The 3rd Cascadia Seminar: Ethnographic Adventures in Medical Anthropology
April 24-26, 2015
at Seattle University and the University of Washington
Seattle, Washington, USA
Kirsten Bell (U of British Columbia)
Leslie Butt (U Victoria)
Johanna Crane (UW-Bothell)
James Pfeiffer (UW-Seattle)
Nicole Berry (Simon Fraser U)
Harriet Phinney of Seattle University hosted the 3rd Cascadia Seminar, with assistance from Janelle Taylor of the University of Washington. Medical anthropologists (from everywhere) were invited to submit abstracts which were reviewed by a committee of medical anthropologists on faculty at our various institutions, all of whom also planed to attend. The committee selected seven abstracts, seeking papers that promised to be ethnographically rich and intellectually exciting (scroll down to view abstracts).
The Cascadia Seminar began 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 was held at Seattle University. Four papers were presented on Saturday April 25th, and three on Sunday April 26th, with no concurrent sessions. Each paper presenter had forty-five minutes to present a substantial, well worked-out paper, with ample time for lively discussion. All participants were asked to attend all papers, and optional no-host meals together will offer additional opportunities for conversation. The Simpson Center for the Humanities at the University of Washington sponsored a reception following the keynote address, and Seattle University sponsored 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, theProgram on Values of the Department of Philosophy, and the UW Bothell’s School of Interdisciplinary Arts and Sciences.
Title: What is metabolism after “big data”? Unearthing the norms, values, and politics of bodies and populations
Recent work in medical anthropology has examined how the objects and practices of biomedicine are changing, and are allowing researchers to engage with the meaning of life in potentially transformative ways. In this paper, I explore how “big data”—the so-called rise of bigger, faster, and better technologies and ways of using data—is impacting how metabolism gets “done”. I argue that big data practices—which involve computational techniques, algorithms, and databases—produce culturally, morally, and politically charged modes of measuring and evaluating health, bodies, and populations. Because biomedical research affects understandings of metabolic processes and organisms, changing configurations of metabolism have fundamental consequences for peoples’ experiences of nutrition and exercise, and also biomedical interventions into diseases and populations.
This paper is based on ethnographic work in the post-genomic field of metabolomics: the study of the molecules and processes that make up metabolism. While some scholars have argued that the post-genomic sciences represent a shift away from reductionism and towards contingency and liveliness, how—in what ways, to what extent, for whom—science is engaging with the complexity of biology, organisms, and society remains to be seen. To explore this, my paper focuses on two examples of the application of metabolomics to clinical issues: to investigations of (1) the role of the microbiome in obesity, and (2) the development of personalized diagnostics for liver transplants. I argue that practices for investigating and intervening into the “complexity” of metabolism and data lead to normative modes of knowledge production and care, by operationalizing the “biological” and “technological,” rather than “social” or “ecological,” interventions into health and disease.
Ultimately, this paper sees metabolism as a rich object from thinking about how the rise of big data—as a new set of practices and a new “culture” of science—is leading to changes in notions of biological and social life, and to the structures and institutions of biomedicine. Moreover, this paper asks how medical anthropology can help to trouble contemporary society’s obsession with measuring and quantifying human life with big data—by unearthing the norms, values, and politics embedded within data-intensive science.
Title: Biomedicine, Healing and Modernity: An Ethnographic Study of Village Doctors in Bangladesh
This study explores the ways that village doctors have increased the profits of corporation and business people through the commodification of health in rural Bangladesh. Drawing on ethnographic data from rural Bangladesh, I argue that rural health provision may be usefully examined in the light of theories of capitalist world systems. Village doctors are currently the preeminent health care providers in terms of the numbers of villagers whom they serve. Although they have neither formal training nor education in biomedicine, this does not influence their acceptability and practice in local settings. Local people value their health advice and services due to their easy availability, accessibility and affordability, in contrast to the unavailability and bureaucratic complexity of public health care services. This popular status encourages other private care providers, including formally trained doctors, clinics and diagnostic centers to maintain a close connection with village doctors to persuade them to refer their patients in exchange for a commission which can be up to one-third of the original cost of a particular service. Similarly, pharmaceutical companies keep in regular contact with village doctors who advise and sell the drugs of particular companies to their patients. One of the significant findings to emerge from this study is that the unique position and social relations of village doctors have established them as the key element in a chain of corporate networks by the clinical captainship in the realm of the rural health culture in Bangladesh. It was observed that much unnecessary medical advice is dispensed as a result of the hidden mutually advantageous contacts among village doctors, pharmaceutical companies and diagnostic centres. One serious health effect is the overuse of antibiotics that may create ‘super-resistance’ in the human body. Nonetheless the ethical codes of the pharmaceutical companies remain silent in this regard. Thus, the activities of this portion of the health sector is directed at ensuring business for the corporations and high profits for most involved on the supply side, rather than the achievement of the comprehensive national health plans which Bangladesh has officially adopted.
