well over a half-century. Despite this abiding focus on socialization, nearly all of the literature on this process in the US is informed by studies of the medical school and residency years, with almost no empirical attention paid to the premedical years. Our study addresses this gap in knowledge. To better understand the premedical years we conducted 49 in-depth interviews with premedical students at a selective, public Midwestern university. We found that students understand and explain decisions made during the premedical years with narratives that emphasize the qualities of achievement-orientation, perseverance, and individualism. We also find that these qualities are also emphasized in narratives employed to account for the choice to collaborate with, or compete against, premedical peers. Examination of premedical narratives, and the qualities they emphasize, enriches our understanding of how premedical education shapes a physician’s moral development, and underscores the need to include the premedical years in our accounts of “becoming a doctor.”

We call it a virus but I want to say it’s the devil inside’: Redemption, moral reform and relationships with God among people living with HIV in Papua New Guinea
Angela Kelly-Hanku, Peter Aggleton, Patti Shih

There is growing recognition of the importance of religion and religious beliefs as they relate to the experience of HIV, globally and in Papua New Guinea in particular. Based on 36 in-depth qualitative interviews conducted with people living with HIV receiving HIV antiretroviral therapy in 2008, this paper examines the cultural aetiology of HIV of in Papua New Guinea, the country with the highest reported burden of HIV in the Pacific. Narratives provided drew upon a largely moral framework, which viewed HIV acquisition as a consequence of moral failing and living an un-Christian life. This explanation for suffering viewed the individual as responsible for their condition in much the same way that neo-liberal biomedical discourses do. Moral reform and re-establishing a relationship with God were seen as key actions necessary to effect healing on the material body infected with HIV. Religious understandings of HIV drew upon a pre-existing cultural aetiology of dis-ease and misfortune widespread in Papua New Guinea. Understanding the centrality of Christianity to explanations of disease, and subsequently the actions necessary to bring about health, is essential in order to understand how people with HIV in receipt of antiretroviral therapies internalise biomedical perspectives and reconcile these with Christian beliefs.

The effect of social support on the health of Indigenous Australians in a metropolitan community
Pippa Waterworth, Michael Rosenberg, Rebecca Braham, Melanie Pescud, James Dimmock

The factors driving the disparity in health outcomes between Indigenous and non-Indigenous Australians continue to be poorly understood. Despite this, studies confirm that social connections are a very important part of Indigenous life, and it is likely these connections play an important role in influencing health outcomes among this population. Examining the support provided by social connections in relation to health behaviour may assist our understanding of health outcomes among Indigenous Australians. The current study is focused on exploring Indigenous participants’ impressions of their social network and social support using Participatory Action Research methodology and qualitative methods. The objective was to identify the influence of social support on the health outcomes of Indigenous people within a Western Australian metropolitan community. Seventeen members of the community were interviewed during the study. The participants had extensive social networks that mainly comprised members of their kinship group. The consequences of this social network included: (1) the positive effects of social support from bonded relationships; (2) the negative effects of social support produced by over-obligation and unidirectional support involving bonded relationships; (3) limited or inadequate social support caused by withdrawal from bonded relationships; (4) lack of social support from bridging relationships; and (5) a strong desire for connection and a sense of belonging.

Social capital, collective action and access to water in rural Kenya
Elijah Bisung, Susan J. Elliott, Corinne J. Schuster-Wallace, Diana M. Karanja, Abudho Bernard

Globally, an estimated 748 million people remain without access to improved sources of drinking water and close to 1 billion people practice open defecation (WHO/UNICEF, 2014). The lack of access to safe water and adequate sanitation presents significant health and development challenges to individuals and communities, especially in low and middle income countries. Recent research indicates that aside from financial challenges, the lack of social capital is a barrier to collective action for community based water and sanitation initiatives (Levison et al., 2011; Bisung and Elliott, 2014). This paper reports results of a case study on the relationships between elements of social capital and participation in collective action in the context of addressing water and sanitation issues in the lakeshore village of Usoma, Western Kenya. The paper uses household data (N = 485, 91% response rate) collected using a modified version of the social capital assessment tool (Krishna and Shrader, 2000). Findings suggest that investment in building social capital may have some contextual benefits for collective action to address common environmental challenges. These findings can inform policy interventions and practice in water and sanitation delivery in low and middle income countries, environmental health promotion and community development.

The psychological toll of slum living in Mumbai, India: A mixed methods study
Ramnath Subbaraman, Laura Nolan, Tejal Shitole, Kiran Sawant, Shrutika Shitole, Kunal Sood, Mahesh Nanarkar, Jess Ghannam, Theresa S. Betancourt, David E. Bloom, Anita Patil-Deshmukh

In India, “non-notified” slums are not officially recognized by city governments; they suffer from insecure tenure and poorer access to basic services than “notified” (government-recognized) slums. We conducted a study in a non-notified slum of about 12,000 people in Mumbai to determine the prevalence of individuals at high risk for having a common mental disorder (i.e., depression and anxiety), to ascertain the impact of mental health on the burden of functional impairment, and to assess the influence of the slum environment on mental health. We gathered qualitative data (six focus group discussions and 40 individual interviews in July–November 2011), with purposively sampled participants, and quantitative data (521 structured surveys in February 2012), with respondents selected using community-level random sampling. For the surveys, we administered the General Health Questionnaire-12 (GHQ) to screen for common mental disorders (CMDs), the WHO Disability Assessment Schedule 2.0 (WHO DAS) to screen for functional impairment, and a slum adversity questionnaire, which we used to create a composite Slum Adversity Index (SAI) score. Twenty-three percent of individuals have a GHQ score ≥5, suggesting they are at high risk for having a CMD. Psychological distress is a major contributor to the slum’s overall burden of functional impairment. In a multivariable logistic regression model, household income, poverty-related factors, and the SAI score all have strong independent associations with CMD risk. The qualitative findings suggest that non-notified status plays a central role in creating psychological distress—by creating and exacerbating deprivations that serve as sources of stress, by placing slum residents in an inherently antagonistic relationship with the government through the criminalization of basic needs, and by shaping a community identity built on a feeling of social exclusion from the rest of the city.

 

Social Studies of Science

Enacting the ‘neuro’ in practice: Translational research, adhesion and the promise of porosity
Caragh Brosnan, Mike Michael

This article attends to the processes through which neuroscience and the neuro are enacted in a specific context: a translational neuroscience research group that was the setting of an ethnographic study. The article therefore provides a close-up perspective on the intersection of neuroscience and translational research. In the scientific setting we studied, the neuro was multiple and irreducible to any particular entity or set of practices across a laboratory and clinical divide. Despite this multiplicity, the group’s work was held together through the ‘promise of porosity’ – that one day there would be translation of lab findings into clinically effective intervention. This promise was embodied in the figure of the Group Leader whose expertise spanned clinical and basic neurosciences. This is theorized in terms of a contrast between cohesion and adhesion in interdisciplinary groupings. We end by speculating on the role of ‘vivification’ – in our case mediated by the Group Leader – in rendering ‘alive’ the expectations of interdisciplinary collaboration.

Ambivalence, equivocation and the politics of experimental knowledge: A transdisciplinary neuroscience encounter
Des Fitzgerald, Melissa M Littlefield, Kasper J Knudsen, James Tonks, Martin J Dietz

This article is about a transdisciplinary project between the social, human and life sciences, and the felt experiences of the researchers involved. ‘Transdisciplinary’ and ‘interdisciplinary’ research-modes have been the subject of much attention lately – especially as they cross boundaries between the social/humanistic and natural sciences. However, there has been less attention, from within science and technology studies, to what it is actually like to participate in such a research-space. This article contributes to that literature through an empirical reflection on the progress of one collaborative and transdisciplinary project: a novel experiment in neuroscientific lie detection, entangling science and technology studies, literary studies, sociology, anthropology, clinical psychology and cognitive neuroscience. Its central argument is twofold: (1) that, in addition to ideal-type tropes of transdisciplinary conciliation or integration, such projects may also be organized around some more subterranean logics of ambivalence, reserve and critique; (2) that an account of the mundane ressentiment of collaboration allows for a more careful attention to the awkward forms of ‘experimental politics’ that may flow through, and indeed propel, collaborative work more broadly. Building on these claims, the article concludes with a suggestion that such subterranean logics may be indissociable from some forms of collaboration, and it proposes an ethic of ‘equivocal speech’ as a way to live with and through these kinds of transdisciplinary experiences.

Rejecting knowledge claims inside and outside science
Harry Collins

Citizens, policy-makers and scientists all face the problem of assessing maverick scientific claims. Via a case study, I show the different resources available to experts and non-experts when they make these judgements and reflect upon what this means for technological decision-making in the public domain.

Linking the subcultures of physics: Virtual empiricism and the bonding role of trust
Luis Reyes-Galindo

This article draws on empirical material concerning the communication and use of knowledge in experimental physics and its relations to the culture of theoretical physics. The role that trust plays in these interactions is used to create a model of social distance between interacting theoretical and experimental cultures. This article thus seeks to reintroduce trust as a fundamental element in answering the problem of disunity in the sociology of knowledge.

Eyeballing expertise
Catelijne Coopmans, Graham Button

‘Tacit’ and ‘explicit’ knowledge, and their relation to expertise, have a long-standing importance within social studies of science and technology. At the centre of the development of thinking about these topics has been the work of Harry Collins and Robert Evans. In this article, we bring to bear observations of the work of people involved in grading eye disease, and their seeming display of expertise, tacit and explicit knowledge, on three thrusts identified in the work of Collins, and Collins and Evans. These thrusts are the following: (1) a concern with the appearance of tacit knowledge in the activities of experts, (2) a commitment to studying expertise as ‘real’ and substantive rather than attributed, and (3) a commitment to promoting the recognition and fostering the management of expertise by providing analytical distinctions regarding expertise and its reliance on tacit knowledge. By considering what is involved in the work of grading eyes, we relocate the interest in tacit and explicit knowledge, and their bearing on expertise, in how expert knowledge is displayed and made recognizable in and through courses of action and interaction.

Actor and analyst: A response to Coopmans and Button
Harry Collins, Robert Evans

We question the logic of Coopmans and Button’s critique of our analysis of expertise on three grounds. First, their critique depends on a clear distinction between actor and analysts that we show cannot be maintained. Second, we question their reticence to allow the use of taxonomies in the analysis of expertise, suggesting that it is contradicted by their own descriptions of expert work, and we accuse them of making a mistake in the way they relate commonsense to specialist skills. Finally, we express our puzzlement at the antiseptic-like precautions that some ethnomethodologists apply to analysts’ categories, especially given that – as we show – analysts’ categories sometimes provide a superior resource for understanding and can change the actors’ world as well as describing it.

 

Theory, Culture, and Society

Toward a New Theory of Waste: From ‘Matter out of Place’ to Signs of Life
Joshua Ozias Reno

This paper offers a counterpoint to the prevailing account of waste in the human sciences. This account identifies waste, firstly, as the anomalous product of arbitrary social categorizations, or ‘matter out of place’, and, secondly, as a distinctly human way of leaving behind and interpreting traces, or a mirror of culture. Together, these positions reflect a more or less constructivist and anthropocentric approach. Most commonly, waste is placed within a framework that privileges considerations of meaning over materiality and the threat of death over the perpetuity of life processes. For an alternative I turn to bio-semiotics and cross-species scholarship around the question of the animal. Specifically, the paper asks what theories of waste would look like if instead of taking ‘dirt’ as their starting point, they began with trans-species encounters with animal scat. Following bio-semiotics and efforts to deconstruct the animal/human binary, it is suggested that the objectual forms commonly referred to as ‘waste’ are not arbitrarily classified but purposefully expended, and thus symptomatic of life’s spatio-temporal continuation. Waste matter, therefore, is best construed not as anthropocentric but as semi-biotic: a sign of the form of life to which it once belonged. This alternative perspective has implications for how approaches to industrial forms of mass waste can be reconceived.

Race, Time and Folded Objects: The HeLa Error
Amade M’charek

Given their commitment to practices, science studies have bestowed considerable attention upon objects. We have the boundary object, the standardized package, the network object, the immutable mobile, the fluid object, even a fire object has entered the scene. However, these objects do not provide us with a way of understanding their historicity. They are timeless, motionless pictures rather than things that change over time, and while enacting ‘historical moments’ they do not make visible the histories they contain within them. What kind of object could embody history and make that history visible? Inspired by Michel Serres, I suggest the folded object is a way to attend to the temporality and spatiality of objects. In this article I explore this new object by unravelling the history of a DNA reference sequence. I show how, ever since it was produced in the early 1980s, attempts have been made to filter race out of the sequence. That effort has failed due to what one could call ‘political noise’. Making and remaking the sequence have left traces that cannot be erased.

Conference Synopsis: The End of biodetermism? New Directions for Medical Anthropology by Samuel Taylor-Alexander

16 Octobre 2014 - 6:55am

What is biodeterminism? Has it ended and did it ever exist? Earlier this month at Aarhus University, these seemingly straightforward questions resulted in three days of fascinating conversation during a conference titled “The End of biodetermism? New Directions for Medical Anthropology.”  The event, co-organized by the Centre for Cultural Epidemics (EPICENTER), the Interacting Minds Centre for the Study of Cognition, and the Department of Culture and Society, entailed a rethinking of the ends of not only genetic determinism but also the human body itself. In a series of three thematic sessions that covered topics ranging from a new meditation/MRI nexus to epigenetics, and PTSD/Ugandan ghosts, the invited speakers engaged the indeterminacy of contemporary technomedicine to raise new conceptual and methodological problems for anthropology. From the opening paper by Margaret Lock who spoke of the “miniaturisation” of the “environment” in molecular epigenetics through to Mette N. Svendsen’s multispecies ethnography where research piglets are configured as sacrificial subjects, numerous questions where opened up about the plural ends of multivariate determinisms. Further, the likes of Allan Young’s intriguing anthropology of bacteria asked us to once again question the human self and its endpoints.  As Young described to the audience how bacteria have become social, he also altered us to their significance in the constitution of our biological selves.

A refiguring of the biological and social nexus provided a key a conceptual tool for presenters. As they opened and closed the space between the two domains and brought in material and environmental factors, they showed how anthropology could contribute to emerging trends in science. David Napier suggested that a possible avenue to do this was by “redefining sociobiology as the impact of social practices on biological mechanisms” as a way to elucidate the “syndemic and symbiotic nature of human practices” and their historical transformations. Daniel Lende provided a neuroanthropology of addiction that recast the “addiction is a brain disease” paradigm. Drawing on his informants’ embodied experiences of a “high” and situating drug use in the lifeworld of the user to inform the sciences of addiction, Lende proposed a more grounded and local approach to combating drug abuse.  Des Fitzgerald spoke about stress in the neurological city post-determinism by telling us how “recent epigenetic and neurodevelopmental attention to the nexus of metropolitan and mental life has significantly re-animated, and torqued” the connection between stress and urban life. Again, produced within this research are oft hidden notions of responsibility that require social scientists to engage with the fluid rights of urban citizens as they are molded to and with urban space itself.

Emerging early was a debate about the ability of anthropology and the social sciences to intervene, to produce experimental modes of collaboration that will themselves act as critique. Should we design new forms of interdisciplinary collaboration in order to inform and influence scientific practice? What would be the benefits and limitations of such projects? In his presentation on “co-laborative ontography,” Jörg Niewöhner suggested that social scientists should abandon criticism from afar in favor of an integrative form of investigation that introduces anthropological insights into molecular biology research. Discussion reminded us that in order for a middle ground to be forged it is necessary first to map out the landscape that is obscured and obfuscated by scientific reductionism. In both his closing remarks and his paper on Mindfulness Based Stress Reduction and their MRI measurements, conference organizer Andreas Roepstorff reminded us that the language and methods of science remain central to institutional modes of understanding the world; the quantification of emerging treatments that may otherwise contravene established biomedical approaches to illness allows them, and the measurement of nature, to remain within the domain of science.

Above and beyond the topic of “biodetermism” a number of talks examined the epistemic and practical suffocation resulting from deterministic projections in science and public policy. Offering the notion of horizons, Adriana Petryna discussed how scientists are “quantifying points of no return for ecosystems under threat” and how these points are perpetually refigured as new understandings of environmental complexity are introduced into scientific models. In the realm of global public health as Susan L. Erikson explained, social determinants of health “distract attention away from the new ways commodifying health makes money and alters health services-scapes.” Using ethnographic insights from India to forge an analysis that moved between how “bacteria get ill,” drug resistant tuberculosis, and WHO-promoted treatment models, Jens Seeberg showed how a TB treatment strategy can be a double-edged sword. While the Directly Observed Treatment – Short-course (DOTS) has improved treatment, it has stumbled when it comes to preventing drug resistance in both public and private healthcare systems.

The final themed panel on “Epidemics – communicability and non-communicability” turned the notion of contagion on its head. Non-communicable diseases like diabetes (Steve Ferzacca), obesity (Simon Cohn), and PTSD/Ghosts in Uganda (Lotte Meinert and Susan R. Whyte) and were examined as infectious and transmittable, challenging again the value of deterministic labeling and pondering new ways to understand illness and the body in the global health-scape. Moreover, the conference speakers emphasized that deterministic thinking reifies dominant logics and closes down the ability to imagine modes of intervention for potentially solvable problems.

A number of times throughout the meeting, organizers and presenters noted how indeterminacy had shaped both the logistical and topical elements of the meeting. Everyone involved in presenting and organizing was taken aback by the interest that the conference attracted; talks were transformed at the last minute into presentations. Similarly, there was sometimes uncertainty surrounding the connection between topics and conference themes, but this indeterminacy was perhaps what was most productive. It allowed for a time of collaboration and conceptual experimentation that demonstrated the import of the topic and the ability of the social sciences to influence the determinisms – social, biological, environmental – emerging within contemporary scientific and policy practice.

The list of abstracts for all of the fifteen presentations is available online at http://epicenter.au.dk/biodeterminism/abstracts/

 

Samuel Taylor-Alexander is currently a Visiting Scholar in the Department of Anthropology, University of Copenhagen. He wrote his PhD at the ANU and was a doctoral fellow in the STS program at Harvard University. Samuel is the author of On Face Transplantation: Life and Ethics in Experimental Biomedicine (Palgrave Macmillan 2014). His research seeks to understand how national imaginaries shape everyday and experimental medical practice.

Anthropology Goes Public in the VA — A special issue of the Annals of Anthropological Practice by Aaron Seaman

14 Octobre 2014 - 2:15pm

The current issue of the Annals of Anthropological Practice is a special issue, entitled, “Anthropology Goes Public in the VA.” Guest-edited by Karen Besterman-Dahan and Alison Hamilton, the issue contains seven articles organized thematically around discussions of what it means to be an anthropologist in the VA, the kinds of interventions anthropologists are making, and the often marginalized groups with whom they work. In addition, the issue has an introduction by Elisa J. Sobo and an afterword by Sarah S. Ono and Samantha L. Solimeo. Articles and abstracts are below. Enjoy!

Anthropologists in the VA: A Generative Force
Elisa J. Sobo

Practicing anthropology within the Veterans Health Administration of the Department of Veterans Affairs (VA) has, until recently, received little serious consideration as a respectable career option for anthropology postgraduates. But times are changing. Anthropologists employed by the VA are responsible for some of the most important and actionable anthropologically informed health research today. Far from being a marginal pursuit, VA anthropology is in fact a generative force for medical anthropology and, indeed, the discipline as a whole.

Practicing Anthropology in the VA

Observers Observed: Exploring the Practice of Anthropology in the  VA
Megan B. McCullough, Bridget Hahm, and Sarah Ono

From our position as publicly funded anthropologists in the Veterans Affairs, we discuss how anthropological research on Veterans health care offers an opportunity to critically engage with ideas about what constitutes public anthropology. As public sector anthropologists, we are conducting theoretically and ethnographically innovative work. In this chapter, we discuss the implications of this work in regard to anthropological theory and practice.

Anthropologist and Government Employee: A Description of Career Paths to Becoming an Applied Anthropologist with the U.S. Department of Veteran Affairs
Gemmae M. Fix

The U.S. government is the largest employer of anthropologists, with an increasing presence in the Department of Veteran Affairs (VA). However, there has been limited discussion of the path from graduate school to an applied career. This article describes the motivations and trajectories of anthropologists employed by VA. Interviewees described their VA work as embodying the principles of anthropology and the ability to see the results of their work as deeply gratifying.

Empowering Veterans

The Role of Social Networks for Veterans with Spinal Cord Injury in Obtaining Employment
Bridget A. Cotner, Jennie Keleher, Danielle R. O’Connor, John K. Trainor, and Lisa Ottomanelli

The purpose of this article is to demonstrate the use of ethnographic methods to explore the types of social support provided to Veterans with spinal cord injuries (SCIs) who are participating in an employment program. Interview data with Veterans and their social support members along with employment narratives written after a job was secured are used to document the types of support provided to Veterans with SCI to facilitate obtaining and maintaining employment. The impact of social support on mental and physical health is well documented in the literature; however, there is a need for research on the influence of social support on employment. As applied in VA spinal cord care, the “individual placement and support (IPS)” model of supported employment for vocational rehabilitation integrates vocational services into clinical treatment, and includes social support members in the pursuit of employment goals. Guided by theories of social capital, the types of social support provided to Veterans were classified into three types: instrumental, informational, and emotional. Analysis of data showed that for all Veterans with SCI, some form of social support was needed to aid in finding and maintaining employment, demonstrating the need for evidence-based supported employment (EBSE) services in the VA spinal cord system of care.

Evaluating Secure Messaging from the Veteran Perspective: Informing the Adoption and Sustained Use of a Patient-Driven Communication Platform
Jolie N. Haun, Jason D. Lind, Stephanie L. Shimada, and Steven R. Simon

Secure messaging (SM) is a secured asynchronous electronic e-mail system within the Veterans Health Administration web-based patient portal, My Health eVet. This electronic tool is part of a national transformation initiative to create new models of care to support patient-provider communication and promote self-care management. SM is designed to empower patients to communicate with their providers, but to date little research has evaluated Veterans’ perspectives on using SM as a communication tool. This article provides an overview of a qualitative mixed-methods study with 33 Veterans who opted-in to use SM. We used a combination of in-depth interviews, user-testing, three-month review of secondary SM data, and three-month follow-up phone interviews to understand Veterans’ experiences using SM. Synthesizing these data, we identified high- and low-volume users and characterized their reasons for using or not using SM. These profiles illustrate the Veteran perspective, enabling clinicians, administrators, and other stakeholders to understand how to adapt marketing and educational strategies and make system changes to promote and facilitate Veteran adoption and sustained use of SM as a communication tool.

Empowering Veterans with PTSD in the Recovery Era: Advancing Dialogue and Integrating Services
Erin P. Finley

As highly effective treatments for posttraumatic stress disorder (PTSD) become increasingly available, how will the VA (Department of Veterans Affairs) and other public institutions navigate complex questions around appropriate services for Veterans with PTSD? This and related questions will be examined in this article in light of epidemiological, clinical, and ethnographic data on combat PTSD in the 21st century.

Working with Veterans at the Margins

Gendered Social Roots of Homelessness among Women Veterans
Alison B. Hamilton, Donna L. Washington, and Jessica L. Zuchowski

Homelessness is one of the most challenging issues facing U.S. Veterans and those who serve Veterans. While the overall number of homeless Veterans is declining, the number of homeless women Veterans is increasing, with little clarity as to why. In previous work, we have examined pathways to homelessness among women Veterans, with a focus on proximal pathways, that is, how women perceived themselves to have become homeless at the time of the study. In this paper, we dig deeper into the roots of homelessness, specifically into the social institutional roots of homelessness. We examine women’s focus group conversations about entering and experiencing the military, particularly with regard to the common occurrence of sexual violence and trauma before and during military service. Drawing on anthropological concepts, we conceptualize trauma at both an individual level as embodied in women’s lived experiences, as well as at a collective, gendered level. Gendered traumatic experiences can accumulate over time, creating or reinforcing vulnerable pathways. For women Veterans, gender and the military are both social institutions that may act in combination to create gendered social roots of homelessness that are particular to women, and that may be relevant to the gender difference in prevalence of homelessness among Veterans.

“You Never Heard Jesus Say To Make Sure You Take Time Out for Yourself”: Military Chaplains and the Stigma of Mental Illness
Karen Besterman-Dahan, Jason D. Lind, and Theresa Crocker

The wars in Iraq and Afghanistan have taken a toll on military chaplains (MCs) who often return from deployment with high levels of stress, yet are expected to counsel on a daily basis without decompression of their own, potentially exacerbating any personal trauma. MC with posttraumatic stress disorder (PTSD) who have had deployments abridged due to their positive PTSD screen have reported shame due to leaving service members in their unit in danger while they went to safety. Many MCs report compassion fatigue, PTSD, reintegration issues, and adverse effects to their personal energy, motivation, and mental and spiritual well-being postdeployment, related to stressors from deployment and combat exposure. Only 23–40 percent of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) service members with a psychiatric disorder seek mental health care, citing stigma as a primary barrier. For MCs, stigma is compounded by a culture in which military health care providers, including MCs, are encouraged to deny their own needs to provide the necessary support to beneficiaries. This paper reviews a pilot study, which explored the impact of operational stress on the psychosocial health and reintegration of MCs, focusing on findings related to mental health and stigma within the military chaplaincy.

Negotiating Domains of Patient Dignity in VA Spinal Cord Injury Units: Perspectives from Interdisciplinary Care Teams and Veterans
Jason D. Lind, Gail Powell-Cope, Margeaux A. Chavez, Marsha Fraser, and Jeffrey Harrow

Patient dignity is a significant concern among inpatient Veterans with spinal cord injuries (SCIs) because they may lack physical control over their bodies and thus rely on others for a variety of specialized needs, including mobility, personal care, wound care, bowel and bladder care, and rehabilitation, among others. This study examines the complexities of providing and negotiating dignified care in the context of interdisciplinary care teams in SCI, and the challenges Veterans with SCI face maintaining dignity in the context of limited independence. Based on a mixed methods approach that included in-depth interviews, observations, and pile sorting at six Veterans Health Administration (VA) SCI units, the goal of this study was to explore ways in which dignity was defined, negotiated, and conferred during patient and provider interactions. Study results have immediate value to VA leadership, VA providers, and Veterans by calling attention to the ways in which the concept of patient dignity can be integrated into clinical practice on SCI units. This study provides a methodological framework to capture complex interactions among interdisciplinary care teams and patients, and offers a significant contribution to our understanding of how patient and provider interactions are conferred and negotiated.

The Intersections of Gender and Power in Women Veterans’ Experiences of Substance Use and VA Care
Ann M. Cheney, Audrey Dunn, Brenda M. Booth, Libby Frith, and Geoffrey M. Curran

In this article, we show that the Veterans Health Administration (VA), similar to military organizations, is a gendered organization where women Veterans’ experiences are embedded in and shaped by gender inequalities and structures of power. Based on an in-depth analysis of women Veterans’ substance use histories and VA treatment seeking experiences, we illustrate how gender power dynamics are (re)produced and maintained through everyday social interactions and organizational practices and processes that render women Veterans both visible and invisible: visible as sexual objects and invisible as suffering subjects. By retelling the illness and treatment experiences of women Veterans with trauma histories and co-occurring substance use and mental health disorders—a highly stigmatized population of Veterans—we highlight the importance of giving voice to their concerns when developing policies and programs to address the unique health care needs of women Veterans.

Afterword: Public Sector Anthropologists and New Directions for a Public Anthropology
Sarah S. Ono and Samantha L. Solimeo

In this final contribution in the edited volume on anthropologists working in the Veterans Health Administration within the Department of Veterans Affairs (VA), the authors reflect on how developments in recent years have brought us to this moment in time from the “insider” perspective of VA anthropologists. These collected papers provide ethnographic evidence for the innovative ways in which anthropologists employed in the public sector constitute a public anthropology that is theoretically informed, actionable, and cognizant of its role in the production of authoritative knowledge. The “afterword” makes connections between the chapters, with their varied topics, and addresses how this volume points to new destinations for engaged and ethical research in the growing field of public sector anthropology.

Duana Fullwiley’s The Enculturated Gene by John Hartigan

14 Octobre 2014 - 9:30am

The Enculturated Gene:
Sickle Cell Health Politics and Biological Difference in West Africa

by Duana Fullwiley

Princeton University Press, 2011. 368 pp.

 

What is the role of cultural analysis in confronting genetic phenomena? Over the past few decades, cultural anthropologists have striven to contest or hold at bay genetic explanations for race, gender, and sexuality. Their analytical approach was to demonstrate the social construction of genetic facts. Often, these contests rehearsed battles that marked the emergence of social analysis, as when Emile Durkheim made the case for the autonomy of social facts by delineating them from biological or psychological dynamics. This stance was strongly reasserted by Marshall Sahlins when, in response to the rise of sociobiology in the 1970s, he maintained the irreducibility of “a social construction of meaning” to “biological determinism,” (1976: 4) To insist otherwise, he concluded, would result in having “to abandon all understanding of the human world as meaningfully constituted, and so the one best hope of knowing ourselves” (1976: 107). When discussing race, “ideology” was deployed as a counter attack; the insistence on race’s social construction entailed assailing the objectivity of genetic facts, rendering them as largely the products of racial ideologies that informed the work of scientists. But all this eventually became more complicated, first as “biosociality,” via Paul Rabinow (1996), inverted “sociobiology” in calling attention to how cultural identities are formulated in response to medical conditions, and then as claims linked to the Human Genome Project (e.g., “the concept of race has no genetic or scientific basis,” Craig Venter, 2000) generated an array of challenges from certain geneticists.

