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Ethnographic presents and futures of ‘health’—a summary of the Ethnographies and Health workshop

In this report we offer an overview of a two-day workshop entitled Ethnographies and Health that was held in October at the London School of Hygiene and Tropical Medicine (LSHTM), and present personal reflections on the discussions and debate from four participants. Critically engaging with ethnography as a practice, methodology, and theoretical orientation, the aim of the workshop was to explore our fieldwork choices and the kinds of knowledge(s) they generate across and within fields of health research (broadly defined). We invited submissions for the workshop from early career researchers from a range of disciplines, acknowledging from our own experiences that while ethnography has increasing presence and recognition within health research, those conducting ethnography may be thinly spread across multiple academic settings, both traditional disciplinary departments in the social sciences and, increasingly, more bio-medically oriented health sciences departments.

The diversity of disciplines and fields of research represented by the 26 people selected to participate in the workshop was matched by the diversity of contemporary modes of ethnographic engagement with, of, and through ‘health’. The workshop encouraged a rich array of questions, focusing on the multiplicity and heterogeneity of ‘healths’ which ethnography opens up and details, and the nuanced ways in which our own entanglements with research settings always encourage additional queries and uncertainties. The opening speakers, Simon Cohn (LSHTM) and Tiago Moreira (Durham University), illuminated in different ways just how ethnography as a practice and mode of making knowledge may come into tension with, for example, biomedical framings of health and/or with the expectations of funders and others in the field. These tensions may also be productive, enabling us to rethink what ‘participating’ in the field is or really means, and to creatively engage with normative assumptions of science and policy. Yet, this also requires us as ethnographers to carefully consider the cuts, classifications and boundaries we make in the practice of our fieldwork, because, as Judy Green (LSHTM) pointed out in her closing summary of the workshop, these decisions are not neutral, and we risk a certain hypocrisy if we challenge the categories of some social actors, but not our own.

Starting out with the notion that ethnography may be better understood as a ‘sensibility’ and health as a ‘multiverse of healths’, the presentations that followed from early career researchers spanned a range of diverse topics including (among others) studies of public health interventions, everyday experiences of health, and structures of care-giving, and described a range of approaches including visual ethnography, auto-ethnography, and historical and linguistic methods. Key themes that emerged through resultant discussions included questioning the different scales of ‘health’ that ethnography highlights and moves between; how a focus on the material and spatial dimensions of health practices open up new modes and models of ‘health’; and the positionality of ethnography in relation to health professional practice and ethical values and structures. We invited workshop participants to reflect on the content and discussions of the workshop, and to consider how it intersected or challenged their own work and approach as early career researchers. By presenting reflections from four participants below we hope to provide both an account of the workshop from those who participated, but also to foreground some of the tensions and questions which were raised and to encourage further dialogue with others adopting ethnographic approaches in, of, and through ‘health’.

 

‘Doing ethics’ as an ethnographer
Gemma Hughes (University of Oxford)

There was a sense of camaraderie at the workshop, created by sharing tales of the field. Mentioning NHS ethics triggered quite a few “war” stories: comparisons of difficulties encountered. Getting ethical approval for my research study, involving vulnerable research participants and multiple organisations, was arduous and intricate. The approval process that safeguards vulnerable people from the potential harms of research is designed for medical, experimental studies. Researchers specify the intervention or procedure participants will receive, as set out in the protocol, so the committee can weigh up potential harms and benefits in deciding if the proposed study is ethical.

Translating this process to a qualitative study requires a stretching of the meaning of “interventions and procedures” to cover interviews and observations. Fitting an ethnographic study into the boxes on the forms is exasperating, as the whole point of taking an ethnographic approach is to try to follow participants into their social world—not controlling the environment, the interview, or conversation but being with people on their terms, taking an interest in what matters to them. So we complete the form by trying to imagine ourselves in the future, and describe what we will ask people we haven’t yet met. Having “got through” the ethics committee, the ethnographer’s ethics work doesn’t end with annual reports containing notification of any breaches in protocol. Instead the nature of ethnographic inquiry is such that we are forced to continually re-evaluate our position. Matt Maycock (University of Glasgow) told us about some of the decisions he had to make during his fieldwork in prisons (e.g. What to wear? What to disclose about himself? Should he carry keys?), demonstrating that those very aspects of ethnographic research that could cause it to fall foul of the ethics process (i.e. its unpredictable, iterative, and unfolding nature) are those that compel the ethnographer not only to think deeply about their position but to act ethically. Matt’s choices to eschew the trappings of power available to him (uniform, non-disclosure, keys) in his efforts to develop respectful relationships with his participants demonstrate an approach to ethics that goes beyond careful planning on paper towards an enacted ethical practice. This is not to say that ethnographers are somehow naturally more ethical than other researchers; rather, if we have a case to conduct research differently from experimental trials then it follows that we also need to “do” ethics differently.

