This month’s “In the Journals…” brings us a body of articles discussing pregnancy, childbirth, nursing, female anatomy, substance abuse, and addiction, with a focus on risk, secrecy, stigma, and strategies of coping and self-preservation.
Critical Public Health
Matilda Hellman & Robin Room
The study inquires into popular myths on addiction in two countries: Finland and the USA. It provides evidence of the manners in which the typical media narratives incorporate basic value traits from their context of origin. We distinguish some main features in the narrative set-ups that support different solution repertoires for dealing with addiction. Belief and hope are crucial story elements associated with the US emphasis on group formation and local empowerment. The individual is assigned obligations and can be morally condemned. In the Finnish journalistic prose, there seems to be an inherent belief that the agenda-setting in itself will propel the question into the institutionalised welfare state solution machinery. The occurrence of a story resolution was customary in the US stories, whereas the Finnish stories were typically left pending. The evidence produced has implications for the ongoing debate regarding the mainstreaming of both definitions of and solutions to addiction problems.
Leia M. Minaker, Susan J. Elliott & Ann Clarke
The aim of this study was to explore experiences and coping strategies of low-income families affected by food allergies. Of particular interest were experiences of allergy-related stigma within the context of poverty stigma. A secondary objective was to offer suggestions for refining a conceptual model of disease stigma. In-depth interviews with 23 individuals (10 key informants and 13 low-income adults affected by food allergies in southwestern Ontario, Canada) were conducted in 2012–2013. Participants reported feeling forced to adopt income-related stigmatized behaviors to obtain food and perceived difficulty in obtaining medication. Participants adopted cognitive distancing strategies to separate themselves from other low-income families affected by food allergies. Key informants frequently perceived low-income allergic individuals to be less vigilant than higher income individuals and attributed higher rates of allergy among higher income individuals to fewer unhygienic exposures and infections in early childhood. Both low-income participants and key informants perceived that inadequate education was a barrier to allergy management: key informants perceived a lack of education as an individual-level failure, while low-income participants perceived the lack of education as a system-level failure. Our findings revealed intersections between allergy stigma and poverty stigma. Results can be used to suggest additions to a conceptual model of disease stigma. Differing perspectives between key informants and low-income individuals have implications for strategies to improve access to education, safe food, and medication for low-income families affected by food allergies.
Health, Risk & Society
Emily Jane Ross
Withholding news of a pregnancy from wider family and friends for the first 12 weeks of gestation is a familiar aspect of the contemporary experience of pregnancy in Britain. In this article, I explore this convention, drawing on interviews conducted in Scotland between 2012 and 2013, with 15 women experiencing a full-term pregnancy for the first time. For the participants in this research, the maintenance of secrecy was a response to their understanding that the risk of a pregnancy loss was at its highest during this stage of gestation. Respondents often articulated their interpretation of this risk in terms of statistics, derived from medical sources. These were substantiated by knowledge of pregnancy losses amongst family and friends, but also by their own ambiguous embodied experiences at this time. Accounts of early gestation resonated with Rothman’s notion of the ‘tentative pregnancy’, a concept rarely invoked outside discussions of prenatal testing. In line with efforts not to get ‘too excited’, demonstrating emotion work, women delayed the announcement of their pregnancy until they perceived the risk of a pregnancy loss to have decreased. During the first 12 weeks of gestation, participants’ accounts demonstrated multiple influences on their understanding of their pregnancy as at risk. Further, their experiences more often resonated with the management of uncertainty than risk per se, and thus offer new perspectives to the study of pregnancy within the social sciences.