Title: Enveloped Care in Lithuania
This paper focuses on a local form of care that is interwoven with informal monetary transactions (payments from patients to doctors) in Lithuania’s public health care system. These transactions often are concealed in actual white envelopes. At the clinic in Vilnius, where I did my fieldwork (2009-2010) patients and their caretakers talked of how they felt “no moral hesitations” to give money to the doctors. Some described “little white envelopes” “as an emotional contact” and “vital system,” while others condemned greedy doctors and called them “bribers;” doctors talked about their conflicted feelings of being grateful yet dependant on “patients’ alms” and obligations to their own families. Almost everyone was enveloped in the dilemmas of giving (or not giving) envelopes. In this paper I reflect on this local form of caring that is enveloped in practices of envelopes. I call it enveloped care. I step back from the gift-bribe debate and focus on caring rather than the material transaction itself. Caring for oneself and others is “contaminated” with things, objects, stories, rumors, affect, money that work together in biomedical settings. Care is always ambiguous and local, argues Anne Marie Mol, and practices of caring entail specific modalities that are not necessarily in accord with ethics of justice (Mol 2010). While articulating ambiguous caring connections, practices of envelopes express particular, situated relationship to caring, leading towards understandings of what “good care” and “bad care” is. Envelopes are an embedded practice and form of care that is experienced though concrete relations that are already embedded in webs of obligations, caring attachments, and unequal social arrangements. This form of caring is neither purely altruistic nor sanitized, nor strictly normative, but rather ambiguous: it includes objects and money yet, it does not work through the logic of the market; it appears individualistic but is not limited to the relationship between individuals; while it invokes attentiveness, and generosity, it is also confining and can be violent to all participants; it is “corrupt” and “good care” at the same time.
Title: The Price of Care: An Analysis of the Merger of Money and Medicine in US Transgender Care
Marieke van Eijk
Health care systems around the world are faced with spiraling health care costs, aging populations, and high demands for expensive high-tech interventions. In attempts to balance between decreasing costs and attending to people’s needs, many countries implement economic models that advocate privatization and “consumer choice.” While economists and policy makers stress the “cost-effectiveness” of these models, opponents argue that they drain medicine from its ethical foundations of compassion and turn care giving into profit-driven enterprises (Kleinman 2010). My ethnographic fieldwork at a U.S. transgender care clinic pushed me to call this, what Zelizer (2013) has termed “love versus money” polarization into question. Transgender care is a highly contested medical field, in which finance and medicine disagree over the “necessity” to cover the costs of care of bodies that transcend conventional understandings of man and woman. Examining the debates over the price of suffering in great ethnographic detail, I show that at the transgender clinic, money and medicine were not two separate fields but were intimately linked and gave rise to what I call a mode of “financial caring,” in which money, love, nurturance, forms, and fiscal calculations could not be easily differentiated. My analysis confirms that caregiving is a practice of compassion (Kleinman 2012:1550) but it also shows that caregiving is always embedded in discussions of whose individual suffering is severe enough to be paid for collectively. I stress that the question how much social value and financial resources a nation is willing to allocate to care giving is not a financial query only. It is also an ethically complex practice that draws in medicine, finance, and many other sociopolitical actors, each of which brings to the table different answers of how to provide “good” care amidst increasing expenditure and cost-containment measures. To understand how medical and financial entities merge and the kinds of intended and unintended consequences they invoke, it is important not to situate economics and health care delivery as residing in two separate domains but to see them as diffusely and intimately linked, creating both viable and devastating means of caring.
Title: A Call for Emergent Practices: Reconsidering Translational Theory as Applied in Diabetes Prevention Programs
This paper critiques translational theories regarding health interventions, suggests promoting “emergent” practices from tribal communities rather than continued use of generic “translated” interventions, and examines ethical quandaries that emerge when linking local emergent practices to national policies and funding. Drawing from an eight-year partnership and 18 months of community based participatory research with Ysleta del Sur Pueblo (YDSP), an American Indian Tribe located on the U.S.-Mexico border, I begin by asking why, despite countless translated biomedical programs, the incidence of diabetes in American Indian communities continues to rise. I suggest a reconceptualition of the literature on translational theory to provide space for what I call “emergent” practices. I argue that there are currently two dominant models, and one emerging model, of diabetes research and intervention among American Indian peoples. Located on a spectrum, they are (1) individual-oriented biomedical models developed predominately for white, Western populations, which are applied to both the general U.S. population and American Indian peoples; (2) modifications, adaptations, or translations of these programs for application in non-white communities, including American Indian communities; and (3) emerging models of communal prevention in which intervention activities derive completely from local cultural practices. In framing the literature in this manner, I offer a counter narrative to biomedical research and provide room for communities and knowledge systems to speak. In the second section of the paper I draw on extensive ethnographic research to highlight failed and successful examples of the three models previously presented. I argue that emergent models as expressed at YDSP — religious community gardens, pilgrimages and religious dancing – all have the potential to emerge as successful wellness programs for obesity and diabetes. However, given the sacredness and knowledge-restrictive properties of many of these emergent practices, various ethical quandaries hinder linking these local programs to national policies and funding streams. As such, I close the paper with a short discussion regarding policy considerations for integrating the efforts of indigenous leaders and community health staff so that emergent practices can be identified and supported at the federal level in an ethically responsible manner.
