Experiments in Scale: Humanitarian Psychiatry in Post-Disaster Turkey

ABSTRACT

A massive earthquake that struck Turkey in 1999 generated an unprecedented mobilization of Turkish psychiatrists and psychologists to address the mental and emotional aftermath of the disaster. In this article I examine how these mental health professionals, swept up in a wave of humanitarian compassion, confronted the limits of their own expertise and struggled to improvise a therapeutic response that could match the scale of psychological suffering precipitated by the earthquake. Framing humanitarian and global health interventions as inescapably scalar projects, I explore the pragmatic and imaginative labor involved in making psychiatric expertise scalable, what I characterize as their “work of therapeutic scalability.” In doing so, I raise a series of questions about the psychological subject of disaster, the transnational mobility of technoscientific expertise, and the politics of both life and scale at play in psychiatric humanitarian intervention.     

Living with HIV as Donor Aid Declines in Tanzania

ABSTRACT

Fluctuations in global health funding can significantly impact the lives of people who depend on donor-funded programs for life-long care. In this article, I examine shifting HIV policies that expanded antiretroviral therapy (ART) while reducing “care” services meant to improve ART access and adherence. I describe how these changes were experienced by HIV+ women accessing ART at a hospital in Tanzania in 2011–2012, highlighting their increasing precarity and uncertainty for care amidst donor instability and eroding program services. This research suggests that stable funding in support of long-term care services is important to help HIV+ people maintain life-long ART.     

Paces of Costly Care: Rare Disease Drug Access in Canada

ABSTRACT

Pharmaceutical industry representatives and public drug plan managers hold competing visions of drug access, ones I theorize as “fast” and “slow” care paces. The relationship between free market imaginaries and population-based biopolitics is negotiated through these paces from within the flexible political category of rare disease. In this article, I explore expensive rare disease drug access in Canada’s universal health system through a temporal lens. I show how two families navigate these powerful negotiations, asserting themselves as deserving of resources while finding ways to consider life and death outside of this clash between health system pragmatics and pharmaceutical promise.     

Sovereign Rules and Rearrangements: Banning Methadone in Occupied Crimea

ABSTRACT

In 2014, Russian authorities in occupied Crimea shut down all medication-assisted treatment (MAT) programs for patients with opioid use disorder. These closures dramatically enacted a new political order. As the sovereign occupiers in Crimea advanced new constellations of citizenship and statehood, so the very concept of “right to health” was re-tooled. Social imaginations of drug use helped single out MAT patients as a population whose “right to health,” protected by the state, would be artificially restricted. Here, I argue that such acts of medical disenfranchisement should be understood as contemporary acts of statecraft.     

Reproductive Travel to Ghana: Testimonies,Transnational Relationships,and Stratified Reproduction

ABSTRACT

In this article, I address reproductive travel to Ghana, based on research conducted in two private fertility clinics. Both clinics attract clients from West African countries as well as Ghanaian people living in the US and Europe. Their motivations to visit these clinics include positive “testimonies” about treatment results, “bioavailability” of matching donor material and surrogates, lower treatment costs and the circumvention of restricting regulations in the country of residence. Communication technologies are central in facilitating reproductive travel. Finally, I argue that the “international choreographies” of reproductive travel are co-shaped by the unique biographies and transnational relationships of the people involved.     

The First Thousand Days: Motherhood,Scientific Knowledge,and Local Histories

ABSTRACT

Since 2013, South African nutrition policy focuses on “the first thousand days,” (conception to two years), informed by Developmental Origins of Health and Disease research. Drawing on ethnographic research, we show how policy foregrounds certain categories of persons and casts “the maternal” as a time frame for interventions to secure future health and argue that this constitutes a “knowledge effect” – the outcome of framing questions in a particular way and with specific knowledge horizons.     

The stories they tell: How third year medical students portray patients,family members,physicians, and themselves in difficult encounters

Background: Physicians have long had patients whom they have labeled “difficult”, but little is known about how medical students perceive difficult encounters with patients.