Western medical approaches to childbirth typically locate risk in women’s bodies, making it axiomatic that ‘good’ maternity care is associated with medically trained attendants. This logic has been extrapolated to developing societies, like Vanuatu, an Island state in the Pacific, struggling to provide good maternity care in line with the World Health Organization’s Millennium Development Goals. These goals include the reduction of maternal mortality by two-thirds by 2015, but Vanuatu must overcome challenging hurdles – medical, social and environmental – to achieve this goal. Vanuatu is a hybridised society: one where the pre-modern and modern coincide in parallel institutions, processes and practices. In 2010, I undertook an inductive study of 30 respondents from four main subcultures – women living in outer rural communities with limited access to Western-trained health workers; women from inner urban communities with ease of access to medical clinics; traditional birth attendants who are formally untrained but highly specialised and practised mainly in remote communities; and Western-trained medical clinicians (obstetricians and midwives). I invited all the participants to comment on what constituted a ‘good birth’. In this article, I show that participants interpreted this variously according to how they believed the uncertainties of childbirth could be managed. Objectivist approaches that define risk as an objective reality amenable to quantifiable measurement are thus rendered inadequate. Interpretivist approaches better explain the reality that social actors not only find risk in different sites but gravitate towards different practices, discourses and individuals they can trust especially those with whom they feel a strong sense of community. Strategies are, therefore, formed less through scientific rationality but according to feelings and emotions and the lived experience. The concept of risk cultures conveys this complexity; they are formed around values rather than calculable rationalities. Risk cultures form self-reflexively to manage contingent circumstances.
Health & Place
Crystal Gibson, Lauren Perley, Jonathan Bailey, Russell Barbour & Trace Kershaw
Social network and area level characteristics have been linked to substance use. We used snowball sampling to recruit 90 predominantly African American emerging adult men who provided typical locations visited (n=510). We used generalized estimating equations to examine social network and area level predictors of substance use. Lower social network quality was associated with days of marijuana use (B=−0.0037, p<0.0001) and problem alcohol use (B=−0.0050, p=0.0181). The influence of area characteristics on substance use differed between risky and non-risky spaces. Peer and area influences are important for substance use among men, and may differ for high and low risk places.
Ryan McNeil, Hannah Cooper, Will Small & Thomas Kerr
Area restrictions prohibiting people from entering drug scenes or areas where they were arrested are a common socio-legal mechanism employed to regulate the spatial practices of people who use drugs (PWUD). To explore how socio-spatial patterns stemming from area restrictions shape risk, harm, and health care access, qualitative interviews and mapping exercises were conducted with 24 PWUD with area restrictions in Vancouver, Canada. Area restrictions disrupted access to health and social resources (e.g., HIV care) concentrated in drug scenes, while territorial stigma prevented PWUD from accessing supports in other neighborhoods. Rather than preventing involvement in drug-related activities, area restrictions displaced these activities to other locations and increased vulnerability to diverse risks and harms (e.g., unsafe drug use practices, violence). Given the harms stemming from area restrictions there is an urgent need to reconsider this socio-legal strategy.
Journal of the History of Medicine and Allied Sciences
Susan P. Mattern
Starting perhaps in the second century BCE, and with Hippocratic precedent, ancient medical writers described a condition they called hysterike pnix or “uterine suffocation.” This paper argues that uterine suffocation was, in modern terms, a functional somatic syndrome characterized by chronic anxiety and panic attacks. Transcultural psychiatrists have identified and described a number of similar panic-type syndromes in modern populations, and a plausible theory of how they work has been advanced. These insights, applied to the ancient disease of hysterike pnix, demystify the condition and illuminate the experience of the women who suffered from it.
This article uses data drawn from the overseers’ accounts and supporting documentation in thirty-six parishes spread over four English counties, to answer three basic questions. First, what was the character, extent, structure, range of activities, and remuneration of the nursing labor force under the Old Poor Law between the late eighteenth century and the implementation of the New Poor Law in the 1830s? Second, were there regional and intra-regional differences in the scale and nature of spending on nursing care for the sick poor? Third, how might one explain such differences? The article suggests that nursing became an increasingly important category of spending for the poor law from the later eighteenth century, but that there were significant variations within and (particularly) between English counties in parochial attitudes toward the provision of nursing for the sick poor. These variations can be explained by applying a matrix of explanatory variables ranging from the minor (differences in how parishes defined “nursing”) through to the major (long-standing cultural attitudes toward the responsibility of parishioners to their sick compatriots and the ingrained expectations of the sick poor). The article also throws new light on the hidden aspects of female labor force participation, pointing to the development of professional nursing networks long before the later nineteenth century.