Duana Fullwiley’s The Enculturated Gene offers several formulations of how cultural analysis frames genetic matters. Some of these will be familiar to readers trained in anthropology over the past two decades, but at least one of these formulations heralds a potentially dramatic challenge to the delineation of distinct domains that first allowed the social fact to be established. The work’s strength lies in its framing the cultural alongside the genetic without reducing the latter to merely a construct. But it is a struggle to maintain this view, which requires Fullwiley to make a variety of efforts to formulate the analytical ground and objects. The genotypic form in question is the sickle cell allele, “a misspelling in the genetic sequence that codes for the beta chain of hemoglobin” (280). Ethnographically, she presents us with doctors, patients, and researchers in Senegal from 1998, when she commenced her fieldwork, to a final research trip in 2010. During that time, sickle cell shifts from being largely ignored by the government, construed as a genetically distinct “mild form,” to becoming characterized as “severe” and made the focus of more concentrated state public health concern. During that trajectory, the responses of sufferers and their caregivers develop: “In other words, actors affected by the disease (as well as scientists who study it) have both built and lived an ontological reality of mild sickle cell, as a well as the possibility of its double” (266). This can be a matter of contesting norms for healthy conditions or even affecting the expression of the disease through ingesting leaves from the medicinal plant, Fagara xanthoxyloïdes, which may play a role in making “sickle cell mild in the first place” (78). The variable responses to a disease have long been a comfortable domain for framing and asserting the relevance of culture to genetics and biology. The bolder set of claims about the role of culture—suggested in the book’s title—seemingly has to vie against these formulations in order to come fully into view.

Predominantly, Fullwiley analyzes the work of culture in two broad, familiar registers: as shaping researchers’ views of the disease, particularly in relation to race, and in peoples’ capacities to live with sickle cell. These two are in ongoing dialogue, and both may be construed as constructs: “Senegalese sickle cell anemia” (7) was produced by French doctors retracing colonial imaginaries via an enduring commitment to finding race naturally inscribed in bodies and territories; as such, “its discursive effects helped to shape people’s intersubjective modes of self-care and self-governance,” thus constituting a culturally “lived experience with the disease” (7-8). This book is primarily an ethnography of the latter: “Almost daily I witnessed people go back and forth between frustration and hope in managing their disease, and more specifically in garnering the necessary resources to live relatively normal lives” (11). Fullwiley documents how “people with the disease…deploy multiple representational strategies that both blended and held separate ideas” (27), something that culture has long worked well to frame and explain.

But what of the disease “itself” or life “itself”? These both gesture toward the genetic and biological aspects of “the construct of mildness,” “born both of geneticists’ ideas about Senegalese biological capacities…and of patients’ informal economies,” “improvisational yet effective” (xx). Initially, this domain is merely refractive for culture: an “ethnographic engagement with sickle cell in Senegal provides an aperture on the social forces that condition disease embodiment, but that also highlight the possibilities for how power shapes people’s subjectivities across the North-South divide” (xxii). The social is glimpsed through the genetic. But her framing of “ideas of difference that cohere through people’s imaginaries about belonging”—stock concerns of cultural anthropology—is quickly followed by an acknowledgement “that biogenetic differences exist” (xviii). The latter, Fullwiley knows, must factor into this account. But when the focus falls on such form of difference, it’s easy to lose sight of culture altogether: “in conceding that health outcomes may be linked to some aspect of genetic variation exhibited between people classed within ethnic and national lines, we must also ask what is lost when we focus on small, highlighted gene differences that are in no way generalizable to the majority of sicklers in these nationally named cohorts” (17).

In response to this loss of focus, sometimes Fullwiley argues for a modest role for culture, imagining how claims-making would shift “if an analysis of sickle cell biological difference in West Africa took seriously the concerted efforts and cultural practices the sickle cell patients themselves have put into surviving in the face of economic scarcity” (xviii). Yet in this moderate stance she contends with the tendency of genetics to block culture from view entirely: “genetic framings often mask the historical and cultural experiences that may lead to a given health outcome (19).” At times, this feels like a zero-sum game: seeing the cultural depends upon bracketing off the genetic, because of the capacity of the genetic, conversely, to block culture out entirely. Patterning at one level precludes an attention to patterning at another level. In writing to “guarantee that affective underpinnings of health outcomes, constellations of poverty, and material inequality are not blotted out for good in our thinking about biological causation” (20), Fullwiley expresses the desire “to get us beyond these modes of query,” which entails “moving past an emphasis on filling quantitative gaps in genetic knowledge” in order “to begin to ask how human biological differences get parsed in the first place,” (18). In such moments, culture displaces an attention to genetics rather than analytically holding both in the frame simultaneously.

Momentarily, she settles on this formulation: “Although the Senegal haplotype (like the ‘Arab-Indian’ haplotype) is ‘strongly associated’ with a high expression of persistent gamma globin (a constituent element of fetal hemoglobin) into adulthood, the causal link between the two remains an open area of research” (15). Here culture becomes a catchall, hinting at additional factors (political, economic, environmental) that make this link irreducible to genetics alone. Then Fullwiley makes another gambit, one that will be familiar to medical anthropologists, positing a perspective in which a genetic condition is neither universal nor uniform: “The larger point to be made here, of course, is that there is no singular disease called sickle cell anemia in the world today” (13). Yes, certainly, but in this case as in most, diseases do cluster; they involve patterns, at the genetic and cultural/social level.

So Fullwiley specifies further: “At most there are near universal terms of disease entities that are nonetheless made and enacted differently in different places through people’s diverse historical engagements with pathology, concepts of human distinction, global standing, economic well- being, and social structures as basic as kin ties that allow one to get by” (13). Here, culture is just a compilation of differences in a non-biological register; some are more consequential (historical, political) than others, but none have much direct impact on the genetic. Framed as a construct, we get the following: “a putatively ‘simple,’ ‘single gene disorder’ becomes infinitesimally layered when analyzed as a lived cultural construct,” and then all disease is “more than their genes” (20). Is this what cultural anthropologists have to say to geneticists and to our respective audiences? That it’s all a matter of infinitesimal layers of unique differences? What does culture amount to, and what does cultural analysis add besides a string of modifiers to remind researchers of the complexity and contingency of their subjects? Here it seems to serve principally as a reminder to practitioners who perhaps don’t know or forget or are literally unable to see these social dimensions. After all, this has been the challenge of social analysis since its inception—to get people to see forces that are as “invisible” as the air we depend upon and breathe.

But the book’s title suggests something more: “enculturation” as a fused set of frames, whereby culture shapes the genetic—perhaps just its expression, but maybe more profoundly, as well. This asserts a greater role for the work of culture than is typically evident in constructionist arguments. “It is in this mix of life and lived experiences that the Senegalese population variant of sickle cell has been made to correspond to a social context where people find ways to live better than expected. In this process the gene itself has become enculturated” (20). Fullwiley pulls back a bit at this moment and offers instead: “enculturation, as the vital adaptation techniques that social groups fashion for themselves, involves making sense of and living with specific referent objects,” (20). Rather than transforming the genetic, it seems we’re back to Sahlins and meaning. But another elaboration follows:

“The referent in this case is the sickle hemoglobin genetic sequence, which becomes enculturated as both patients and biomedical practitioners engage its supposed dictate of fate and subsequent constraints on (or chances for) living a normal life” (20).

Fullwiley’s formulation here attends to the constraints and potential of human plasticity, with the genetic as marking a limit point to what can be fully plastic and the cultural as the domain that acts in focused ways on that plasticity. How these relations are transformed over the long term is the subject of topics such as domestication, on one hand, and evolution on the other. The line between is hardly absolute: culture shapes genomes, but (channeling and paraphrasing Marx) not entirely as we please, always “under circumstances existing already, given and transmitted from the past,” and with a reminder that “the tradition of all dead generations weighs like a nightmare on the brains of the living” (1852). This is not yet the domestication of genes in everyday life, but we can glimpse it from here.

Consider the following passage, as an opening emerges here for agency of the gene:

“When the sickle cell gene in Senegal mediates social relations that range from postcolonial engagements about science equity to public health funding set by North- South donor priorities, when patients conjure healing strategies that range from silencing pain to an emphasis on normalcy at all costs, when the bounty of biomedicine merely consists of folic acid, painkillers, simple surveillance, and the doctor’s touch, and when Senegalese traditional plants are believed to curb sickle cell crises, and perhaps incite the biological production of fetal hemoglobin, people absorb these points of social fact, in body, society, and mind, and express an illness result in the process. This is sociosomatic genetics, and it is made possible when people enculturate sickle cell’s effects through soma and psyche in a societal context, in this case, of material scarcity,” (21).

In this fascinating rendition, Fullwiley draws the gene into view and frames certain biological processes but then returns us principally to its “effects” or expression. She construes this as a “dissolution of the nature/culture split” (21), which matters for constructivist arguments more than addressing geneticists. But more fundamentally, it is a challenge to the division between “artificial” and “natural” versions of selection by which we understand evolution. We know culture shapes genomes (Laland et al., 2010). But generally this is a matter of deep-time; can this knowledge be borne out or embellished via ethnography? Would it be at the risk of reintroducing evolution into cultural accounts?

Evolution is an anxious matter for social analysis, which, since its inception, has largely aimed to bracket off evolutionary explanations as inherently biologically reductivist and inevitably simply reiterating Social Darwinism. Nicholas Wade’s recent book, A Troublesome Inheritance, which has generated heated commentary regarding its claims about race, is as much animated by a critical assertion that social scientists, in regarding modern humans, believe evolution stopped a long time and no longer pertains. Whether this assertion is mostly a caricature or fairly accurate, I’m not sure. But it does help frame the challenge of Fullwiley’s enculturation argument—in opening up the genetic this way we no longer can keep evolutionary frames at bay, construing them simply as ideological representations or relevant only to nonhumans. We are going to need new ways to think about plasticity and fixity—“culture and nature” just won’t do. Perhaps the greatest value of Fullwiley’s ethnography is articulating this: “At stake is our willingness and, in some sense, disciplinary ability, to see that cultural practices and genetic effects are attached before birth” (19).

 

John Hartigan is Professor of Anthropology and Director of the Américo Paredes Center for Cultural Studies at the University of Texas, Austin. His recent books include Anthropology of Race: Biology, Genes, and Culture, (School of Advanced Research Press, 2013), What Can You Say? America’s National Conversation on Race (Stanford University Press 2010) and Race in the 21st Century: Ethnographic Approaches, (Oxford University Press 2010). His current project is Aesop’s Anthropology: A Multispecies Approach, at https://twitter.com/aesopsanthro and http://www.aesopsanthropology.com/blog/

 

References:

Emile Durkheim, 1982 [1895] Rules of Sociological Method, The Free Press,

Kevin N. Laland, John Odling-Smee, and Sean Myles. 2010. “How Culture Shaped the Human Genome: Bringing Genetics and the Human Sciences Together.” Nature Reviews Genetics 11 (2): 137–48.

Karl Marx, 1852 The Eighteenth Brumaire of Louis Bonaparte.

Paul Rabinow. 1996. Artificiality and enlightenment: from sociobiology to biosociality. In Essays on the Anthropology of Reason. Princeton University Press. (pp. 91–111).

Marshall Sahlins, The Use and Abuse of Biology, University of Michigan Press, 1976.

On Relevance (The Very Idea) by Martin Savransky

13 Octobre 2014 - 9:30am

As someone who thinks and works on the edges of the social sciences I am always curious about—and fascinated by—the ways in which ideas, feelings, propositions, demands, and attachments of various kinds have dynamically contributed and continue to contribute to articulating both the knowledge-practices of social scientific disciplines and the habits or ethical sensibilities that inform those forms of inquiry as well as their dreams, hopes, and fears. This is not to rehearse again the old dictum that it is merely ideas that make the world go round. Oftentimes, if not always, ideas emerge from unexpected, material encounters that force one to think something (a)new. But it seems nevertheless true, at least to me, that while the world is not made solely of ideas, it does partake in what, after philosopher Alfred North Whitehead (1967), we might refer to as its own adventure of ideas.

The idea of ‘relevance’ has recently become almost ubiquitous in the ways in which the knowledge-practices of the social sciences are articulated, justified, funded, judged, criticised, and experienced. That the practices of such sciences must ‘be’ or ‘become’ relevant seems to have become a demand that is extremely hard to resist. And who would want to resist it? Who would want to suggest that the activity to which one dedicates one’s best efforts is irrelevant or that its relevance should not be a matter of concern? Yet, at the same time, there is often a sceptical tone that lies at the center of the various demands for relevance. One that, by posing the very question ‘how is this relevant?’, suspects that in fact the practices of the social sciences might, and likely do, fall short of convincing responses. Indeed, demands for relevance have materialised in a myriad of forms: in rather ‘apocalyptic’ texts about ‘the end’ of the social sciences and of universities more generally; in calls for ‘public engagement’, ‘impact’, ‘interdisciplinarity’, ‘self-auditing’, and ‘scientific accountability’; in public and policy debates around how funding should be allocated; in purportedly ‘emancipatory’ calls emerging within the social sciences that demand that ‘wider public issues’ be addressed; and many more.

Fuelling the recent sense that, yet again, the future of the social sciences is far from guaranteed, such a series of demands has become so widely disseminated and pressing, so much a part of daily scientific activities, that it has failed to give rise to more profound reflections as to what ‘relevance’ might mean. As soon as the question ‘what does it mean for something to be relevant?’ is posed, however, all those multiple demands begin to appear under a different light. On the one hand, demands for relevance emerge in the context of a proposed reformation of the institutional and intellectual organisation of scientific activity that might foster more interdisciplinarity and greater accountability for scientific and technological innovation by becoming ‘embedded’ throughout research and development programmes, thereby better contributing to and informing policy and innovation (e.g. Felt 2014, Levidow & Neubauer 2014, Gibbons et al. 1994, Mayer et al. 2013, Nowotny et al. 2001, Rappert 1999). Thus, the 2013 Vinilus Declaration on the 2020 Horizons of the Social Sciences and Humanities in Europe states:

Making use of the wide range of knowledge, capabilities, skills and experiences readily available in SSH [Social Sciences and Humanities] will enable innovation to become embedded in society and is necessary to realise the policy aims predefined in the ‘Societal Challenges’. (Vinilus Declaration 2013)

On the other hand, calls for a more relevant social science emerge from a number of heterogeneous positions that see the latter as already complicit in forms of neoliberal governance and hence detached from wider moral and political public concerns (e.g. Burawoy, 2005, Evans 2005). In any case, questions about the extent to which the contemporary social sciences are ‘relevant’ are pervasive in the field.

Despite the aforementioned demands, it is somewhat puzzling that almost none of them emerges from any in-depth exploration of what ‘relevance’ entails, what place it occupies in the worlds that the social sciences encounter, which modes of inquiry it might require, and what kinds of habits of thought and feeling its understanding might help cultivate. ‘Relevance’ has become so ubiquitous and multifarious a demand, it has become such a ‘tyranny’—as political scientist Matthew Flinders (2013) has recently put it—that it has failed to raise any substantial, theoretical reflection on what it itself might involve. Enforced by some and dismissed by others, the notion of ‘relevance’ has become something of an empty placeholder that heralds an ideal solution to general, anonymous, and pre-existing problems. A solution whose conditions of success are said to be definable in advance, thus turning ‘relevance’ into an abstract criterion of demarcation (Fraser 2009).

That this be the case, however, is no reason to dismiss the concept. Quite to the contrary, in my view, it is an opportunity to wonder about what ‘relevance’ might come to entail while, at the same time, attempting to produce a response that may allow us to resist the tyranny that often becomes associated with its demands and to speculate about what a social science that would take the question of relevance seriously could look like. The task, then, is to take relevance seriously while not immediately complying with what the demands that are posed in its name seem to assume about it.

Indeed, the idea that ‘relevance’ constitutes a solution to a pre-existing problem (whatever the problem might be) is common to most if not all of these demands as well as to some theories that use the concept in the information sciences. Relevance appears as a value that is added to the knowledges produced by the social sciences and whose conditions of success depend upon a process of recognition performed by a public. Interestingly, such a characterisation finds some support in one of the very few theories of relevance produced within the social sciences—namely, Alfred Schutz’s (1970) phenomenological theory, which proposes that relevance be conceived as the process whereby an individual consciousness encounters an unfamiliar object within an otherwise familiar surrounding and deploys efforts to interpret it. According to Schutz, this act of interpretation, combined with the subject’s own motivations, will transform the subject’s phenomenal field and future behaviour. Now, while there might be some psychological value in such an account, to reduce the question of relevance to a theory of subjective responses is, to my mind, deeply problematic.

Such an assumption forgets something crucial—namely, that the very emergence of a ‘response’ depends upon a situation posing a perplexing question. In other words, we cannot solve the perplexity induced by the problem of how things become relevant by saying that there is a subject recognising them as such. For the very experience of worth that allows something to be characterised as relevant involves a sense that there is value beyond ourselves, that something that is not ourselves matters. Thus, to include in our interrogation of the concept of relevance the perplexing questions that may elicit responses of diverse kinds is to cease thinking of relevance as a subjective appreciation of an otherwise irrelevant problem, and to restore to it its character as an event that belongs to the world. In other words, I want to entertain the proposition that relevance is not a value that the social sciences, or their publics, ‘add’ to the knowledges the former produce, but that it already inheres, as an event and as a problem to be developed, in the situations into which they inquire. In order to entertain this second understanding of relevance I propose we begin from a simpler and more self-evident expression, one that may allow us to turn the ‘tyranny’ that is often associated with the concept of relevance into a productive constraint upon social inquiry. This is the expression that things matter.

 

Things matter

This is at once an obvious and potentially powerful proposition. However, it is also one that our habits of thought, which have taught us to distrust our direct experiences, make surprisingly difficult to grasp. We should therefore tread carefully. In this sense, the riddling character of the verb ‘to matter’ might prove instructive. To say that things matter contains a double proposition, just like the verb ‘to matter’ conveys two senses. The key is to conjoin the two senses and propositions into one. On one pole, things matters as they materialise—they come into and remain temporarily in existence, they acquire a certain stubbornness. On the other, and at the same time and by the very same process, they matter as they become relevant to some degree and in some manner. The point is that there is not one sense of mattering without the other. Indeed, to the extent that something comes into existence, its coming in(to) matter is always specific and situated, and it is that situated specificity which makes the thing what it is—even if only momentarily—and which makes it matter. Minimally, then, everything that has a determinate existence (this human, this table, this keyboard, this idea, this feeling) has some relevance by virtue of being what it is—it matters that this thing is what it is, and that it is not something else. Indeed, as philosopher Tristan Garcia (2014) has recently argued, only a generic, indeterminate ‘anything’ is what does not matter—anything is ‘no-matter-what’. Namely, it does not matter what it is.

In other words, facts exist to the extent that they come (in)to matter in specific situations, and they matter insofar as they come into existence. In this way, relevance might be said to belong to what Whitehead (1968) described as the primary experience—it should be noted, not necessarily a ‘psychological’, ‘subjective’ or even ‘human’ experience—of the actual world. Namely, a value experience whose expression is none other than ‘Have a care, here is something that matters’ (1968: 116). As he argues (1968: 111):

Existence, in its own nature, is the upholding of value intensity. Also no unit can separate itself from the others, and from the whole. And yet each unit exists in its own right. It upholds a value intensity for itself, and this involves sharing value intensity with the universe. Everything that exists has two sides, namely, its individual self and its signification in the universe.

In this way, something comes (in)to matter for itself, for other things with which it composes a situation, and for the world of things to which it becomes added. It is to this event of a coming (in)to matter, and to the problem it poses to those with whom it is concerned, that I want to associate the question of relevance.

Important implications follow from the seemingly obvious suggestion that things matter. The first implication is that the relevance of things is not something that is added to them by reason of a subjective process of recognition of worth. In contrast, relevance belongs to the world—it inheres in the nature of things. Second, if everything that exists matters in some degree and in some manner, then, conversely, everything that matters has some mode and degree of existence, even if this mode is not entirely ‘material’ or physical. This means that we should not confuse this proposition with what in recent years we have come to refer to as the ‘new materialisms‘. Not because they’re ‘wrong’, but because, in this context, such a name might be misleading—matter matters, most certainly, but so does everything that exists, somewhere, in some way or another; ideas matter, ghosts matter, words matter, feelings matter.

Third, because the coming (in)to matter of things is always situated and specific, ‘there is no such thing a bare value’ (Whitehead 1926: 90); that is, there are no pure, general, universal, values. Values too are only specific, arising within the many situations in and for which things matter in different degrees and manners. In this way, the idea of relevance cannot become a general criterion that could demarcate what matters from what doesn’t, but needs to be approached as a question for wondering about how, to what degree, and in what manner, things come (in)to matter within specific situations.

To suggest that things matter is, then, to resist the longstanding bifurcation between fact and value, a side of a many-headed monster that Whitehead (2004) famously named ‘the bifurcation of nature‘. As is well known, the bifurcation of nature consists in separating the world into two realms of reality. As Whitehead (2004: 30) phrases it, one side of this bifurcation would be ‘the nature apprehended in awareness’. The other, ‘the nature which is the cause of awareness’:

The nature which is the fact apprehended in awareness holds within it the greenness of the trees, the song of the birds, the warmth of the sun, the hardness of the chairs, and the feel of the velvet. The nature which is the cause of awareness is the conjectured system of molecules and electrons which so affects the mind as to produce the awareness of apparent nature.

We can see such a bifurcation at work in many demands for relevance: on the one hand there are the “true” and “objective”, bare facts that science discovers; on the other, there is the relevance of those facts from the public’s point of view. That contemporary demands for relevance place truth and objectivity on the first side of reality is, to be sure, no surprise. Since the inauguration of modern science, the bifurcation of nature has been key to define the ‘value-neutrality’, ‘objectivity’, and ‘truth’ of scientific knowledge.

To suggest that facts matter, then, is a way of resisting this bifurcation. It is however certainly neither the first nor the only form of resistance; it is probably not the last one either. Another prominent attempt at resisting the distinction between fact and value is, for example, Bruno Latour’s call to move from the anonymous and supposedly pure ‘matters of fact‘ of modern epistemology, to always controversial and hybrid ‘matters of concern’ or ‘things’, as he calls them after Heidegger. Latour’s (2004a: 246. emphasis in original) call was an attempt to simultaneously draw social scientists’ attention to the liveliness of objects and to draw scientists’ attention to their sociality, thereby simultaneously multiplying and distributing the many heterogeneous agencies that labour towards the making of things:

what is presented here is […] a multifarious inquiry launched with the tools of anthropology, philosophy, metaphysics, history, sociology to detect how many participants are gathered in a thing to make it exist and to maintain its existence.

While I am appreciative of Latour’s project and of his notion of “matters of concern” as a way of anchoring a different kind of social study of science, his project differs considerably from mine and, consequently, so does his way of resisting the modern distinction between facts and values.

Indeed, by inquiring into the question of relevance in contemporary social science, I am not calling anthropologists, philosophers, metaphysicians, historians, sociologists, political scientists, or psychologists to delve in to the making of ‘things’. Things matter not just because many other things converge in their making, but quite simply because their coming into existence makes a difference to the worlds they help compose—they come into matter, and they matter to them. Thus, what concerns me is the exploration of what might be required—intellectually, ethically, and politically—for social scientific practices to take up ‘relevance’ as a question of the situated patterns that organise and relate humans, other-than-humans, ideas, feelings, and so on in ways that matter for those with which a problematic situation might be concerned. What I am interested in is not so much a different job description for social inquiry, but the possibility of a different ethos of social inquiry that would seek to negotiate the question ‘how is it, here, that things matter?’, without imposing on the ‘thing’ either a specific nature or a number in advance, and without singlehandedly delimiting the horizon that defines where ‘here’ ends.

As a taster of what is a much longer project, I will just say that the key to this question is that any possible answer be negotiated in practice. Whenever a social scientist encounters a problematic situation as an object of inquiry, it is not simply her practice that makes that situation ‘matter’. Rather, the situation is already constituted by an ecology of dynamic and fragile patterns of relevance, heterogeneous objects and relations, to which her questions, her assumptions, theories, and methods, in sum, her mode of knowledge-production become added. Such an addition, to be sure, is never innocent, that is, it has effects—it affects the ecology of such patterns in different ways. Thus, the point is that ‘negotiation‘ means neither that it is her questions or methods themselves that, as it were, produce that ecology out of thin air, nor that her goal is that of discovering the relevant way of defining the problem that characterises the situation as if such a way could be said to fully preexist the questions themselves. By contrasts, problems are always a matter of ‘invention’—a notion that, in my reading, conjoins discovery and creativity. Isabelle Stengers (1997: 6) expresses the nature of a negotiation of relevance with notable clarity in the case of experimental sciences when she argues:

What is noteworthy about ‘relevance’ is that it designates a relational problem. One speaks of a relevant question when it stops thought from turning in circles and concentrates the attention on the singularity of an object or situation. Although relevance is central to the effective practices of the experimental sciences, in their public version it often boils down to objective truth or arbitrary decision: to objective truth when the question is justified by the object in itself, and to arbitrary decision when it refers to the use of an instrument or experimental apparatus whose choice is not otherwise commented on. In the first case, the response appears to be “dictated” by reality. In the second, it appears to be imposed by the all-powerful categories of which the investigative instrument is bearer. Relevance designates, on the contrary, a subject that is neither absent nor all-powerful.

Thus, the question of relevance is one which affects the modes by which social scientific practices interrogate and negotiate how things come (in)to matter—it is a question that makes social scientific inquiry into a risky process. In this way, relevance should be understood as a problem that affects the very situated exchanges that make every answer dependent upon the question that calls for it, and every solution to a problem dependent on, or deserving of, the manner in which the problem is defined (Deleuze 1994). For every definition of a problem guiding inquiry and every question that may point to an unknown that a scientific practice of knowledge-making may seek to address also produces a pattern of contrasts that productively constrains the range of possible answers that might matter to it.

Nothing guarantees, however, that the pattern of contrasts will address the object in a manner that matters to it, her, or him. If relevance is to become capable of affecting the manner of directing practical inquiries in the social sciences, of feathering the arrow of questions in a way that matters for those to whom the questions are posed, then the term cannot designate, ex post, or worse, ex ante, the effect that a knowledge-product has in relation to the public to which it may be communicated. Relevance needs to be thought as an active constraint upon practice—a constraint that forces social scientists to put the pattern of contrast that a question generates, that is, the assumptions that underpin it, at risk.

 

Martin Savransky is currently Teaching Fellow in Sociology of Science and Technology at the Department of Science and Technology Studies, University College London, and Researcher at the Department of Sociology, Goldsmiths, University of London. Prior to this he was Whitehead Scholar at the Centre for the Study of Invention and Social Process (Goldsmiths). He works at the interdisciplinary intersection of process philosophy, STS, and the philosophy of social science, with a focus on the ethics and politics of inquiry of the contemporary social sciences and the humanities. He is currently preparing a monograph, based on his doctoral research, on relevance and a speculative ethics of inquiry for the social sciences.

 

Note

This is a slightly revised version of a talk delivered in Barcelona in July 2014, organised by the STS-b group at the Open University of Catalonia (I especially want to thank Daniel López, Israel Rodríguez-Giralt, Tomás Sánchez Criado and Manuel Tironi for their responses to the paper). The text has been mostly left as originally presented, and therefore reflects an oral style of presentation, with no ambition of peer-reviewed accuracy. As such, it constitutes no more than a snippet of a book-length research on the development of a new ethics of inquiry for the contemporary social sciences oriented by the question of relevance.

 

References

Burawoy, M. (2005) ‘For Public Sociology’. American Sociological Review, 70(1), 4-28

Deleuze, G. (1994) Difference and Repetition. New York: Columbia University Press.

Evans, M. (2005) Killing Thinking: The Death of Universities. London: Continuum.

Felt, U. (2014) ‘Within, Across and Beyond: Reconsidering the Role of Social Sciences and Humanities in Europe’. Science as Culture, 23(3), 384-396

Flinders, M. (2013) ‘The Tyranny of Relevance and the Art of Translation’. Political Studies Review, 11(2), 149-167

Fraser, M. (2009) ‘Experiencing Sociology’. European Journal of Social Theory, 12, 63-81

Garcia, T. (2014) Form and Object: A Treatise on Things. Edinburgh: Edinburgh University Press.

Gibbons, M., Limoges, C., Nowotny, H., Schwartzman, S., Scott, P., & Trow, M. (1994) The New Production of Knowledge: The Dynamics of Science and Research in Contemporary Societies. London: Sage.

Latour, B. (2004) ‘Why Has Critique Run Out of Steam? From Matters of Fact to Matters of Concern’. Critical Inquiry, 30(2), 225-248

Mayer, K., König, T., & Nowotny, H. (2013) Horizons for Social Science and Humanities: Conference Report. Vilnius: Mykolas Romeris University Publishing.

Nowotny, H., Scott, P., & Gibbons, M. (2001) Re-Thinking Science: Knowledge and the Public in an Age of Uncertainty. Cambridge: Polity Press.

Rappert, B. (1999) ‘The Uses of Relevance: Thoughts on a Reflexive Sociology’. Sociology, 33(4), 705-723

Schutz, A. (1970) Reflections on The Problem of Relevance. New Haven: Yale University Press.

Stengers, I. (1997) Power and Invention: Situating Science. Minneapolis, MN: University of Minnesota Press.

Vilnius Declaration (2013) ‘Vilnius declaration—horizons for social sciences and humanities’. Available from http://horizons.mruni.eu/vilnius-declaration-horizons-for-social-sciences-and-humanities [Accessed July 2014]

Whitehead, A. N. (1926) Religion in the Making. Cambridge: Cambridge University Press.

Whitehead, A. N. (1967) Adventures of Ideas. New York: Free Press.

Whitehead, A. N. (1968) Modes of Thought. New York: Free Press.

Whitehead, A. N. (2004) The Concept of Nature. Mineola, NY: Dover Publications.

Treating the Sick Continent, Top of the Heap with Warwick Anderson by Maria Cecilia Dedios

8 Octobre 2014 - 9:15am

For this installment of the Top of the heap we spoke to Warwick Anderson, Professor at the Department of History and Centre for Values, Ethics and the Law in Medicine at the University of Sydney, and an Australian Research Council Laureate Fellow.