Methods: In this study, we analyzed 134 third year medical students’ reflective essays written over an 18-month period about difficult student–patient encounters. We used a qualitative computerized software program, Atlas.ti to analyze students’ observations and reflections.

Results: Main findings include that students described patients who were angry and upset; noncompliant with treatment plans; discussed “nonmedical” problems; fearful, worried, withdrawn, or “disinterested” in their health. Students often described themselves as anxious, uncertain, confused, and frustrated. Nevertheless, they saw themselves behaving in empathic and patient-centered ways while also taking refuge in “standard” behaviors not necessarily appropriate to the circumstances. Students rarely mentioned receiving guidance from attendings regarding how to manage these challenging interactions.

Conclusions: These third-year medical students recognized the importance of behaving empathically in difficult situations and often did so. However, they often felt overwhelmed and frustrated, resorting to more reductive behaviors that did not match the needs of the patient. Students need more guidance from attending physicians in order to approach difficult interactions with specific problem-solving skills while maintaining an empathic, patient-centered context.     

Searching for Love and Test-Tube Babies: Iraqi Refugee Men in Reproductive Exile on the Margins of Detroit

ABSTRACT

In this article, I explore the reproductive health problems faced by Iraqi refugees, one of America’s most rapidly growing immigrant populations. Based on anthropological research in “Arab Detroit,” the “capital” of Arab America, I explore the experiences of Iraqi refugee men seeking medical help for their infertility. Most required intracytoplasmic sperm injection (ICSI), a variant of in vitro fertilization (IVF). However, in America’s privatized medical system—where a single cycle can cost more than $12,000—few could possibly afford this assisted reproductive technology (ART). Although Iraqi refugees had diasporic dreams of making a test-tube baby, they were stuck in a situation of “reproductive exile”—forced out of their home country by war, but unable to access costly ARTs in the country that led to their displacement. I elaborate on the concept of reproductive exile, attempting to translate Iraqi refugee men’s reproductive agency and desires, but also their profound disappointments.     

Chinese Bioethicists Speak Out on Covid-19, and Others Follow

Shortly after Wuhan, the city where the novel coronavirus was first identified, was placed on lockdown in January, I received an email from two Hastings Center fellows in China: Renzong Qiu, of Renmin University of China in Beijing, and Ruipeng Lei, of Huazhong University of Science and Technology in Wuhan. Attached was a post for our blog, Hastings Bioethics Forum, that raised ethical and legal questions about China's response. “Hegel says, ‘We learn from history that we do not learn from history,’” their piece began. “The recurrence of the coronavirus epidemic in China proves his insight to be right.” This bold report from bioethicists in China was courageous and eye-opening. It was among the first discussions in bioethics of what has since become a global crisis, and it turned out to be the first in a string of commentaries in Hastings Bioethics Forum with insights about the crisis, the issues it raises, and how the world should respond to it.     

Development of a phenomenologically derived method to assess affective learning in student journals following impactive educational experiences

Background: Assessment of affective learning (AL) is difficult but important, particularly for health professional students, where it is intimately linked to the development of professional values. This study originally aimed to determine whether an emotionally impactive, extended, multimethod, interprofessional simulation experience enhanced the AL of senior medical students, compared to conventional seminars and workshops alone. This necessitated the development of a method to assess for the presence and quality of AL.

Methods: We developed a “double hermeneutic” method, derived from Smith’s Interpretative Phenomenological Analysis, to identify examples of AL, according to Krathwohl’s hierarchy (“receiving,” “responding,” “valuing,” “organization,” “characterization”), in the journals of students from each arm of a randomized educational trial. Three assessors rated the highest level of AL seen in each journal and then we compared ratings from the two study arms.