 

Balancing normative concerns for health with an ethnographic sensibility
Periklis Papaloukas (De Montfort University)

When I was initially asked to provide a reflective account on the Ethnographies and Health workshop, I was perplexed as I was thinking about it. Was this an event which helped me advance my research skills in any way, and more specifically with regard to my PhD project? In that aspect, how is ethnography even involved with my own topic, exploring the experiences of LGBT persons diagnosed with multiple sclerosis, a project mostly influenced by critical health psychology? The answer to that is not straightforward. Notwithstanding the ambiguity, visual ethnography has allowed me to expand my research perspective. This was made clear by the end of the workshop, as multiple presenters offered their own meaningful understandings with regard to that. The repositioning of the visual ethnographical component of my theoretical and methodological aspect of my project was an immediate outcome. The echoing of the idea that (visual) ethnography allows for the capturing of an expanding and multiversal social reality of a health experience resonated with my aims and objectives. Visual ethnography influenced by the participatory paradigm of photovoice was not just a tool of data collection anymore. I now see it as an equally important theoretical approach with both critical health psychology and interpretative phenomenological analyses which are producing the integrative theoretical framework which informs the design of the research.

Additionally, the discussions—including the feedback I received and the common exploration of the ‘zooming in and out’ concept—have allowed me to self-critically acknowledge that in spite of my (perhaps over-ambitious) goal of social action and transformation, I need to be careful as to not reproduce normatively created classifications, categories, or labels, or not to create new ones which might be equally oppressive and/or arbitrary. Is the title LGBT inclusive enough? Does the term ‘person with multiple sclerosis’ capture adequately the lived experience of these individuals? My presence at the workshop has given me the opportunity to recognise these essential questions (in a critical health sense) or even create new ones which will provide me with further theoretical enhancement which any PhD project needs. This convergence of practitioners and researchers with such varied research backgrounds and positions, coupled with the all-inquiring eye of more experienced academics, has given me the privilege to take part in productive discussions, to get meaningful feedback, and to enrich my theoretical and practical understandings of the (visually-oriented) ethnographical components of my health and illness related project.

 

Confronting different—and difficult—subjectivities of health
Carys Banks (University of Bath)

Following the excellent workshop at LSHTM in October this year, I would be interested in exploring further the question: What is the role of the anthropologist/ethnographer within health and social care sectors? It was repeatedly affirmed at the ethnographies workshop that as anthropologists and ethnographers our role is to challenge normative notions of lived experiences of health and illness with a view to proliferating and opening up new interpretations of these.

Placing importance on the subjectivity of lived experiences can be viewed as emancipatory in that it suggests there is potential for people to flourish in ways that are meaningful to them. Yet, this all-encompassing approach to health subjectivities is perhaps challenged when faced with the objective fact that some ‘ways of living’ are more likely than others to cause life-limiting illnesses and physical suffering. Though there are many exceptions within our society—for instance religious interpretations of the importance of suffering—generally speaking, within societies (Britain being one) where scientific advancement has led to an overwhelming focus on improving medical treatments and alleviating pain, human experiences such as illness and physical suffering have come to be seen as experiences to fear and, if possible, to avoid.

I am interested in exploring what the role of the anthropologist/ethnographer is and/or should be in situations when, for example, it becomes apparent that certain ‘ways of living’ carry with them high possibilities of developing life-threatening illnesses that are likely to cause real physical suffering. One highly pertinent example of this tension was indicated through Zoran Milosavljevic’s (University of Hull) presentation, which explored online interactions between gay men in HIV/AIDS communities. In these situations, is it our role to ‘educate’ individuals and groups with a view to encouraging them to adhere to lifestyle behaviours which aim to avoid, even negate, ill health and physical suffering? Alternatively, do we remain on the margins of these arguably normatively shaped notions of responding to health and illness, attempting to understand the internal and external factors and power relations that come to shape people’s lives?

Finally, this prompts us to consider what are the implications of this for how anthropologists/ethnographers attempt—or not—to influence policy and practice in these areas?

 

Attuning to the materiality of ‘healths’
Francesca Morra (Oxford Brookes University)

I arrived at the Ethnographies and Health workshop aiming at getting new insights on how to do anthropology of mental health, and certainly I came back with much more than I expected. In my presentation, I argued that mental distress, and symptom experience in particular, can offer the ethnographer a view on the implicit and nonsensical angles of social and cultural environments. As suggested by Joanna Reynolds (LSHTM), in this way we can build a scalar perspective, connecting trivial fragments to broad dynamics. But how can we access, or prompt, those fragments?