 

Warwick Anderson

Having written provocatively—and somewhat irritatingly, it seems—on the impossible history of global health already this year, perhaps I should wait till the dust settles before broaching the topic again. But in a time of Ebola, that obscure object called global health demands further critical attention. We need to know what to expect from global health in the current emergency. Accordingly, over the past few weeks I’ve set about reading, and reading again, some recent books that might come under the rubric of global health history. In general, I’ve found that the most compelling accounts of global health manage to localize medical interventions: they examine the messy and often confusing, even conflicted, interactions of foreign doctors and aid-workers, domestic and traditional health practitioners, and their patients. No surprise, then, that historically sensitive anthropologists, rather than medical historians, have written many of the more plausible of these situated narratives. An ethnographic sensibility appears to be a requirement for understanding global health—for explaining its past as well as contemporary forms. I’m also struck by the prevalence of “crisis” in the discourse of global health, whether in reference to humanitarian crises or biosecurity crises. Thus the acute timescale of global health (which often proves more rhetorical than practical) seems distinct from the chronicity of late-colonial medicine, and other programs of development and modernization—indeed, from normal public health. Perhaps those who are anthropologically minded can deal better with “crisis talk” than most historians.

If recent case studies are a reliable guide, then Africa has emerged as a sort of laboratory for global health. In the late-nineteenth century, Henry M. Stanley (1878) described his journeys through the “dark continent”; but in the 1980s, Africa became known as the “sick continent”—Gwyn Prins in 1989 must have been among the first scholars to use the term. The obvious prompt was the HIV/AIDS epidemic ravaging African societies. All the books I’ve read over the past few weeks imply that global AIDS became the major incitement to global health—and Africa was regarded as the seedbed and prime grounding for AIDS. Of course, a few telling supplements to the African global health story are now emerging to complicate it, especially studies like Elizabeth F.S. Roberts’ God’s Laboratory (2012), located in Ecuador, and Alice Street’s forthcoming Biomedicine in an Unstable Place (2014), set in Papua New Guinea. One might even re-interpret Paul Farmer’s early work on Haiti as providing an alternative Caribbean story for global health. But Africa evidently is global health’s hot zone.

In just a few years, Julie Livingston’s Improvising Medicine (2012) has become a classic among studies of global health. As most readers of Somatosphere are aware, Livingston, trained as a historian, describes movingly the conditions of life and death on Botswana’s sole dedicated cancer ward—the chapter on the moral intimacies of nursing care is stunning. Writing in the aftermath of AIDS, she uses ethnography to complicate facile diffusionist or triumphalist accounts of global health: this is not, she tells us, one of those “tales of redemption via biomedicine that make up the fantasies of global health” (p. x). And yet, she concludes, the cancer ward is nonetheless “an instantiation of global health” (p. 181), perhaps in the very failure of its sovereign claims. For me, however, Livingston’s interruptions to address North American and European readers, to appeal to their sensitivities, mar this excellent evocation of global health’s decomposition in Africa. Despite this redolence of Margaret Mead, Improvising Medicine brilliantly shows us how ethnography can contribute to the postcolonial critique of the ambitions –and hubris- of global health. It therefore sits on my bookshelf next to Clare Wendland’s A Heart for the Work (2010), that revealing ethnography of a Malawian medical school.

Stacey A. Langwick in Bodies, Politics, and African Healing (2011) engages with the “postcolonial ontological politics” of medical experts and their patients in Tanzania. Her study of the interaction of traditional and modern medicine makes visible a range of new entities, from “enchanted parasites” to “biomedical devils” (p. 7). Drawing artfully on postcolonial science studies, Langwick demonstrates the continuing colonial shaping of hybrid healing practices in East Africa, thereby complicating and challenging notions of global health. The word “colonial” appears in this book far more frequently than “global.” In Scrambling for Africa (2013), Johanna Tayloe Crane takes even further the postcolonial critique of the supposedly laminar flows of global health. In this extraordinary transnational ethnography of Ugandan AIDS clinics and medical laboratories in San Francisco and Seattle, Crane shows how global health programs extract value from neocolonial structural inequalities. Disease-centered global health projects can displace and thus cripple local public health systems. North American universities divide up Africa as they scramble for “clinical material” for their global health programs. While not discounting the good that comes from many interventions, Crane reveals the dark side of North American and European humanitarianism.

Many of the anthropologists who contributed to Ruth J. Prince’s and Rebecca Marsland’s edited collection, The Making and Unmaking of Public Health in Africa (2013), also argue that public health must be studied on the ground, not through the sovereign telescope of global health. Too often, Prince explains in her introduction, from that distant viewpoint estimates of health are “reduced to survival needs, and public health care provision is reduced to a technologically driven humanitarian intervention” (p. 31). Prince explicitly criticizes what is sometimes a “pharmaceutical paradigm of health” (p. 33). In contrast, these critical studies of the terrain of public health in Africa trace the legacies of colonialism, developmentalism, and modernization theory. Another collection of essays, Global Health in Africa (2013), edited by Tamara Giles-Vernick and James L.A. Webb, Jr., also addresses the colonial antecedents of global health and emphasizes the impact of the AIDS epidemic—but I expect its functional tone will prove far more appealing to global health faculty and students in U.S. medical schools.

In Life in Crisis (2013), anthropologist Peter Redfield recounts sympathetically the history of Médecins sans Frontières since its foundation in 1971, post-Biafra. His book is an ethnographic Bildungsroman: it is the story of the self-formation of a global humanitarian organization, the growth and institutional condensation of a worldwide emergency sensibility. Redfield uses this story to examine globalization on the ground in Africa. He tries to subvert the view from the Land Cruiser as much as the view from Paris. At one point he asks if MSF’s prized mobility had fostered disconnection from the devastated communities it serves: “Had MSF simply devolved into a neocolonial enterprise?” (p. 133). Redfield charts the painful steps that its staff took toward “decolonization” early in this century, the hard-won benefits of interrogating and deconstructing colonial legacies.

And now I’m about to turn to Renée Fox’s Doctors Without Borders (2014)….

As you no doubt can tell, my reading over the past two weeks has been as depressing as it is illuminating—particularly in the light of the Ebola epidemic, which is both human tragedy and, increasingly, global health debacle.

 

Warwick Anderson is an Australian Research Council Laureate Fellow and Professor at the University of Sydney. His most pertinent contribution to what might loosely be called global health history is The Collectors of Lost Souls: Turning Kuru Scientists into Whitemen (Baltimore: Johns Hopkins University Press, 2008). For a recent attempt to use postcolonial studies to reframe global health see “Making Global Health History: The Postcolonial Worldliness of Biomedicine,” Social History of Medicine 27 (2014): 372-84.

 

Image: ‪White Library, Wilfredo Prieto. MONA, Museum of Old and New Art, Hobart, Tasmania, Australia.‬

CFP: Cascadia Seminar, April 24-26, 2015 in Seattle by Janelle Taylor

8 Octobre 2014 - 5:28am

The Cascadia Seminar: Ethnographic Adventures in Medical Anthropology

http://cascadiaseminar.wordpress.com/

April 24-26, 2015
at Seattle University and the University of Washington
Seattle, Washington

Plans are underway for the 3rd Cascadia Seminar!  The Cascadia Seminar is a small, intimate, high-interest, low-cost weekend conference organized collaboratively by medical anthropologists on faculty at a number of different universities and colleges in the US Pacific Northwest and British Columbia (the Cascadia region), rotating among our various institutions. Previous Cascadia Seminars (at the University of Washington in 2011, and at Simon Fraser University in Vancouver BC in 2013) have proven this model to be successful in creating a new kind of intellectual space for medical anthropology.

Harriet Phinney of Seattle University is hosting the 3rd Cascadia Seminar, with assistance from Janelle Taylor of the University of Washington. Medical anthropologists (from everywhere) are invited to submit abstracts. Please send your abstract (350 words maximum) by November 7th, as an electronic attachment to cascadiaseminar@gmail.com. Abstracts will be reviewed by a committee of medical anthropologists on faculty at our various institutions, all of whom also plan to attend. The committee will select seven abstracts, seeking papers that promise to be ethnographically rich and intellectually exciting.  Decisions will be announced by December 19th.

The Cascadia Seminar will begin the evening of Friday April 24th with a keynote address at the University of Washington by Mette Nordahl Svendsen (University of Copenhagen). The rest of the weekend conference will be held at Seattle University. Four papers will be presented on Saturday April 25th, and three on Sunday April 26th, with no concurrent sessions. Each paper presenter will have forty-five minutes to present a substantial, well worked-out paper, with ample time for lively discussion. All participants will attend all papers, and optional no-host meals together will offer additional opportunities for conversation. The Simpson Humanities Center at the University of Washington will sponsor a reception following the keynote address, and Seattle University will sponsor coffee and snacks during the weekend sessions. The organizers gratefully acknowledge additional support from UW Seattle’s Department of Anthropology, the Program in Comparative History of Ideas, the Program on Values of the Department of Philosophy, and the UW Bothell’s School of Interdisciplinary Arts and Sciences.

The conference will be free of charge, though preregistration will be required in order to keep numbers manageable. Some people may want to stay with family or friends in the Seattle area; a block of rooms will also be available at a reduced rate at a nearby hotel.

We look forward to a stimulating & fun weekend!

Review Committee:
Kirsten Bell (U of British Columbia)
Leslie Butt (U Victoria)
Johanna Crane (UW-Bothell)
James Pfeiffer (UW-Seattle)
Stacy Pigg (Simon Fraser U)

Host / Organizer:
Harriet Phinney (Seattle University), with assistance from Janelle S. Taylor (University of Washington)

(See the website for live links to preregistration and more information)

Aslihan Sanal’s New Organs Within Us by Elizabeth DeLuca

7 Octobre 2014 - 9:15am

New Organs Within Us: Transplants and the Moral Economy

by Aslihan Sanal

Duke University Press, 2011. 244 pp.

 

Sensitively written and deeply insightful, Aslihan Sanal’s ethnography of kidney transplantation in Turkey in the 1990s and 2000s is an intimate stitching of life histories, national and institutional narratives, and shifting meanings of life, death, and the body. Sanal takes the book’s beautifully multivalent title from a Goethe quotation about the psychic imbrication of external and inner worlds, foreshadowing her deep engagement with the psychological and her attention to realms of uncanny, unsettling experience. These “new organs within us” stand at once for bodily organs that are donated and transplanted, the creation of organ transplantation as an ethical and viable medical technology, and the psychic and bodily transformations of her informants in their personal and social lives. Sanal terms this complex topography a biopolis, a “universe” of technologies made local and personal (11). New Organs Within Us makes a unique contribution to a rich literature on how organ transplantation is made commensurable with cultural and religious cosmologies through the book’s unique attention to the ways these processes of commensuration leave residues of uncertainty and excess in individual and shared psychic worlds.

The book is divided into two parts titled “The Desirable” and “The Impossible.”  Topically, Part One approaches the life histories of six Turkish transplant patients as well as an institutional history of transplant technologies and biomedical ethics in Turkey told by medical professionals. Part Two follows what Sanal calls “a geneaology of life-less objects all stemming from efforts to utilize the human body for medical ends: the suicide, the insane, the cadaver, and the sacrifice” (109). Together, these careful explorations address the book’s most explicit question: How did the transplant of cadaveric organs, once considered impossible in light of Muslim notions of a body on loan from God (emanet), become something to be desired? The concept of the biopolis allows her to speak at once of the ethical and epistemological landscapes forged through technology as well as the personal and social psychic spaces that make these shifts possible. Object relations theory from psychology and a subtle reworking of van Gennep’s rites of passage allow her to present organ transplantation as a ritual at multiple social scales: A young woman whose organs are harvested after she commits suicide becomes a posthumous hero for her sacrifice to the social body. Years later, seeking eternal solitude, another woman’s suicide note asks that her organs be left unharvested, to be allowed to “rot” along with her buried corpse.

Just as important to the unfolding of the “impossible” and the “desirable” is the uneasy relationship between the “known” and the “unknown”. Sanal uses these words in italics to track throughout the book the persistence of a deep entanglement between transplant organs and shadowy spaces “full of invisible beings and forces – ghosts, jinn, terror, oppression” (94). The unknown endures even as living and cadaveric organ transplants become logistical and ethical possibilities. As emerging technologies do boundary work on the realms of the known and the unknown, patients often find themselves deeply destabilized by their engagement with the biotechnological biopolis; a man cannot explain why he became violent towards the wife who donated him her kidney, a young woman question her religious beliefs and biological relationship with her family. Even surgeons and anatomists whose entire careers focused on making transplantation a locally acceptable and viable practice are not immune from experiencing the uncanny shadows of the unknown. A particularly innovative and compelling way Sanal represents this only partly exposed world of the unknown is by populating her biopolis with narratives and other discursive forms such as Islamic law, linguistic idiom, and writing and performance forms such as poetry and theatre. Most memorable is her discussion of artist Nazif Topcuoglu, whose work incorporates animal blood, organs, and bodies into social commentary. Here, Sanal subtly brings together the threads woven throughout the text by finding them in Topcuoglu’s artwork: the arresting uncanniness of the cadaver, the double entendre of sacrifice for God and the social body, and the rich social life of organs.

Narratives of the Turkish nation and its medical institutions are also woven through this story of transitions to possibility. It is here that her literary style is most in tension with the complexities of these histories; a historian or anthropologist of Turkey may desire a more fine-grained accounting of the events and trajectories that emerge through the text. At times it seems that the biopolis may be doing work for the unnamed concept of culture. Yet it seems to me that Sanal presents these national and institutional histories as something more like a life history than as empirical claims for certain kinds of Ottoman and Turkish pasts. Instead, she seems to present these histories as they may emerge in the field, that is, as parts of the dominant narratives comprising the topography she wishes to sketch. In this way, her literary style leaves open the possibility of complexity even as it may at times seem to obscure it.

In Sanal’s biopolis, bodies – living or dead, or somewhere in between – always exceed the scientific and religious spaces that work to contain them. Each current of life is handled with care, presented to the reader as deeply contextual as it is followed through transforming social and technological landscapes. New Organs Within Us therefore lays a powerful foundation for future contributions at the intersection of psychological anthropology, the anthropology of religion and ethics, and the anthropology of medicine and technology. The text almost threatens to burst at the careful seams that bring together these entanglements, yet the book thrives in this very tension. This bulging at the stitches helps convey complex imbrications of life, death, body and medicine while allowing for the uncertainty that runs throughout. True to her dedication to explore the excess in these processes of cutting and transforming, to attend to the ways in which technologies are incorporated through processes of social and personal internalization, this book cannot be simply dissected. It must also be felt.


Elizabeth DeLuca is a PhD student in Anthropology at the University of California, Irvine. Her main research involves aging and affective caretaking labor in Istanbul, Turkey in the context of health care privatization and biomedical treatment for Alzheimer’s Disease.

On gloves, rubber and the spatio-temporal logics of global health by Uli Beisel

6 Octobre 2014 - 7:24pm

On the 5th of September, 2014, the blog Konakry Express recounted a report from Mme Fatou Baldé Yansané that there are severe shortages of gloves in health facilities in Guinea. Mme Baldé Yansané writes that midwives have only one or two pair of gloves each week. As a consequence, they have to reuse gloves or merely rub their hands with chlorine after consultations. This message was written over five months after the WHO’s confirmation of an Ebola outbreak in Guinea on their webpage. When I read the blog piece, I was completely stunned: how could it be that five months after the outbreak had entered the world stage, the simplest and cheapest personal protective equipment was still missing in health facilities in the subregion?

Sadly, this is not an isolated incidence. Drew Hinshaw from the Wall Street Journal reports this heartbreaking scenario from Sergeant Kollie Town, Liberia in August:

“Rubber gloves were nearly as scarce as doctors in this part of rural Liberia, so Melvin Korkor would swaddle his hands in plastic grocery bags to deliver babies. His staff didn’t bother even with those when a woman in her 30s stopped by complaining of a headache. Five nurses, a lab technician—then a local woman who was helping out—cared for her with their bare hands. Within weeks, all of them died. The woman with a headache, they learned too late, had Ebola.”

There is a particular irony to the story of missing gloves in Liberia, as the country is also home to the “largest single natural rubber operation in the world”, Firestone Natural Rubber Company. Although Liberian rubber is mainly used in Bridgestone car tires, the company says it also supplies rubber to companies manufacturing “vital medical components”, such as the latex gloves desperately needed in health facilities in the region. However, latex products are not manufactured in Liberia, the natural rubber is only harvested in Liberia and then shipped elsewhere for production—an all too familiar story of natural resource extraction on the African continent. A timely reminder too that not only are troubling racial immuno-logics at play, but that the epidemic is also deeply rooted in colonial histories of expansion and extraction (for a wonderful piece on the history of the Firestone Plantation and the crucial role science and medicine played in its establishment see Mitman and Erickson, 2010).

The lack of gloves is another reiteration of these violences and inequities, but this time refracted through the contemporary configurations of ‘global health’. How can it be that after decades of unprecedented financial investments in healthcare in developing nations, and in particular on the African continent, health facilities are still missing the most basic supplies?

Medical anthropologist James Pfeiffer has, in a recent podcast of Humanosphere, brilliantly analyzed the problems that Structural Adjustment Programmes and the logics of the aid industry more generally have created for health systems in economically poor countries. I do not want to rehash those important points here again; please check out the podcast directly for that. Instead, I want to focus on the temporal and spatial logics of global health that underlie many of the processes James describes.

Over the last decades and not least through the UN’s Millennium Development Goals, health initiatives have received unprecedented attention and funding, and many advances have been made. However, together with the MDGs came a particular framing of health and health interventions. The MDGs name HIV and malaria (‘and other diseases’), as well as malnutrition, child mortality and maternal health as priorities, and this has real-life consequences for policy and funding decisions. HIV, malaria and tuberculosis still receive the biggest share of the funding. Additionally, all MDGs have clear numerical aims: e.g. “reduce child mortality by two-thirds, between 1990 and 2015”. This clear-cut numerical focus has performative effects, as it renders health and progress measureable and accountable, and so – it is assumed – keeps momentum going and funders on board. However, it has also meant that we have in recent years overwhelmingly focused on vertical, single–disease interventions. The rationale behind this is exemplified by a statement from Melinda Gates in 2007, when she introduced the Gates Foundation’s focus on malaria eradication: “And because we can’t fix the whole health care system in all of Africa, (…) the only way to end death from malaria is to end malaria”. For many, the focus on vertical interventions and technological fixes was, and continues to be, pragmatic: the promise is that with the appropriate tools and benchmarks, progress can be measured and the messy realities of international politics and local infrastructures circumvented for more effective results. This has led to a proliferation of vertical disease projects, many of them hybrids involving international donors, NGOs, public-private ventures, research and data collection enterprises. Social studies of global health have shown that this has led to a fragmentation of health care provision, which in turn has resulted in massive uncertainties for patients. In many places it is difficult for patients to determine where medications and care are currently available. Spatially, the logic is one of parachuting specific interventions into selected places. It not only leaves out many places, but also many diseases and illnesses. It is a logic of patchworks, adjuncts and circumvention, or an ‘archipelago of care’ (Geissler, 2013; Rottenburg, 2009).

The temporal imaginary of global health contributes to this dynamic. Interventions are not only patchy, but they are also time-limited. Today most come in the form of projects, a process that has been discussed as ‘projectification’ (Whyte et al., 2013). Under the label of evidence-based medicine, new intervention strategies and technologies are trialed, scaled-up and then all too often handed-over to Ministries of Health that lack the financial and operational means to sustain the interventions (note, most Ministries of Health do not lack the expertise!).

West Africa’s Ebola epidemic all too painfully shows that this spatio-temporal logic of patchy, vertical and time-bound projects has significant shortcomings. Health care infrastructures cannot be circumvented when one aims to improve health care sustainably.[1] Well-functioning infrastructures are flexible and adaptive, able to change gear and respond to shifting disease landscapes. Just like the harvesting of rubber and the production of gloves, they are rooted in history and configured in specific political economies. The predominant logic in global health is based on and has led to an impoverished understanding of health and wellbeing. We assume we know which diseases and ailments are relevant and crucial to address. Ebola teaches us that we are well advised not work from this bold assumption. A humble version of Socrates’ classic “I know that I know nothing” seems to be a better guide to navigating complex and rapidly shifting disease landscapes. The lack of gloves, personal protective equipment and skilled personnel in West Africa’s health facilities is not only a result of war or weak states, but also of the spatio-temporal logic of global health, and it presents us with an urgent call for change in global health approaches and logics.

 

 

Uli Beisel is Assistant Professor of Culture and Technology at Bayreuth University. She has worked on human-mosquito-parasite intertwinings in malaria and its control in Ghana and Sierra Leone, where she was particularly interested in how we live together with organisms that are harmful to human health. Her current work focuses on translations of new health technologies in global health initiatives, and their relation to uneven geographies of access to health care in Uganda and Rwanda.

 

Acknowledgments

Thanks to Ann H. Kelly for feedback on the draft and encouragement.

 

References

Geissler, P. W. (2013). The Archipelago of public health. Comments on the landscape of medical research in 21st century Africa., In Ruth Jane Prince & Rebecca Marsland (ed.),  Making and Unmaking Public Health in Africa: Ethnographic and Historical Perspectives.  Ohio University Press.  pp.231 – 256

Mitman, G. and Erickson, P. (2010). Latex and Blood: Science, Markets, and American Empire. Radical History Review 107 (2010): 45-73

Rottenburg, R. (2009). Social and public experiments and new figurations of science and politics in postcolonial Africa. Postcolonial Studies 12 (4): 423-440.

Whyte, S. R., Whyte, M.A., Meinert, L. and Twebaze, J. (2013) Therapeutic Clientship: Belonging in Uganda’s Mosaic of AIDS Projects. In J. Biehl and A. Petryna (eds.) When People Come First: Anthropology and Social Innovation in Global Health. Princeton: Princeton University Press. pp.140-165

 

Note

[1] The global health community started to learn this lesson and health systems strengthening has started to receive more support and funding. However, most HSS initiatives still happen within the logic and institutional frameworks of vertical, numerical interventions, and are thus limited in their scope and reach.

 

Ebola and emergency anthropology: The view from the “global health slot” by Crystal Biruk

3 Octobre 2014 - 9:16am

Hoses spraying disinfectant, white spacesuits, and police roadblocks: these are the tangible technologies of expertise in West Africa. Amid images of ongoing efforts to contain Ebola, I find myself asking: What is the role of the medical anthropologist in a global health emergency? What expertise can we contribute? As of 1 October 2014, the World Health Organization (WHO) counts 7178 reported cases of Ebola, and 3338 deaths. On 8 August 2014, the WHO authoritatively declared the Ebola epidemic an “extraordinary event” and indicated that conditions for a public health emergency of international concern (PHEIC) had been met. The New York Times suggests that Ebola cases could top one million within four months. Meanwhile, Sierra Leoneans have been quarantined or put under lockdown and curfew to curtail the spread of the virus. The rhetoric of emergency, that familiar anchor of compassion, is not new, but nonetheless urgently calls upon us to do, to act, to document, and to intervene in this present crisis (Fassin and Pandolfi 2010:16).

By nature (or culture), however, anthropology is slow, tedious, and careful; these descriptors gain currency in their juxtaposition with the fast-paced and urgent nature of global health. Yet, our species of cultural expertise is in demand. The rise of a global health industry has furthered the institutionalization of medical anthropology in the past decade. The relatively large number of medical anthropology faculty jobs available in recent years and the demand for seats in our classes suggest that the sub-field is a “hot” one. We have carved a (small) niche as expert global health commentators and practitioners: our classes “enhance” and “complement” medical school or pre-med curricula by instilling in future scientists, doctors, and public health workers an anthropological approach to health, the body, and intervention. Anthropologists of global health have come to occupy a clear compartment in a wider discursive field: recalling Trouillot’s “savage slot” (1991), we might term it the “global health slot.” As anthropology emerged as a discipline, it established a monopoly over speaking about “primitive” people. Returning to Trouillot’s work, Joel Robbins (2013) argues that anthropological production today is driven by “suffering slot” ethnography, which centers the subject living in pain, in poverty, or under conditions of oppression. Celina Callahan-Kapoor reminds us that as medical anthropologists, our ethnographic accounts emerge from and reinforce a kind of medicalized savage slot. Here, I use the phrase “global health slot” to draw attention to two things. First, the work produced by anthropologists of global health—even as it speaks to authors’ moral and epistemological commitments—attains value in a wider discursive and economic field, here, “global health.” Second, although the kinds of subjects (people) that appear in our work reflect our discipline’s investments, we might also consider how these subjects are always already illuminated against the objects they move through, negotiate, come up against, and are narrated by (here, global health and its anthropologists).

How might the turn to global health work to separate scholarly analysis from the specificities of local history and politics? What implications does our own embeddedness in the very offices and economies we critique have for the knowledge we generate? The unfolding Ebola epidemic sparks these questions for me, although I think they point to issues that anthropologists of global health face even in “non-emergency” times (if any remain).

 

The “global health slot”

The emergency of Ebola in West Africa, and the global health slot I have been describing, compels medical anthropologists, if not to “do” something, to “say” something. Rightly so, I think, anthropologists have long blurred the lines between these verbs, resisting the overwhelming pressures to “align, to be useful, to be active in regimes of intervention” (Marcus 2010:373). Yet, Ebola is a tragedy that cuts across almost all of the commitments shared by anthropologists of global health, science, and medicine: it exposes the political economy of health and illness; it illustrates flows and stoppages that direct the mobility of science and technology; it brings to light the shortcomings of “quick fix” or magic bullet solutions to structural problems; it draws attention to the health consequences of reconfigured social relations produced by health and development regimes of governance; and it tragically accentuates the racialized logics that have long determined which lives “count.” Some anthropologists are right now on the front lines of the epidemic, and Sharon Abramowitz recently compiled a concise list of ten real things anthropologists can do to fight Ebola in West Africa. Action-oriented approaches are crucial in times of emergency, and I concur that ethnographic expertise would likely improve the response in West Africa. However, my interests in this essay center on more humble and mundane kinds of “doing”: writing, thinking, and teaching about an unfolding epidemic to various audiences, including ourselves.

As a bystander in Ohio to an epidemic taking place in West Africa, I’ve been jotting down notes, collating articles documenting the unfolding events, following Twitter, and discussing Ebola with students and colleagues. In August, I sat down and spent a day trying to get some thoughts on paper; like many of you, I was horrified by both the epidemic’s toll and media coverage of Ebola. I wanted to place accounts of riots, mistrust, and violence amid Ebola in historical context. I wanted to question the turn to “informed consent” as the bottom line of global research ethics through close analysis of the tragic decision not to give a Sierra Leonean doctor the Zmapp serum. I found myself balancing the compulsion I felt—as a medical anthropologist and a “Malawianist”—to say something, and my hesitance to graft theoretical frameworks I’ve been socialized into on to places I have never been to. I felt unsettled by: 1) My impulse to rely on comparative ethnographic data and theoretical packaging in my analysis; 2) My willingness to speak from a general position—as an anthropologist of global health—about particular places. The latter, especially, felt too “global health-ish.” In other words, I feared that my reading might overlook the significance of small-scale organization and phenomena, in its emphasis of large-scale social patterns common to “Africa.”

To probe my own discomfort, I thought it might be interesting to excerpt from the essay I wrote back in August in order to subject it to a critical re-reading. Maybe you can help. I imagined a general audience (of non-anthropologists), but it was precisely in re-reading what I wrote that I felt that sharing it publicly might generate more questions than answers, and might do injustice to what I see as the potential of an rigorous anthropology of global health. In staging a reading of my own words, I hope to encourage medical anthropologists to occupy the global health slot more ambivalently and to push forward readings that seem to apply everywhere and anywhere to more effectively capture the particularities of place. I hope my essay can serve as a platform for pondering what might be the goals of anthropology in an emergency, and for serious consideration of the promises and pitfalls of the global health boom for anthropology.

 

“Angry mobs” and “Ebola is not real!”

Let’s look at an anthropological reading of violence leveled against doctors, clinicians, and those trying to manage and contain the epidemic in West Africa. This reading is symptomatic of my own occupation of the “global health slot;” you might imagine yourself or a colleague making similar points for a general audience (and certainly, many anthropologists have):

If you have been following the epidemic, you will recall that on 17 August 2014, BBC reported that an “angry mob” attacked a health center in Monrovia’s densely populated West Point township, with some suggesting the protesters were unhappy that patients were being brought in from other parts of the capital, others shouting “There’s no Ebola!,” and still others believing that Ebola is a “hoax.” “Ignorance is high and many people are reluctant to cooperate with medical staff,” suggested health experts. In his depiction of the situation on the ground, Sierra Leonean journalist Umaru Fofana describes how his colleague watched relatives of Ebola patients “pelt the hospital with stones;” he goes on to bemoan conspiracy theories and denialism, and explains how locals are blaming medical workers for the disease. On 20 August 2014, journalist Norimitsu Onishi, writing for the New York Times, documented “clashes” in the same neighborhood where the patients escaped on 18 August, “hurling rocks” and “storming barricades.”

These outbursts of anger and outrage, and the physical violence they engender, have largely been read in the mainstream press as spontaneous violent reactions to those “who are only trying to help” (cf. accounts of the protests and “clashes” in Ferguson, Missouri). Claims that “There is no Ebola!” or beliefs that medical workers are bringing rather than managing Ebola are read as tragic expressions of African ignorance and irrationality. Such accounts prompt even a critical reader to bemoan the persistence of irrational beliefs in conspiracy theories, witchcraft, and superstition; these beliefs are taken to be a major obstacle to the rational and scientifically proven interventions and efforts to contain and manage Ebola. “Culture” explains these beliefs, just as it takes up much space in WHO guidelines that emphasize “funerals and burials” and “misperceptions” and misinformation as issues to be dealt with in the ongoing fight against Ebola. (We should note that a recent Harvard poll shed light on “misperceptions’ of the virus within the US: More than 25 percent of a sample of Americans said they were concerned than they or someone in their immediate family might contract Ebola in the next year, and 39 percent were concerned there would be a large Ebola outbreak in the US in the next year). While there are real transmission risks associated with funerary practices in West Africa, and with circulating “misinformation” about Ebola, I draw your attention to how, in all of the above statements, “culture” in the time of crisis is always already pathological, irrational, non-innovative, and bad.

