© 2013 C. Chandler, W. Geissler
2014 – № 1 (7)
* Reproduced with the permission of the London School of Hygiene & Tropical Medicine
INFORMATION
Clare Chandler (PhD) is a Lecturer in Social Science in the department of Global Health and Development, LSHTM. She has a background in anthropology as well as epidemiology and now works as the lead social scientist for the ACT Consortium, conducting and supervising fieldwork in several projects relating to malaria in Africa and Asia. Her research concerns include the dynamics of the treatment of non-severe illness in communities, at drug shops and at health centres; the social position of primary health care workers; and the interpretation and implications of malaria diagnostics. Methodologically, she is concerned with how anthropology can contribute to intervention design and to the evaluation of how interventions are taken up and the effects of this. Her research also concerns the ways medical research is carried out and interpreted by those involved, particularly in clinical trials. Email: Clare.Chandler@lshtm.ac.uk
Wenzel Geissler (PhD) is Senior Lecturer in Social Anthropology in the department of Global Health and Development, LSHTM. Before training as a social anthropologist, he studied zoology. Since converting to social anthropology, his research interests have broadened from an interest in infectious diseases, school health and medicine use, to questions of kinship/relatedness and generation, as well as of social change, history and memory. Since 1994, he has been engaged in long-term fieldwork in western Kenya. His recent work is on the ethnography of medical research in different African study sites, bringing together Africanist anthropology, anthropological interest in science, and questions of medical research ethics. Email: Wenzel.Geissler@lshtm.ac.uk
Keywords: Medical Anthropology, Public Health, Global Health, medicalization, biomedicine as a cultural product, anthropology of biomedicine, disease and illness, commodification, globalization and pharmaceutical industry, social studies of science and technology, biological citizenship, biomedical subjectivities, bio-socialities.
Summary: This course can be attended by any MSc students of the London School of Hygiene & Tropical Medicine regardless of specialisation and previous training. The aims of the course consists in providing an introduction to concepts, perspectives, theories and methods in medical anthropology, and illustrating their relevance to public health issues. The module is expected to include sessions addressing the following topics: (1) The way anthropologists have problematized public health and have responded to public health issues; (2) Anthropological conceptualisations of health, medicine and public health, including those around illness and disease, personhood, risk, structural violence, medicalization, citizenship, research participation and bioethics; (3) Introduction to anthropological methodologies and how to apply these to issues in public health. You can find more details of the course by visiting the School’s website at http://www.lshtm.ac.uk/.
AIM
To provide an introduction to concepts, perspectives, theories and methods in medical anthropology, and illustrate their particular relevance and application to public health issues.
OBJECTIVES
By the end of this module students should be able to:
1. Demonstrate familiarity and understanding of a range of concepts, principles and definitions used in medical and social anthropology;
2. Apply these concepts and principles in the analysis of particular public health issues in specific contexts;
3. Demonstrate the relevance of anthropological investigation and analysis to the formulation of appropriate public health interventions;
4. Critically evaluate, from an anthropological perspective, epidemiological and medical approaches in public health.
CONCEPTUAL OUTLINE
Students will learn about the way anthropologists have problematized public health and have responded to public health issues. Students will become familiar with anthropological conceptualisations of health, medicine and public health, including those around illness and disease, personhood, risk, structural violence, medicalization, citizenship, research participation and bioethics. Students will also be introduced to anthropological methodologies and will consider how to apply these to issues in public health.
TEACHING STRATEGY
The course is delivered through lectures (9 contact hrs), seminars (13,5 contact hrs), 2 discussions (2 contact hours), two film sessions (5 hrs). The module has a textbook (Pool, R. and Geissler, W., 2005, Medical Anthropology, Open University Press) which students are recommended to purchase. Students are required to read the relevant chapters of the module textbook prior to the lectures and seminars. Other essential references pertaining to lectures and seminars (1-2 per lecture topic) are provided in a course reader. A library box for the course contains additional references and students are encouraged to consult the library for further readings listed for those interested in the topic.
Lectures: The lectures will build on key concepts and debates introduced in the module textbook (Pool and Geissler 2005), illustrating their relevance and application through examples from anthropological research in the fields of public health and medicine.
Seminars: The seminars encourage discussion around the issues raised in the lecture and associated readings. Some entail practical exercises, where students will work with other resources, for example in-depth data transcripts, that highlight central themes from the lectures and readings.
LEARNING TIME
The module is made up of 150 Notional Learning Hours – 36 hours contact time, 38 hours directed self-study, 31 hours self-directed learning, and 45 hours assessment, review and revision.
ASSESSMENT
The module will be assessed through a take home essay-based assignment (100%) to be submitted at the end of the module. For the assignment, students are required to write an essay (2500 words) on a subject chosen from a range of questions based on the topics covered in the course.
In the case of a re-sit, the student will be asked to complete an essay on a different topic to that completed originally. The student will be given 3 weeks to complete the essay.
RE-SITS
In the case of a re-sit, the student will be asked to complete an essay on a different topic to that completed originally. The student will be given 3 weeks to complete the essay.
MODULE CREDIT
15 M-level credits.
PROFILES OF TEACHING STAFF
Ginny Bond’s (PhD) first fieldwork was on refugees in South-West Uganda in 1987. After working briefly in the AIDS Unit in the Panos Institute, since 1991, she has been based within research projects housed by the University of Zambia. For over eight years, she worked on an interdisciplinary research project in rural Zambia funded by SAREC within which she conducted a PhD (University of Hull, UK) on the ability of rural Zambian households to manage adversity. Since 1999, she has worked for LSHTM based at ZAMBART Project where she now heads a social science unit and has led social science components within three community based randomized trials focused on reducing Tuberculosis and HIV and mortality at population level in Zambia and South Africa. Her areas of interest include disease related stigma, the capability of local systems to respond to epidemics, managing food insecurity alongside illness and developing research methodology for rapid research on management of serious illness and for working with children. A Director of ZAMBART Project since 2004, she also plays a key managerial role.