Results: A total of 135 journals were available for assessment (81 Intervention, 54 Control). The method proved to be effective in identifying and characterizing examples of uniprofessional and interprofessional AL. The median level identified in Intervention journals (“valuing”) was significantly higher than Control journals (“responding,” p?Conclusions: The method described provides a means to assess affective learning among health professional students. An extended, immersive simulation experience appears to enhance affective learning.     

Lyme Disease and the Epistemic Tensions of “Medically Unexplained Illnesses”

ABSTRACT

In the US, disagreement over the biological basis of “chronic Lyme disease” has resulted in the institutionalization of two standards of care: “mainstream” and “Lyme-literate.” For mainstream physicians, chronic Lyme disease is a “medically unexplained illness” that presents with an abundance of “symptoms” in the absence of diagnostic “signs.” For Lyme-literate physicians, and complementary and alternative medicine practitioners more generally, symptoms alone provide sufficient evidence for medical explanation. Drawing upon ethnographic research among mainstream and Lyme-literate physicians, I suggest that medically unexplained illness is not a biomedical anomaly but an intrinsic feature of biomedicine.     

Boosting clinical performance: The impact of enhanced final year placements

Background: This study follows on from a study that investigated how to develop effective final year medical student assistantship placements, using multidisciplinary clinical teams in planning and delivery.

Aims: This study assessed the effects on objective structured clinical examination (OSCE) performance of the in-course enhanced “super-assistantship” placement introduced to a randomly selected sample of 2013–14 final year medical students at Leeds medical school.

Methods: Quantitative data analysis was used to compare the global grades of OSCE stations between students who undertook this placement against those who did not.

Results: There was a small overall improvement in the “super-assistantship” student scores across the whole assessment (effect size?=?0.085). “Pre-op Capacity”, “Admissions Prescribing” and “Hip Pain” stations had small-medium effect sizes (0.226, 0.215, and 0.214) in favor of the intervention group. Other stations had small effect sizes (0.107–0.191), mostly in favor of the intervention group.

Conclusions: The “super-assistantship” experience characterized by increasing student responsibility on placement can help to improve competence and confidence in clinical decision-making “in a simulated environment”. The clinical environment and multidisciplinary team must be ready and supported to provide these opportunities effectively. Further in-course opportunities for increasing final year student responsibility should be developed.     

The Promise and Perils of Open Medical Data

Not long ago I visited the Personal Genome Project's website. The PGP describes its mission as “creating public genome, health, and trait data.” In the “Participant Profiles” section, I found several entries that disclosed the names of individuals along with their date of birth, sex, weight, height, blood type, race, health conditions, medications, allergies, medical procedures, and more. Other profiles did not feature names but provided all of the other details. I had no special access to this information. It is available to absolutely anyone with Internet access. The PGP is part of a trend known as “open data.” Many government and private entities have launched initiatives to compile very large data resources (also known as “big data”) and to make them available to the public. President Obama himself has endorsed open data by issuing a May 2013 executive order directing that, to the extent permitted by law, the federal government must release its data to the public in forms that make it easy to locate, access, and use.     

Numbers that Matter: Right to Health and Peruvian Maternal Strategies

ABSTRACT

The rights to health and to culturally respectful care are inextricably linked in the documents supporting Peruvian Maternal Health Policy. Strategies of Intercultural Birthing and Maternal Waiting Houses were purported to reduce maternal deaths, while extending the right to health to marginalized indigenous women. Based on 17 months of field research in Peru, I argue that the narrow focus on achieving “good numbers” creates and sustains coercive modes of strategy applications. As a result, the on-the-ground implementation of these innovative strategies made them incompatible with right to health and culturally respectful care approaches.     

The “Last Child”: Lone Family Caregivers in St. Croix,US Virgin Islands

ABSTRACT

I investigate local explanations for a common family configuration of care for older relatives on the island of St. Croix, U.S. Virgin Islands: the “lone family caregiver.” Through the examination of a paradigm case emerging from these explanations, I argue that local logics can divest some children of obligations to care for their older parents. I suggest that this case is an important addition to recent discussions within the anthropology of care that emphasize how families practice “care across distance,” as it offers an alternative example of how families manage care in the context of migration.     