As we consume representations of angry Africans hurling stones at intrepid health workers, we must consider such events not as out-of-the-blue clashes between irrationality and rationality, but as symptoms of underlying tensions between insiders and outsiders, the researched and the researchers, the poor and the rich, and the immobile and the mobile. These interactions are not new, even if they are made more visible to us by the spectacular and horrifying real time documentation of Ebola’s travels: blood soaked mattresses, angry mobs, and feces covered floors.

Anthropologists and historians have long taken conspiracy theories and rumors across sub-Saharan Africa (and elsewhere) not as mere silly “stories” but as reservoirs of information about the particular kinds of unequal and often exploitative relations between outsider-led projects and local people and places. In her book Speaking with Vampires: Rumor and History in Central Africa, for example, historian Luise White (2000) documents and analyzes colonial-era rumors and conspiracy theories in East and Central Africa, viewing them as viable sources of historical insight about the fraught relations between ruler and ruled. These stories are not so different from those circulating right now in West Africa that accuse health workers of bringing Ebola; the ‘rumors’ White documents accused game rangers of capturing Africans, mine managers of keeping them in pits, or firemen of subduing Africans with injections. In 2007-08, I documented similar kinds of stories in rural Malawi that accused foreign researchers collecting survey data of being “bloodsuckers” (opopa magazi) who steal blood and information from them. Archival sources from 1930s Malawi (then Nyasaland) indicate that health campaigns, surveys, and vaccination efforts were often stymied by similar rumors, dismissed by colonial officials as “African superstition”. The accounts of Liberians hurling stones at health offices also find corollaries in stories I heard about rural health posts and survey research vehicles in 2007-08 Malawi being vandalized by stone-throwing crowds of villagers.

Taken in bulk, the widely circulating conspiracy theories, violence, and rumors in times of health crisis (notably not unique to Africa) that so effectively capture headlines bolster our imaginary of Africans as superstitious, in need of help and education, and ignorant of the wonders of science. These stereotypes are reinforced by imagery that feeds into pre-existing caricatures of Africans as hemmed in by their culture. They are closed off, not only to science, but to the western world; a recent Times headline described a village (“a mud brick community of rice and cassava farmers deep in the forest”) “frozen” by fear and death. In its report on the Ebola situation in Nigeria and Guinea, the WHO described 26 villages as “highly resistant to outside help,” until they were penetrated (saved?) by health workers and “opened” to the outside.

It behooves us to remember that the “opening” of Africa to medicine and the arrival of western or western trained “health workers” was often concurrent with the violent opening of Africa to racialized capitalism. In south central Africa, for example, one of colonial medicine’s main objectives was to ensure that black bodies remained fit enough to labor under poor conditions in mines in Southern Rhodesia or South Africa. Across Empire(s), health workers became “police” who toured villages to forcibly oversee vaccination; in early 20th century Uganda, Africans were forcibly moved from tsetse fly habitats (also important sites of fishing and hunting livelihoods) to prevent sleeping sickness (Vaughan 1991, Headrick 2014). In mid-nineteenth century Senegal, French colonial health authorities used yellow fever policy to justify forced removals that targeted the ‘unsanitary’ and ‘uncivilized’ indigenes, but left merchant families alone (Ngalamulume 2004). Of course, such instances of militarized and racialized medicine augment suspicions stoked by scandals such as the Trovan clinical trial in Nigeria and the perinatal AZT trials in South Africa, just two memorable examples from among many others that dot the landscape of an Africa that has long been the world’s “living laboratory”(Tilley 2011).

We recognize this account as anthropological because it asks readers to destabilize dominant representations of “African culture,” to consider the historical circumstances and particularities that have produced these events, and to place them squarely in the long and still unfolding contexts and politics of intervention across Africa. These agendas are those we instill in our students and give to our universities (or other institutions) through our intellectual and other labor. They are valuable precisely because they contend with or complicate dominant narratives of well-intentioned global health or science encountering “stubborn culture.” Anthropology establishes its legitimacy by drawing its objects into the global health slot, reframing them, and generating knowledge for interested parties (ourselves and others).

Now, I ask you: What do we really learn about Ebola in a particular time and place after reading the above? We learn, perhaps, that we should “historicize” so as to better understand the present. Rumors and irrational responses to health workers are not inexplicable or random: they are products of a long history of fraught encounters between insiders and outsiders. Yet, while my effort above to draw connections between a constellation of historical examples (from Malawi, Uganda, Senegal) of similar phenomena is useful, a close examination of the relations and conflicts between various kinds of insiders and outsiders in the specific West African locales affected by Ebola would help us better understand the “clashes” between medicine and culture we witness there. To draw connections and comparisons is useful, but can also evacuate events of their particularity. Re-reading my own reading, I have so many questions, and maybe I just haven’t looked in the right places for the answers: What sorts of projects (medical and otherwise, recent and in the distant past) have been working in the areas where these violent responses have occurred? How have they variously engendered trust, hope, frustration, suspicion, and fear? How might a particular history of these affects in these places help us to really understand this present moment of crisis? How, specifically, has “culture” been packaged and instrumentalized in state, development, and other projects, and how might this local politics of culture play into efforts to alter risky practices amid a health emergency? Though anthropologists these days focus on “NGOization”, I wonder about the historical relations of trust and distrust between a citizenry (and all the different kinds of people who make up the citizenry) and its government. (I have found Ashoka Mukpo’s reflections on the history of cynicism toward government in Liberia very useful in beginning to consider this question). Inevitably, we draw connections between what we know and what we wish to know: I work in Malawi, so I wonder whether Sierra Leone, Guinea, or Liberia are also over-researched or cross-cut by dense networks of NGOs and projects. (An aside: Of course, my reading is imprecise and broad strokes, you might say, because I don’t work in West Africa. To assume, however, that a medical anthropologist not working in one of the countries most affected by Ebola has nothing of value to say about an ongoing epidemic is dangerous. My critique is less about the lack of “local color” than it is about how particularity might disrupt the narratives we—anthropologists—tell ourselves about global health or, in this case, a global health emergency).

 

Slow(er) theory?

Like any discipline, anthropology has its buzzwords, its pet theories, and its investments. We read accounts about other places in the pages of our journals and books and often what we remember most are the inventive interpretive concepts generated by their authors: therapeutic citizenship, scientific sovereignty, states of exception, pharmaceuticalization, humanitarian logics, and so on.[i] (Though I did not deploy any buzzwords above, my account is symptomatic of its machinery of production: the global health slot). I worry that anthropologists of global health, situated as they are in the global health slot, may fall prey to the very logics we are so fond of critiquing. Even as we identify the portability of workshops, emergency responses, and health education programming –just a few of the trappings of ‘global health’–as universalizing, imprecise, and ineffective, might we be guilty of overusing popular theoretical concepts that “travel well?”

Medical anthropologists are committed to excavating the structures and political logics that enable and fail to mitigate suffering amid Ebola. They have shed light on the question: Why is Ebola so out of control? Paul Farmer gets at the heart of the matter in pointing out that surviving Ebola is a matter of “care” rather than drugs. Others have drawn attention to massive brain drain and crumbling health infrastructure in the region. Yet, these explanations immediately raise more questions for me: Why have Liberian or Sierra Leonean doctors and nurses left for greener pastures (and how does this differ from the push and pull forces driving emigration of Kenyan or Malawian doctors)? How do the particular movements of people inevitable during conflict and post-conflict periods in Liberia play into the lack of healthcare personnel? Who are the people on the front lines of the epidemic? What are their dreams, hopes, and struggles, and how do their everyday lives influence the work they do (which has, finally, thrust them into a spotlight usually claimed by renowned researchers or foreigners)? We may agree that global health and epidemic containment efforts, in rhetoric and form, emerge from imperial (or militarized) humanitarian logics. Yet, how does this look in one place versus another? How do our readings across places reify—perhaps unhelpfully—a global health that looks different in all of its locales?

Ebola exposes the fault lines of global society, and brings to light the calculus that underlies questions of who can leave, who can access treatment, and who should be saved. This calculus maps onto ‘pre-sorted’ social divisions, but ones that far exceed “local” and “global” or black and white. In analyzing the hierarchies of value that propagate the uneven distribution of suffering and death, a nuanced consideration of how local bodies are marked by their position in matrices of power, class, gender, able-bodiedness in a particular place would be very helpful. How does a medical anthropologist navigate between the impulse to say something, and the glaring gaps she sees in her accounts? How can we convincingly connect structures to lives and theory to ethnography even, or especially, in times of emergency and for various audiences (and here I include fellow anthropologists)?

I am continually struck by the familiarity of stories I read about AIDS programming, knowledge production, NGOization, and so on in anthropological journals. I strain to see something I didn’t see before, and hesitantly note the seeming commensurability between very different places (this is not to discount a wonderful body of work; I am being somewhat polemical and sloppy). I have begun to wonder if the “sameness” I see all around me is difference dressed up in articles of clothing all anthropologists have in their closets: biopolitics, regimes of value, politics of ontology, traveling technologies, the politics of becoming, boundary objects, and multispecies ethnography (see Footnote xii). Anthropologists of global health take significant interest in how global standards and formalizing practices serve to fix, stabilize, and make “other” realities workable for scientists, policy makers, and development workers; so, too, do they operate in our own discipline.

In our willingness to graft theory or concepts onto places, do we mirror global health’s own penchant for traveling toolkits and standards? It seems I have come round to calling for a more “particular” anthropology of global health. This surprises me, a bit. I think I am pushing myself—and all of us—to be open to the particular, to invite it in to the “global health slot” so as to mess up or slow down its machineries of production. Maybe, on the heels of Vincanne Adams and colleagues’ (2014) recent call for “slow research” in global health, I am simply calling for “slow(er) theory.” Even as we unpack rhetoric that casts culture as static, stubborn, and a stumbling block to health and science, might there be value in considering that, for the purposes of thinking, culture does have a certain stubborn—and productive–particularity? How do we not lose sight of this particularity, even in times or places where our usual toolkit of slow methods fails us because of urgency? The Ebola epidemic is a particularly good site for pondering these questions, precisely because plagues—long a favored topic of some of history’s greatest novelists and writers—seem to look so similar across time and space: “The truth is that nothing is less sensational than plague, and by reason of their very duration great misfortunes are monotonous” (Camus 1991: 179). But, even as we recognize the suffering, the social fissures, and the narrative arc of Ebola as timeless and familiar, is it not anthropology’s responsibility to illuminate something more, to carefully narrate a story that is nonetheless local in its universality? How do we move beyond “It’s complicated,” to unravel the particular strands that make it so?

I close by asking more questions, for which I have no solid answers, but which I look forward to discussing further (and maybe the role of anthropology in an emergency is to generate questions): What should anthropologists say about Ebola? How might what we say, and even our impulse to speak in the first place, be symptomatic of a certain culture of standardization across a sub-field that is currently riding a wave of popularity? I suggest that it might be helpful to think about ways to struggle against a “global health slot” that seduces us to: 1) Reify the global, and “global health” to achieve our own critical impulse or fit into ongoing conversations in our discipline; 2) Obscure our own complicity with the rise of global health as a powerful governance structure on a global scale; and 3) Become swept up in a global health market—including our own discipline—that privileges those things it can most easily digest, commodify, and translate across difference. Moments of health crisis abroad urgently invite us into the global health slot. What is the nature of the knowledge we want to produce? What questions should we be asking? Who can speak? Isn’t it time we theorize not only global health, but the “global health” anthropology has created for itself?

Crystal Biruk is Assistant Professor of Anthropology at Oberlin College. She is writing a book titled Cooking Data: Culture and Politics in an African Research World.

 

Acknowledgements: Thanks to Julie Kleinman for helpful conversations.

References

Adams, Vincanne, Nancy J. Burke, and Ian Whitmarsh. (2014). “Slow research: Thoughts for a movement in global health.” Medical Anthropology 33(3):179-197.

Camus, Albert. (1991 [1948]). The Plague. Vintage International.

deLaet, Marianne and Annemarie Mol. (2000). “The Zimbabwe bush pump: Mechanics of a fluid technology.” Social Studies of Science 30(2):225-263.

Fassin Didier and Mariella Pandolfi, eds. (2010). Contemporary States of Emergency: The Politics of Military and Humanitarian Intervention. Zone Books.

Headrick, Daniel R. (2014). “Sleeping sickness epidemics and colonial responses in East and Central Africa, 1900-1940,” PLoS Negl Trop Dis 8(4).

Marcus, George. (2010). “Experts, reporters, witnesses: the making of anthropologists in States of Emergency,” in Fassin, Didier and Mariella Pandolfi, eds. Contemporary States of Emergency: The Politics of Military and Humanitarian Intervention. Zone Books.

Ngalamulume, Kalala. (2004). “Keeping the city totally clean: Yellow fever and the politics of prevention in colonial Saint-Louis-Du-Senegal, 1850-1914,” Journal of African History 45:183-202.

Robbins, Joel. (2013). “Beyond the suffering subject: toward an anthropology of the good.” JRAI 19:447-462.

Tilley, Helen. (2011). Africa as a Living Laboratory: Empire, Development, and the Problem of Knowledge, 1870-1950. University of Chicago Press.

Trouillot, Michel-Rolph. 1991. “Anthropology and the savage slot: The poetics and politics of Otherness.” In Recapturing Anthropology: Working in the Present. Santa Fe, NM: School of American Research.

Vaughan, Megan. (1991). Curing their Ills: Colonial Power and African Illness. Stanford University Press, pp. 43-44.

White, Luise. (2000). Speaking with Vampires: Rumor and History in Central Africa. University of California Press.

 

Note

[i] These concepts are critically useful in my own thinking and writing. My point is not to single them out as colonizing forces of in the larger wordscape of anthropology. This essay is not adverse to “theory” but points, as others have, to how theory itself is a traveling technology that we learn to love, not unlike the good old Zimbabwe bush pump (deLaet and Mol 2000).

Teaching ‘Mental Disorder’ by Nichola Khan

2 Octobre 2014 - 6:02pm

This undergraduate course introduces ways anthropologists theorise and research mental disorder, treatment and recovery. It reflects a growing interest in anthropology’s encounter with the key ‘psych’ disciplines and the human and social sciences, evident in the well-spring of new university courses in psychological and psychiatric anthropology in the U.S, Canada and Australia, and the transnational migration of this interest to Europe, Asia, and the global South. Taking as given the shifting meanings of ‘abnormality’, the title reflects the priority given to the term disorder over disease. Disorder, as Good (2012) argues, can encompass historical, political, psychoanalytic, postcolonial studies and other comparative approaches—linking the madness of the state and individuals, and forcing attention to the often violent ways political moral and epistemic ‘orders’ are established (518).

The challenge lies in synthesising diffuse classic, and burgeoning contemporary, literatures in a concise engaging and accessible way for students. In designing this course for primarily psychology students, I found older readers in psychological anthropology engaging heavily with psychological theory and applications across diverse topics not necessarily related to mental health—hence the focus ‘too general’. In engaging mental health and illness, others tended to prioritise the lens of culture, or else single disorders—hence the focus, although rich, ‘too narrow’. So one way I’ve tried to bridge the lacuna is by compiling lists of key and additional readings—and of ethnographic films and websites like Somatosphere which are valuable tools for cutting through the complexity of the literature.

This course addresses ten diverse topics, linked via some key paradigmatic and theoretical frames. These broadly encompass anthropological representations of ‘culture’, and their relation to (the equally unwieldy terms) ‘biology’ and ‘structure’. One objective is to consider anthropological thinking about psychiatric illness in order to identify how anthropologists can assist thinking through classificatory problems of cultural and conceptual translation. A second concerns the goals of treatment, rehabilitation or therapy. What underpins expectations of a ‘return to normality’? Does medicine’s goal to ‘cure the symptom’ mean suppressing rather than exploring their problems? Third, can, how, or even should an anthropology of mental disorder bring its expertise and methods to improve the suffering of patients? These questions about positioning are presented as driven partly by funding priorities, governments, universities and research councils; but also by anthropology’s struggles to overcome its own identity problems rooted in esotericism, elitism and the legacy of colonialism.

One broad aim is to overview the epistemic shift from explanations dominated by cultural and structural ecologies to those from studies in biomedicine, biological and global psychiatry, neuroscience and global mental health. These shifts have been shaped by a confluence between local intervention and specificity—through ‘local biologies’ (Lock 1993)— alongside the mass reconceptualization of mental illness as neuro-psychiatric or brain disorders. In U.S. psychiatry the ‘brain disease’ model of mental health is dominant. Whilst anthropologists typically emphasize social, contextual and cultural influences on mental illness, challenges to assumptions about context and the environment are increasingly coming from biocultural anthropologists, and from critiques that draw on emerging techniques in clinical science and brain studies.

The re-turn to biology via brain studies and neuroscience is of course not the whole story. It has met with strong critiques from cultural psychiatry, psychoanalysts, activists (including psychiatrists) and political movements. This short course cannot solve the irresolvable question of theory’s relation to practice. Rather, it seeks commensurability in relation to some interpretations crafted by anthropologists of mental illness, abnormality and disorder. It does this by tracing these debates through time, across varied social and cultural settings, through their geographical distribution across the globe, and by subjecting single ‘disorders’ to political, cultural, social and biomedical scrutiny.

Mental disorder can provide an innovative, challenging way to think about the ongoing transformation of anthropological knowledge at a time of increasing fragmentation of inquiry, while also connecting it to traditional forms of anthropological scholarship and debate. This is a work in progress for both teachers and students. Please do share suggestions for readings, films, links to wider topics etc.

If you are unable to view or download the pdf embedded through Scribd, you can also access it here.

 

Nichola Khan is a Senior Lecturer in the School of Applied Social Sciences at the University of Brighton, UK. Her research interests in social and psychological anthropology have developed around violence, transnational migration, mental disorder and theories of suffering—via a regional focus on Pakistan, Afghanistan and Afghan diasporas.

 

References

Good, B. 2012. Theorizing the ‘subject’ of medical and psychiatric anthropology. Journal of the Royal Anthropological Institute, 18:515–535.

Lock, M. 1993. Encounters with Aging: Mythologies of Menopause in Japan and North America. Berkeley, CA: University of California Press.

Web Roundup: Death and Technology by Lily Shapiro

30 Septembre 2014 - 6:47pm

When my parents came to visit a few weeks ago, they brought with them legal documents for my siblings and me to sign relating to their wills and end of life care. Happily, they did not do this because such an event is considered imminent; rather, they recently retired and are simply putting their affairs in order. The ensuing conversations revealed a tiny glimpse into how complicated and surprisingly bureaucratic death in America is. I therefore chose death and technology as the subject for this week’s Web Roundup.

The Atlantic interviewed Caitlin Doughty (of Ask a Mortician) about death practices in America, the work of a mortician, and how she would like to die. They have another piece on how deaths are covered by the media, that is to say, whose deaths are covered, and in what way, to what end. Researchers looked at the American news media’s coverage of deaths outside America and determined that the depth of coverage an event received was directly related to the country’s proximity to the US, and to the number of American tourists who visit the country in question per year. By depth of coverage, they mean the degree to which an article or series focused on individuals killed, rather than reporting deaths as a statistic with little humanizing information.

NPR did a story about how and where Americans die. The focus is on New York City, though there is some data on the rest of the country. Due to a combination of medical culture and structural constraints, although most Americans say they would prefer to die at home, a great number spend many, if not all, of their last days in a hospital.

The Hollywood Reporter did an interesting in-depth piece on the anti-vaccine movement in affluent LA neighborhoods, including an interactive map, based on state vaccination records, of the risk of potential infection in over 3500 preschool, daycare, and kindergarten institutions.

Ezekiel Emanuel wrote an article about how he hopes to die at 75. It’s an interesting read, though I wouldn’t recommend forwarding it to your parents, as they tend to take it the wrong way.

Changing gears slightly, in You Should Be Terrified of Superintelligent Machines, a writer for Slate argues that we have something to fear from the development of technology that is purportedly “more intelligent” than humans, though not, perhaps, for the reasons you might expect.

Vice interviews Martin Rees (professor of cosmology and astrophysics at the University of Cambridge) about the ways in which humans will have to change to live in space or on other planets, and a post-human future in which beings are capable of manufacturing such changes in themselves.

The magazine, The Baffler, hosted a debate between Peter Thiel (the co-founder of PayPal) and David Graeber about the failed promises of and potential futures of technology. You can read a write-up of it on Inc.com or in the New York Times. Both Graeber and Thiel agree, though for very different reasons, that technology has largely failed to live up to its expectations over the last half-century. Slate has an article arguing that urban designers and policy makers should read more science fiction. This article is part of the lead-up to an event in New York City on October 2nd on science fiction and public policy, which takes as its starting point the assumption that technology has largely failed to deliver on its promises. Info on the event, which you can stream as a live webcast, is here.

In the wake of GoPro going public (now valued at about USD 3 billion), the New Yorker did a long piece on the pros and cons of constantly recording everything. It’s a story we’ve all heard, but no less thought provoking for having been told before. “GoPro, like Google Glass, has the insidious effect of making the pervasiveness of cameras seem playful and benign when it may one day be anything but. The Economist called the film-everything culture “the people’s panopticon”—the suggestion being that with all these nifty devices we might be unwittingly erecting a vast prison of self-administered surveillance.” They also discuss the idea that having cameras like this pushes athletes to attempt more and more daring feats and that, in the event of an accident or death, the GoPro can become a kind of black box.

To balance all this talk of death with one thing about birth: The New Yorker has an interesting video on how and why C-sections became so common in the US.

Book Forum––Introduction, Jeremy Greene’s “Generic” by Todd Meyers

29 Septembre 2014 - 8:14pm

Welcome to our inaugural “Book Forum.”  Our aim is simple: to promote lively exchange between a group of scholars and an author, allowing for experimental and inventive engagements that are not so much about evaluation but rather draw on concepts and shared commitments.  It’s probably worth noting that Somatosphere will continue to feature book reviews, which have been a mainstay from the beginning.  Our hope is that the forums will follow along a well-trod path made by the reviews, into new clearings.

Our first book is Jeremy Greene’s Generic: The Unbranding of Modern Medicine (Johns Hopkins University Press, 2014).   Greene’s book is a dizzying historical-political-social-cultural account of the forms generic drugs have taken over past several decades.  The book is a story about the development and circulation of these drugs––their makers and consumers, advocates and detractors, within and between the domains of ethics and markets––as “generics” stir debate and catalyze change (seen and unseen, felt and unperceived) in the healthcare marketplace.

We hope you enjoy the forum.  We have more planned in the coming months, which will include books by Warwick Anderson, Sameena Mulla, Lisa Stevenson, and Christian McMillen.

Below are links to four brief comments on Generic written by Anne Pollock, Nancy Campbell, Joseph Dumit, and Stefan Ecks, as well as Jeremy Greene’s response to his interlocutors.  The entire forum is also available as a single pdf here and is embedded below.

Comments on: Greene, Jeremy. Generic: The Unbranding of Modern Medicine. Baltimore: Johns Hopkins University Press, 2014.

Generic virtue and vice
Anne Pollock

Nostalgia is always about the present
Nancy Campbell

The Generic that is Right for You
Joseph Dumit

Generics and their Doppelgängers
Stefan Ecks

Response to comments:

the specificity of Generic
Jeremy Greene

 

Ten Things that Anthropologists Can Do to Fight the West African Ebola Epidemic by Sharon Abramowitz

26 Septembre 2014 - 5:59pm

Like other anthropologists who have woken up mid-career and found the countries where they’ve lived and worked awash in mass deaths (and let’s be real… that’s quite a lot of us), my initial response to the Ebola outbreak in West Africa was to hope that the experts had the situation under control, and bury my head in the sand.

Soon, the epidemic outpaced the global health response, and the calls for help grew more urgent, but anthropologists’ phones have stayed startlingly quiet. While leaders at the Centers for Disease Control (CDC), Médecins Sans Frontières (MSF), and the World Health Organization explained how factors like culture, weak governance systems, human behavior, and social organization made the outbreak unintelligible to the global health community, academics who work in the region like Danny Hoffman, Rosalind Shaw, Mats Utas, Chris Coulter, Mary Moran, Susan Shepler, Adia Benton, Mike McGovern, Sasha Newell, Gwen Heaner, and Marianne Ferme, not to mention anthropologist from the global south like Sylvain Landry Faye, have remained untapped as resources for understanding and creating innovative new approaches to attacking the Ebola outbreak at its source.

Let me share one example from a recent phone call that I made to the New York City office of Doctors Without Borders:

SA: Hi. I’m a medical anthropologist with 14 years of experience studying healthcare, health systems, and humanitarian aid in Guinea, Liberia, and Cote d’Ivoire. I heard your director put out a call for help on Ebola on NPR today, and I really think I can help you.

MSF: I’m sorry, but we don’t work with medical anthropologists in general, except for under very rare circumstances. If you really want to help out Doctors Without Borders, you are going to have to go to our website to register as a volunteer. The process takes nine to twelve months, and even if we decide that we need your skills, we still won’t guarantee that you will go to the county where you have done research. But please understand that it’s extremely rare that we ever have a need for a medical anthropologist.

A more concerted engagement between anthropology and global health is needed to address the unique challenges of the Ebola outbreak. Anthropologist-physicians like Jim Kim, the current President of the World Bank, and Paul Farmer, who is opening four new hospitals in Liberia as I write, are both closely involved with the Ebola response in their capacities with the World Bank and Partners in Health. Other African and Western anthropologists have been hired singly, or on a consultancy basis, to bring an anthropological perspective to World Health Organization local assessments and MSF activities in Liberia. Many more anthropologists of West Africa are being invited to write commentaries on the current outbreak. But this does not go far enough.

In this article, I share a 10-point list of actions that anthropologists could take, right now, to improve the global response to the West African Ebola outbreak. Take notice, global health and national and international biosecurity communities. There exists an entire discipline of anthropology that is dedicated to connecting the global and the local, to understanding and mapping populations in crisis, and serve as interlocutors[1] between international institutions and local populations in this region.

1. Anthropologists can teach epidemiologists how to count the dead in West Africa. It is common knowledge that there is an enormous gap between counted Ebola deaths and actual deaths. In the space between, critical intelligence is lost concerning the patterning, movement, and expansion of the epidemic. Cultural anthropologists routinely work with local institutions to track morbidity and mortality in contexts that lack formal birth and death registration systems, public health infrastructures, or modern industrial burial industries. Two examples come to mind:

  1. In her ethnographic work on infant starvation in Bom Jesus, Brazil, Nancy Sheper-Hughes counted child-sized coffins to gather data on seasonal infant mortality related to malnutrition, starvation, opportunistic infections, and diarrheal diseases.
  2. In a forthcoming publication[2], Alex de Waal triangulated data on lethal mortality in the Darfur region of Sudan (tribal reports, UN mission reports, and UN incident reports) to generate improved analyses of lethal mortality patterns (see also de Waal 2014).

Novel ways of tracking the toll of Ebola can be generated quickly using ethnographic methods to collect data. But new partnerships between anthropology and epidemiology – and a greater tolerance for multi-disciplinary collaboration – are required to proceed.

2. Anthropologists can systematically observe, report on, interpret, and explain local perspectives on the Ebola epidemic response. This is the most expected function of anthropologists, and it is, indeed, the function for which we are most often employed. In order to get past distorting reports of unreasonable local populations, disinterested local medical professionals, and “blaming the system,” anthropologists are able to make sense of local ideas, beliefs, and behaviors in ways that are actionable. Three examples suggest themselves:

  1. When residents of West Point, the Monrovia, Liberia ghetto, are told not to touch the bodies or corpses of individuals who have shown symptoms of Ebola, is it acceptable for them to use cheap plastic market bags instead of latex gloves?
  2. How can a neighborhood-based quarantine systems work in a way that doesn’t increase local contagious risk?
  3. What are the financial costs to poor populations who are asked to call in to Ebola hotlines, and are those costs bearable under current conditions of food shortages and economic crises? If the costs are not bearable, what communication systems can be put into place to facilitate “ground-up” communication with regional, national, and international systems

3. Anthropologists can detect emerging health risks in the “noise” around Ebola. Consider the following: On September 12th, the WHO reported that a black market had emerged for Ebola survivor’s serum. Anthropologists have developed sophisticated ethnographic approaches to track black market flows, and are skilled at making visible invisible connections between donors and dealers, buyers and healers. We can also work in partnership with local institutions to seek out emerging public health threats that are arising in concert with Ebola, and craft swift and effective responses.

4. Anthropologists can identify local health capabilities and latent social structural capacities for emergent Ebola responses. As #3 suggests, the people who live in Ebola affected regions of West Africa are tremendously innovative and inventive. In fact, one of the most extraordinary outcomes of this current epidemic has been the resilience of local populations under extreme systemic stress and perceived mortal threat. Rather than focusing on “culturalist” issues like Ebola-denialism, funerary practices, news of violence against aid workers, and labor strikes, anthropologists are sensitive to the fact that the populations in Ebola-affected regions are, in fact, human, and that they are inventive, adaptive, able to respond to impending threats in their environments, and deeply clannish – they love, they provide care, and they are, above all, concerned with the well-being of their families and communities.

For example, ethnographer, religion scholar, and development consultant Gwen Heaner noted in a recent personal communication that Pentecostal and Seventh-Day Adventist networks of pastors in Liberia remain untapped as potent allies in the fight against Ebola, while the CDC has already reached out to mainstream churches. At the same time, Pentecostal and Seventh-Day Adventist pastors are implementing strict protections against Ebola by banning touching during church activities. They support their actions with the New Testament verse 1 Timothy 5:22: “Do not lay hands upon anyone too hastily and thereby share responsibility for the sins of others; keep yourself free from sin.”

5. Anthropologists can convene university-based multi-disciplinary study groups that include undergraduate students, graduate students, and faculty to track the epidemic in real time, focusing on the sociological, economic, political, and cultural aspects of the outbreak. These groups can serve as sites for education and advocacy, fundraising, original research, and coordination in local communities across Europe and the United States. Using very few resources, they can serve as clearinghouses that link scholars with prior experiences of Ebola (e.g., Uganda, Democratic Republic of the Congo) or other epidemic containment efforts with academics and practitioners who are involved in the current effort.