Hannah Brown (PhD) is a Lecturer in Medical Anthropology at the University of Durham. She holds a PhD in Social Anthropology from the University of Manchester (2010) and held a postdoctoral fellowship at LSHTM between 2010-2012, during which she was a co-organiser of this course. Her research interests include gendered care work and domestic economies of care; nursing, hospital ethnography, health management, community health, Home-Based Care, HIV/AIDS and anti-retroviral therapy. Her regional expertise is in Western Kenya where she has carried out fieldwork sites in a district hospital, a community-based organisation and the homes of people living with and caring for others with HIV/AIDS. Her more recent work with health managers seeks to produce an ethnographic account of how low-level Ministry of Health management structures operate.
Clare Chandler (PhD) is a Lecturer in Social Science in the department of Global Health and Development, LSHTM. She has a background in anthropology as well as epidemiology and now works as the lead social scientist for the ACT Consortium, conducting and supervising fieldwork in several projects relating to malaria in Africa and Asia. Her research concerns include the dynamics of the treatment of non-severe illness in communities, at drug shops and at health centres; the social position of primary health care workers; and the interpretation and implications of malaria diagnostics. Methodologically, she is concerned with how anthropology can contribute to intervention design and to the evaluation of how interventions are taken up and the effects of this. Her research also concerns the ways medical research is carried out an interpreted by those involved, particularly in clinical trials.
Wenzel Geissler (PhD) is Senior Lecturer in Social Anthropology in the department of Global Health and Development, LSHTM. Before training as a social anthropologist, he studied zoology. Since converting to social anthropology, his research interests have broadened from an interest in infectious diseases, school health and medicine use, to questions of kinship/relatedness and generation, as well as of social change, history and memory. Since 1994, he has been engaged in long-term fieldwork in western Kenya. His recent work is on the ethnography of medical research in different African study sites, bringing together Africanist anthropology, anthropological interest in science, and questions of medical research ethics.
Melissa Parker (PhD) completed a BA Honours Degree in Human Sciences in 1982 and a DPhil in Biological Anthropology in 1989. This involved living in a village in northern Sudan for 18 months, learning Arabic and investigating the social and biological consequences of infection with Schistosoma mansoni on the health of women and children. Melissa went on to develop her interests in global health and international development at the London School of Hygiene and Tropical Medicine (1990 – 1993) and Imperial College (1993 – 1996); before moving to Brunel University in 1997.
Ferdinand Okwaro (PhD) is a postdoctoral research fellow in the department of Global health and Development, LSHTM. His postdoctoral project is funded by the Wellcome Trust and is on the perceptions and experiences of collaboration between scientists in transnational biomedical research as an emergent bioethical issue. Before joining the GHD, he wrote his PhD on Ritual Healing and Modernity in Kenya from the University of Heidelberg in Germany. His MA Thesis was on health seeking practices of the rural poor in societies with plural medical systems.
Branwyn Poleykett (PhD) is a research fellow in the department of Global Health and Development, LSHTM. Her PhD research explores the history of the regulation of prostitution in Dakar and traces the changes that have taken place in the regulation of commercial intimacy in Dakar following the integration of an experimental regime at the state clinic and the creation of the identity “clandestine prostitute” by non-governmental organizations. She is interested in using feminist approaches to bioethics to try to interpret complex questions of affect, agency, contingency and discontinuity in African experimental histories.
David Reubi (PhD) is a lecturer at the Centre for Global Health Policy, University of Sussex. After having studied law at the Universities of Neuchatel and Bern in Switzerland, he has worked as a lawyer for the UN’s Human Rights Committee in Geneva, the UN’s High Commissioner on Human Rights in Bosnia and the Swiss Government. He went on to study anthropology and sociology at the University of Geneva and the London School of Economics (LSE), where he completed his PhD on the genealogy of biomedical research ethics in the UK and Singapore. He was a Research Fellow at both the LSE’s Centre for the Study of Human Rights, the Brocher Foundation in Geneva and the LSHTM before moving on to Sussex. Drawing on the work of Foucault, he is interested in the genealogy of contemporary forms of global governance and the way the knowledge, expertise and techniques associated with these forms are reshaping subjectivities and citizenship. In particular, his work is focused on modern ethical discourses like human rights and bioethics as well as global health governance.
Lecture 1 – Introduction: Anthropology and Global Health
Clare Chandler
Learning objectives:
By the end of the lecture, you should be able to…
Describe the foundations of the anthropological approach
Deconstruct the concept of ‘global health’
Describe the role of medical anthropology in relation to global health
Lecture content overview:
This lecture will introduce medical anthropology within the wider context of global health. We will introduce the cornerstones of the anthropological approach including its commitment to understanding local knowledge, whether that be the perspectives of traditional healers or of scientists, showing how anthropology’s relativist position contrasts with rationalist and positivist viewpoints. We will then deconstruct the term ‘global health’ and outline the intersects of anthropology with global health. Following Kleinman, we distinguish four broad theoretical groupings: (1) social constructions of reality, when anthropologists research the values and moral contexts of local worlds, from villages to hospitals to research groups, and how these cultures affect the behaviour of members, with consequences for health and health programmes; (2) social suffering, a framework which looks at the socio-economic and socio-political forces that can cause disease, such as structural violence, and collapses the distinction between health problems and social problems, with consequences for the scope of global health interventions; (3) consequences of purposive action, when anthropologists research the unintended consequences of health interventions through evaluation and contribute to the modification and design of programmes; and (4) analysis of the way bodies and populations are controlled by political governance, from local governments to global bodies intended to improve health and maintain ethical standards in research. Across these different fields of research and theoretical development, the ultimate goal for anthropologists in global health is to contribute to the reduction of global health inequities and to the development of sustainable social, political and economic systems.
Essential Reading
Pool & Geissler. 2005. Chapter 1 ‘Anthropology and Culture’ and Chapter 2 ‘anthropological perspectives’ in ‘Medical Anthropology’. Open University Press
Kleinman, A. 2010. The art of medicine: Four social theories for global health. Lancet. 375: 1518-9.