César E. Abadía-Barrero
Workers at the oldest maternity hospital in Colombia experienced the privatization of health care and the flexibilization of their labor. Drawing on their experience, I illustrate how neoliberalism transforms the value of life. This transformation occurs first in terms of its moral worth: the worth of life changes over time, as people and public hospitals are stigmatized as the ‘living memory’ of the old. Second, the hospital buildings, the land on which they sit, and the roles of workers within the hospital are all transformed. Both similarities and differences emerge between a type of systemic or chronic violence that is inherent to the capitalist system and modern practices of torture. Examining how capitalist forces transform the value of life opens up new fields of inquiry to study links between critical political economy and subjectivity.
Anatomy and cadavers trigger fear and produce contradictory responses. In these circumstances, allegedly Western models of learning and the exposure to death have to be appropriated to become viable. Furthermore, references to the religious and cultural backgrounds of students shape their responses. According to students, death is an event when the deceased acquires supernatural powers; thus, they take shield in religion to ward off potential dangers caused by spirits. The exposure to the interior of the body also produces heightened feelings of religiosity and perceiving the body as a miracle. Befriending skulls and body parts and giving them names are strategies to humanize dead bodies and render them familiar. However, in order to legitimize working with cadavers and the dissection of bodies, students tend to dehumanize cadavers and observe them as mechanical objects.
American feminist health activists in the 1970s created representations of genital anatomy intended to replace the abstracted images of biomedicine’s ‘modest witness,’ with what Michelle Murphy has called the ‘immodest witness,’ authority explicitly derived from personal and embodied experience. Decades later, a feminist publication in the tradition of the immodest witness called Femalia was adopted into the practice of an American surgeon specializing in trans- genital sex reassignment surgery (GSRS). Based on ethnographic and textual research, I show how oppositional claims to represent the ‘natural’ female body—one valued for its medical objectivity and the other for its feminist subjectivity—effectively foreclosed these as modes of authority through which the trans- patient might contribute to her surgical care. I argue that trans- patients’ double epistemological exclusion contributes to a broader asymmetry in the use of patients’ subjective reports in the everyday practice of GSRS and the clinical research by which it is evaluated.
Amanda Pavey, Narelle Warren, and Jacquelyn Allen-Collinson
People living with motor neuron disease (MND) experience profound and rapidly progressing impairment. In order to maintain their physical and social functioning, people so affected employ a range of technologies and technological aids (body auxiliaries) to enhance their life and maintain well-being. Using a phenomenological study design, we explored the experiences of 42 men and women who had been diagnosed with MND. Although many participants initially resisted the adoption of aids (often-electronic devices that enabled continued participation in daily life) or tools (the instruments that allowed achievement of specific tasks), such technologies offered a way for people with MND to overcome, to some extent, the limitations posed by their physical degeneration. Through generating a sense of ‘normality,’ these kinds of ‘enabling’ technologies promoted social engagement and the maintenance of valued relationships or activities. Technologies can provide people with MND with some positive experiences within a way of being-in-the-world that has become so difficult and challenging.
People living with a disability or illness and health care professionals often have different perspectives on what needs to be done, and why, in order to create a life they can recognize as good. Focusing on home modifications, I explore the enactment of diverging perspectives on the desired good. I show how one couple living with the effects of motor neuron disease in Wales tried to create a way of living. Drawing from a narrative-based study, I explore what happens when there is an interaction of different perspectives of what is considered to be a desirable outcome. I argue that the construction of some expectations as needs, and others as desires, serves to subjugate people to certain technologies. These technologies are those deemed necessary, following a neo-liberal language of cost-effectiveness where desires can be seen as liabilities.