6. Anthropologists can share their networks of local contacts with global health experts who are trying to coordinate a response. Anthropologists who work in coordination with local communities often have close, long-term personal and professional relationships with research assistants, community members, and private and public sector leaders. Increasingly, it appears as though a coordinated local response will be required to slow the pace of the epidemic. In sharing our networks informants, friends, and colleagues with local health professionals and international aid organizations, we can facilitate the development of bi-directional communication across local, national, and international institutions.

7. Anthropologists can provide training, coordination, and qualitative data analysis to support to local Liberian, Sierra Leonean, and Guinean teams who try to use local information to design effective interventions. Much of the social and cultural analysis that has emerged from the Ebola epidemic has been fragmented, anecdotal, and sensationalized. This need not be the case. Working remotely from academic centers in the West, anthropologists can work in collaboration with local research teams based in NGOs, at Ministries of Health, and with the WHO to systematically gather, analyze, and report upon real-time data regarding the social and cultural conditions that are impacting the Ebola outbreak. This information can then be factored into real-time decisions about public health strategies like mass communication campaigns, treatment center access, infrastructure development priorities, staffing allocations, and material and human resource investments.

8. Anthropologists can take the lead in generating innovative solutions to the global health community’s mass health communication challenges. As a community, we can come together to publicly “brainstorm” strategies and interventions. We can offer counter-interpretations of current events, alternative readings of histories, and refined analyses of systems challenges in order to more precisely isolate actionable areas for improving the Ebola response. Under the rubric of the AAA, we can organize a National Task Force on Ebola, create opportunities for scholarly exchange, debate, and reports through the coming AAA conference, and use the AAA national platform to maximally engage national anthropological resources.

9. Anthropologists, especially through the leadership of the American Anthropological Association, the European Association of Social Anthropologists, or the World Council of Anthropological Associations, can advocate more strenuously for a “seat at the table” for the social sciences to contribute to the Ebola effort. As individuals and as an Association, anthropologists can reach out to our colleagues in government, public policy, public health, and medicine to remind them of the unique social and cultural challenges that Ebola poses, and identify missed opportunities that have resulted from failing to integrate the social sciences into a truly robust, multi-disciplinary response. A far more sophisticated understanding and operationalization of culture and human subjectivity needs to be integrated at every level into the global response to this epidemic, or – as current projections suggest – the possible human toll will rival those of genocides. Present approaches are failing, and the current devastation of the economic and medical systems in these countries, and the existential threat confronting their national food security, emerging economies, and post-conflict democratic political systems, needs to be monitored and responded to as carefully as the growing case counts reported daily in the international media.

10. Anthropologists in the U.S. can increase pressure on Congress to provide funding for NSF RAPID Research Grants for Ebola research, and for all other basic social science research that seeks to engage with real-time emergencies. Presently, in the United States, there are few robust mechanisms for funding emergency anthropological research, or partnerships between anthropologists and other disciplines, in order to address critical human health issues. NSF RAPID Research Grants are an exception. These grants are designed to bypass a lengthy process of external review in order to facilitate the accelerated development of research projects in emergency situations. Within NSF’s cultural anthropology section, however, NSF RAPID Research Grants are funded in the same pool as conventional NSF senior, NSF CAREER, and graduate student dissertation (DDIG) proposals. A dedicated funding line should be established that commits national resources to rapidly drawing upon anthropological knowledge and research in global emergencies at the NSF, at the CDC, and in the Department of Homeland Security. Moreover, anthropologists should be encouraged to draw upon all of the resources that can facilitate their research in affected regions.

Sharon Abramowitz is an assistant professor of anthropology and African Studies at the University of Florida. She is the author of Searching for Normal in the Wake of the Liberian War (University of Pennsylvania Press 2014) and co-editor, with Catherine Panter-Brick, of Medical Humanitarianism: Ethnographies of Practice (University of Pennsylvania Press 2015). She served as a Peace Corps volunteer in Cote d’Ivoire from 2000-2002, and has been working on mental illness, gender-based violence, post-conflict reconstruction, humanitarian intervention, and post-war health system transitions in Guinea and Liberia since 2003.

Acknowledgements:

This piece was reviewed, and greatly improved, by Lauren Carruth, Gwen Heaner, Michael Herzfeld, Arthur Kleinman, Emily Mendenhall, Sarah McKune, Mary Moran, and Noelle Sullivan. Thanks, as always, for your generous comments and keen insights.

Works Cited:

de Waal, Alex, Chad Hazlett, Christian Davenport, and Joshua Kennedy. “The epidemiology of lethal violence in Darfur: using micro-data to explore complex patterns of ongoing armed conflict.” Social Science & Medicine (2014).

Scheper-Hughes, Nancy. Death without weeping: The violence of everyday life in Brazil. Univ of California Press, 1993.

Notes

 

[1] I send a credit to Dorothy Hodgson for her unique understanding of the term “interlocutor.”

[2] In forthcoming edited volume Abramowitz. S. and C. Panter-Brick, Eds. (2015) Medical Humanitarianism: Ethnographies of Practice. University of Pennsylvania Press.

Ontology as an analytical approach to concerns of medical anthropology by Tanja Ahlin

23 Septembre 2014 - 9:15am

What might arise from an encounter between medical anthropology and science and technology studies (STS) as they investigate the common subject of health and (bio)medicine? One answer could be found at the panel Repositioning health, illness and the body: the challenge of new theoretical approaches to medical anthropology, organized by Simon Cohn and Rebecca Lynch at ASA[1] decennial conference in Edinburgh this past June. The panel presenters were tinkering with the application of “the ontological turn” as an analytical tool in medical anthropology, inspired by the STS notion of “ontology,” which posits the existence of multiple realities of the body (Mol 2002, Farquhar et al. 2014).

As Simon Cohn noted in his introduction, the analytic approach(es) offered by the ontological turn might inspire new insights into old distinctions – such as nature/culture and reality/representation – that persist in medical anthropology. According to Cohn, by emphasizing cultural variation, anthropology has perhaps “not only reproduced but also reinforced the position that reality is fixed and singular.” Since anthropology has historically focused strategically on representation it has “left it to other disciplines to make claims about reality itself,” Cohn suggested.[2] In following the way in which STS has unpacked representation, medical anthropologists are reminded that realities, including those of the body, are constructed through practices.[3] Along this line of thought lies a realization that not only culture, but nature too is plural: the scientific (biomedical) idea of the body as a universal standard becomes questionable, since the human body is not the same in societies around the world.

Rebecca Lynch and Simon Cohn illustrated this point through their ethnography of self-monitoring technologies in weight reduction. They proposed that the body is not culturally, but literally constructed by medical practices, scientific discoveries, and individual actions and experiences. In the trial that Lynch and Cohn analyzed, the medical body was “done” through measurements and monitoring of the participants’ bodies (i.e. their body mass index, height, weight, blood pressure and so on), as well as through participants’ own experiences of fitness. In the cases they unpacked, monitoring became “a further means to know how the body is in the present, and to experience the body through new terms, new concepts and new forms of bodily knowledge.” Bodies, they found, were objects and subjects simultaneously.

Maryon McDonald also investigated how the body is “done” in the biomedical context, though in the case she presented this happened not through measurements of the body, but through its various representations. She explored the construction of biomedical realities of the body in anatomy classes. McDonald showed that medical education was not simply about learning to “see what is there,” but that becoming a biomedical practitioner involved acquiring “a particular kind of vision.” Such medical “eyes” were trained through a number of two- or three-dimensional representations of bodies, from photos to skeleton models to cadavers and live bodies. According to McDonald, these representations testify to the multiplicity of the body in anatomy with which students live all the time. In order for students to become (good) doctors, they must learn what McDonald referred to as “ontological choreography,” namely rapid switching between different representations, from bodies as x-ray images to bodies as live patients.

Susie Kilshaw’s study of miscarriage in Qatar illustrated that biomedical categories are far from fixed, as there is considerable movement and flexibility of definitions within the medical field. While miscarriage could be defined in terms of measurements such as “weeks of completed pregnancy” or “weight of the fetus at the time of miscarriage,” Kilshaw’s fieldwork showed that there is no definite answer to the question of how many weeks have passed or how much a fetus weighs. Further, both obstetricians and patients constantly shifted between various medical and religious (in this case Islamic) categories: there was much ambivalence about when an object was a fetus, a baby, an (imagined) child, or, in case of miscarriage, a “bird in heaven.” Kilshaw noted that each fetus may hold multiple realities for those that come into contact with it, such that the body of a miscarriaged fetus may be at the same time a piece of the mother’s body tissue, an embodiment of a lost potential, and a missed opportunity for a mother (and father) to secure social standing.

In a project examining interdisciplinary research on appetite and weight loss after obesity surgery in Denmark, Bodil Just Christensen found it crucial that medical scientists use their clinical knowledge much like the “lay ethnographers” described by Mol (2002). This enabled biomedical doctors and anthropologists to work together, rather than alongside each other. The joint exploration of the practices through which appetite was enacted led the researchers to a shared definition of appetite, which arose as a fractional “material-semiotic assemblage consisting of layered meanings of many ontological kinds.” This approach revealed how the taken-for-granted “nature” of appetite was constructed through the scientific categories of the biological, the psychological, and the social. Biology and society were not ontologically given, but brought into reality in specific, situated ways.

A notable argument made in the panel was that the ontological turn should perhaps not focus on multiple realities of “the body” to the degree that it has. Based on her case study of weight reduction in Guatemala, Emily Yates-Doerr explained why she was wary of “the body” as a focus of medical anthropology. The field of medical anthropology has long divided “the body” into individual, social, and political forms (see Scheper-Hughes and Lock 1987). While this division may be an attempt to add complexity to the biomedical treatment of the body as a biological unit, it also risks inserting the analytic of “the body” into arenas where bodies are not (or ought not to be) a central matter of concern. In her research, a division between individual and political bodies “allowed practitioners to treat obesity as a problem of personalized medicine,” thereby ignoring the health concerns of those seeking obesity treatment, in which personal health was not separable from food and land sovereignty or the well being of spirits and networks of kin. Yates-Doerr suggested that the theoretical approach of the ontological turn was useful in its encouragement of “engagement with empirical specificity”; rather than aiming to establish the truth of the body and its health, it made space for “a possible truth that exists among others.” Her final appeal to the audience was to “consider what might emerge if we depart from a focus on ‘the body’ and its enumeration.”

Else Vogel’s presentation turned away not only from the body, but also from biomedicine as the research context. In her study, participants of a “mindful weight loss” course in the Netherlands strove to see weight loss as one of the consequences of a renewed relationship with eten, which in Dutch refers to both food and eating. As course attendees explored eight different types of hunger (of eye, nose, ear, mouth, belly, body, mind, and heart), the body became much less important than it appears in the biomedical approach to obesity, which emphasizes the correction and normality of the body. In contrast, in the practice of mindful eating, obesity and weight loss were about relationships with one’s emotions, one’s self, and one’s body, which Vogel discussed in terms of hungers, desires, and needs respectively. In illustrating that the pressing issue for the people she worked with was not “what is the body?” but “what can the body be made to be?” Vogel reminded us that ontology may not be the most salient concern for the analysis of all bodily practices.

As Cohn noted in his introduction, “talking about ontologies is talking about power and politics … in terms of close and proximal ways in which diverse ontologies sometimes contradict, sometimes cohere, and at times manifestly compete with each other.” But what are the risks of juxtaposing ontologies that arise from different disciplines or social contexts? Stefan Reinsch, for example, discussed multiple realities in the case of early detection of schizophrenia in Germany through patients’ self-reporting and specialists’ diagnoses that were based largely on “gut feeling.” This practice was directly related to early detection and prevention of psychosis, before the actual onset of the condition. The key was to discover who was at risk and, as Reinsch showed, this was done by means of comparison with representations of actual patients, specifically their eyes and particular utterances. The risk in this kind of practice is, of course, the possibility of false identifications that entail potentially unnecessary preventive measurements.

Similarly, Sahra Gibbon’s work on cancer genetics in southern Brazil mentioned the danger of juxtaposing the ontology of molecular biology and the ontology of inheritance as explained by (potential) cancer patients. According to the latter, a person may inherit cancer not through genes, but through the conjoined effects of emotions, stress, problematic family relations, and traumatic events. As Gibbon explained, the notion that the body can be biologically altered by the impact of emotions across generations evokes a particular neo-Lamarckian conceptualization of inheritance and transforms the understanding of epigenetic mechanisms of disease. In the Brazilian context of expanding neoliberal ideas of the self, particular evangelic Christian beliefs and practices, and the rising media discourse on self-improvement, the emerging idea that cancer risk is embodied through intersubjective emotions could influence (perhaps in troublesome ways) how cancer is assessed and treated. Since such “local biologies” have real and far-reaching political consequences, Gibbon suggested that this was an important area for further anthropological analysis.

Some papers in the panel also evoked possible problematic aspects of applying the ontological approach too broadly. For example, Kilshaw suggested that in the contemporary social and political context in which the trope of Islamic terrorism thrives, the ontological turn could be misused against some groups of people. Following Vigh and Sausdal (2014), Kilshaw warned that advocating incommensurable difference as an analytical point of departure could lend itself quickly to (potentially dangerous) political constructions of Otherness. Ontology as a tool to investigate reality construction seems to be a useful approach for studying biomedical practices, but extending it to other contexts requires thoughtful caution.

In the panel conclusion, the discussant Judith Farquhar emphasized that the notion of multiple realities, which is central to the ontological turn, is not really news to medical anthropology. This point was also made by some of the presenters; among them, Kilshaw suggested that social scientists should not completely neglect “a certain commonality (which is) a methodological precondition for our research.” Instead, she recommended that we try to engage with both the notion of alterity and commonality simultaneously, as they are both parts of reality. Additionally, despite some hints that this question has already been dealt with in some other time and place (though it is unclear, exactly, where), I would have found useful a more engaged discussion of how the term “ontology” differs from expressions such as “representation,” “perspectives,” “point of view,” and so on, and in what ways these words are more than synonyms.

Finally, Farquhar also stressed that there were concerns more pressing than that of overcoming Cartesian dichotomies. Instead of rendering everybody’s history equally as empiricists, she proposed that we bring the focus back to ethnography, not forgetting its main aim, which is, in Farquhar’s view, “an intervention from outside medicine.” The panelists had indeed offered some hints about the answer to this query in their presentations. Christensen, for instance, said that health interventions might improve because of the recognition of “ecological complexity” (Cohn et al. 2013), which could help to avoid simple reductionism, make way for alternative explorations of knowledge production, and make space for different and better intervention practices. Likewise, Yates-Doerr called for a “chang[e in] how we understand – and do – politics.” Instead of prescriptive politics, “made of stable, countable, knowable units to be added together and subtracted apart,” she advocated for a descriptive politics that “incorporates mess and contradiction” and “makes room for a health not located within a bounded body.”

But I wonder if it is perhaps time to make our interventions more explicit than that. One of the post-ASA conference reports pointed to the irony of social scientists having theoretical conversations about society (societies) among themselves while happily ignoring that very society. This concern is especially pertinent to medical anthropology, where our informants may have to tackle yet another distinction – that of life and death, however fluidly and complexly they might think of these terms. The question that remains is how to introduce and discuss these and other related important observations from the panel to the biomedical and patient societies that were talked about, but not with, in the event. What new universes would come into being if, for instance, this panel were presented at some other kind of conference, outside the realms of social sciences? What politics and futures would follow if we were to launch such discussions with the biomedical scientific community, health practitioners, and patients in the audience?

This may seem like an ambitious venture, but long journeys are always undertaken in small steps. For example, just before the ASA conference took place, a workshop on narratives and dementia was organized at the Amsterdam Institute of Social Science Research (AISSR), which included anthropologists as well as practitioners working with people with dementia. Among other topics, the discussion considered how the two groups could enrich each other’s work. Naturally, the workshop involved some tensions of approach and framework, but far beyond that, it shed light on the potential rewards of social scientists reaching beyond the ivory tower. It seems that these grounds could and, I suggest, should be more fruitfully explored in the future.

 

Tanja Ahlin is a PhD candidate at AISSR of the University of Amsterdam and at the Institute of Tropical Medicine in Antwerp. She received her fellowship through the transdisciplinary program TransGlobalHealth, which is a part of the Erasmus Mundus Joint Doctorate Program and which allows her to work across the disciplines of STS and medical anthropology. Her research is on the role of information and communication technologies (ICT) in everyday elderly care practices in transnational families of Indian nurses working in Oman. She is an active member of Critical Anthropology of Global Health, a special interest group of the Society for Medical Anthropology (SMA), and an IT Officer of Medanthnet, a mailing list of the EASA Medical Anthropology Network.

 

Acknowledgements

The author would like to thank Roberta Raffaetà, Anna Mann, and Emily Yates-Doerr for their comments on an earlier draft of this review.


References

Cohn, S., M. Clinch, C. Bunn and P. Stronge. (2013). Entangled complexity: why complex interventions are just not complicated enough. Journal of Health Services Research & Policy 18(1): 40-43.

Farquhar, J., J. Lezaun, M. A. Pedersen and A. Mol (2014). A reader’s guide to “ontological turn.” Somatosphere, Jan-Feb-Mar 2014.

Latour, B. (2014). Another way to compose the common world. HAU: Journal of Ethnographic Theory 4(1): 301-307.

Mol, A. (2002). The Body Multiple: Ontology in Medical Practice. Durham and London: Duke University Press.

Scheper‐Hughes, N., & Lock, M. M. (1987). The mindful body: A prolegomenon to future work in medical anthropology. Medical Anthropology Quarterly 1(1): 6-41.

Vigh, H. E., & Sausdal, D. B. (2014). From essence back to existence: Anthropology beyond the ontological turn. Anthropological Theory 14(1): 49-73.


[1] Association of Social Anthropologists of the UK and Commonwealth.

[2] This echoes Mol’s (2002: 21ff) statement that by trying to add their specific knowledge about bodies (explained through meaning, experience and embodiment) to the medical conception of the body, anthropologists have both solved and created the problem of nature/culture distinction in medicine, which exemplified by the disease/illness dichotomy.

[3]Among others, Bruno Latour reiterated this point in his opening statement as a part of “The ontological turn in French philosophical anthropology,” an executive session of the AAA Annual Meeting in 2013. A revised version of the speech has been published recently (Latour 2014).

In the Journals, September 2014 – Part II by Melanie Boeckmann

22 Septembre 2014 - 7:03pm

As a follow-up to Anna’s post, here are additional September articles of interest.

Anthropology and Medicine 
Special Issue: Mediating Medical Technologies: Flows, Frictions and New Socialities

Medical technologies: flows, frictions and new socialities
Anita Hardon & Eileen Moyer

While social scientists often highlight the way medical technologies mediate biomedical hegemony, this special issue focuses on the creative and often unexpected ways in which medical technologies are appropriated by diverse actors in homes, clinics and communities. The authors highlight key insights from twelve ethnographic case studies conducted in North and South America, Western Europe, Sub-Saharan Africa and Southeast Asia. The case studies focus on, among other issues, how sperm donors in Denmark, despite being subjugated to medical surveillance, experience the act of donating sperm as liberating; how sex workers in Indonesia turn to psychoactive painkillers to feel confident when approaching clients; why some anorexic patients in the United States resist prescribed antidepressant drugs; and how adolescent sex education workshops in Ecuador are appropriated by mothers to monitor their daughters and shame their ‘lying husbands’. Hardon and Moyer conclude that studies of medical technology need to be sensitive to the micro-dynamics of power, the specificities of local markets in which medical technologies generate value, the social and intergenerational relations in which they are embedded, and their intersections with class hierarchies.

After the withdrawal of ‘informed choice’: the meanings and social effects of mothers’ choice for HIV prevention in Senegal
Alice Desclaux

To prevent HIV transmission through breastfeeding, African health services in 1998 implemented the World Health Organization’s approach of ‘informed choice’ when recommending infant feeding options to HIV-positive mothers. In 2010, ‘informed choice’ was withdrawn in favour of antiretroviral prophylaxis with breastfeeding. A 2010–11 ethnographic study conducted in Senegal among HIV-positive mothers revealed three broad responses to the withdrawal of choice and formula provision: ‘resistance’ from association members claiming the health system was responsible for providing formula to ensure efficient prevention; ‘compliance’ among mothers adopting ‘protected breastfeeding’ without complaints; and ‘self-reliance’ among women trying to obtain formula through other means without mentioning choice. These three responses shed light on the meanings attributed to choice and on the social impact of formula provision during the ‘informed choice era.’ The analysis shows that the top-down introduction of ‘informed choice’ as an ethical and management imperative was appropriated and re-signified locally, making space for new forms of sociality within medical and associative social spaces. These social forms could not easily be maintained after the withdrawal of formula provision; women who continue to exert choice do so silently. By focusing on the upheaval of social care arrangements after the introduction of prophylaxis by pharmaceuticals, this paper sheds light on the understudied local consequences of changes in public health policies and the social framing of ‘choice’ in low-income countries’ health systems.

The ambiguity of patient-centred practices: the case of a Dutch fertility clinic
Trudie Gerrits

When in-vitro fertilization (IVF) was introduced in the 1970s, doctors were criticized for not properly informing prospective users about its possible risks and limited success rates as well as for medicalizing fertility problems. Nowadays, many fertility clinics are seeking to improve their accountability to stakeholders through patient-centred practices. Based on an ethnographic study of a Dutch fertility clinic, outspoken in its aims to provide patient-centred medicine and to empower clients, this paper addresses how patient-centred medicine affects couples’ decision-making to use IVF and related reproductive technologies. The author contends that while patient-centred practices facilitate informed decision-making and support couples emotionally, they may also have unintended disciplining and normalizing effects. The information and support provided, the trust couples have in clinic staff, the ongoing visualization of conception mediated by medical technology – all can be seen as practices that strengthen lay people’s ‘medical gaze’ in how they come to view their bodies, fertility problems and possible solutions. These unintended effects are labelled ‘the ambiguity of patient-centeredness’ as they (may) interfere with processes of autonomous decision-making.

When families fail: shifting expectations of care among people living with HIV in Nairobi, Kenya
Eileen Moyer & Emmy Kageha Igonya

The availability of free antiretroviral treatment in public health facilities since 2004 has contributed to the increasing biomedicalization of AIDS care in Kenya. This has been accompanied by a reduction of funding for community-based care and support organizations since the 2008 global economic crisis and a consequent donor divestment from HIV projects in Africa. This paper explores the ways that HIV interventions, including support groups, home-based care and antiretroviral treatments have shaped expectations regarding relations of care in the low-income area of Kibera in Nairobi, Kenya, over the last decade. Findings are based on 20 months of ethnographic research conducted in Nairobi between January 2011 and August 2013. By focusing on three eras of HIV treatment – pre-treatment, treatment scale-up, and post-crisis – the authors illustrate how family and community-based care have changed with shifts in funding. Many support groups that previously provided HIV care in Kibera, where the state is largely absent and family networks are thin, have been forced to cut services. Large-scale HIV treatment programmes may allow the urban poor in Nairobi to survive, but they are unlikely to thrive. Many care needs continue to go unmet in the age of treatment, and many economically marginal people who had found work in care-oriented community-based organizations now find themselves jobless or engaged in work not related to HIV.

Peer mentors, mobile phone and pills: collective monitoring and adherence in Kenyatta National Hospital’s HIV treatment programme
Eileen Moyer

In 2006, the Kenyan state joined the international commitment to make antiretroviral treatment free in public health institutions to people infected with HIV. Less than a decade later, treatment has reached over 60% of those who need it in Kenya. This paper, which is based on an in-depth ethnographic case study of the HIV treatment programme at Kenyatta National Hospital, conducted intermittently between 2008 and 2014, examines how HIV-positive peer mentors encourage and track adherence to treatment regimens within and beyond the clinic walls using mobile phones and computer technology. This research into the everyday practices of patient monitoring demonstrates that both surveillance and adherence are collective activities. Peer mentors provide counselling services, follow up people who stray from treatment regimens, and perform a range of other tasks related to patient management and treatment adherence. Despite peer mentors’ involvement in many tasks key to encouraging optimal adherence, their role is rarely acknowledged by co-workers, hospital administrators, or public health officials. Following a biomedical paradigm, adherence at Kenyatta and in Kenya is framed by programme administrators as something individual clients must do and for which they must be held accountable. This framing simultaneously conceals the sociality of adherence and undervalues the work of peer mentors in treatment programmes.

Beyond motivation: on what it means to be a sperm donor in Denmark
Sebastian Mohr

This paper, analyzing interviews with men that donate their semen in Denmark, explores what it means to be a sperm donor. Breaking with the assumption that men have a specific and clearly identifiable motivation to become sperm donors, this paper leaves the confinement of such an accountable actor model implied in asking for men’s motivations to donate semen. Instead, the author describes the experiences of sperm donors to show how the moral, organizational, and biomedical-technological context of sperm donation in Denmark makes for enactments of moral selves as well as specific embodiments of masculinity. Instead of looking for motivations that can be accounted for, the author engages with the question of how donating semen affords men the experience of moral and gendered selves.

‘At the hospital I learnt the truth’: diagnosing male infertility in rural Malawi
Fiona R. Parrott

This paper examines how men’s reproductive bodies are problematised in rural northern Malawi as access to biomedically defined diagnoses of the health of men’s sperm contribute to the visibility of male infertility. Ethnographic research with infertile and fertile men explored pathways into the sexual health and fertility services offered in district hospitals, men’s clinical engagements and masculine imaginaries. The research suggested that men’s willingness to be referred for semen analysis is an extension of intensive and persistent help-seeking for childlessness instigated by couples and encouraged by families. Within the laboratory, acceptable social arrangements for semen sample collection are negotiated between male clients and laboratory staff, which emphasise heterosexual and marital virility. Following diagnosis, counselling by clinical officers, without any significant therapeutic interventions, focuses on compassion in marriage. This paper considers: what is the role of semen analysis within public health facilities and why do men participate? How do men experience an infertility diagnosis and what do they and their partners do with this knowledge? In addition, how do these practices shape gendered relationships in families and communities? The analysis builds on Inhorn’s (2012) concept of ‘emergent masculinities’ to better understand the connections between male subjectivities, medical technologies and the globalisation of male reproductive health, as they relate to men’s lives in rural Malawi.

The unintended consequences of sex education: an ethnography of a development intervention in Latin America
Erica Nelson, Alexander Edmonds, Marco Ballesteros, Diana Encalada Soto & Octavio Rodriguez

This paper is an ethnography of a four-year, multi-disciplinary adolescent sexual and reproductive health intervention in Bolivia, Nicaragua and Ecuador. An important goal of the intervention – and of the larger global field of adolescent sexual and reproductive health – is to create more open parent-to-teen communication. This paper analyzes the project’s efforts to foster such communication and how social actors variously interpreted, responded to, and repurposed the intervention’s language and practices. While the intervention emphasized the goal of ‘open communication,’ its participants more often used the term ‘confianza’ (trust). This norm was defined in ways that might – or might not – include revealing information about sexual activity. Questioning public health assumptions about parent–teen communication on sex, in and of itself, is key to healthy sexual behavior, the paper explores a pragmatics of communication on sex that includes silence, implied expectations, gendered conflicts, and temporally delayed knowledge.

Medical borderlands: engineering the body with plastic surgery and hormonal therapies in Brazil
Alexander Edmonds & Emilia Sanabria

This paper explores medical borderlands where health and enhancement practices are entangled. It draws on fieldwork carried out in the context of two distinct research projects in Brazil on plastic surgery and sex hormone therapies. These two therapies have significant clinical overlap. Both are made available in private and public healthcare in ways that reveal the class dynamics underlying Brazilian medicine. They also have an important experimental dimension rooted in Brazil’s regulatory context and societal expectations placed on medicine as a means for managing women’s reproductive and sexual health. Off-label and experimental medical use of these treatments is linked to experimental social use: how women adopt them to respond to the pressures, anxieties and aspirations of work and intimate life. The paper argues that these experimental techniques are becoming morally authorized as routine management of women’s health, integrated into mainstream Ob-Gyn healthcare, and subtly blurred with practices ofcuidar-se (self-care) seen in Brazil as essential for modern femininity.

On Coba and Cocok: youth-led drug-experimentation in Eastern Indonesia
Anita Hardon & Nurul Ilmi Idrus

The everyday lives of contemporary youths are awash with drugs to boost pleasure, moods, sexual performance, vitality, appearance and health. This paper examines pervasive practices of chemical ‘self-maximization’ from the perspectives of youths themselves. The research for this paper was conducted among male, female and transgender (male to female, so-called waria) sex workers in Makassar, Indonesia. It presents the authors’ ethnographic findings on how these youths experiment with drugs to achieve their desired mental and bodily states: with the painkiller Somadril to feel happy, confident and less reluctant to engage in sex with clients, and contraceptive pills and injectable hormones to feminize their male bodies and to attract customers. Youths are extremely creative in adjusting dosages and mixing substances, with knowledge of the (mostly positive) ‘lived effects’ of drugs spreading through collective experimentation and word of mouth. The paper outlines how these experimental practices differ from those that have become the gold standard in biomedicine.

Biomedical subjectivities and reproductive assumptions in the CAMELIA clinical trial in Cambodia
Pascale Hancart Petitet

The inclusion of women in clinical trials has raised a variety of ethical and practical issues in their implementation. In the recent CAMELIA clinical trial in Cambodia, the inclusion criteria included a negative pregnancy test and signature of the consent form confirming commitment to double contraceptive use as patients were given drugs contra-indicated in case of pregnancy. But despite precautions and the requirement stated in the informed consent form, 19 out of 236 enrolled women became pregnant during the trial. The current paper describes the frictions and subjectivities that emerge as new medical technologies travel to resource-poor settings – and more specifically, how trial researchers, health workers, and research subjects involved in the CAMELIA trial negotiate the injunction to avoid pregnancy while using a teratogenic drug.