Additional Reading
Nichter M. 2008. Global Health: Why Cultural Perceptions, Social Representations, and Biopolitics Matter. Tucson: Univ. Ariz. Press
Janes, C.R., Corbett, K.K. 2009. Anthropology and Global Health. Annu. Rev. Anthropol. 38:167–83
Seminar 1 – Anthropology and Global Health
Central themes: Understanding the importance of ‘culture’ in medical anthropology and situating the field of medical anthropology within social anthropology. The seminar will address the relationship of anthropology to public health, medicine and medical systems. Theoretical approaches and applications of medicine in public health will also be introduced.
Seminar Activity:
Students will be divided into three groups and provided a short case study of a public health intervention. They are asked to reflect upon the roles anthropologists might have in advising on the intervention/project – both from an applied, pragmatic approach as well as an approach that examines the assumptions underlying the intervention through critical reflection and contextualization.
Questions to be discussed in the seminar:
(1) What is the importance of ‘culture’ in addressing public health issues in your discipline?
(2) What can public health research gain from anthropology? Approaches, methods or more…?
(3) How can anthropologists balance practical application of their approaches with critical reflection?
Recommended readings (not essential prior to seminar):
Porter, J. (2006) Epidemiological reflections of the contribution of anthropology to public health policy and practice. Journal of Biosocial Sciences. 38: 133-144
Parker, M. and Harper, I. (2006) The anthropology of public health. Journal of Biosocial Sciences. 38:1-5
Lecture 2 – Doing Anthropology
Wenzel Geissler
Learning objectives:
By the end of this lecture you should be able to:
Understand basic methodological approaches in social and medical anthropology, such as ‘fieldwork’, ‘participation’ and ‘ethnography’.
Distinguish wider ‘methodology’ from ‘methods’ such as ‘in-depth interviews’ and ‘focus group discussions’.
Discuss different claims to validity in anthropology and the natural sciences.
Compare different understandings of ‘the field’ and of ‘community’ in anthropology.
Appreciate the difficulties that methodological differences and mutual ignorance can create in interdisciplinary health research.
Lecture content overview
Concepts from anthropological methodology – for example, the term ‘ethnography’ – are increasingly used in public health to refer to non-anthropological methods such as ‘Focus Group Discussions’, while ignoring the methodological core of anthropology. In the light of this frequent misconception, the first half of the lecture aims to clarify what is meant by an anthropological approach and methods. While there is great variation in styles of writing anthropology, all anthropological research is based on long-term presence in ‘the field’ (fieldwork), on subjective positioning and personal engagement rather than on ‘objectivity’ as defined in the sciences. The second half of the lecture explores changing notions of ‘the field’. We discuss notions of the ‘field’ in some depth, because the misconception that anthropologists are experts on ‘the community’ (often characterised as poor, local, non-scientific etc) is still common. While the focus of early anthropology was often rural and ‘non-western’ communities, contemporary anthropologists explore social relations beyond strictly ‘local attachments’, studying wider, often trans-local, networks. To this end, we will explore the gradual change from ‘community based’ studies to global ethnographies. Finally, we try to discern the core of anthropological fieldwork in a time when anthropologists study anything from healing rituals to scientific laboratories and UFO abductions. What does anthropological ‘expertise’ lie -if not in ‘the community’- and what use might it have for public health?
Essential Reading
Chapter 2 in Pool and Geissler (2005) “Anthropological perspectives”. Pp 15-27.
Chapter 3 in Pool and Geissler (2005) “Approaches to Medical Anthropology” Pp 28-38.
Additional Reading
Gluckman, M. (1940). “Analysis of a Social Situation in Modern Zululand.” Bantu Studies 14: 1-30.
Pool, Robert (1994) Dialogue and the Interpretation of Illness. Chapters 1 & 2 Pp. 1-53. (available in LSHTM library)
Collier, S. J. and A. Ong (2005). Chapter 1: Global assemblages, anthropological problems. In Global Assemblages. Technology, Politics, and Ethics as Anthropological Problems. A. Ong and S. J. Collier. Oxford, Blackwell: 3-21. (available in LSHTM library)
Seminar 2 – Anthropological Approaches and Methods
Central themes:
Methods and methodology used in medical anthropology
Exploring concepts of ‘culture’ and ‘context’
Positionality and reflexivity in the anthropological approach
Seminar Activity:
Students will explore the steps taken in adopting an anthropological approach, through discussion of photographic images and what can be understood from them. In small groups, students will review a set of images, discuss ‘themes’ arising, and the assumptions underlying the choice of interpretive lens. This will lead to a discussion of how analysis and interpretation in anthropology reflects the researcher’s positioning and preconceptions. (45 mins)
These discussions will be fed back to the wider group and students will be asked to reflect upon the process of applying the anthropological ‘lens’ to examine phenomena. Students will then participate in an open discussion about the feasibility and implications of using an anthropological approach in public health research, as well as the adoption of anthropological methods for investigating public health issues. (45 mins)
Questions to be addressed in the seminar:
(1) What is the difference between methods and methodology in anthropology?
(2) How feasible is it to use a flexible, iterative methodology in public health research?
(3) Do all public health issues lend themselves to an anthropological approach? Why or why not?
Film & Discussion 1 – “Adhiambo, Born in the Evening: Six Weeks in the Life of a Kenyan Mother” (Prince, R. et al 2002)
Theme: Method and representation in medical anthropology (Part I)
Learning Objectives:
To learn about participant observation and interview methods and discuss their validity. Is this a science?
To discuss the problems of anthropological representation: how does one depict the ‘other’?
To identify and discuss the ethical problems inherent to anthropological and other participatory research. Which research ethics apply?
(Added value: To learn about health seeking behaviour in an African village.)
Film overview:
‘Adhiambo’ follows about six weeks in the life of a mother in western Kenya (and in her anthropologists’ lives) during which she gives birth to a child. The film shows various medicinal treatments and health seeking behaviour, ranging from family based herbal treatment to hospital care. We watch the film because it raises issues about method, validity, representation and ethics, which medical anthropologists (and those working with them) need to think about.
Additional reading:
Geissler PW & Prince RJ. The Land is Dying: Creativity, Contingency and Conflict in Western Kenya. 2010. Oxford: Berghahn Publishers. (Especially chapters 5 and 6.)