All the contributions taught me something about the ways in which we can practice ethnography. Firstly, I noticed a common interest in the materiality—the ‘doing’—of illness. Precisely, it was argued that materiality is expressed by objects and actions mediating the relation between bodies and environments: a cut undershirt in my work, clothing and handbags in Christina Buse’s (University of York) research, and the techniques du corp—washing, dressing, eating—mentioned by Ursula Read (King’s College London).

Secondly, since these sensory experiences are mostly non verbal, the ethnographer can approach them borrowing some tools from other disciplines. In particular, Ursula Read suggested using occupational therapy’s methods to account for details of everyday gestures, “to learn to make the familiar strange.” Alternatively, Periklis Papaloukas (De Montfort University) employed Photovoice to explore places that are usually taken for granted, such as public toilets and sidewalks.

Finally, I think that all the contributions engaged with what was emphasized during the workshop’s opening reflections: ethnography has a creative potential, that of re-thinking and possibly re-constructing its object, to truly ‘participate’ in the field. If we consider that the history of mental health is a history of competing narratives, it becomes clear how crucial could be the ethnographer’s position within the the discourse.

 

Reflections and next steps as Early Career Researchers

It is clear from these series of workshop reflections that contemporary ethnographic engagements with health are rich and diverse, contributing to both lively debate between different disciplines and fields of practice, as well as in the development of social and cultural theory more specifically. As organizers and contributors, we have valued the opportunity to create a shared space for the articulation of ‘uncomfortable’ fieldwork encounters and explicitly discuss the practical work of doing (and achieving) ethnography in, of, and through ‘health’. We hope that the workshop will be the start of a continuing dialogue—establishing an email list being the first step—for early career ethnographers (and others) engaging with the ever-shifting and complex fieldwork relations which make up contemporary ethnographic engagements with ‘health’.

 

Further Information

Participants and abstracts from the Ethnographies & Health workshop

Further reflections on the workshop, by Judy Green (LSHTM)

 

Carys Banks is a third-year doctoral student based within the Department for Health at the University of Bath, UK. Her academic training is in social anthropology and through her doctoral research she is ethnographically exploring the translation of policy into everyday practice within social care support settings for adults with learning disabilities. In particular, she is focusing on how the value of ‘choice’ is constructed within these contexts of care.

Emma Garnett, PhD, is a post-doctoral researcher at the London School of Hygiene & Tropical Medicine (LSHTM). She recently completed her PhD in Anthropology and Science and Technology Studies, which was an ethnographic exploration of data practices in a multi-disciplinary public health project studying air pollution and health. Research interests include social studies of science and technology, environmental health, and the politics of knowledge making in science-policy practices.

Gemma Hughes is currently studying (part-time) for a DPhil in Evidence-Based Health Care at Oxford University, developing a case study of integrated care. Gemma also holds a senior (part-time) post in a Clinical Commissioning Group. Gemma has an MSc in Social Policy and Planning from the LSE and a BA in Philosophy and Literature (University of Essex) and is interested in tracing the connections between policy intentions and the lived experience of everyday lives through ethnography.

Sarah Milton, PhD, is a Research Fellow in Medical Anthropology at LSHTM. She has research interests in ageing, gender, and the body, and local practices of public health in the UK. Her PhD was an ethnographic account of women dating in later life, focusing on the intersections between class, heterosexuality, and femininity. More recently she has researched how welfare shapes later life and how alcohol licensing is shaping neighbourhoods in London. She has a strong commitment to ethnographic methodology.

Francesca Morra is a PhD student in the department of Social Sciences at Oxford Brookes University. She is also a clinical psychologist. Her research examines the experience of mental distress within the Italian asylum system, focusing on the interactions between psychic life, migratory pathways, and categories of citizenship.

Periklis Papaloukas is a PhD candidate with the School of Applied Social Sciences at De Montfort University (DMU), Leicester, UK. His doctoral thesis research is focusing on the experience of lesbian, gay, bisexual, trans, and queer (LGBT) persons living with the chronic condition of multiple sclerosis. He has an MSc in Health Psychology from the Department of Psychology, University of Bath, UK and a bachelor’s in Psychology from Panteion University of Social and Political Sciences at Athens, Greece. His research interests lie in critical health and social psychology, chronic illness and its psychosocial impacts, and human rights, and he strongly advocates for an inclusive society with equality and equity at its core.

Joanna Reynolds is a PhD student in the Department of Social & Environmental Health Research at LSHTM. She has a background in social anthropology and public health and is committed to applying anthropological theories, methodologies, and critical perspectives to public health ‘problems’. Her PhD thesis explores enactments of ‘community’ in relation to a community-based empowerment programme, and aims to contribute to approaches to evaluating the health impacts of such programmes. Her interests lie in health and social inequalities, qualitative methods, ethnography, and public health evaluation.


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