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.     

Humanitarianism from Below: Sowa Rigpa,the Traditional Pharmaceutical Industry,and Global Health

ABSTRACT

In this article I explore, for the first time, the relationship between Sowa Rigpa (Tibetan medicine) and global health, tracing “the global” in ethical discourses and pharmaceutical innovation practices of Tibetan medical practitioners. I argue that Sowa Rigpa’s engagement with the world and its global health activities outside China can be understood as a form of “humanitarianism from below,” while its industrialization in China aligns with global health in different ways. In providing new insights into recent developments of Sowa Rigpa, I aim to decenter the notion of humanitarianism and contribute to a broader understanding of global health.     

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.     

Policy as Product: Morality and Metaphor in Health Policy Discourse

Where we once spoke in military terms, we now often wield the language of the market: health care is a “product” and we are its “providers” and “consumers.” The market metaphor constrains in various ways our vision of the goals we pursue in making health policy, of the options available to us in pursuing them, indeed—because policy implies a certain view of moral agency—of the way we relate to each other.     

Making Women into Protagonists: Midwives Reimagine the Mexican Childbirth Narrative

ABSTRACT

I examine midwives’ interpretation of – and efforts to reimagine – the contemporary Mexican birth narrative. Throughout my research, midwives argued that, for birth outcomes to improve, women need to become “the protagonists of their own births”. I analyze midwives’ creative representations of how birth is and could be, and argue that the counter narrative they promote reveals the conditions within which they believe women can become empowered. By centering women’s choice as the measure of success, this counter narrative stands in contrast to development initiatives and contemporary biomedical approaches to care. It also emphasizes the continued need for midwifery in Mexico. Examino los esfuerzos de parteras mexicanas para reinventar la narrativa mexicana sobre el nacimiento. Las parteras dijeron que, para que los resultados del parto mejoren, las mujeres deben convertirse en “las protagonistas de sus propios partos”. Analizo las representaciones creativas de las parteras acerca del nacimiento, y sostengo que la contra-narrativa que promueven revela las condiciones dentro de las cuales creen que las mujeres pueden empoderarse. Al centrar el poder de las mujeres como la medida del éxito, esta contra-narrativa contrasta con las iniciativas de desarrollo y los enfoques biomédicos contemporáneos. También enfatiza la necesidad continuada de partería en México.     

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.     

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.     

Towards Communicative Justice in Health

This article approaches care from a different angle by looking ethnographically at how it is shaped by structural differences in the power to control the circulation of knowledge. I focus on an investigation conducted by people classified as “indigenous”, of an epidemic that killed 38 children and young adults in a Venezuelan rainforest. I trace how health/communicative inequities structured clinical interactions, documents, epidemiological investigations, news stories, and dialogues with healers, thwarting the identification of the epidemic, clinically identified as rabies. Although the Bolivarian socialist government provided access to care, professionals denigrated parents’ contributions to care and communication and reduced complex, unequal relations between languages to practical problems of translation. Pointing to parallels with US social movements, I suggest that responding to demands for communicative justice in health requires seeing how health inequities are entangled with health/communicative inequities. The typographical slash points to importance of challenging the subdisciplinary boundary-work that relegates their study to non-overlapping conversations in medical and linguistic anthropology.     

Unhealthy Partnerships and Public Health: Breaking Free of Industry

In the ambitious new book The Perils of Partnership: Industry Influence, Institutional Integrity, and Public Health, Jonathan Marks argues that far too much baggage is being piled on an old workhorse, conflict of interest. It’s an important concept, he asserts, but public‐sector actors can transgress their ethical obligations even when their relations with industry don’t create conflicts of interest. Yet policy‐makers have been immersed in public‐private partnerships for so long that they do not see the broader implications of such relationships. Marks aims to move the discourse from reassuring terms like “engagement” and “inclusiveness” to concepts that capture the problematic side of the liaisons, like “webs of influence” and “agenda distortion.” Above all, he issues a challenge to public health policy‐makers: Ditch the comfortable hand‐in‐hand industry relationships, which prioritize efficacy over ethics, threatening both the public’s health and the integrity of public health institutions. Adopt instead a paradigm that is “mano a mano,” involving tension, struggle, and, at times, direct conflict with private industry.     

Mental Health and the Maintenance of Kinship in South Africa

ABSTRACT

At the turn of the millennium, people with mental disturbance often lived in circumstances of economic marginalization in South Africa. The historical material of one low-income urban area reveals the place of kin relations and reciprocity in enabling negotiation of a more fluid set of responses to mental illness. In this sociocultural context, “stigma” was not an inevitable reaction to mental illness, and a more complex set of social dynamics could mitigate marginalization. Research on how changing informal care practices relate to state-based community care continues to be important to inform contemporary health reforms.     