Questions to be addressed in the discussion
(1) Is knowledge gained through ethnography valid? What different concepts of validity are there?
(2) Does the film give a truthful picture of a western Kenyan village? Could such a picture be useful for public health?
(3) What ethical misgivings could one have about the film? Any ethical achievements?
Lecture 3 – Medical Pluralism: paradigms, actors and pragmatic action
Ferdinand Okwaro
Learning objectives:
By the end of this lecture and associated seminar, you should be able to:
Demonstrate a critical understanding of the concept of medical pluralism
Show how health seeking behaviour is influenced both by the interpretation of illness as well as by the dynamics of medical pluralism.
Understand the shift in focus in Anthropology from Medical pluralism to syncretism.
Lecture content and overview
Medical anthropologists have studied and discussed medically pluralistic societies for over 50 years, emphasizing different perspectives of professionals, users, patients, institutions and the multiplicity of realities within each field. This has provided insights into the ways in which different therapeutic traditions act side by side. As new medical techniques and their associated artefacts spread all over the world, social actors not only alter their therapeutic practices, but also the ways in which they think and perceive their bodies and treatment processes. Moreover, the travel of medical techniques and artefacts, including biomedicine, is often accompanied by processes of appropriation (indigenisation) that are put to work to make them fit into distinct local and moral worlds and thus generating even more diversity. Medical pluralism is not only concerned with the spread of biomedicine but of other therapeutic traditions, each with particular drugs, techniques and artefacts, into societies dominated by biomedical therapies. The dynamics of medical pluralism involves diverse actors and institutions who have different goals and pursue different interests that deeply shape health policies in a variety of ways contributing directly and indirectly to the hierarchical organisation of pluralistic medical arrangements and to their constant renegotiation.
This lecture examines both the concept of medical pluralism and the different pathways to health seeking that emerge in the context of diverse illness interpretations and the varying organisation of plural health systems in different communities. Most of the examples will be derived from studies conducted in Kenya (East Africa). The lecture will comprise of a 30 minutes presentation, a 10 minute video, followed by discussions on the interplay between illness interpretations and plural medical systems and their implication for public health and public health policy.
Essential Reading
Pool, R and Geissler, W. Chapter 4: Medical Systems and Medical Syncretism in Medical Anthropology. Open University Press.
Pool, R and Geissler, W. Chapter 5: Interpreting and explaining sickness in Medical Anthropology. Open University Press.
Additional Reading
Kaptchuk T.J, Eisenberg D.M. Varieties of Healing. Medical pluralism in the United States. Ann Intern Med. 2001; 135: 189 – 195 (PMID: 1187486)
Goldstein S. Michael. The Persistence and resurgence of Medical pluralism. Journal of Health Politics, Policy and Law. Vol. 29 (2004)(4-5) 925 – 925.
Seminar 3 – Medical Pluralism
Central themes:
Interplay between interpretation of illness and medical pluralism.
Treatment-seeking behaviours and medical pluralism
Medical pluralism, power relations, reconfiguration and reinvention of therapeutic practices.
Medical anthropological approaches to Medical pluralism.
Seminar activity:
The first part of the seminar will comprise an exercise in which students will explore the processes of both communicating and extracting narratives of illness experience. Students will work in pairs, taking turns to conduct an in-depth interview with each other about an illness experience (either personal, or from a professional/family etc situation). (2 x 10 mins)
Each student will then be given time to interpret the findings from the interview, and report to the wider group on how the findings were constructed. (20 mins)
In the second part of the seminar students will be divided into 3 groups and each provided with a case study of health seeking in the context of plural medical therapies. Each group will discuss the interplay between illness interpretations, plural medical therapies and health seeking behaviours and their implications for public health interventions. (30 minutes).
Questions to be addressed in the seminar:
1. How do we interpret our own illness experiences and those of others, and how are these interpretations related to culturally-embedded models of thought/ How are culturally embedded systems of thought in turn affected by Medical pluralism?
2. How do different therapeutic practices coexist and change within a medical pluralistic context
3. How might you use an anthropological approach to explore the reconfiguration, reinvention and representations of different medical practices in contexts characterised by medical pluralism?
Literature.
1. Groleau. D., Young. A., Kirmayer L.J. The McGill Illness Narrative interview: An interview schedule to elicit meaning and modes of reasoning related to illness Experience. Transcultural Psychiatry, 43(4), 671-691.
2. Gangadharan D. & Shankar D. Medical pluralism – The challenges ahead. Indian Journal of Traditional Knowledge. 8 (2) 2009: 181 – 184.
Lecture 4 – Anthropology and Biomedicine
Ginny Bond
Learning objectives:
By the end of the lecture, you should be able…
To critically review different theoretical and empirical paradigms that have emerged in the anthropological study of medicalisation and biomedicine over the past 20-30 years
To distinguish between disease and illness
To reflect on the extent and limitations of collaborations between anthropology and biomedicine
The relationship between anthropology and biomedicine has historically been a tumultuous and divisive one; within medical anthropology, diverse positions have developed regarding how anthropology should relate to, regard and analyse biomedicine and the way it tends to “medicalise” everyday life. Though interest in the anthropology of biomedicine has only recently emerged, anthropologists now claim that in order to understand health and illness in other cultures properly, we must first engage in critical studies of the history, culture and globalisation of biomedicine. The first part of this lecture will review these different positions, while the second will reflect on examples of collaborations between anthropologists and bio-medics.
Essential Reading:
Chapter 7 in Pool and Geissler (2005) ‘The relationship between anthropology and biomedicine.’ Pp 76-87.
Lock, M. (2001). “The Tempering of Medical Anthropology: Troubling Natural Categories.” Medical Anthropology Quarterly 15(4): 478-92.
Further reading for those interested in the topic:
Lock M, Nguyen V-K. (2010) ‘Chapter 3: Anthropologies of Medicine’ In An Anthropology of Biomedicine: An Introduction. Oxford: Wiley-Blackwell.