Health as moral failing: medication restriction among women with eating disorders
Rebecca Lester

Individuals with eating disorders often exhibit profound ambivalence towards taking prescribed medications. They may actively restrict their intake of medications, take them and then purge them, or hoard them and ‘binge’ on them. Such behaviors are often labeled clinically as ‘treatment resistance,’ and power struggles over medication adherence between clinicians and clients often ensue. This paper advances an alternative perspective. Based on extensive ethnographic and clinical engagements with women with eating disorders who restrict their medication intake, the analytical focus is pivoted to consider medication refusal not only as communicative in the interpersonal realm, but also as a powerful means of self-communication within the context of a larger ethical and moral project. This larger project makes visible the underside of what Lakoff (2008) calls the logic of pharmaceutical reason, which presumes that people naturally strive for optimal health. For these clients, by contrast, the optimal state is not health, but deprivation, which is experienced as a moral imperative extending well beyond issues related to body weight and shape. Within a broader cultural context where medication use is increasingly viewed as a legitimate and even superior means of self-management, medication restriction among people with eating disorders signals layers of meaning far beyond ‘treatment resistance.’ Refusing needed or useful medication can become a private and personally meaningful practice, largely independent of the material or interpersonal effects of the drugs. This suggests that the symbolic significance of medications must in some cases be discerned by their selective absence.

Caring on the margins of the healthcare system
Aline Sarradon-Eck, Cyril Farnarier & Takeo David Hymans

This paper addresses the working practices of a mobile mental health outreach team in a large French city, one that ‘targets’ homeless people with severe psychiatric disorders who are considered ‘hard to reach’ by the public health authorities and medical services. Analysis of the team’s work – where acts of curing and caring are closely tied – reveals the importance of moving beyond a polarized vision of cure and care. The paper departs from much of the literature on the medicalization of social problems by arguing that medicalization is not only a means of social control, but has ethical value as well. In examining the practices of frontline health workers, it aims to show that integrating the methods and theoretical approaches of social work in medical practice is necessary to address the specific problems of homeless people, to enable health professionals to pursue medical cures, and to challenge the shortcomings of public policy.

 

Anthropology and Medicine Issue 3

Measuring risk, managing values: health technology and subjectivity in Denmark
Julie Høgsgaard Andersen & Susan Reynolds Whyte

Based on fieldwork among Danes with a diagnosed risk of type 2 diabetes or cardiovascular disease, this paper investigates how the technological possibilities of diagnosing and monitoring invisible risks shape understandings of health and form subjectivity. It focuses on the experiences of being diagnosed with a risk condition in the form of high blood pressure or elevated blood glucose and the ensuing use of measuring devices. It argues that measurements of these conditions can be seen as ‘formative processes’ that produce and maintain a view of health as something that can best be known through the use of medical technology. The numerical values such measurements yield are seen as true indicators of health, and doing something about risk conditions is felt to be a personal imperative. The formative processes illustrated in this paper are motivational and thought provoking. The informants do not experience new symptoms after being diagnosed; rather they reflect upon their health in a new way and numbers become associated with personal responsibility and morality. However, because numbers influence subjective experiences, they can come to take up too much space in everyday life. Therefore, people have reservations about how often they should measure their values at home. The formative processes of being diagnosed with a risk condition are thus about subjectivity both in the sense of being subject to the demands of living with an illness and of being a subject who acts to keep life from being colonized by concerns about health.

Deep healing: ritual healing in the teshuvah movement
Asaf Sharabi

Based on an ethnographic analysis of religious healing rituals in Israel, this paper addresses the question of how healer–client relations are structured on these rituals. An examination of what takes place at the rallies held by Rabbi Amnon Yitzhak indicates that, apart from the regular blessings, which can be referred to as ordinary healing, there are some ritual events that can be referred to as ‘deep healing’. The current paper demonstrates how deep healing rituals are generally conducted in severe cases through give-and-take between the rabbi and the person upon whom the blessing is bestowed, and that they are linked to relationships between people and the ethic of mutual support.

‘The land is now not fertile’: social landscapes of hunger in south-eastern coastal Tanzania
Mai-Lei Woo Kinshella

Based on ethnographic fieldwork in a coastal village in south-eastern Tanzania, this paper examines how social inequalities and social suffering become embodied in the lived experiences of hunger. The paper explores local meanings of food, fertility and hunger and how these concepts interconnect and materialize on a landscape impacted by two large-scale conservation and development projects, the Mtwara Development Corridor and the Mnazi Bay Ruvuma Estuary Marine Park. Fourteen in-depth interviews Sinde villagers were conducted to elicit narratives about their food experiences in addition to 24 hour food recall and pile sort to explore local taxonomies of food. One focus group discussion with six women was also conducted. The study finds displacement from resources by the conservation and development projects has exacerbated existing food security issues of irregular rains, increasing food prices and malnourished bodies. The downward cycle of food insecurity has local villagers worried about the viability of their community’s future, embodied in the health of local children and their performance in school. Increasing food insecurity is internalized within the community as infertility where the health of the landscape is connected to the health of society.

Indigenous ethnopsychiatry in the north-west of England: the case of ‘Barrow Man’
Anthony Page

This paper describes the appearance and subsequent disappearance of ‘Barrow Man’ and uses anthropological and social psychological theory to examine the socio-cultural, psychological and economic conditions for the existence of the phenomenon. It argues that these conditions were the result of both specific local labour market circumstances and of the effects of global political changes, and argues that to talk about ‘Barrow Man’ as if it was a psychiatric diagnosis was to identify a moral construct as a mental disorder. It also argues that at the same time the phenomenon was expressive of certain core values that were not readily acknowledged in everyday clinical practice and that it might therefore best be understood as an institutional category.

Power, change, and ‘the culture of psychiatry’
Sadeq Rahimi

It is not uncommon to encounter ‘the culture of psychiatry’ used as a descriptive or even explanatory concept in discussions of psychiatric practices and services, specifically in research addressing cultural aspects of psychiatry. Drawing on data from research on the role of culture in psychiatric services in the Boston area, this paper critically examines the attribution of a ‘culture’ to psychiatry, which is prevalent not simply in mainstream psychiatric literature, but also in certain lines of cultural psychiatry, specifically those dedicated to political and anti-racist activism. It is argued that the use of such terminology could be misleading as it implicitly attributes a sense of coherence and agency to what may best be described as a set of related discourses and sociopolitical practices. It is further suggested that, given the implications of using such terminology as ‘culture’ in our discussions of psychiatry as a social institution, a scientific discourse, or a clinical practice, it would be more fruitful to address the analytic concepts of power, meaning, and the sociopolitical functions of psychiatry instead.

Listening to disembodied voices: anthropological and psychiatric challenges
Helen Basu

What is the role of the voice in Indian explanatory models of madness and psychiatric nosology? Anthropological and psychiatric challenges, it is argued, are crystallised in the voice, a medium that signifies the intersection of models of occult madness and schizophrenia. The psychiatry and religious healing practised at a Sufi shrine in Gujarat differed in terms of the status accorded to the voice: psychiatry interpreted the voice as a symptom of mental disorder, whereas religious healing used the medium in ambiguous practices of possession trance, combining performances of madness and healing. Although ‘doing trance’ is considered an essential part in the process of healing, patients diagnosed with schizophrenia do not experience trance. Their patiency is displaced onto a caretaker. Psychiatric theories resting on the somatised mind partly converge with theories of madness based on sorcery and possession in so far as both posit a direct link between the brain and behaviour. Against the background of the contested religious healing sites that are currently debated in Indian public mental health, attention to multiple dimensions of the voice reveals its significance as an alternative to the psychiatric institutionalisation of people coping with mental disorder. The voice reconciles the dichotomy between scientific psychiatry and traditional ritual healing, partly by making sense of madness by engaging with the sense of hearing.

The importance of contextualization. Anthropological reflections on descriptive analysis, its limitations and implications
Rikke Sand Andersen & Mette Bech Risør

This paper regards a concern for the quality of analyses made on the basis of qualitative interviews in some parts of qualitative health research. Starting with discussions departing in discussions on studies exploring ‘patient delay’ in healthcare seeking, it is argued that an implicit and simplified notion of causality impedes reflexivity on social context, on the nature of verbal statements and on the situatedness of the interview encounter. Further, the authors suggest that in order to improve the quality of descriptive analyses, it is pertinent to discuss the relationship between notions of causality and the need for contextualization in particular. This argument targets several disciplines taking a qualitative approach, including medical anthropology. In particular, researchers working in interdisciplinary fields face the demands of producing knowledge ready to implement, and such demands challenge basic notions of causality and explanatory power. In order to meet these, the authors suggest an analytic focus on process.

 

Anthropological Theory
Special issue on New Directions in the Anthropology of Morality
Edited by: Julia L Cassaniti and Jacob R Hickman

Moralizing emotion: A breakdown in Thailand
Julia L Cassaniti

Emotional practices serve as privileged sites for moral action in a Buddhist community in Northern Thailand. In this article I draw out some of the theoretical implications of this emphasis for the study of morality, combining an anthropological focus on moments of moral breakdown with a psychological claim about the importance of emotion in moral practice. I do this through a case of emotions experienced surrounding a Northern Thai man afflicted with a severe alcohol-related illness. I trace the emotions experienced by the man, his friends, and his family during this difficult time, and analyze the ways in which their emotions are moralized within their community. Contrasting these emotions with quite different reactions raised by the same situation by members of a nearby Christian Karen community, I show how such emotions are broadly connected to locally constructed religious ideas about the value of calmness and the letting go of affective attachments. Through this study I argue that emotions provide new evidence for culturally variable expressions of morality, less as the underpinning of moral judgments and more as objects of moral assessments, and in doing so suggest a new theoretical and methodological domain for the anthropological study of morality.

 

Configurations

Empathetic Reform and the Psychedelic Aesthetic:  Women’s Accounts of LSD Therapy
Lana Cook

Both written under pseudonym, Constance Newland’s My Self and I (1962) and Jane Dunlap’s Exploring Inner Space (1961) are firsthand accounts of psychedelic drug use taken in therapeutic research settings that demonstrate how women’s access to discursive legitimacy was negotiated in mid-twentieth-century life-writing. Newland and Dunlap use realism to connect readers to their psychedelic subjects, while estranging readers’ familiar worldviews through metaphor. Through reader recognition and estrangement, Newland and Dunlap develop readers’ empathy as a reformist tool to challenge standard narratives of literature and science and carve out new representational space for alternative states of consciousness.

The Dialectics of Vulnerability: Breast Cancer and the Body in Prognosis
Nadine Ehlers

This essay argues that breast cancer prognosis potentially produces a dialectic in which the subject is compelled to perceive the body as vulnerable and separate (alien) to the self and that the treatments required make the body more vulnerable and more alien, and that this is held in tension with the fact that the very alienation and heightened vulnerability of the body in breast cancer treatment are productive. Such alienation and vulnerability collapse the boundaries through which the body and self are understood, often demand a conscious intimacy of/with the body, and point to critical enactments and understandings of embodied subjectivity.

 

Journal of the Royal Anthropological Institute

Anthropology and emotion
Andrew Beatty

The centrality of emotion in thought and action is increasingly recognized in the human sciences, though basic questions of definition and scope remain unresolved. Where do emotions begin and end? How should we identify and analyse them? How should we write about them? Ethnographic fieldwork, as pioneered by Malinowski, offers powerful insights into the place of emotion in social life; but emotions are peculiarly difficult to capture in the generalizing format of case study and ethnographic summary. In this article I argue that semantic, structural, and discourse-based approaches tend to miss what is most important – what counts for the persons concerned and therefore what makes the emotion. I review the conceptual and methodological issues and conclude that only a narrative approach can capture both the particularity and the temporal dimension of emotion, restoring verisimilitude and fidelity to experience.

 

Medical Anthropology Quarterly

Encounters in Cancer Treatment: Intersubjective Configurations of a Need for Rehabilitation
Mette Terp Høybye & Tine Tjørnhøj-Thomsen

Based on extensive ethnographic material from in-depth interviews with Danish cancer patients after treatment, this study analyzes their stories to explore how interactions with the physician configures and situates a need for rehabilitation. We identify three themes in the illness stories: (1) attentiveness and care; (2) fragmentation and objectification; and (3) mistrust and dehumanization. These are all closely tied to the concept of recognition, showing how the themes are configured by the social interaction between the patient and the physician and how the need for rehabilitation is shaped by this encounter. The significance of the social encounters in cancer treatment is elucidated through this analysis, and we demonstrate how the need for recognition of the complex effects of cancer on one’s life is central to counter experiences of objectification and dehumanization.

Patient Agency Revisited: “Healing the Hidden” in South India
Roman Sieler

It is often argued that biomedicine alienates patients from doctors, from ailments and from understanding treatment processes, while indigenous and alternative healing systems are portrayed as respectful of patients and their experience. Specifically, South Indian siddha medicine has been seen as diverging from biomedicine in empowering its patients. This approach not only assumes biomedicine to be a homogeneous practice, but also lumps together diverse therapeutic techniques under the labels of “traditional” or “alternative.” Analysis of a manual subdiscipline of siddha medicine cautions against such analytic imprecision and active/passive binaries in physician–patient encounters. Practitioners of vital spot medicine claim to “heal the hidden.” They rarely communicate diagnostic insights verbally and object to auxiliary devices. However, their physical engagement with patients’ ailing bodies highlights the corporeal nature of manual medicine in particular and processual, situational, and reciprocal characteristics of curing in general.

Tainted Commons, Public Health: The Politico–Moral Significance of Cholera in Vietnam
Martha L. Lincoln

In October 2007, a series of cholera epidemics broke out in Hanoi, interrupting a moment of economic triumphalism in post-transition Vietnam. In seeking the source of a refractory disease associated with poverty and underdevelopment, officials, media, and citizens not only identified scapegoats and proposed solutions, they also endorsed particular visions of moral conduct, social order, and public health. Controversy over cholera, a potent politico–moral symbol, expressed an imaginary of “tainted commons” (i.e., an emergent space of civil society and small-scale entrepreneurship from which the state has partially withdrawn, while still exercising some measure of scrutiny and control). The ambiguities of this situation permitted the state to assume moral postures, evade responsibility, and deflect criticism to convenient targets. Prevalent outbreak narratives thus played on anxieties regarding specifically classed and gendered social groups, whose behavior was imagined to contravene ideals of public health and order.

“Here Nobody Holds Your Heart”: Metaphoric and Embodied Emotions of Birth and Displacement among Karen Women in Australia
Sara Niner, Renata Kokanovic, Denise Cuthbert & Violet Cho

Our objective was to explore the ways in which displaced Karen mothers expressed emotions in narrative accounts of motherhood and displacement. We contextualized and analyzed interview data from an ethnographic study of birth and emotions among 15 displaced Karen mothers in Australia. We found that women shared a common symbolic language to describe emotions centered on the heart, which was also associated with heart “problems.” This, along with hypertension, collapsing, or a feeling of surrender were associated responses to extremely adverse events experienced as displaced peoples. A metaphoric schema of emotional terms centered on the heart was connected to embodied expressions of emotion related to illness of the heart. This and other embodied responses were reactions to overwhelming difficulties and fear women endured due to their exposure to political conflict and global inequity.

How Women in Bangladesh Confront the Stigma of Childlessness: Agency, Resilience, and Resistance
Papreen Nahar & Sjaak van der Geest

In a context where motherhood is an integral part of a woman’s stereotype, being childless is a devastating experience. We explore how these so-called deviant women manage this situation. The objective of this article is to contribute to the debate regarding infertile women’s agency, resilience, and resistance. This article is based on anthropological fieldwork among urban middle-class and rural poor women. Their life histories reveal that childless women in Bangladesh, a pro-natalist, patriarchal society, are not passive victims, but rather actively fight their stigmatization and manage to survive. The childless women follow overt and covert strategies to overcome their stigmatized identity and create space for themselves in various innovative ways. The women do not resist in a coordinated way as a group, but do so individually. Given the collective nature of a society like rural Bangladesh, we believe that the women’s individual acts will eventually have collective effects.

“Suffering Twice”: The Gender Politics of Cesarean Sections in Taiwan
Chen-I Kuan

Women’s pursuit of medical interventions in childbirth has been a challenging issue in feminist and medical anthropological research on the medicalization of reproduction. This article addresses the gender politics surrounding maternal requests for cesarean sections in Taiwan. Since the 1990s, Taiwanese cesarean rates have been reported as among the highest in the world. That is not the case now, yet they are still perceived as such, and the current rate of 37% is indeed high by any standards. The government and public discourses attribute the high cesarean rate to women’s demand for this intervention. However, my ethnographic research indicates that the Taiwanese hospital birthing system leads to the prevalence of cesareans, and that women’s requests for them constitute strategic responses to the system and its existing high cesarean rates. Using women’s attempt to avoid “suffering twice” as an example, I argue that maternal requests for cesareans often lie at the intersection between their restricted control over childbirth and their agency within the medical system.

Chucaque and Social Stress among Peruvian Highlanders
Benjamin Blakely Brooks

Highland agriculturalists complain of the cultural syndrome chucaque in the Peruvian Andes. The first aim of this research was to ethnographically document cases of a cultural syndrome utilizing theoretical elements borrowed from cognitive anthropology. Another aim was to use case-control sampling to determine if there was a relationship between higher social stress levels and the development of a cultural syndrome. The research reported here integrated qualitative and quantitative methods. The social stress gauge developed by Rubel et al. (1984) was adapted to the Andean cultural environment and utilized to assess highland social stressors. Chucaque was found to be locally defined as a specific type of head pain commonly associated with the episode of a traumatic event. Chucaque and household social stress levels were found to be significantly related, especially when the ratio of males to females, which often was imbalanced, was included in the analysis.

A Biocultural Perspective on Fictive Kinship in the Andes: Social Support and Women’s Immune Function in El Alto, Bolivia
Kathryn Hicks

This article examines the influence of emotional and instrumental support on women’s immune function, a biomarker of stress, in the city of El Alto, Bolivia. It tests the prediction that instrumental support is protective of immune function for women living in this marginal environment. Qualitative and quantitative ethnographic methods were employed to assess perceived emotional and instrumental support and common sources of support; multiple linear regression analysis was used to model the relationship between social support and antibodies to the Epstein-Barr virus. These analyses provided no evidence that instrumental social support is related to women’s health, but there is some evidence that emotional support from compadres helps protect immune function.

 

Philosophy, Ethics, and Humanities in Medicine

Reassessing the approach to informed consent: the case of unrelated hematopoietic stem cell transplantation in adult thalassemia patients
Salvatore Pisu, Giovanni Caocci, Ernesto d’Aloja, Fabio Efficace, Adriana Vacca,Eugenia Piras, Maria Grazia Orofino, Carmen Addari, Michela Pintor, Roberto Demontis, Federica Demuru, Maria Rita Pittau, Gary S Collins & Giorgio La Nasa

Introduction
The informed consent process is the legal embodiment of the fundamental right of the individual to make decisions affecting his or her health., and the patient’s permission is a crucial form of respect of freedom and dignity, it becomes extremely important to enhance the patient’s understanding and recall of the information given by the physician. This statement acquires additional weight when the medical treatment proposed can potentially be detrimental or even fatal. This is the case of thalassemia patients pertaining to class 3 of the Pesaro classification where Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment. Unfortunately, this kind of intervention is burdened by an elevated transplantation-related mortality risk (TRM: all deaths considered related to transplantation), equal to 30% according to published reports. In thalassemia, the role of the patient in the informed consent process leading up to HSCT has not been fully investigated. This study investigated the hypothesis that information provided by physicians in the medical scenario of HSCT is not fully understood by patients and that misunderstanding and communication biases may affect the clinical decision-making process.
Methods
A questionnaire was either mailed or given personally to 25 patients. A second questionnaire was administered to the 12 physicians attending the patients enrolled in this study. Descriptive statistics were used to evaluate the communication factors.
Results
The results pointed out the difference between the risks communicated by physicians and the risks perceived by patients. Besides the study highlighted the mortality risk considered to be acceptable by patients and that considered to be acceptable by physicians.
Conclusions
Several solutions have been suggested to reduce the gap between communicated and perceived data. A multi-disciplinary approach may possibly help to attenuate some aspects of communication bias. Several tools have also been proposed to fill or to attenuate the gap between communicated and perceived data. But the most important tool is the ability of the physician to comprehend the right place of conscious consent in the relationship with the patient.

 

Science as Culture

The Therapeutic Promise of Pluripotency and its Political use in the Italian Stem Cell Debate
Lorenzo Beltrame

Stem cell research is considered one of the most promising branches of contemporary biomedicine. The capacity to develop into almost any cell type of the mature organism—pluripotency—is associated with human embryonic stem cells (hESCs) and is regarded as having great therapeutic potential. Harvesting stem cells destroys the human embryo, however; so research on embryonic stem cells has provoked controversies. In some countries such as Italy, the use of human embryos for research and therapeutic purposes is strictly forbidden. The Italian restrictive regulation has been explained by structural–cultural factors such as religion, but a better explanation lies in the policy dramaturgies deployed in the Italian debate. It was a struggle between two research trajectories—research on hESCs and on adult stem cells—for monopoly over the most credible therapeutic promise. Each was linked to different views of the Italian social order; each was epistemically legitimized by discourses on pluripotency and on the therapeutic potential of different stem cell types. Catholic actors articulated epistemic discourses on the therapeutic promises of different stem cell sources. The battle to define the social order—between a secular and a confessional view—became a struggle between two research trajectories for monopoly over the most credible therapeutic promise. The restrictive regulatory framework resulted from successfully transforming a policy dramaturgy into a new regulatory order. Thus structural–cultural variables such as religiosity matter only through the agency of institutional actors in local political cultures.

Fighting Fat: The Role of ‘Field Experts’ in Mediating Science and Biological Citizenship
Vienna Setälä & Esa VäLiverronen

Diet, fitness, and healthy living have become popular topics of media coverage and public health campaigns. Stories about the health hazards of fat draw heavily on scientific knowledge, the expertise of scientists and medical doctors, and increasingly on new field experts such as nutrition consultants and personal health trainers. A case study of an anti-fat campaign—the Fat Rebellion—run by Finland’s biggest daily newspaper Helsingin Sanomat, shows that field experts have become important mediators of scientific expertise. Nutrition therapists, personal fitness trainers, lifestyle coaches, and other field experts were the most cited actors in the campaign. The field experts promoted dietary foods, guidance, measurement technologies, and health training. The field experts in the Fat Rebellion also acted as mediators of biological citizenship: participants of the campaign were encouraged to take a greater responsibility for their health and vitality. Compared to scientific experts, field experts did not appear so much as sources of scientific information, but instead as authorised users of that information and specialists of employing commercial health technologies. They give advice and encourage citizens to record their weight and offer detailed prescriptions of healthy lifestyles. This combination of theoretical and practical knowledge as well as their daily or weekly face-to-face relationship with people in quest of healthy lifestyles makes them powerful mediators of biological citizenship.

 

Science in Context

An Uncertain Risk: The World Health Organization’s Account of H1N1
Sudeepa Abeysinghe

Scientific uncertainty is fundamental to the management of contemporary global risks. In 2009, the World Health Organization (WHO) declared the start of the H1N1 Influenza Pandemic. This declaration signified the risk posed by the spread of the H1N1 virus, and in turn precipitated a range of actions by global public health actors. This article analyzes the WHO’s public representation of risk and examines the centrality of scientific uncertainty in the case of H1N1. It argues that the WHO’s risk narrative reflected the context of scientific uncertainty in which it was working. The WHO argued that it was attempting to remain faithful to the scientific evidence, and the uncertain nature of the threat. However, as a result, the WHO’s public risk narrative was neither consistent nor socially robust, leading to the eventual contestation of the WHO’s position by other global public health actors, most notably the Council of Europe. This illustrates both the significance of scientific uncertainty in the investigation of risk, and the difficulty for risk managing institutions in effectively acting in the face of this uncertainty.

 

Science, Technology, & Human Values

Constructing the East–West Boundary: The Contested Place of a Modern Imaging Technology in South Korea’s Dual Medical System
Eunjeong Ma & Michael Lynch

This article presents a case study of a recent controversy over the use of computed tomography (CT) as a diagnostic technology in South Korean hospitals. The controversy occurred in the wake of a series of conflicts in the late twentieth century over the legitimate placement of healing practices, medicinal substances, and medical technologies within Korea’s separate “Western Medicine” (WM) and “Korean Medicine” (KM) systems of health care and pharmaceutical distribution. The controversy concerned an attempt to use hi-tech imaging technology—the epitome of modern medicine—in a clinic that maintains a strong ideological attachment to Korean healing traditions. A close study of this dispute, based on interviews, participant observation, and documentary analysis, showed that discursive positions taken about the translatability of medical technologies changed with the context of dispute, and did not reflect a stable epistemic boundary between rival medical paradigms.

Flush and Bone. Funeralizing Alkaline Hydrolysis in the United States
Philip R. Olsen

This article examines the political controversy in the United States surrounding a new process for the disposition of human remains, alkaline hydrolysis (AH). AH technologies use a heated (sometimes pressurized) solution of water and strong alkali to dissolve tissues, yielding an effluent that can be disposed through municipal sewer systems, and brittle bone matter that can be dried, crushed, and returned to the decedent’s family. Though AH is legal in eight US states, opposition to the technology remains strong. Opponents express concerns about public health and safety and about the dignity of our mortal remains. Proponents focus on AH’s environmental benefits over cremation and earth burial, aligning the technology with the “green burial” movement. Drawing from historical sources, Science, Technology, and Society literature, interviews with funeral professionals, industry literature, and various media sources, this article examines four prominent conceptions of the dead human body as they are deployed (and inflected) by various funeral stakeholders seeking to exercise authority over the dead human body, to influence the trajectory of AH technology in the United States, and to chart a course for US deathcare culture in the twenty-first century.

 

Transcultural Psychiatry
Special Issue: Indigenous Youth Resilience in the Arctic

Mapping resilience pathways of Indigenous youth in five circumpolar communities
James Allen, Kim Hopper, Lisa Wexler, Michael Kral, Stacy Rasmus & Kristine Nystad

This introduction to the Special Issue Indigenous Youth Resilience in the Arctic reviews relevant resilience theory and research, with particular attention to Arctic Indigenous youth. Current perspectives on resilience, as well as the role of social determinants, and community resilience processes in understanding resilience in Indigenous circumpolar settings are reviewed. The distinctive role for qualitative inquiry in understanding these frameworks is emphasized, as is the uniquely informative lens youth narratives can offer in understanding Indigenous, cultural, and community resilience processes during times of social transition. We then describe key shared cross-site methodological elements of the Circumpolar Indigenous Pathways to Adulthood study, including sampling, research design, procedures, and analytic strategies. The site-specific papers further elaborate on methods, focusing on those elements unique to each site, and describe in considerable detail locally salient stressors and culturally patterned resilience strategies operating in each community. The concluding paper considers these across sites, exploring continuities and discontinuities, and the influence of cross-national social policies.

Attaining khinem: Challenges, coping strategies and resilience among Eveny adolescents in northeastern Siberia
Olga Ulturgasheva

This article examines challenges, coping strategies, and resilience among Eveny adolescents in northeastern Siberia. It explores situations which the study participants associate with challenge and hardship, namely their experiences of transition from life in the family reindeer herding camp to schooling at the age of 7, bullying, boredom, and violence. By situating the data within the Eveny framework of resilience (khinem), the study provides the ethnographic context for coping strategies and efforts (e.g., sharing, inter- and intragenerational support, availability of safe homes) undertaken by the community in order to mitigate the situations of risk and hardship and to facilitate adolescents’ resilience. The account emphasizes that instead of identifying adolescents as either resilient or vulnerable, it is necessary to explore culturally specific processes and practices which potentially contribute to their acquisition of resilience.

Community resilience factors among indigenous Sámi adolescents: A qualitative study in Northern Norway
Kristine Nystad, Anna Rita Spein & Benedicte Ingstad

This qualitative study explores community resilience factors within an indigenous Sámi community in Northern Norway. Semistructured interviews were conducted with 22 informants, 12 females and 10 males, ranging in age from 13 to 19 years old, 12 of whom had reindeer husbandry affiliation. Data analysis used a modified grounded theory approach and narrative analysis. Interpretation of the data was based on ecological perspectives theory and the identification of possible community resilience factors including Sámi language competence, use of recreational and natural resources, and traditional ecological knowledge, such as reindeer husbandry related activities. These cultural factors appear to strengthen adolescents’ ethnic identity and pride, which in turn act as potential resilience mechanisms. Land was a significant arena for traditional practices and recreation. The majority of the youth reported support from relationships with extended godparents (fáddarat) and extended family (sohka) networks. The fáttar network was particularly strong among adolescents with reindeer husbandry affiliations. Native language competence and reindeer husbandry were key components in adolescent social networks. Interconnectedness among the community members and with the environment seemed to promote resilience and well-being. Two factors that excluded adolescents from full community membership and participation were being a nonnative Sámi language speaker and the absence of extended Sámi family networks.

Tunngajuq: Stress and resilience among Inuit youth in Nunavut, Canada
Michael J. Kral, Ida Salusky, Pakkak Inuksuk, Leah Angutimarik & Nathan Tulugardjuk

As part of a cross-national collaborative study of resilience among circumpolar youth, we examined the life experiences, stressors, and coping or resilience strategies of Inuit youth in the community of Igloolik, Nunavut, Canada. An Inuit steering committee was formed with youth, adults, and one elder. The steering committee led this project in the community, informing community members of progress and helping direct all aspects of the study from research questions to methods to data collection to dissemination. A structured interview used across sites allowed youth to describe what matters to them, that is, what is at stake for them in terms of challenges and successes. Developing stable and secure relationships with one’s friends and family members enabled Inuit youth to become more resilient in the face of stresses related to social change in the Canadian Arctic.

Arctic indigenous youth resilience and vulnerability: Comparative analysis of adolescent experiences across five circumpolar communities
Olga Ulturgasheva, Stacy Rasmus, Lisa Wexler, Kristine Nystad & Michael Kral

Arctic peoples today find themselves on the front line of rapid environmental change brought about by globalizing forces, shifting climates, and destabilizing physical conditions. The weather is not the only thing undergoing rapid change here. Social climates are intrinsically connected to physical climates, and changes within each have profound effects on the daily life, health, and well-being of circumpolar indigenous peoples. This paper describes a collaborative effort between university researchers and community members from five indigenous communities in the circumpolar north aimed at comparing the experiences of indigenous Arctic youth in order to come up with a shared model of indigenous youth resilience. The discussion introduces a sliding scale model that emerged from the comparative data analysis. It illustrates how a “sliding scale” of resilience captures the inherent dynamism of youth strategies for “doing well” and what forces represent positive and negative influences that slide towards either personal and communal resilience or vulnerability. The model of the sliding scale is designed to reflect the contingency and interdependence of resilience and vulnerability and their fluctuations between lowest and highest points based on timing, local situation, larger context, and meaning.