Title: Scripting Dissent: Abortion Laws, Medicine, and the Politics of Scripted Speech
Scripts and scripting are of particular interest in social theory because these concepts invite questions about longstanding tensions in contemporary theoretical debates—between structure and agency, determinism and emergence, compulsion and choice. In this paper, I focus on a highly specialized type of script to consider the micro-politics of agency and resistance at the intersection of medicine and the law. I draw on an investigation of the experience of abortion providers in North Carolina practicing under the 2011 “Woman’s Right to Know Act,” which mandates that women receive counseling with specific, state-prescribed information at least 24 hours prior to an abortion. Such laws appropriate the standard script of medical informed consent (Hoeyer and Hogle 2014), in which healthcare providers are expected to inform patients about the risks of medical procedures. By compelling providers to ventriloquize an ideological and non-medical message, mandated counseling abortion laws enable the state to speak to its citizens and transform medical providers into agents of the state. Moreover, by enacting laws ostensibly aimed at more fully informing women about abortion risks, the state flips the script (Carr 2011) of medical informed consent, coopting its language, format, and authoritative voice for another purpose. However, I illustrate that abortion providers are not completely powerless in this process. Instead, providers in my study flipped the script back at the state by prefacing it with disclaimers and apologies. As one physician noted, “As long as I speak the words that’s not illegal.” By this, she meant that as long as she expressed the required content, she had complied with the law. Yet her statement also reveals that reciting the script may be infelicitous (cf. Austin 1962) insofar as it can expose a rift between meaning and intention. This demonstrates that the social and moral force of the script stretches beyond its lexical meanings to encompass the way it is performed within a particular context. By illustrating the interactional strategies through which abortion providers reject, challenge, or otherwise subvert the scripts they have been handed, I contribute to anthropological work on the grounded, everyday strategies for resisting state power.
Title: Global Fund-ization: Funding mechanisms and HIV/AIDS program survival in Sierra Leone
The ‘vertical’ versus ‘horizontal’ debate to healthcare delivery and financing has been discussed globally, for decades. Over the past twenty years, research has detailed the negatives of a ‘vertical’ (i.e. disease-specific) approach, including program instability. Recently this delivery trajectory has shifted towards a ‘diagonal’ approach, which encourages gradual integration by strengthening the larger health system, while still working towards specific program goals. Current arguments suggest that ‘diagonal’ financing might be essential for maintaining HIV/AIDS treatment in low-income countries; however, donor conditionalities can create space for negative characteristics (i.e. instability) of ‘vertical’ programs, to manifest. This project critically analyzes donor expectations and conditionalities through an ethnographic account of HIV/AIDS programs and practices in Sierra Leone, focusing on the Global Fund, which provides 97% of the country’s HIV/AIDS funding. The Global Fund has taken up Health Systems Strengthening (HSS) as a cross-cutting and ‘diagonal’ element to their funding approach. This move towards HSS in the global health community has simultaneously provoked a largely technocratic shift for programming efforts, with increased funding from donors to strengthen disease surveillance, data collection and reporting mechanisms. Drawing on three months of ethnographic fieldwork in Sierra Leone, I demonstrate how the realities of this technocratic push and conditionalities are challenging due to current infrastructure, increasing the administrative burden on HIV/AIDS program workers. From participant-observation in clinics, government agencies and multi-entity meetings, and semi-structured interviews with HIV/AIDS counselors and program officers, I show how donor expectations and stipulations have altered the perceptions and foci of many HIV/AIDS personnel, which can have detrimental outcomes. By closely examining the structures and mechanisms in place in Sierra Leone, this research magnifies the complexity of expectations and stipulations by ‘assembling’ this global form with other elements that are shaping, and shaped by it. As a country whose HIV/AIDS programs rely 99% on external resources, the donor conditionalities in place cannot be rebuffed. While recognizing the potential of ‘diagonal’ service delivery, I argue that closer examination needs to be paid to the ‘friction’ created between donor conditionalities and their implementation and influence on HIV/AIDS programs and practices in the particular Sierra Leonean context.