Good B. J. (1994) How medicine constructs its objects. Chapter 3 in Good, BJ Medicine, Rationality, and Experience. An Anthropological Perspective. Cambridge: Cambridge University Press, pp 65-87
Seminar 4 – Anthropology and Biomedicine
Central themes: Medicalisation; practised medicine; biomedicine as a cultural product; anthropology in/of biomedicine; disease and illness
Seminar activity:
Biomedicine is often examined (and critiqued) as a monolithic system, however there are multiple ‘biomedicines’ as applied, practiced, and transformed in different health care settings through the local dynamics, and socio-political context of medical systems in different countries. Here, we will examine how biomedical practitioners in a range of settings reflect on their ‘everyday’ practice, identity, and social relations within the health system as well as with patients.
Students will be divided into 3 groups and provided with short transcripts from anthropological work on health providers of different types (e.g. clinicians, nurses, community health workers).
Students will be given some guidance notes and asked to produce an anthropologically sensitive analysis of the ethnographic material, making reference to the lecture and readings. The analyses will be presented to the group as a whole at the end of the seminar session.
Students are therefore asked to read and take notes on the essential readings (Chapter 7 of Pool and Geissler; Lock article) in preparation for the activity.
Questions to be addressed in seminar:
(1) How do the transcripts from the health providers exemplify notions of medical pluralism and syncretism in biomedicine?
(2) What are the main debates relating to changes in the practice of biomedicine and medicalisation of care that these informants highlight?
(3) How might different forms and ways of practicing biomedicine develop and evolve as a result of local social, political, and economic influences and in response to an epidemic?
(4) What are the distinctions between illness and disease in this data?
Lecture 5 – Medicines in Global Health
Melissa Parker
Learning objectives:
By the end of the lecture, you should be able to…
Appreciate how insights emerging from ethnographic research can usefully inform the design and implementation of biomedical interventions seeking to improve the health and well-being of adults and children
Appreciate the limits of relying upon clinical and epidemiological data to evaluate biomedical interventions
Lecture content overview:
Global aspirations to achieve the Millennium Development Goals by ‘making poverty history’ and alleviating the suffering of ‘the bottom billion’ has generated unprecedented attention on neglected tropical diseases in sub-Saharan Africa. Drawing upon ethnographic fieldwork undertaken at selected sites in Uganda and Tanzania, this lecture examines the roll-out of national mass treatment programmes among adults and children to address the following questions: how do political, historical, economic and social processes influence the uptake of drugs for NTDs? To what extent does the distribution of drugs through Ministry of Health hierarchies consolidate existing relations of power and authority? What is the relationship between the uptake of drugs for schistosomiasis, lymphatic filariasis and soil-transmitted helminths and local understandings and responses to these diseases as well as other locally-understood afflictions and misfortune? By addressing these questions, two further questions will come to the fore: What role can public policy realistically play in the alleviation of poverty? Is ethnographic data only valued in the international arena if it elaborates a rhetoric of success?
Essential Reading
Chapter 8 in Pool and Geissler (2005) “Substances of power” Pp. 88-99
Additional Reading
Allen T and Parker M 2012. Conflicts and compromises: experiences of doing anthropology at the interface of public policy. In: Sage Handbook of Social Anthropology. Edited by R Fardon, pp:184-195.
Parker, M., Allen T & Hasting, J. 2008. Resisting Control of Neglected Tropical Diseases: Dilemmas in the Mass Treatment Of Schistosomiasis and Soil-Transmitted Helminths In North-West Uganda J.Biosoc.Sci, 40, 161–181.
Parker M, Allen T, Pearson G, Peach N, Flynn R and Rees N, 2012. Border Parasites: Schistosomiasis Control among Uganda’s Fisherfolk. Journal of Eastern African Studies, 6(1): 97-122.
Seminar 5 – Medicines: Meaning, Power, and Circulation
Central themes: Commodification, commodified pharmaceuticals, globalisation & the pharmaceutical industry, role of anthropology in addressing public health issues related to pharmaceuticals.
Seminar activity:
Students will be divided into two groups and given one of two handouts: an article on cultural variations in the placebo effect or a chapter on the use of buprenophine to treat heroin addiction in France.
Students in the placebo group will be asked to discuss the “charm” of medicines and also to what extent differences in placebo effectiveness can be considered “cultural” differences and also what other factors may be involved in cross-country differences.
Students in the buprenophine group will be asked to consider the factors involved in marketing and distributing an addiction pharmaceutical in France (a high revenue drug, but one which meets vehement public opposition); they will also be asked to consider the role of the global pharmaceutical industry. The “social lives” and meanings of addiction pharmaceuticals change as they move between formal and informal addiction markets. Analysing addiction pharmaceuticals in a global context requires examining both markets simultaneously.
Questions to be addressed in the seminar:
(1) What is meant by the “charm of medicines” and the “social life of medicines?”
(2) How are pharmaceuticals embedded in social context and how are societies changed by pharmaceuticals?
(3) How can anthropology inform public health policy and health care planning?
(4) How might the pharmaceutical industry influence what kind of medicines are available or desirable?
References
Moerman D (2000) Cultural variations in the placebo effect: ulcers, anxiety and blood pressure. Medical Anthropology Quarterly 14: 51–72.
Van der Geest S and Whyte SR (1989) The charm of medicines: metaphors and metonyms. Medical Anthropology Quarterly 3: 345–67.
Lecture 6 – Global Medical Research: Experimental subjects, ethics & value
Ginny Bond
Learning Objectives
By the end of the lecture, you should be able to…
Explain why medical research and intervention settings lend themselves to anthropological study.
Understand the historical, social and cultural situatedness of medical research and intervention.
Appreciate the need to understand research as a social practice in its specific context in order to improve scientific research, intervention and health.
Lecture content outline:
The growth and expansion of the global clinical research enterprise – whether conducted by multinational companies, public-private partnerships or ‘big charity’ – has widened the range of theories used to understand the value of human experimentation and that of the humans enrolled in them.
This lecture will begin by exploring how medical research or public health interventions can become objects of ethnographic study. Drawing both from historical and contemporary examples, it will consider the ways in which biomedicine research has intersected with international political and commercial interests, and how it has shaped the everyday life of study populations.