Epigenetics in the Neoliberal “Regime of Truth”

Recent findings in epigenetics have been attracting much attention from social scientists and bioethicists because they reveal the molecular mechanisms by which exposure to socioenvironmental factors, such as pollutants and social adversity, can influence the expression of genes throughout life. Most surprisingly, some epigenetic modifications may also be heritable via germ cells across generations. Epigenetics may be the missing molecular evidence of the importance of using preventive strategies at the policy level to reduce the incidence and prevalence of common diseases. But while this “policy translation” of epigenetics introduces new arguments in favor of public health strategies and policy‐making, a more “clinical translation” of epigenetics is also emerging. It focuses on the biochemical mechanisms and epigenetic variants at the origin of disease, leading to novel biomedical means of assessing epigenetic susceptibility and reversing detrimental epigenetic variants. In this paper, we argue that the impetus to create new biomedical interventions to manipulate and reverse epigenetic variants is likely to garner more attention than effective social and public health interventions and therefore also to garner a greater share of limited public resources. This is likely to happen because of the current biopolitical context in which scientific findings are translated. This contemporary neoliberal “regime of truth,” to use a term from Michel Foucault, greatly influences the ways in which knowledge is being interpreted and implemented. Building on sociologist Thomas Lemke's Foucauldian “analytics of biopolitics” and on literature from the field of science and technology studies, we present two sociological trends that may impede the policy translation of epigenetics: molecularization and biomedicalization. These trends, we argue, are likely to favor the clinical translation of epigenetics—in other words, the development of new clinical tools fostering what has been called “personalized” or “precision” medicine. In addition, we argue that an overemphasized clinical translation of epigenetics may further reinforce this biopolitical landscape through four processes closely related to neoliberal pathways of thinking: the internalization and isolation (aspects of liberal individualism) of socioenvironmental determinants of health and increased opportunities for commodification and technologicalization (aspects of economic liberalism) of health care interventions.     

Indigenous Healing Knowledge and Infertility in Indonesia: Learning about Cultural Safety from Sasak Midwives

In this article I demonstrate what can be learned from the indigenous healing knowledge and practices of traditional Sasak midwives on Lombok island in eastern Indonesia. I focus on the treatment of infertility, contrasting the differential experiences of Sasak women when they consult traditional midwives and biomedical doctors. Women’s and midwives’ perspectives provide critical insight into how cultural safety is both constituted and compromised in the context of reproductive health care. Core components of cultural safety embedded in the practices of traditional midwives include the treatment of women as embodied subjects rather than objectified bodies, and privileging physical contact as a healing modality. Cultural safety also encompasses respect for women’s privacy and bodily dignity, as well as two-way and narrative communication styles. Local understandings of cultural safety have great potential to improve the routine practices of doctors, particularly in relation to doctor–patient communication and protocols for conducting pelvic exams.     

Indigenous Identification by Health Professionals in a Mexican Hospital Setting

ABSTRACT

In this article, we describe and analyze the identification of people as Indigenous by health-care professionals in a hospital in Mexico City. This socially constructed identification is based on a “contrasting identity” of essentialist and stereotyped categories (language, place of origin, cultural practices, and poverty) that promote the normalization of inequity, marginality, and racism. The ambivalence of the invisibility of the indigenous in the health-care context also marginalizes and generates inequity when it comes to the access to healthcare.     

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.     

Health Inequalities

Health inequalities are embedded in a complex array of social, political, and economic inequalities. Responding to health inequalities will require systematic action targeting all the underlying (“upstream”) social determinants that powerfully affect health and well-being. Systemic inequalities are a major reason for the rise of modern populism that has deeply divided polities and infected politics, perhaps nowhere more so than in the United States. Concerted action to mitigate shocking levels of inequality could be a powerful antidote to nationalist populism. A basic yet critical start to addressing health inequalities is to recognize them, which demands improving data collection and analysis. Certainly, global indicators show vast progress in reducing poverty and extending life. Yet aggregate health data mask a deeper reality: health gains have disproportionately benefited the well-off, leaving the poor and middle-class behind.     

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.     

Health advocacy*

In the medical profession, activities related to ensuring access to care, navigating the system, mobilizing resources, addressing health inequities, influencing health policy and creating system change are known as health advocacy. Foundational concepts in health advocacy include social determinants of health and health inequities. The social determinants of health (i.e. the conditions in which people live and work) account for a significant proportion of an individual’s and a population’s health outcomes. Health inequities are disparities in health between populations, perpetuated by economic, social, and political forces. Although it is clear that efforts to improve the health of an individual or population must consider “upstream” factors, how this is operationalized in medicine and medical education is controversial. There is a lack of clarity around how health advocacy is delineated, how physicians’ scope of responsibility is defined and how teaching and assessment is conceptualized and enacted. Numerous curricular interventions have been described in the literature; however, regardless of the success of isolated interventions, understanding health advocacy instruction, assessment and evaluation will require a broader examination of processes, practices and values throughout medicine and medical education. To support the instruction, assessment and evaluation of health advocacy, a novel framework for health advocacy is introduced. This framework was developed for several purposes: defining and delineating different types and approaches to advocacy, generating a “roadmap” of possible advocacy activities, establishing shared language and meaning to support communication and collaboration across disciplines and providing a tool for the assessment of learners and for the evaluation of teaching and programs. Current approaches to teaching and assessment of health advocacy are outlined, as well as suggestions for future directions and considerations.     

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.     

Much More than a Clinic: Chicago’s Free Health Centers 1968-1972

ABSTRACT

Drawing on archival evidence, I document the emergence and florescence of three free health clinics in Chicago in the late 1960s. I trace the centers’ forceful removal by the city’s Board of Health, and their subsequent replacement by Federally Qualified Health Centers (FHQCs). I argue that the demise of the free centers is exemplary of a broader trend in US health policy of regulating and diminishing the health care options of poor Americans. By highlighting the stark contrast between Chicago’s free health centers of the 1960s and the health care services offered by contemporary FQHCs, I reveal a gradual shift from health care rights to accessing care in the US health care safety net.