Rationing Care through Collaboration and Shared Values

Although “rationing” continues to be a dirty word for the public in health policy discourse, Nir Eyal and colleagues handle the concept exactly right in their article in this issue of the Hastings Center Report. They correctly characterize rationing as an ethical requirement, not a moral abomination. They identify the key health policy question as how rationing can best be done, not whether it should be done at all. They make a cogent defense of what they call “rationing through inconvenience” as a justifiable allocational technique. And they wisely call for research on the effectiveness and fairness of this approach and other methods of rationing. I fully agree with their approach to rationing and with their argument that the process they provocatively label “rationing through inconvenience” should not be rejected out of hand. But I believe they have underestimated two ways in which the practical impacts of rationing through inconvenience limit its potential usefulness: the asymmetry of its effect on patients and physicians and the way in which it reduces the capacity of health systems to learn from experience.     

Dementia Matters: User-Building Interactions Shaping Institutional Life in the Netherlands

ABSTRACT

In this article, I examine building-user interactions on three dementia wards in the Netherlands. I coin the concept of “sociomaterial awareness” to articulate a collective situational sensitivity to the ways in which the built environment invites its users (professionals, but also people with dementia themselves) to act in specific ways, as well as to possibilities to adjust (elements of) the building. I argue that along with different enactments of dementia, different positions become available for residents when the built environment is acknowledged as actively shaping care interactions.     

Reproductive Governance and the (Re)definition of Human Rights in Poland

ABSTRACT

Reproductive rights struggles have continued to dominate public debates in Poland since the political resurgence of the Catholic church in 1989. In 2015, the state passed a landmark “In Vitro Policy” to regulate assisted reproductive technologies. Its religiously based compromises may jeopardize other reproductive rights. I argue that the new policy negotiations demonstrate how versions of competing human rights claims are central to reproductive governance and struggles in the new Polish “ethical order.” These negotiations reveal a reciprocal and temporal effect between infertility and abortion laws, in which previously enacted abortion restrictions are used to limit and define “In Vitro” rights.     

Interprofessional learning through shadowing: Insights and lessons learned

Background: Interprofessional education (IPE) aims to improve patient outcomes. Interprofessional shadowing improves students’ knowledge of different roles and attitudes toward other professionals.

Aim: This study evaluates (1) how pre-clinical medical students describe the roles of the healthcare professionals they shadowed, and (2) whether shadowing can be used to introduce medical students to the benefits of interprofessional collaboration, and if so, in what ways.

Methods: Second-year medical students shadow another discipline and write a reflection on the shadowed discipline (SD)’s role and collaboration in patient care. A non-proportional stratified random sample of these reflections was coded during an iterative process. Any number of the 13 possible codes could be assigned to each reflection. Codes relevant to the research questions underwent narrative analysis.

Results: The most frequent codes were “specific function of SD” (88%), “SD’s general purpose” (86%), and “value of SD’s role” (68%). One-third of reflections referenced “communication,” and one-third mentioned “teamwork.” Insights gained included an appreciation for interprofessional care and a global perspective on patient care, extending beyond the inpatient encounter.

Conclusion: Through shadowing, students achieve several IPE core competencies and a broader perspective on patient care. Shadowing is an effective pedagogical method for IPE in the pre-clerkship curriculum.     

Right to Health: A Buzzword in Health Policy in Indonesia

ABSTRACT

The “right to health” operates as a buzzword in Indonesia to frame health policies as beneficial to citizens. Right to health is equated with access to Western biomedical services. Within the policy on partnership between biomedical and traditional midwives, only the biomedical midwife can fulfill the right to health. The “traditional” midwife is reframed as her assistant. Right to health language hides underlying tensions in relationships between these two categories of midwives by presenting the policy as mutually beneficial. Right to health language is effective in the post-Suharto era as it aligns with other incontestable values, including democracy and modernity.