It will then review the concepts developed by anthropologists to gain analytical purchase on how everyday clinical work has shaped the social life and wellbeing of populations. It will emphasise two critical themes of that literature: first, how the economics of clinical research impact their practice; second, the specific ethical dilemmas attendant to global clinical trials. In discussing these two themes, we will discuss some of the gaps in conceptualising the material and social significance of clinical research for those engaged in its practice. The lecture will conclude by suggesting some of the ways anthropological studies can contribute to a better understanding of the local responses to clinical research and to advancing bioethics.
Essential Reading
Chapter 11 in Pool and Geissler (2005) “Medical research”. Pp 141-150.
Chapter 12 in Pool and Geissler (2005) “Health interventions as a field of social practice”. Pp 151-162.
Additional Reading:
Fairhead, J., M. Leach, et al. (2006). Where techno-science meets poverty: medical research and the economy of blood in The Gambia, West Africa. Social Science and Medicine 63: 1109-1120.
Geissler, P. W. and R. Pool (2006). Popular concerns with medical research projects in Africa – a critical voice in debates about overseas research ethics. Tropical Medicine and International Health 11(7): 975-982.
Further readings for those interested in the topic:
Petryna, A. 2007. Experimentality: On the global mobility and regulation of human subjects research. PoLAR: Political and Legal Anthropology Review 30(2):288-304.
Seminar 6 – Ethnography of Medical research and Interventions
Central themes: Social studies of science and research, public health interventions, research ethics
Seminar activity: Students will be divided into groups and given a research or scientific site (e.g. molecular laboratory, a clinical trial for a new technology in the UK, malaria vaccine trial in Africa) and asked to consider how they might conduct ethnographic research on these activities: (a) what activities would you explore, (b) where would you focus your attention, (c) what kinds of questions would you ask to your ‘informants’ and (d) what would you hope to find?
After presenting a proposal of research for their sites, the seminar discussion will pick up on some issues raised in the lecture, such as: the legacy of colonial medicine for medical research; representations of the ‘diseased’ subject in colonial and/or ‘modern’ health discourses; the role and interpretation of rumours about health intervention and medical research; the cultural/historical ordering of disease control paradigms.
Questions to be addressed in the seminar:
(1) What social relations does a health research programme consist of and establish?
(2) What questions would it be interesting to pursue regarding these relations?
(3) What could ethnographic research contribute to the debate about (overseas) research ethics?
(4) What is the relation between medical science, citizenship, and government? What should it be?
Lecture 7 – Anthropological contributions to health interventions
Clare Chandler
Learning objectives:
By the end of this lecture, you should be able to:
Assess public health interventions for their epistemological basis
Describe why public health interventions may not achieve intended behaviour change goals
Describe anthropological approaches to intervention design
Assess the advantages and disadvantages of top-down and bottom-up intervention designs
Lecture content outline:
In this lecture, we turn our gaze to the arena of health interventions, when the worlds of individuals and groups are deliberately mediated by programmes intended to promote specific health-related behaviours. Billions of dollars are poured into health promotion campaigns around the world each year. Yet, people still smoke, do not use condoms, sleep outside of bed nets and engage in other ‘risky’ behaviours that contradict evidence communicated to them about cancer, HIV or malaria. In this lecture, we start with an examination of the assumptions behind popular health interventions. We discuss how particular notions of risk and models of understanding behaviour are privileged over others. Specifically, we discuss the influence of behavioural cognitive theories such as the health belief model, which emphasises individual rationality within a biomedical framework, to the exclusion of the lived reality of individuals in their social contexts. We consider how such conceptualisations of risk and behaviour may have contributed to interventions whose results that have disappointed public health workers.
In the second part of the lecture, we explore the role medical anthropology can play in contributing to interventions to improve the health of populations. The cornerstone of the anthropological approach to intervention design is often engagement with the ‘target’ population. This involves in-depth research with groups to understand the realities and priorities in their lives in relation to public health issues of interest to the public health programme plays in their lives. This can be in the form of formative research, which precedes or sometimes incorporates participatory research approaches. Participatory research intends that researchers/facilitators and participants work together to recognise and solve locally important problems through critical thinking and analysis. We will discuss a case study of ‘Health Workers for Change’ to illustrate how critical theories of power and inequality can be joined by theories of behaviour change to design effective interventions.
Essential Reading
Lupton, D. (1995). Chapter 2: Technologies of Health: Contemporary Health Promotion and Public Health. Pp48-76 in The Imperative of Health. Public Health and the Regulated Body, London: Sage Publications.
Van der Geest, S. Training shopkeepers and schoolchildren in medicine use: experiments in applied medical anthropology in East Africa. Medical Anthropology Quarterly 1999; 13: 253-255
Additional reading
Haaland A, Vlassoff C. Introducing Health Workers for Change: from transformation theory to health systems in developing countries. Health Policy Planning 2001;16 (Suppl 1):1-6.
Seminar 7 – Health interventions
Central themes:
Anthropological approaches to the identification of public health problems
Anthropological approaches to intervention design
Strengths and limitations of anthropological approaches to public health interventions
Seminar activity:
Students should read the two case studies in advance of the seminar. They should then work in two groups to discuss one of the readings and to answer the questions below:
How did the authors conceptualise the ‘problem’ they aimed to intervene with?
How did the authors go about their intervention?
What are the strengths and weaknesses of the approach described by the authors in their intervention design?
Each group should feedback on their case study to the main group and a general discussion about the role of anthropology in designing public health interventions will then be held.
Readings:
Schensul, S.L., Verma, R.K., Nastasi, B.K., Saggurti, N. And Mekki-Berrada, A. 2009. Sexual Risk Reduction among Married Women and Men in Urban India: An Anthropological Intervention. Pages 363 to 393 in Hahn, R.A. and Inhorn, M.C. (eds) ‘Anthropology and Public health: bridging differences in culture and society’. Oxford University Press.
Nichter, M., Nichter M., Padmawti, S., Thresia, C.U., and Project Quit Tobacco International Group. 2009. Anthropological Contributions to the Development of culturally Appropriate Tobacco Cessation Programs: A Global Health Priority. Pages 298 to 331 in Hahn, R.A. and Inhorn, M.C. (eds) ‘Anthropology and Public health: bridging differences in culture and society’. Oxford University Press.