“Being responsible, respectful, trying to keep the tradition alive:” Cultural resilience and growing up in an Alaska Native community
Lisa Wexler, Linda Joule, Joe Garoutte, Janet Mazziotti & Kim Hopper

Indigenous circumpolar youth are experiencing challenges of growing up in a context much different from that of their parents and their grandparents due to rapid and imposed social change. Our study is interested in community resilience: the meaning systems, resources, and relationships that structure how youth go about overcoming difficulties. The research reflects an understanding that social and cultural ecologies influence people’s available and meaningful options. The in-depth, qualitative study of 20 youth from the same Arctic community shows Inupiat (Alaska Native) youth are navigating challenges. Findings from this research suggest that Inupiat youth reflect more flexible patterns of resilience when they are culturally grounded. This cultural foundation involves kinship networks that mediate young people’s access to cultural and material assets. Our participants emphasized the importance of taking care of others and “giving back to the community.” Being “in the country” linked youth to traditional ontology that profoundly shifted how youth felt in relation to themselves, to others, and the world. The vast majority of participants’ “fulfillment narratives” centered on doing subsistence and/or cultural activities. In relation to this, young people were more likely to demonstrate versatility in their resilience strategies when deploying coherent self-narratives that reflected novel yet culturally resonant styles. Young women were more likely to demonstrate this by reconfiguring notions of culture and gender identity in ways that helped them meet challenges in their lives. Lastly, generational differences in understandings signal particular ways that young people’s historical and political positioning influences their access to cultural resources.

“Where I have to learn the ways how to live:” Youth resilience in a Yup’ik village in Alaska
Stacy M. Rasmus, James Allen & Tara Ford

What is it like to grow up Yup’ik and come of age today in a traditional hunting-gathering community setting located in a remote region of Alaska? Current research describes a contemporary experience often laden with trauma and crisis. Youth in Yup’ik communities today face threats to their very survival as they encounter, early on, things that their ancestors never faced—including alcohol-related deaths, violence in many forms, and high rates of suicide among their young peers. Yet all is not despair for the youth growing up in these remote indigenous communities. Many youth grow-up to become skilled hunters, strong leaders, and able parents. This paper reports findings from the Alaskan Yup’ik site of the Circumpolar Indigenous Pathways to Adulthood (CIPA) study. The goal of this study is to identify strengths and resilience in youth living in a Yup’ik community in southwest Alaska. Interviews were conducted with 25 youth age 11–18, currently residing in a southwest Alaska community. Qualitative analysis revealed important connections between local stressors, community-level protective resources, and youth-driven, solution-focused strategies for overcoming hardship and learning the “ways how to live.” Findings from this study contribute critical information on indigenous youth protection and resilience, including community and cultural resilience processes beyond the individual level, and enhance our understanding of the types of resources that can lead to improved outcomes for Alaska Native youth.

In the Journals, September 2014 – Part II by Melanie Boeckmann

22 Septembre 2014 - 3:18pm

As a follow-up to Anna’s post, here are additional articles for September.

Anthropology and Medicine

Special Issue: Mediating Medical Technologies: Flows, Frictions and New Socialities

Medical technologies: flows, frictions and new socialities 

Anita Hardon & Eileen Moyer

While social scientists often highlight the way medical technologies mediate biomedical hegemony, this special issue focuses on the creative and often unexpected ways in which medical technologies are appropriated by diverse actors in homes, clinics and communities. The authors highlight key insights from twelve ethnographic case studies conducted in North and South America, Western Europe, Sub-Saharan Africa and Southeast Asia. The case studies focus on, among other issues, how sperm donors in Denmark, despite being subjugated to medical surveillance, experience the act of donating sperm as liberating; how sex workers in Indonesia turn to psychoactive painkillers to feel confident when approaching clients; why some anorexic patients in the United States resist prescribed antidepressant drugs; and how adolescent sex education workshops in Ecuador are appropriated by mothers to monitor their daughters and shame their ‘lying husbands’. Hardon and Moyer conclude that studies of medical technology need to be sensitive to the micro-dynamics of power, the specificities of local markets in which medical technologies generate value, the social and intergenerational relations in which they are embedded, and their intersections with class hierarchies.

After the withdrawal of ‘informed choice’: the meanings and social effects of mothers’ choice for HIV prevention in Senegal

Alice Desclaux

To prevent HIV transmission through breastfeeding, African health services in 1998 implemented the World Health Organization’s approach of ‘informed choice’ when recommending infant feeding options to HIV-positive mothers. In 2010, ‘informed choice’ was withdrawn in favour of antiretroviral prophylaxis with breastfeeding. A 2010–11 ethnographic study conducted in Senegal among HIV-positive mothers revealed three broad responses to the withdrawal of choice and formula provision: ‘resistance’ from association members claiming the health system was responsible for providing formula to ensure efficient prevention; ‘compliance’ among mothers adopting ‘protected breastfeeding’ without complaints; and ‘self-reliance’ among women trying to obtain formula through other means without mentioning choice. These three responses shed light on the meanings attributed to choice and on the social impact of formula provision during the ‘informed choice era.’ The analysis shows that the top-down introduction of ‘informed choice’ as an ethical and management imperative was appropriated and re-signified locally, making space for new forms of sociality within medical and associative social spaces. These social forms could not easily be maintained after the withdrawal of formula provision; women who continue to exert choice do so silently. By focusing on the upheaval of social care arrangements after the introduction of prophylaxis by pharmaceuticals, this paper sheds light on the understudied local consequences of changes in public health policies and the social framing of ‘choice’ in low-income countries’ health systems.

The ambiguity of patient-centred practices: the case of a Dutch fertility clinic

Trudie Gerrits

When in-vitro fertilization (IVF) was introduced in the 1970s, doctors were criticized for not properly informing prospective users about its possible risks and limited success rates as well as for medicalizing fertility problems. Nowadays, many fertility clinics are seeking to improve their accountability to stakeholders through patient-centred practices. Based on an ethnographic study of a Dutch fertility clinic, outspoken in its aims to provide patient-centred medicine and to empower clients, this paper addresses how patient-centred medicine affects couples’ decision-making to use IVF and related reproductive technologies. The author contends that while patient-centred practices facilitate informed decision-making and support couples emotionally, they may also have unintended disciplining and normalizing effects. The information and support provided, the trust couples have in clinic staff, the ongoing visualization of conception mediated by medical technology – all can be seen as practices that strengthen lay people’s ‘medical gaze’ in how they come to view their bodies, fertility problems and possible solutions. These unintended effects are labelled ‘the ambiguity of patient-centeredness’ as they (may) interfere with processes of autonomous decision-making.

When families fail: shifting expectations of care among people living with HIV in Nairobi, Kenya

Eileen Moyer & Emmy Kageha Igonya

The availability of free antiretroviral treatment in public health facilities since 2004 has contributed to the increasing biomedicalization of AIDS care in Kenya. This has been accompanied by a reduction of funding for community-based care and support organizations since the 2008 global economic crisis and a consequent donor divestment from HIV projects in Africa. This paper explores the ways that HIV interventions, including support groups, home-based care and antiretroviral treatments have shaped expectations regarding relations of care in the low-income area of Kibera in Nairobi, Kenya, over the last decade. Findings are based on 20 months of ethnographic research conducted in Nairobi between January 2011 and August 2013. By focusing on three eras of HIV treatment – pre-treatment, treatment scale-up, and post-crisis – the authors illustrate how family and community-based care have changed with shifts in funding. Many support groups that previously provided HIV care in Kibera, where the state is largely absent and family networks are thin, have been forced to cut services. Large-scale HIV treatment programmes may allow the urban poor in Nairobi to survive, but they are unlikely to thrive. Many care needs continue to go unmet in the age of treatment, and many economically marginal people who had found work in care-oriented community-based organizations now find themselves jobless or engaged in work not related to HIV.

Peer mentors, mobile phone and pills: collective monitoring and adherence in Kenyatta National Hospital’s HIV treatment programme

Eileen Moyer

In 2006, the Kenyan state joined the international commitment to make antiretroviral treatment free in public health institutions to people infected with HIV. Less than a decade later, treatment has reached over 60% of those who need it in Kenya. This paper, which is based on an in-depth ethnographic case study of the HIV treatment programme at Kenyatta National Hospital, conducted intermittently between 2008 and 2014, examines how HIV-positive peer mentors encourage and track adherence to treatment regimens within and beyond the clinic walls using mobile phones and computer technology. This research into the everyday practices of patient monitoring demonstrates that both surveillance and adherence are collective activities. Peer mentors provide counselling services, follow up people who stray from treatment regimens, and perform a range of other tasks related to patient management and treatment adherence. Despite peer mentors’ involvement in many tasks key to encouraging optimal adherence, their role is rarely acknowledged by co-workers, hospital administrators, or public health officials. Following a biomedical paradigm, adherence at Kenyatta and in Kenya is framed by programme administrators as something individual clients must do and for which they must be held accountable. This framing simultaneously conceals the sociality of adherence and undervalues the work of peer mentors in treatment programmes.

Beyond motivation: on what it means to be a sperm donor in Denmark

Sebastian Mohr

This paper, analyzing interviews with men that donate their semen in Denmark, explores what it means to be a sperm donor. Breaking with the assumption that men have a specific and clearly identifiable motivation to become sperm donors, this paper leaves the confinement of such an accountable actor model implied in asking for men’s motivations to donate semen. Instead, the author describes the experiences of sperm donors to show how the moral, organizational, and biomedical-technological context of sperm donation in Denmark makes for enactments of moral selves as well as specific embodiments of masculinity. Instead of looking for motivations that can be accounted for, the author engages with the question of how donating semen affords men the experience of moral and gendered selves.

‘At the hospital I learnt the truth’: diagnosing male infertility in rural Malawi

Fiona R. Parrott

This paper examines how men’s reproductive bodies are problematised in rural northern Malawi as access to biomedically defined diagnoses of the health of men’s sperm contribute to the visibility of male infertility. Ethnographic research with infertile and fertile men explored pathways into the sexual health and fertility services offered in district hospitals, men’s clinical engagements and masculine imaginaries. The research suggested that men’s willingness to be referred for semen analysis is an extension of intensive and persistent help-seeking for childlessness instigated by couples and encouraged by families. Within the laboratory, acceptable social arrangements for semen sample collection are negotiated between male clients and laboratory staff, which emphasise heterosexual and marital virility. Following diagnosis, counselling by clinical officers, without any significant therapeutic interventions, focuses on compassion in marriage. This paper considers: what is the role of semen analysis within public health facilities and why do men participate? How do men experience an infertility diagnosis and what do they and their partners do with this knowledge? In addition, how do these practices shape gendered relationships in families and communities? The analysis builds on Inhorn’s (2012) concept of ‘emergent masculinities’ to better understand the connections between male subjectivities, medical technologies and the globalisation of male reproductive health, as they relate to men’s lives in rural Malawi.

The unintended consequences of sex education: an ethnography of a development intervention in Latin America

Erica Nelson, Alexander Edmonds, Marco Ballesteros, Diana Encalada Soto & Octavio Rodriguez

This paper is an ethnography of a four-year, multi-disciplinary adolescent sexual and reproductive health intervention in Bolivia, Nicaragua and Ecuador. An important goal of the intervention – and of the larger global field of adolescent sexual and reproductive health – is to create more open parent-to-teen communication. This paper analyzes the project’s efforts to foster such communication and how social actors variously interpreted, responded to, and repurposed the intervention’s language and practices. While the intervention emphasized the goal of ‘open communication,’ its participants more often used the term ‘confianza’ (trust). This norm was defined in ways that might – or might not – include revealing information about sexual activity. Questioning public health assumptions about parent–teen communication on sex, in and of itself, is key to healthy sexual behavior, the paper explores a pragmatics of communication on sex that includes silence, implied expectations, gendered conflicts, and temporally delayed knowledge.

Medical borderlands: engineering the body with plastic surgery and hormonal therapies in Brazil

Alexander Edmonds & Emilia Sanabria

This paper explores medical borderlands where health and enhancement practices are entangled. It draws on fieldwork carried out in the context of two distinct research projects in Brazil on plastic surgery and sex hormone therapies. These two therapies have significant clinical overlap. Both are made available in private and public healthcare in ways that reveal the class dynamics underlying Brazilian medicine. They also have an important experimental dimension rooted in Brazil’s regulatory context and societal expectations placed on medicine as a means for managing women’s reproductive and sexual health. Off-label and experimental medical use of these treatments is linked to experimental social use: how women adopt them to respond to the pressures, anxieties and aspirations of work and intimate life. The paper argues that these experimental techniques are becoming morally authorized as routine management of women’s health, integrated into mainstream Ob-Gyn healthcare, and subtly blurred with practices ofcuidar-se (self-care) seen in Brazil as essential for modern femininity.

On Coba and Cocok: youth-led drug-experimentation in Eastern Indonesia

Anita Hardon & Nurul Ilmi Idrus

The everyday lives of contemporary youths are awash with drugs to boost pleasure, moods, sexual performance, vitality, appearance and health. This paper examines pervasive practices of chemical ‘self-maximization’ from the perspectives of youths themselves. The research for this paper was conducted among male, female and transgender (male to female, so-called waria) sex workers in Makassar, Indonesia. It presents the authors’ ethnographic findings on how these youths experiment with drugs to achieve their desired mental and bodily states: with the painkiller Somadril to feel happy, confident and less reluctant to engage in sex with clients, and contraceptive pills and injectable hormones to feminize their male bodies and to attract customers. Youths are extremely creative in adjusting dosages and mixing substances, with knowledge of the (mostly positive) ‘lived effects’ of drugs spreading through collective experimentation and word of mouth. The paper outlines how these experimental practices differ from those that have become the gold standard in biomedicine.

Biomedical subjectivities and reproductive assumptions in the CAMELIA clinical trial in Cambodia

Pascale Hancart Petitet

The inclusion of women in clinical trials has raised a variety of ethical and practical issues in their implementation. In the recent CAMELIA clinical trial in Cambodia, the inclusion criteria included a negative pregnancy test and signature of the consent form confirming commitment to double contraceptive use as patients were given drugs contra-indicated in case of pregnancy. But despite precautions and the requirement stated in the informed consent form, 19 out of 236 enrolled women became pregnant during the trial. The current paper describes the frictions and subjectivities that emerge as new medical technologies travel to resource-poor settings – and more specifically, how trial researchers, health workers, and research subjects involved in the CAMELIA trial negotiate the injunction to avoid pregnancy while using a teratogenic drug.

Health as moral failing: medication restriction among women with eating disorders

Rebecca Lester

Individuals with eating disorders often exhibit profound ambivalence towards taking prescribed medications. They may actively restrict their intake of medications, take them and then purge them, or hoard them and ‘binge’ on them. Such behaviors are often labeled clinically as ‘treatment resistance,’ and power struggles over medication adherence between clinicians and clients often ensue. This paper advances an alternative perspective. Based on extensive ethnographic and clinical engagements with women with eating disorders who restrict their medication intake, the analytical focus is pivoted to consider medication refusal not only as communicative in the interpersonal realm, but also as a powerful means of self-communication within the context of a larger ethical and moral project. This larger project makes visible the underside of what Lakoff (2008) calls the logic of pharmaceutical reason, which presumes that people naturally strive for optimal health. For these clients, by contrast, the optimal state is not health, but deprivation, which is experienced as a moral imperative extending well beyond issues related to body weight and shape. Within a broader cultural context where medication use is increasingly viewed as a legitimate and even superior means of self-management, medication restriction among people with eating disorders signals layers of meaning far beyond ‘treatment resistance.’ Refusing needed or useful medication can become a private and personally meaningful practice, largely independent of the material or interpersonal effects of the drugs. This suggests that the symbolic significance of medications must in some cases be discerned by their selective absence.

Caring on the margins of the healthcare system

Aline Sarradon-Eck, Cyril Farnarier & Takeo David Hymans

This paper addresses the working practices of a mobile mental health outreach team in a large French city, one that ‘targets’ homeless people with severe psychiatric disorders who are considered ‘hard to reach’ by the public health authorities and medical services. Analysis of the team’s work – where acts of curing and caring are closely tied – reveals the importance of moving beyond a polarized vision of cure and care. The paper departs from much of the literature on the medicalization of social problems by arguing that medicalization is not only a means of social control, but has ethical value as well. In examining the practices of frontline health workers, it aims to show that integrating the methods and theoretical approaches of social work in medical practice is necessary to address the specific problems of homeless people, to enable health professionals to pursue medical cures, and to challenge the shortcomings of public policy.

 

Anthropology and Medicine Issue 3

Measuring risk, managing values: health technology and subjectivity in Denmark

Julie Høgsgaard Andersen & Susan Reynolds Whyte

Based on fieldwork among Danes with a diagnosed risk of type 2 diabetes or cardiovascular disease, this paper investigates how the technological possibilities of diagnosing and monitoring invisible risks shape understandings of health and form subjectivity. It focuses on the experiences of being diagnosed with a risk condition in the form of high blood pressure or elevated blood glucose and the ensuing use of measuring devices. It argues that measurements of these conditions can be seen as ‘formative processes’ that produce and maintain a view of health as something that can best be known through the use of medical technology. The numerical values such measurements yield are seen as true indicators of health, and doing something about risk conditions is felt to be a personal imperative. The formative processes illustrated in this paper are motivational and thought provoking. The informants do not experience new symptoms after being diagnosed; rather they reflect upon their health in a new way and numbers become associated with personal responsibility and morality. However, because numbers influence subjective experiences, they can come to take up too much space in everyday life. Therefore, people have reservations about how often they should measure their values at home. The formative processes of being diagnosed with a risk condition are thus about subjectivity both in the sense of being subject to the demands of living with an illness and of being a subject who acts to keep life from being colonized by concerns about health.

Deep healing: ritual healing in the teshuvah movement

Asaf Sharabi

Based on an ethnographic analysis of religious healing rituals in Israel, this paper addresses the question of how healer–client relations are structured on these rituals. An examination of what takes place at the rallies held by Rabbi Amnon Yitzhak indicates that, apart from the regular blessings, which can be referred to as ordinary healing, there are some ritual events that can be referred to as ‘deep healing’. The current paper demonstrates how deep healing rituals are generally conducted in severe cases through give-and-take between the rabbi and the person upon whom the blessing is bestowed, and that they are linked to relationships between people and the ethic of mutual support.

‘The land is now not fertile’: social landscapes of hunger in south-eastern coastal Tanzania

Mai-Lei Woo Kinshella

Based on ethnographic fieldwork in a coastal village in south-eastern Tanzania, this paper examines how social inequalities and social suffering become embodied in the lived experiences of hunger. The paper explores local meanings of food, fertility and hunger and how these concepts interconnect and materialize on a landscape impacted by two large-scale conservation and development projects, the Mtwara Development Corridor and the Mnazi Bay Ruvuma Estuary Marine Park. Fourteen in-depth interviews Sinde villagers were conducted to elicit narratives about their food experiences in addition to 24 hour food recall and pile sort to explore local taxonomies of food. One focus group discussion with six women was also conducted. The study finds displacement from resources by the conservation and development projects has exacerbated existing food security issues of irregular rains, increasing food prices and malnourished bodies. The downward cycle of food insecurity has local villagers worried about the viability of their community’s future, embodied in the health of local children and their performance in school. Increasing food insecurity is internalized within the community as infertility where the health of the landscape is connected to the health of society.

Indigenous ethnopsychiatry in the north-west of England: the case of ‘Barrow Man’

Anthony Page

This paper describes the appearance and subsequent disappearance of ‘Barrow Man’ and uses anthropological and social psychological theory to examine the socio-cultural, psychological and economic conditions for the existence of the phenomenon. It argues that these conditions were the result of both specific local labour market circumstances and of the effects of global political changes, and argues that to talk about ‘Barrow Man’ as if it was a psychiatric diagnosis was to identify a moral construct as a mental disorder. It also argues that at the same time the phenomenon was expressive of certain core values that were not readily acknowledged in everyday clinical practice and that it might therefore best be understood as an institutional category.

Power, change, and ‘the culture of psychiatry’

Sadeq Rahimi

It is not uncommon to encounter ‘the culture of psychiatry’ used as a descriptive or even explanatory concept in discussions of psychiatric practices and services, specifically in research addressing cultural aspects of psychiatry. Drawing on data from research on the role of culture in psychiatric services in the Boston area, this paper critically examines the attribution of a ‘culture’ to psychiatry, which is prevalent not simply in mainstream psychiatric literature, but also in certain lines of cultural psychiatry, specifically those dedicated to political and anti-racist activism. It is argued that the use of such terminology could be misleading as it implicitly attributes a sense of coherence and agency to what may best be described as a set of related discourses and sociopolitical practices. It is further suggested that, given the implications of using such terminology as ‘culture’ in our discussions of psychiatry as a social institution, a scientific discourse, or a clinical practice, it would be more fruitful to address the analytic concepts of power, meaning, and the sociopolitical functions of psychiatry instead.

Listening to disembodied voices: anthropological and psychiatric challenges

Helen Basu

What is the role of the voice in Indian explanatory models of madness and psychiatric nosology? Anthropological and psychiatric challenges, it is argued, are crystallised in the voice, a medium that signifies the intersection of models of occult madness and schizophrenia. The psychiatry and religious healing practised at a Sufi shrine in Gujarat differed in terms of the status accorded to the voice: psychiatry interpreted the voice as a symptom of mental disorder, whereas religious healing used the medium in ambiguous practices of possession trance, combining performances of madness and healing. Although ‘doing trance’ is considered an essential part in the process of healing, patients diagnosed with schizophrenia do not experience trance. Their patiency is displaced onto a caretaker. Psychiatric theories resting on the somatised mind partly converge with theories of madness based on sorcery and possession in so far as both posit a direct link between the brain and behaviour. Against the background of the contested religious healing sites that are currently debated in Indian public mental health, attention to multiple dimensions of the voice reveals its significance as an alternative to the psychiatric institutionalisation of people coping with mental disorder. The voice reconciles the dichotomy between scientific psychiatry and traditional ritual healing, partly by making sense of madness by engaging with the sense of hearing.

The importance of contextualization. Anthropological reflections on descriptive analysis, its limitations and implications

Rikke Sand Andersen & Mette Bech Risør

This paper regards a concern for the quality of analyses made on the basis of qualitative interviews in some parts of qualitative health research. Starting with discussions departing in discussions on studies exploring ‘patient delay’ in healthcare seeking, it is argued that an implicit and simplified notion of causality impedes reflexivity on social context, on the nature of verbal statements and on the situatedness of the interview encounter. Further, the authors suggest that in order to improve the quality of descriptive analyses, it is pertinent to discuss the relationship between notions of causality and the need for contextualization in particular. This argument targets several disciplines taking a qualitative approach, including medical anthropology. In particular, researchers working in interdisciplinary fields face the demands of producing knowledge ready to implement, and such demands challenge basic notions of causality and explanatory power. In order to meet these, the authors suggest an analytic focus on process.

 

Anthropological Theory

Special issue on New Directions in the Anthropology of Morality

Edited by: Julia L Cassaniti and Jacob R Hickman

Moralizing emotion: A breakdown in Thailand

Julia L Cassaniti

Emotional practices serve as privileged sites for moral action in a Buddhist community in Northern Thailand. In this article I draw out some of the theoretical implications of this emphasis for the study of morality, combining an anthropological focus on moments of moral breakdown with a psychological claim about the importance of emotion in moral practice. I do this through a case of emotions experienced surrounding a Northern Thai man afflicted with a severe alcohol-related illness. I trace the emotions experienced by the man, his friends, and his family during this difficult time, and analyze the ways in which their emotions are moralized within their community. Contrasting these emotions with quite different reactions raised by the same situation by members of a nearby Christian Karen community, I show how such emotions are broadly connected to locally constructed religious ideas about the value of calmness and the letting go of affective attachments. Through this study I argue that emotions provide new evidence for culturally variable expressions of morality, less as the underpinning of moral judgments and more as objects of moral assessments, and in doing so suggest a new theoretical and methodological domain for the anthropological study of morality.

 

Configurations

Empathetic Reform and the Psychedelic Aesthetic: Women’s Accounts of LSD Therapy

Lana Cook

Both written under pseudonym, Constance Newland’s My Self and I (1962) and Jane Dunlap’s Exploring Inner Space (1961) are firsthand accounts of psychedelic drug use taken in therapeutic research settings that demonstrate how women’s access to discursive legitimacy was negotiated in mid-twentieth-century life-writing. Newland and Dunlap use realism to connect readers to their psychedelic subjects, while estranging readers’ familiar worldviews through metaphor. Through reader recognition and estrangement, Newland and Dunlap develop readers’ empathy as a reformist tool to challenge standard narratives of literature and science and carve out new representational space for alternative states of consciousness.

The Dialectics of Vulnerability: Breast Cancer and the Body in Prognosis

Nadine Ehlers

This essay argues that breast cancer prognosis potentially produces a dialectic in which the subject is compelled to perceive the body as vulnerable and separate (alien) to the self and that the treatments required make the body more vulnerable and more alien, and that this is held in tension with the fact that the very alienation and heightened vulnerability of the body in breast cancer treatment are productive. Such alienation and vulnerability collapse the boundaries through which the body and self are understood, often demand a conscious intimacy of/with the body, and point to critical enactments and understandings of embodied subjectivity.

 

Journal of the Royal Anthropological Institute

Anthropology and emotion

Andrew Beatty

The centrality of emotion in thought and action is increasingly recognized in the human sciences, though basic questions of definition and scope remain unresolved. Where do emotions begin and end? How should we identify and analyse them? How should we write about them? Ethnographic fieldwork, as pioneered by Malinowski, offers powerful insights into the place of emotion in social life; but emotions are peculiarly difficult to capture in the generalizing format of case study and ethnographic summary. In this article I argue that semantic, structural, and discourse-based approaches tend to miss what is most important – what counts for the persons concerned and therefore what makes the emotion. I review the conceptual and methodological issues and conclude that only a narrative approach can capture both the particularity and the temporal dimension of emotion, restoring verisimilitude and fidelity to experience.

 

Medical Anthropology Quarterly

Encounters in Cancer Treatment: Intersubjective Configurations of a Need for Rehabilitation

Mette Terp Høybye & Tine Tjørnhøj-Thomsen

Based on extensive ethnographic material from in-depth interviews with Danish cancer patients after treatment, this study analyzes their stories to explore how interactions with the physician configures and situates a need for rehabilitation. We identify three themes in the illness stories: (1) attentiveness and care; (2) fragmentation and objectification; and (3) mistrust and dehumanization. These are all closely tied to the concept of recognition, showing how the themes are configured by the social interaction between the patient and the physician and how the need for rehabilitation is shaped by this encounter. The significance of the social encounters in cancer treatment is elucidated through this analysis, and we demonstrate how the need for recognition of the complex effects of cancer on one’s life is central to counter experiences of objectification and dehumanization.

Patient Agency Revisited: “Healing the Hidden” in South India

Roman Sieler

It is often argued that biomedicine alienates patients from doctors, from ailments and from understanding treatment processes, while indigenous and alternative healing systems are portrayed as respectful of patients and their experience. Specifically, South Indian siddha medicine has been seen as diverging from biomedicine in empowering its patients. This approach not only assumes biomedicine to be a homogeneous practice, but also lumps together diverse therapeutic techniques under the labels of “traditional” or “alternative.” Analysis of a manual subdiscipline of siddha medicine cautions against such analytic imprecision and active/passive binaries in physician–patient encounters. Practitioners of vital spot medicine claim to “heal the hidden.” They rarely communicate diagnostic insights verbally and object to auxiliary devices. However, their physical engagement with patients’ ailing bodies highlights the corporeal nature of manual medicine in particular and processual, situational, and reciprocal characteristics of curing in general.

Tainted Commons, Public Health: The Politico–Moral Significance of Cholera in Vietnam

Martha L. Lincoln

In October 2007, a series of cholera epidemics broke out in Hanoi, interrupting a moment of economic triumphalism in post-transition Vietnam. In seeking the source of a refractory disease associated with poverty and underdevelopment, officials, media, and citizens not only identified scapegoats and proposed solutions, they also endorsed particular visions of moral conduct, social order, and public health. Controversy over cholera, a potent politico–moral symbol, expressed an imaginary of “tainted commons” (i.e., an emergent space of civil society and small-scale entrepreneurship from which the state has partially withdrawn, while still exercising some measure of scrutiny and control). The ambiguities of this situation permitted the state to assume moral postures, evade responsibility, and deflect criticism to convenient targets. Prevalent outbreak narratives thus played on anxieties regarding specifically classed and gendered social groups, whose behavior was imagined to contravene ideals of public health and order.

“Here Nobody Holds Your Heart”: Metaphoric and Embodied Emotions of Birth and Displacement among Karen Women in Australia

Sara Niner, Renata Kokanovic, Denise Cuthbert & Violet Cho

Our objective was to explore the ways in which displaced Karen mothers expressed emotions in narrative accounts of motherhood and displacement. We contextualized and analyzed interview data from an ethnographic study of birth and emotions among 15 displaced Karen mothers in Australia. We found that women shared a common symbolic language to describe emotions centered on the heart, which was also associated with heart “problems.” This, along with hypertension, collapsing, or a feeling of surrender were associated responses to extremely adverse events experienced as displaced peoples. A metaphoric schema of emotional terms centered on the heart was connected to embodied expressions of emotion related to illness of the heart. This and other embodied responses were reactions to overwhelming difficulties and fear women endured due to their exposure to political conflict and global inequity.