Danish sperm donors face a particular kind of kinship trouble: they find themselves in a cultural and organizational context that offers different and contrary ways of how to make connections to donor-conceived individuals meaningful. Whereas Danish sperm banks and Danish law want sperm donors to regard these connections as contractual issues, the dominant kinship narrative in Denmark asks sperm donors to also consider them as family and kinship relations. Based on interviews with Danish sperm donors and participant observation at Danish sperm banks, I argue that Danish sperm donors make sense of connections to donor-conceived individuals as a particular kind of relatedness that cannot be reduced to either contractual or kinship relations. Making sense of these connections, sperm donors negotiate their social significance and thereby participate in opening a space which offers avenues for new kinds of sociality.
Medicine Anthropology Theory
In this article I seek to develop a conceptual framework for anthropological work on ‘the gut’ by bringing together reflections on ethnographic fieldwork on nutrition and well-being in KwaZulu-Natal, South Africa, with recent advances in the sciences of the gastroenterological and enteric nervous systems. While new evidence suggests that diet, immune system functioning, memory, and behaviour are shaped by the characteristics and processes of the enteric nervous system, it has also come into the public sphere as an object of intense disputation. Despite an ethnographic archive elaborating the diverse ways in which the gut contributes to well-being, it is still seen as a collection of folk systems incommensurable with scientific knowledge. I suggest that the mutual absorption of the natural and the social in the mediating membrane of the gut requires a more robust concept than either illness narrative or biosociality, and I ask: what would an anthropology of the gut look like?
Theoretical work in critical medical anthropology and biomedicine on substance use in pregnancy has yet to develop a cohesive framework of the maternal-fetal unit (MFU) as a dynamic object. As a result, patient history, risk, and agency continue to be driven by an Enlightenment-era, monolithic conception of individual will. I use the example of Carla, a young woman actively using heroin in her pregnancy, to illustrate the limits of the MFU as it is currently conceived. By using critiques of subjective utilitarianism, as discussed by Byron Good, and the concept of becoming, as elucidated by Gilles Deleuze and Félix Guattari, this article seeks to articulate an ethics of accompaniment, focused on both individual patient care and wider sociopolitical advocacy. These ethics help to redefine the MFU, and support new and unique ways of providing services to this often marginalized and vulnerable population.
Jens Seeberg and Lotte Meinert
This article argues that the concept of communicability that is central to the distinction between communicable diseases (CDs) and noncommunicable diseases (NCDs) is poorly conceptualized. The epidemic spread of NCDs such as diabetes, depression, and eating disorders demonstrates that they are communicable, even if they are not infectious. We need to more critically explore how they might be communicable in specific environments. All diseases with epidemic potential, we argue, should be assumed to be communicable in a broader sense, and that the underlying medical distinction between infectious and noninfectious diseases confuses our understanding of NCD epidemics when these categories are treated as synonymous with ‘communicable’ and ‘noncommunicable’ diseases, respectively. The dominant role accorded to the concept of ‘lifestyle’, with its focus on individual responsibility, is part of the problem, rather than the solution, and the labelling of some NCDs as ‘lifestyle diseases’ is misleading. Founded on a critical understanding of global health and globalized medicine, we propose to explore the dynamics of the phenomena of contamination and biosocial contagion in networks. An analytics of biosocial epidemics needs to be developed by a medical anthropology that is engaged in a critical dialogue with both medicine and biology.
Philosophy, Ethics and Humanities in Medicine
- Naguleswaran, T. Tribedi, J. Fenn, S.B. Patel & Peninsula College of Medicine and Dentistry
The inaugural southwest medical debate, between Exeter and Plymouth medical schools and respective health services, was held on the 3rd December 2014. Plymouth proposed the motion “This house believes the NHS should be privatised?” In an increasingly political climate, the National Health Service (NHS) has become a constant topic for discussion in the media. On this occasion, all those debating were involved in the medical profession with roles encompassing clinical medicine, education, ethics, economics and policy. By allowing those with knowledge of the NHS to speak, we hoped to spark novel discussions based on evidence and experience.