Lecture 8 – Structural Violence & Reinterpreting Risk
Hannah Brown
Learning objectives:
By the end of this lecture, you should be able to:
To critically engage with the concept of ‘risk behaviour’
To situate and historicize risk as a modern indicator to manage uncertainty
To identify forms of social vulnerability that place people at greater ‘risk’ of infection
To define ‘structural violence’ and reflect upon its usefulness as a way of understanding factors that shape and constrain health and well-being.
Lecture content overview
In this lecture, we consider the social, cultural and structural constraints on health and how these are/are not taken into account by behavioural models. The lecture begins with a discussion of the concept of ‘risk’, comparing its contemporary statistical significance with its former usage as a synonym for ‘danger’. Drawing from historical resources on the emergence of insurance, we consider how risk is translated from probabilistic models of population to individual lives and circumstances. We reflect on the wider socio-economic and socio-political forces that may be obscured by a discussion of ‘risks’ and the kinds of responsibility risk-benefit analysis places on individuals. With particular reference to the HIV/AIDS epidemic, we discuss some of the different ways in which anthropologists and other social scientists have used concepts of risk to explore people’s vulnerability to illness, and how these understandings of risk have shaped responses to the epidemic. Finally, we critically examine the usefulness of the concept of ‘structural violence’ as a way of rethinking risk.
Essential Reading
Pool & Geissler. 2005. Chapter 6 “Situating sickness and health”
Campbell, Catherine. 2003. “Going underground and going after women: Sexuality and HIV-Transmission among mineworkers”. Chapter One of Letting them die: Why AIDS prevention programmes fail. James Currey: Oxford
Additional Reading
Owczarzak, Jill. 2009. “Defining HIV Risk and Determining Responsibility in Postsocialist Poland.” Medical Anthropology Quarterly 23:417-435.
Farmer, Paul. 2004. “An anthropology of structural violence.” Current Anthropology 45(3): 305-325.
Further reading for those interested in the topic
Douglas, M and Wildavsky, A. Introduction. Risk and Culture, University of California Press, 1982
Packard, R., M., and P. Epstein. 1991. Epidemiologists, social scientists, and the structure of medical research on AIDS in Africa. Social Science and Medicine 33:771-794.
Schoepf, B. G. 1997. “Inscribing the body politic: women and AIDS in Africa,” in Pragmatic women and body politics. Edited by M. Lock and P. Kaufert. Cambridge: Cambridge University Press.
Seminar 8 – Structural Violence
Central themes: Defining and elaborating concepts of risk, social vulnerability, structural violence; considering power relationships in public health, linking micro-experiences with the macro-economic determinates of health; the social construction of indicators.
Seminar activity:
The seminar will begin by comparing different ‘risk’ factors and ‘risky behaviours’ in malaria, HIV and breast cancer. Students will be asked to analyze factors of public health and concentrate on how measures of risk reflect current trends in global health funding (1 hour).
The second part of the seminar (30 min) will apply these insights to examples from the assigned reading (particularly Campbell, 2003 and Farmer, 2004), and extend discussion to notions of risk in modern life more broadly.
Questions to be addressed in the seminar:
(1) Risk is at one hand a bureaucratic devise of measurement and yet also a ‘perceived’ feature of individual existence. What is the difference between a risk, a threat, and a danger?
(2) In what way does ‘structural violence’ shape who is at risk for disease?
(3) What different roles does structural violence play in the incidence and experience of HIV and of malaria?
(4) How do we create less risky individuals? What factors might affect a person’s willingness and/or ability to adhere to a treatment regime?
Discussion session – Doing anthropology in organisations and facilities
Clare Chandler and Hannah Brown
Description:
In this session we invite you to engage a discussion with two anthropologists by reading work that they have produced through ethnographic fieldwork in organisations and health facilities. This is an opportunity to learn more about the relationships between doing fieldwork and producing anthropological analyses, and to reflect upon the practicalities of doing fieldwork in institutional settings. Students are encouraged to think up their own questions, and to develop other topics for discussion. However, the following are indicative of the kinds of questions that you mind find interesting to raise:
(1) What are the ethic and metholodogical challenges of doing ethnography in these kinds of settings
(2) How does one gain access to such fieldwork sites?
(3) What form of collaboration does this kind of fieldwork require?
(4) What is the relevance of such fieldwork for public health?
Required reading:
Brown, Hannah, 2012. Hospital domestics: Care work in a Kenyan hospital. Space and Culture 15(1):18-30
Chandler, Clare et al, 2008. Guidelines and mindlines: Why do clinical staff over-diagnose malaria in Tanzania? A qualitative study. Malaria Journal 7: 53
van der Geest, Sjaak, and Samuel Sarkodie, 1998. The fake patient: A research experiment in a Ghanian hospital. Social Science & Medicine 47(9):1373-1381.
Lecture 9 –Citizenship, Governance and Health
David Reubi
Learning objectives:
By the end of this lecture, you should be able:
To define the concepts of biological citizenship, biomedical subjectivities and bio-sociality;
To explain how these concepts can be used to analyse the complex relationships between biomedicine, logics of governance and identities;
To discuss and give examples (from the literature) of existing configurations of biological subjectivities and socialities from different historical periods and geographical regions.
Lecture content outline:
Medical technologies are inextricably linked with mentalities of rule and the knowledge and practices that make up these medico-political assemblages overflow and come to shape the way we understand and relate to ourselves and others. This lecture introduces three related concepts – ‘biological citizenship;’ ‘biomedical subjectivities;’ ‘bio-socialities’ – as a way to think about and analyse the complex relationships between biomedicine, logics of governance and identities. Returning to some of the themes covered in the lecture on Cultures and Personhood, this lecture will draw on examples from the anthropological and sociological literature to examine different historical and geographical configurations of biomedical subjectivities and socialities.