How Women in Bangladesh Confront the Stigma of Childlessness: Agency, Resilience, and Resistance

Papreen Nahar & Sjaak van der Geest

In a context where motherhood is an integral part of a woman’s stereotype, being childless is a devastating experience. We explore how these so-called deviant women manage this situation. The objective of this article is to contribute to the debate regarding infertile women’s agency, resilience, and resistance. This article is based on anthropological fieldwork among urban middle-class and rural poor women. Their life histories reveal that childless women in Bangladesh, a pro-natalist, patriarchal society, are not passive victims, but rather actively fight their stigmatization and manage to survive. The childless women follow overt and covert strategies to overcome their stigmatized identity and create space for themselves in various innovative ways. The women do not resist in a coordinated way as a group, but do so individually. Given the collective nature of a society like rural Bangladesh, we believe that the women’s individual acts will eventually have collective effects.

“Suffering Twice”: The Gender Politics of Cesarean Sections in Taiwan

Chen-I Kuan

Women’s pursuit of medical interventions in childbirth has been a challenging issue in feminist and medical anthropological research on the medicalization of reproduction. This article addresses the gender politics surrounding maternal requests for cesarean sections in Taiwan. Since the 1990s, Taiwanese cesarean rates have been reported as among the highest in the world. That is not the case now, yet they are still perceived as such, and the current rate of 37% is indeed high by any standards. The government and public discourses attribute the high cesarean rate to women’s demand for this intervention. However, my ethnographic research indicates that the Taiwanese hospital birthing system leads to the prevalence of cesareans, and that women’s requests for them constitute strategic responses to the system and its existing high cesarean rates. Using women’s attempt to avoid “suffering twice” as an example, I argue that maternal requests for cesareans often lie at the intersection between their restricted control over childbirth and their agency within the medical system.

Chucaque and Social Stress among Peruvian Highlanders

Benjamin Blakely Brooks

Highland agriculturalists complain of the cultural syndrome chucaque in the Peruvian Andes. The first aim of this research was to ethnographically document cases of a cultural syndrome utilizing theoretical elements borrowed from cognitive anthropology. Another aim was to use case-control sampling to determine if there was a relationship between higher social stress levels and the development of a cultural syndrome. The research reported here integrated qualitative and quantitative methods. The social stress gauge developed by Rubel et al. (1984) was adapted to the Andean cultural environment and utilized to assess highland social stressors. Chucaque was found to be locally defined as a specific type of head pain commonly associated with the episode of a traumatic event. Chucaque and household social stress levels were found to be significantly related, especially when the ratio of males to females, which often was imbalanced, was included in the analysis.

A Biocultural Perspective on Fictive Kinship in the Andes: Social Support and Women’s Immune Function in El Alto, Bolivia

Kathryn Hicks

This article examines the influence of emotional and instrumental support on women’s immune function, a biomarker of stress, in the city of El Alto, Bolivia. It tests the prediction that instrumental support is protective of immune function for women living in this marginal environment. Qualitative and quantitative ethnographic methods were employed to assess perceived emotional and instrumental support and common sources of support; multiple linear regression analysis was used to model the relationship between social support and antibodies to the Epstein-Barr virus. These analyses provided no evidence that instrumental social support is related to women’s health, but there is some evidence that emotional support from compadres helps protect immune function.

 

Philosophy, Ethics, and Humanities in Medicine

Reassessing the approach to informed consent: the case of unrelated hematopoietic stem cell transplantation in adult thalassemia patients

Salvatore Pisu, Giovanni Caocci, Ernesto d’Aloja, Fabio Efficace, Adriana Vacca,Eugenia Piras, Maria Grazia Orofino, Carmen Addari, Michela Pintor, Roberto Demontis, Federica Demuru, Maria Rita Pittau, Gary S Collins & Giorgio La Nasa

Introduction

The informed consent process is the legal embodiment of the fundamental right of the individual to make decisions affecting his or her health., and the patient’s permission is a crucial form of respect of freedom and dignity, it becomes extremely important to enhance the patient’s understanding and recall of the information given by the physician. This statement acquires additional weight when the medical treatment proposed can potentially be detrimental or even fatal. This is the case of thalassemia patients pertaining to class 3 of the Pesaro classification where Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment. Unfortunately, this kind of intervention is burdened by an elevated transplantation-related mortality risk (TRM: all deaths considered related to transplantation), equal to 30% according to published reports. In thalassemia, the role of the patient in the informed consent process leading up to HSCT has not been fully investigated. This study investigated the hypothesis that information provided by physicians in the medical scenario of HSCT is not fully understood by patients and that misunderstanding and communication biases may affect the clinical decision-making process.

Methods

A questionnaire was either mailed or given personally to 25 patients. A second questionnaire was administered to the 12 physicians attending the patients enrolled in this study. Descriptive statistics were used to evaluate the communication factors.

Results

The results pointed out the difference between the risks communicated by physicians and the risks perceived by patients. Besides the study highlighted the mortality risk considered to be acceptable by patients and that considered to be acceptable by physicians.

Conclusions

Several solutions have been suggested to reduce the gap between communicated and perceived data. A multi-disciplinary approach may possibly help to attenuate some aspects of communication bias. Several tools have also been proposed to fill or to attenuate the gap between communicated and perceived data. But the most important tool is the ability of the physician to comprehend the right place of conscious consent in the relationship with the patient.

 

Science as Culture

The Therapeutic Promise of Pluripotency and its Political use in the Italian Stem Cell Debate

Lorenzo Beltrame

Stem cell research is considered one of the most promising branches of contemporary biomedicine. The capacity to develop into almost any cell type of the mature organism—pluripotency—is associated with human embryonic stem cells (hESCs) and is regarded as having great therapeutic potential. Harvesting stem cells destroys the human embryo, however; so research on embryonic stem cells has provoked controversies. In some countries such as Italy, the use of human embryos for research and therapeutic purposes is strictly forbidden. The Italian restrictive regulation has been explained by structural–cultural factors such as religion, but a better explanation lies in the policy dramaturgies deployed in the Italian debate. It was a struggle between two research trajectories—research on hESCs and on adult stem cells—for monopoly over the most credible therapeutic promise. Each was linked to different views of the Italian social order; each was epistemically legitimized by discourses on pluripotency and on the therapeutic potential of different stem cell types. Catholic actors articulated epistemic discourses on the therapeutic promises of different stem cell sources. The battle to define the social order—between a secular and a confessional view—became a struggle between two research trajectories for monopoly over the most credible therapeutic promise. The restrictive regulatory framework resulted from successfully transforming a policy dramaturgy into a new regulatory order. Thus structural–cultural variables such as religiosity matter only through the agency of institutional actors in local political cultures.

Fighting Fat: The Role of ‘Field Experts’ in Mediating Science and Biological Citizenship

Vienna Setälä & Esa VäLiverronen

Diet, fitness, and healthy living have become popular topics of media coverage and public health campaigns. Stories about the health hazards of fat draw heavily on scientific knowledge, the expertise of scientists and medical doctors, and increasingly on new field experts such as nutrition consultants and personal health trainers. A case study of an anti-fat campaign—the Fat Rebellion—run by Finland’s biggest daily newspaper Helsingin Sanomat, shows that field experts have become important mediators of scientific expertise. Nutrition therapists, personal fitness trainers, lifestyle coaches, and other field experts were the most cited actors in the campaign. The field experts promoted dietary foods, guidance, measurement technologies, and health training. The field experts in the Fat Rebellion also acted as mediators of biological citizenship: participants of the campaign were encouraged to take a greater responsibility for their health and vitality. Compared to scientific experts, field experts did not appear so much as sources of scientific information, but instead as authorised users of that information and specialists of employing commercial health technologies. They give advice and encourage citizens to record their weight and offer detailed prescriptions of healthy lifestyles. This combination of theoretical and practical knowledge as well as their daily or weekly face-to-face relationship with people in quest of healthy lifestyles makes them powerful mediators of biological citizenship.

 

Science in Context

An Uncertain Risk: The World Health Organization’s Account of H1N1

Sudeepa Abeysinghe

Scientific uncertainty is fundamental to the management of contemporary global risks. In 2009, the World Health Organization (WHO) declared the start of the H1N1 Influenza Pandemic. This declaration signified the risk posed by the spread of the H1N1 virus, and in turn precipitated a range of actions by global public health actors. This article analyzes the WHO’s public representation of risk and examines the centrality of scientific uncertainty in the case of H1N1. It argues that the WHO’s risk narrative reflected the context of scientific uncertainty in which it was working. The WHO argued that it was attempting to remain faithful to the scientific evidence, and the uncertain nature of the threat. However, as a result, the WHO’s public risk narrative was neither consistent nor socially robust, leading to the eventual contestation of the WHO’s position by other global public health actors, most notably the Council of Europe. This illustrates both the significance of scientific uncertainty in the investigation of risk, and the difficulty for risk managing institutions in effectively acting in the face of this uncertainty.

 

Science, Technology, & Human Values

Constructing the East–West Boundary: The Contested Place of a Modern Imaging Technology in South Korea’s Dual Medical System

Eunjeong Ma & Michael Lynch

This article presents a case study of a recent controversy over the use of computed tomography (CT) as a diagnostic technology in South Korean hospitals. The controversy occurred in the wake of a series of conflicts in the late twentieth century over the legitimate placement of healing practices, medicinal substances, and medical technologies within Korea’s separate “Western Medicine” (WM) and “Korean Medicine” (KM) systems of health care and pharmaceutical distribution. The controversy concerned an attempt to use hi-tech imaging technology—the epitome of modern medicine—in a clinic that maintains a strong ideological attachment to Korean healing traditions. A close study of this dispute, based on interviews, participant observation, and documentary analysis, showed that discursive positions taken about the translatability of medical technologies changed with the context of dispute, and did not reflect a stable epistemic boundary between rival medical paradigms.

Flush and Bone. Funeralizing Alkaline Hydrolysis in the United States

Philip R. Olsen

This article examines the political controversy in the United States surrounding a new process for the disposition of human remains, alkaline hydrolysis (AH). AH technologies use a heated (sometimes pressurized) solution of water and strong alkali to dissolve tissues, yielding an effluent that can be disposed through municipal sewer systems, and brittle bone matter that can be dried, crushed, and returned to the decedent’s family. Though AH is legal in eight US states, opposition to the technology remains strong. Opponents express concerns about public health and safety and about the dignity of our mortal remains. Proponents focus on AH’s environmental benefits over cremation and earth burial, aligning the technology with the “green burial” movement. Drawing from historical sources, Science, Technology, and Society literature, interviews with funeral professionals, industry literature, and various media sources, this article examines four prominent conceptions of the dead human body as they are deployed (and inflected) by various funeral stakeholders seeking to exercise authority over the dead human body, to influence the trajectory of AH technology in the United States, and to chart a course for US deathcare culture in the twenty-first century.

 

Transcultural Psychiatry

Special Issue: Indigenous Youth Resilience in the Arctic

Mapping resilience pathways of Indigenous youth in five circumpolar communities

James Allen, Kim Hopper, Lisa Wexler,  Michael Kral, Stacy Rasmus & Kristine Nystad

This introduction to the Special Issue Indigenous Youth Resilience in the Arctic reviews relevant resilience theory and research, with particular attention to Arctic Indigenous youth. Current perspectives on resilience, as well as the role of social determinants, and community resilience processes in understanding resilience in Indigenous circumpolar settings are reviewed. The distinctive role for qualitative inquiry in understanding these frameworks is emphasized, as is the uniquely informative lens youth narratives can offer in understanding Indigenous, cultural, and community resilience processes during times of social transition. We then describe key shared cross-site methodological elements of the Circumpolar Indigenous Pathways to Adulthood study, including sampling, research design, procedures, and analytic strategies. The site-specific papers further elaborate on methods, focusing on those elements unique to each site, and describe in considerable detail locally salient stressors and culturally patterned resilience strategies operating in each community. The concluding paper considers these across sites, exploring continuities and discontinuities, and the influence of cross-national social policies.

Attaining khinem: Challenges, coping strategies and resilience among Eveny adolescents in northeastern Siberia

Olga Ulturgasheva

This article examines challenges, coping strategies, and resilience among Eveny adolescents in northeastern Siberia. It explores situations which the study participants associate with challenge and hardship, namely their experiences of transition from life in the family reindeer herding camp to schooling at the age of 7, bullying, boredom, and violence. By situating the data within the Eveny framework of resilience (khinem), the study provides the ethnographic context for coping strategies and efforts (e.g., sharing, inter- and intragenerational support, availability of safe homes) undertaken by the community in order to mitigate the situations of risk and hardship and to facilitate adolescents’ resilience. The account emphasizes that instead of identifying adolescents as either resilient or vulnerable, it is necessary to explore culturally specific processes and practices which potentially contribute to their acquisition of resilience.

Community resilience factors among indigenous Sámi adolescents: A qualitative study in Northern Norway

Kristine Nystad, Anna Rita Spein & Benedicte Ingstad

This qualitative study explores community resilience factors within an indigenous Sámi community in Northern Norway. Semistructured interviews were conducted with 22 informants, 12 females and 10 males, ranging in age from 13 to 19 years old, 12 of whom had reindeer husbandry affiliation. Data analysis used a modified grounded theory approach and narrative analysis. Interpretation of the data was based on ecological perspectives theory and the identification of possible community resilience factors including Sámi language competence, use of recreational and natural resources, and traditional ecological knowledge, such as reindeer husbandry related activities. These cultural factors appear to strengthen adolescents’ ethnic identity and pride, which in turn act as potential resilience mechanisms. Land was a significant arena for traditional practices and recreation. The majority of the youth reported support from relationships with extended godparents (fáddarat) and extended family (sohka) networks. The fáttar network was particularly strong among adolescents with reindeer husbandry affiliations. Native language competence and reindeer husbandry were key components in adolescent social networks. Interconnectedness among the community members and with the environment seemed to promote resilience and well-being. Two factors that excluded adolescents from full community membership and participation were being a nonnative Sámi language speaker and the absence of extended Sámi family networks.

Tunngajuq: Stress and resilience among Inuit youth in Nunavut, Canada

Michael J. Kral, Ida Salusky, Pakkak Inuksuk, Leah Angutimarik & Nathan Tulugardjuk

As part of a cross-national collaborative study of resilience among circumpolar youth, we examined the life experiences, stressors, and coping or resilience strategies of Inuit youth in the community of Igloolik, Nunavut, Canada. An Inuit steering committee was formed with youth, adults, and one elder. The steering committee led this project in the community, informing community members of progress and helping direct all aspects of the study from research questions to methods to data collection to dissemination. A structured interview used across sites allowed youth to describe what matters to them, that is, what is at stake for them in terms of challenges and successes. Developing stable and secure relationships with one’s friends and family members enabled Inuit youth to become more resilient in the face of stresses related to social change in the Canadian Arctic.

Arctic indigenous youth resilience and vulnerability: Comparative analysis of adolescent experiences across five circumpolar communities

Olga Ulturgasheva, Stacy Rasmus, Lisa Wexler, Kristine Nystad &Michael Kral

Arctic peoples today find themselves on the front line of rapid environmental change brought about by globalizing forces, shifting climates, and destabilizing physical conditions. The weather is not the only thing undergoing rapid change here. Social climates are intrinsically connected to physical climates, and changes within each have profound effects on the daily life, health, and well-being of circumpolar indigenous peoples. This paper describes a collaborative effort between university researchers and community members from five indigenous communities in the circumpolar north aimed at comparing the experiences of indigenous Arctic youth in order to come up with a shared model of indigenous youth resilience. The discussion introduces a sliding scale model that emerged from the comparative data analysis. It illustrates how a “sliding scale” of resilience captures the inherent dynamism of youth strategies for “doing well” and what forces represent positive and negative influences that slide towards either personal and communal resilience or vulnerability. The model of the sliding scale is designed to reflect the contingency and interdependence of resilience and vulnerability and their fluctuations between lowest and highest points based on timing, local situation, larger context, and meaning.

“Being responsible, respectful, trying to keep the tradition alive:” Cultural resilience and growing up in an Alaska Native community

Lisa Wexler, Linda Joule, Joe Garoutte, Janet Mazziotti & Kim Hopper

Indigenous circumpolar youth are experiencing challenges of growing up in a context much different from that of their parents and their grandparents due to rapid and imposed social change. Our study is interested in community resilience: the meaning systems, resources, and relationships that structure how youth go about overcoming difficulties. The research reflects an understanding that social and cultural ecologies influence people’s available and meaningful options. The in-depth, qualitative study of 20 youth from the same Arctic community shows Inupiat (Alaska Native) youth are navigating challenges. Findings from this research suggest that Inupiat youth reflect more flexible patterns of resilience when they are culturally grounded. This cultural foundation involves kinship networks that mediate young people’s access to cultural and material assets. Our participants emphasized the importance of taking care of others and “giving back to the community.” Being “in the country” linked youth to traditional ontology that profoundly shifted how youth felt in relation to themselves, to others, and the world. The vast majority of participants’ “fulfillment narratives” centered on doing subsistence and/or cultural activities. In relation to this, young people were more likely to demonstrate versatility in their resilience strategies when deploying coherent self-narratives that reflected novel yet culturally resonant styles. Young women were more likely to demonstrate this by reconfiguring notions of culture and gender identity in ways that helped them meet challenges in their lives. Lastly, generational differences in understandings signal particular ways that young people’s historical and political positioning influences their access to cultural resources.

“Where I have to learn the ways how to live:” Youth resilience in a Yup’ik village in Alaska

Stacy M. Rasmus, James Allen & Tara Ford

What is it like to grow up Yup’ik and come of age today in a traditional hunting-gathering community setting located in a remote region of Alaska? Current research describes a contemporary experience often laden with trauma and crisis. Youth in Yup’ik communities today face threats to their very survival as they encounter, early on, things that their ancestors never faced—including alcohol-related deaths, violence in many forms, and high rates of suicide among their young peers. Yet all is not despair for the youth growing up in these remote indigenous communities. Many youth grow-up to become skilled hunters, strong leaders, and able parents. This paper reports findings from the Alaskan Yup’ik site of the Circumpolar Indigenous Pathways to Adulthood (CIPA) study. The goal of this study is to identify strengths and resilience in youth living in a Yup’ik community in southwest Alaska. Interviews were conducted with 25 youth age 11–18, currently residing in a southwest Alaska community. Qualitative analysis revealed important connections between local stressors, community-level protective resources, and youth-driven, solution-focused strategies for overcoming hardship and learning the “ways how to live.” Findings from this study contribute critical information on indigenous youth protection and resilience, including community and cultural resilience processes beyond the individual level, and enhance our understanding of the types of resources that can lead to improved outcomes for Alaska Native youth.

 

Joseph Dumit’s Drugs for Life by Kristin Peterson

22 Septembre 2014 - 9:10am

Drugs for Life: How Pharmaceutical Companies Define Our Health

by Joseph Dumit

Duke University Press, 2012. pp. 280.

Since the 1970s, scholarly work on pharmaceuticals has long engaged a number of concerns, debates and controversies: the socialities and politics of consumption, the commercialization of the life sciences, and restricted access to life-saving medicines as a result of global patent and trade laws – to name a few.

In his book, Drugs for Life, Joseph Dumit completely resituates our understanding of a highly studied topic. A key critical intervention is his ethnographic approach. Pharmaceuticals, drug companies, health care systems, and doctor-patient interactions are not sites of ethnographic inquiry per se – even though they are completely integral to the story. Rather, the ethnography focuses on the drug industry’s shifting logics — from former investments in individual health to future-oriented investments in mass health. As a result, the project is located within an entirely unique scale of analysis such that individual patient subjectivities are effortlessly tied to strategies for making drug markets grow.

From this methodological approach, we learn that pursuing high rates of economic growth requires the drug industry to reimagine medicine itself. Medicine is no longer exclusively about enhancing individual health, especially acute symptoms for which treatments end when health is restored. But rather it is more about treating health risks at a larger, aggregate scale. Health risks are quantifiable thresholds that connect cholesterol levels to heart conditions, glucose levels to diabetes, blood pressure to hypertension, etc. High-risk thresholds can be indefinitely symptomless yet projected as always life-threatening. The industry recognizes that getting more people on more prescription drugs is key to expanding market growth; and focusing on health risk presents novel ways to get patients to indefinitely take treatments. Importantly, health risks themselves can be highly flexible in ways that increase long-term market share. For example, Dumit describes how the risk thresholds for cholesterol have been lowered three times over the last decade, increasing the potential to get more patients prescribed more cholesterol-lowering statins.

Much work must go into producing these logics. Dumit shows how the patient is viewed from marketing perspectives as inherently ill, always at risk; she is constructed as responsible for taking charge of her preventative care – what Dumit refers to as “objective self-fashioning” (see also Dumit’s Picturing Personhood, Princeton University Press, 2004). Patients and doctors are not fools in this scenario, but rather they are congealed into drug industry “facts” that result in a small range of treatment options. Such facts are generated by clinical trials that are designed to create evidence for more treatment and ultimately larger market share. For example, a clinical trial may indicate that hundreds of asymptomatic people should take a daily pill in order to prevent a handful of heart attacks – the individual is treated but the mass-produced data estimates aggregate health risk and quantifies market potential. Some trials fail to show such “good” results, but as Dumit points out, clinical trials never study when a patient should stop taking a drug, which would be the end to this strategy for maximizing prescriptions.

The key concept in Drugs for Life is “surplus health,” which Dumit defines as ‘the capacity to add medications to our life through lowering the level of risk required to be “at risk.”’ Dumit shows how surplus health operates throughout the book, as I have briefly illustrated, but he leaves out some key theoretical work that he conceptualized elsewhere (see “Prescription Maximization and the Accumulation of Surplus Health in the Pharmaceutical Industry: The BioMarx Experiment” that appeared in Lively Capital: Biotechnologies, Ethics, and Governance in Global Markets, Ed. Sunder Rajan, Duke University Press, 2012). It is worth exploring because surplus health has implications for a wide range of issues in medical anthropology and science and technology studies.

Dumit describes the shift from individual health to mass health when medicine “as an arm of capital (charged with maintaining workers for work) became an industry itself…” (“Prescription Maximization”, 52-53). In reading Marx, Dumit discusses how early capitalism needed healthy workers because they were essential to industrial production. That is, medicine was critical to reproducing the conditions that made healthy workers possible. Dumit compares Marx’s analysis of commodity production to surplus health. Marx argued that commodity production became a self-perpetuating means to an end, geared toward primarily generating surplus value. Similarly, Dumit shows that ‘health for workers’ shifts to ‘health as an industry in and of itself,’ one also geared toward the generation of surplus value. He writes:

The healthcare industry has its own imperatives for growth that on the face of it are contradictory to capital; that is, healthcare grows by treating more illnesses, yet it should not remove workers from the workplace. The solution is to appropriate that part of health that is not needed for work. This surplus health includes those persons who are too young or too old to work, and it includes illnesses that can be treated “on- the- job,” so to speak, without keeping the worker from working. The latter encompasses both illnesses of the everyday (like mild depression) and illnesses of the future (like risk factors and symptomless illnesses like cholesterol). Each of these areas of illness can easily be shown to be major targets of diagnostic and therapeutic development, and each has had phenomenal growth in the last fifty years, intensifying especially in the last decade (“Prescription Maximization”, 52-53).

This conceptualization is critical to understanding just how pharmaceutical value works in almost classic Marxian contradiction: patients who are healthy and do not take medicine are not valuable to this drug economy. What is valuable is the construction of the inherently ill, at-risk patient who recognizes the chronic need to take pharmaceuticals over the long-term – taking drugs now is the key to future good health and future productive markets.

Drugs for Life is a brilliant and provocative analysis of the new cultural and business logics of science, medicalization, and the drug industry. While it largely focuses on the U.S., it has further implications for how we understand the circulation and social meaning of pharmaceuticals in other regions. Drugs may encounter similar or different sets of industry logics throughout the world, but such logics are nevertheless geared toward ensuring market share, pricing strategies, and market expansion. It is, in sum, an inspiring and generative book that is certain to spark future significant inquiry.

Kristin Peterson is an associate professor of anthropology at UC Irvine. She is the author of Speculative Markets: Drug Circuits and Derivative Life in Nigeria (Duke UP, 2014).

Race and the immuno-logics of Ebola response in West Africa by Adia Benton

19 Septembre 2014 - 4:40pm

On September 14, 2014, I woke up to the news that a fourth Sierra Leonean doctor, Dr. Olivet Buck, had died after having treated patients with Ebola. By then, there had been nearly 2,300 confirmed deaths, with about 150 of them being health care workers at the front line of the epidemic. All Ebola deaths are tragic, and many of them could have been prevented with better and earlier response by government and international health authorities. But Dr. Buck’s death is all the more significant for what it represents in these months of sluggish response to the West African Ebola crisis. The government of Sierra Leone feared that Dr. Buck’s death would further diminish an already understaffed health workforce and demoralize exhausted health workers. They arranged for her medical evacuation to Germany, where a hospital was awaiting her arrival. President Koroma requested assistance for Buck’s transport from the World Health Organization (WHO), the international body coordinating the international Ebola response.

The WHO rejected the president’s request. As Buck battled illness in a Freetown hospital, two Dutch doctors, fearing that they had been exposed to Ebola through patients they had treated for malaria, fled to the Dutch embassy in Ghana. There, they sought immediate evacuation to the Netherlands. The doctors — thankfully for the Ghanaians and others who surely crossed their path — had yet to experience symptoms and, therefore, were unlikely to have transmitted the disease to others. They have since been evacuated. The simultaneous unfolding of the stories of Dr. Buck and the two Dutch physicians raises important questions about the character of emergency response to this outbreak: How are we to interpret the Dutch doctors’ evacuation and WHO’s refusal to assist in Dr. Buck’s? And what might be revealed by reading these two stories together?

Some have suggested that bureaucratic red tape was most likely to blame for this differential treatment; others have asked whether it was fair to evacuate any national health workers under the circumstances. As I have written elsewhere, for observers watching the outbreak unfold, these situations entail assessments about the value of life. These assessments are not isolated or neutral forms of triage (Sierra Leone’s premier virologist also died amidst negotiations for his medical evacuation and possible treatment with an experimental drug, ZMapp). Rather, these assessments about the value of life lie at the core of humanitarian emergency response; they are part of its operating logic.

This operating logic has a racial dimension, which has for too long gone unexamined and whose impact has been woefully underestimated. Among West Africans living in or hailing from the affected areas and within the African diaspora, there is a sense that when it comes to decisions about who will live, who will die, and who will receive the best care, white Westerners who come to help will often — if not always — be the priority.

US Peace Corps volunteers, as well as employees from mining companies, international NGOs and foreign embassies, have been evacuated or placed on voluntary temporary leave from their posts. The Peace Corps evacuation is, perhaps, noteworthy because one of the organization’s mandate for its volunteers is that they ‘live in a manner similar to the local people in [their] community.’ The simulation of local life appears to reach its limit when the threat of Ebola nears, despite the fact, as Kim Yi Dionne notes, that (1) avoiding contact with bodily fluids of infected persons and maintaining strict hygiene practices minimizes risk of infection and (2) volunteers are highly educated adults who can certainly understand and adhere to public health instructions. (This is not to say that volunteers wanted to be evacuated from the sites; in fact, many of them were reluctant to leave).

For the foreign doctors and technicians who stayed on and have fallen ill, no expense was spared, no form of care or protection was off-limits. Kent Brantly and Nancy Writebol, the two American missionaries who became sick in August, were evacuated to Emory Hospital in Atlanta and treated with the experimental drug, ZMapp. The racial immuno-logic to which I have been alluding rests on a critical assumption: that wealthy whites are not supposed to die or fall ill when they are helping ‘others’; they are believed to be immune to the tragedies that befall black Africans. In some ways, it seems that falling ill is a failure to fully capitalize on protection of privilege. It is why we hear, “how could this have happened to them?” or “Why were they there in the first place?”

Former science journalist and senior fellow in global health at the Council of Foreign Relations pursues this line of reasoning in a tweet, couching it in terms of practical matters:

The content of the tweet is not unique; nor does it really offer a useful suggestion. As many noted in their responses to Garrett, when any health worker gets sick with Ebola while treating others, it’s usually because of a disruption in good infection control practices. When trained health workers become exhausted and use their protective equipment incorrectly, accidents can happen. When health workers live in a community of sick persons, they may contract the illness outside the clinic. Yet the question is regularly posed: “How did these foreign health workers get sick? Why did they get sick at this point in time?” (It’s Evans-Pritchard all over again). To assert that the infection control situation must be investigated because three (white) Americans are sick is also to say that the thousands who fell ill before the Americans do not matter. (And that there are other expatriates — notably MSF — who get it right).

It is not easy being a clinician treating Ebola patients. At least half of your patients die. Working in the protective gear is uncomfortable and exhausting. The conditions in the hospitals are often sub-standard, leaving clinicians themselves worried about what would happen should they become sick from Ebola. A physician on twitter, Megan Coffee, recently wrote: “There is always that fear that if you’re a doctor working with little there is nowhere to turn if you become sick.” So it probably came as no surprise that the US Department of Defense, heeding MSF’s call for military and civilian medical aid, pledged the rapid deployment of a military hospital to Liberia specifically for health workers.

We were soon to learn the terms of that pledge: $22 million for 25 beds in an unstaffed hospital. It was also reported that only foreign health workers — which many people read to mean “white” and not the African workers who have also been called to assist in the Ebola response — were to be the recipients of care in this hospital. Amidst a loud outcry amongst observers, the statement has since been “corrected” on Twitter; an official statement was expected during Obama’s speech on September 16, but it never happened. These events cannot be undone; these words cannot be unspoken. It was only one of many messages about the value of West African lives that fanned the flames of distrust and anger directed at the international response to Ebola.

Earlier in September, two US-based clinicians eulogized Sam Brisbane, the first Liberian physician to die from Ebola. Since then, Liberia has suffered even greater loss of health workers than in Sierra Leone, where Dr. Buck died. The eulogy is a moving piece, sharing the authors’ sense that despite the despair it causes for his family, friends and colleagues, Brisbane died a “good death.” For all its poignancy, the idea of a “good death” rubs many of us raw, as we recognize that better care is possible — no, necessary — for those frontline West African doctors and nurses who put themselves at deadly risk and whose survival is essential for already fragile and overextended health systems.

 

Adia Benton is an assistant professor of anthropology at Brown University. She is the author of HIV Exceptionalism: Development through Disease in Sierra Leone (University of Minnesota Press, 2015).

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