Essential Reading
Nguyen, Vinh-kim. 2005. Antiretroviral Globalism, Biopolitics and Therapeutic Citizenship. In: Aihwa Ong and Stephen Collier (eds), Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems, Malden, MA: Blackwell, 124 –144.
Reubi, David. 2010. Blood Donors, Development and Modernisation: Configurations of Biological Sociality and Citizenship in Post-Colonial Singapore, Citizenship Studies, 14(5):473-493
Novas, C and Rose, N. 2000. Genetic Risk and the Birth of the Somatic Individual, Economy and Society, 29(4):485-513
Additional Reading
Nguyen, Vinh-kim. 2009. Government-by-Exception: Enrolment and Experimentality in Mass HIV Treatment Programmes in Africa, Social Theory and Health, 7:196-217
Petersen, Alan and Deborah Lupton. 1996. The ‘Healthy’ Citizen. In: A. Petersen and D. Lupton, The New Public Health: Health and Self in the Age of Risk, London: Sage, pp.61-88
Rose, Nikolas and Carlos Novas. 2005. Biological citizenship. In Aihwa Ong and Stephen Collier (eds), Global assemblages: technology, politics, and ethics as anthropological problems. Oxford, Blackwell: 439–463.
Seminar 9 – Citizenship, Governance and Health
Central themes:
Biological citizenship; biomedical subjectivities; bio-socialities; relationships between biomedicine, politics and identities.
Seminar activity:
Students should be divided into two groups. Each group will work with one of the following essential readings:
1) Reubi, D. (2010), Blood Donors, Development and Modernisation: Configurations of Biological Sociality and Citizenship in Post-Colonial Singapore, Citizenship Studies, 14(5):473-493
2) Nguyen, Vinh-kim. 2005. Antiretroviral Globalism, Biopolitics and Therapeutic Citizenship. In: Aihwa Ong and Stephen Collier (eds), Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems, Malden, MA: Blackwell, 124 –144.
Given that these are essential readings, every student is expected to have read both articles before coming to the seminar. Each group should discuss the biomedical subjectivity and sociality described in their article. They should, in particular, ask and discuss the following questions:
Which country and time period does the article focus on? What is the social, political and economical context there and then?
Which medical technology is the article focusing on? Is a particular medical technology necessarily linked to a particular politics? Is genetics necessarily neo-liberal? Is blood donation necessarily about nation-building?
What are the key characteristics of the subjectivity and sociality described in the article? What experts, institutional forms, spaces, beliefs, categories, language, technologies, practices, etc. are characteristic of the subjectivity and sociality described in the article?
What happens when a medical technology (e.g. transfusion medicine) or political technology (e.g. patient group) moves from one country and political context to another?
When finished discussing and answering the questions, the groups should come together and compare and contrast the biomedical subjectivities and socialities described in their respective articles. They should also compare and contrast their answers to the questions above.
Questions to be addressed in the seminar:
(1) What is meant by ‘biological citizenship,’ ‘biomedical subjectivity’ and ‘bio-sociality’?
(2) What happens when a medical technology moves from one country and political context to another?
(3) How can we think about and analyse the complex relationships between medical technologies, political forms and identities?
Lecture 10 – Post-coloniality and Medicine
Branwyn Poleykett
Content Overview:
Following up on some of the seminar discussions about the ways in which colonial medicine may shape current experiences of medical research, we return to the past, to reflect on how colonial medicine was experienced and understood at the time. Through three case studies we will 1) examine the logics underpinning colonial public health interventions, 2) review available evidence as to how different people participated and responded to these interventions, and 3) think about the continued impact of the policies and priorities of colonial medicine for contemporary public health interventions.
Case studies: The sanitary regulation of prostitution in Senegal; the colonial response to bubonic plague in Senegal; psychiatry in colonial Nigeria.
Questions to be addressed:
1. What is ‘colonial’ about colonial medicine?
2. How did different medical traditions encounter one another in a colonial context?
3. How has the colonial period left traces in contemporary arrangements of global health & biomedical research?
Essential Reading:
Worboys, M. “Colonial and imperial medicine”. In D Brunton, ed, Medicine transformed: health, disease and society in Europe, 1800–1930. Manchester: Manchester University Press, 2004, 211-38.
Hunt, N.R. (1988) “Le Bebe en Brousse”: European Women, African Birth Spacing and Colonial Intervention in Breast Feeding in the Belgian Congo The International Journal of African Historical Studies , Vol. 21, No. 3, pp. 401-432
Additional Reading:
Fanon, F. (1965) “Medicine and Colonialism,” in A Dying Colonialism, trans. by Haakon Chevalier New York: Grove
Keller, Richard C. (2006) Geographies of Power, Legacies of Mistrust: Colonial Medicine in the Global Present. Historical Geography 34: 26-48
Further reading for those interested in the topic:
Jackson, L. (2002). “When in the White Man’s Town”: Zimbabwean Women Remember Chibheura (Compulsory VD Examinations). In J. Allman, S. Geiger & M. Nakanyike (Eds.), Women in Colonial Africa: An Introduction: Indiana University Press
Vaughan, M. (1991). “Rats’ Tails and Trypanosomes: Nature and Culture in Early Colonial Medicine” in Curing their ills: Colonial power and African illness, Stanford University Press.
Film 2 – Shifting historical contexts of community engagement in health intervention and research
Title: DDT Against Malaria & Kilifi Community Engagement
Branwyn Poleykett
Theme:
The film “DDT against malaria”, directed by Dr Heisch, from the division of vector borne diseases in late colonial Kenya (and later for a short time with the London School of Hygiene), describes research and intervention against highland malaria in Kenya in a context shaped by colonial administrative practices and ideology. One key element of the film are relations to local people–what what today would be referred to as “community engagement”– and how central this is for the success of research and interventions.
The 2nd short film was produced recently by the social scientists and community engagement specialists of a large-scale medical research and intervention programme in Kenya. It shows local attitudes and ideas about research and researchers, and how researchers and their institutions are dealing with them.
The contrast between the two films serves to reflect upon changes and continuities between the two periods, and above all to highlight the complexities of engaging local communities, within a historically shaped wider political economic context, in biomedical research projects and health care interventions.
The article is available in full version in Russian