In addition to our regular roundup of journal articles, these two special issues were published this month:
- In Medical Anthropology Quarterly, “Toward an Anthropology of Insurance and Health Reform.” The issue includes a policy statement: The Council on Anthropology and Reproduction (CAR) Opposes Legislation that Creates Barriers to Safe Abortion Care.
- In Health, Risk & Society, “Digitised Health, Medicine and Risk“
Toward an Anthropology of Insurance and Health Reform: An Introduction to the Special Issue
Amy Dao & Jessica Mulligan
This article introduces a special issue of Medical Anthropology Quarterly on health insurance and health reform. We begin by reviewing anthropological contributions to the study of financial models for health care and then discuss the unique contributions offered by the articles of this collection. The contributors demonstrate how insurance accentuates—but does not resolve tensions between granting universal access to care and rationing limited resources, between social solidarity and individual responsibility, and between private markets and public goods. Insurance does not have a single meaning, logic, or effect but needs to be viewed in practice, in context, and from multiple vantage points. As the field of insurance studies in the social sciences grows and as health reforms across the globe continue to use insurance to restructure the organization of health care, it is incumbent on medical anthropologists to undertake a renewed and concerted study of health insurance and health systems.
A major goal of The Patient Protection and Affordable Care Act is to broaden health care access through the extension of insurance coverage. However, little attention has been given to growing disparities in access to health care among the insured, as trends to reduce benefits and increase cost sharing (deductibles, co-pays) reduce affordability and access. Through a political economic perspective that critiques moral hazard, this article draws from ethnographic research with the United Steelworkers (USW) at a steel mill and the Retail, Wholesale and Department Store Union (RWDSU) at a food-processing plant in urban Central Appalachia. In so doing, this article describes difficulties of health care affordability on the eve of reform for differentially insured working families with employer-sponsored health insurance. Additionally, this article argues that the proposed Cadillac tax on high-cost health plans will increase problems with appropriate health care access and medical financial burden for many families.
Insurance Accounts: The Cultural Logics of Health Care Financing
The financial exuberance that eventually culminated in the recent world economic crisis also ushered in dramatic shifts in how health care is financed, administered, and imagined. Drawing on research conducted in the mid-2000s at a health insurance company in Puerto Rico, this article shows how health care has been financialized in many ways that include: (1) privatizing public services; (2) engineering new insurance products like high deductible plans and health savings accounts; (3) applying financial techniques to premium payments to yield maximum profitability; (4) a managerial focus on shareholder value; and (5) prioritizing mergers and financial speculation. The article argues that financial techniques obfuscate how much health care costs, foster widespread gaming of reimbursement systems that drives up prices, and “unpool” risk by devolving financial and moral responsibility for health care onto individual consumers.
Neoliberal Justice and the Transformation of the Moral: The Privatization of the Right to Health Care in Colombia
César Ernesto Abadía-Barrero
Neoliberal reforms have transformed the legislative scope and everyday dynamics around the right to health care from welfare state social contracts to insurance markets administered by transnational financial capital. This article presents experiences of health care–seeking treatment, judicial rulings about the right to health care, and market-based health care legislation in Colombia. When insurance companies deny services, citizens petition the judiciary to issue a writ affirming their right to health care. The judiciary evaluates the finances of all relevant parties to rule whether a service should be provided and who should be responsible for the costs. A 2011 law claimed that citizens who demand, physicians who prescribe, and judges who grant uncovered services use the system’s limited economic resources and undermine the state’s capacity to expand coverage to the poor. This article shows how the consolidation of neoliberal ideology in health care requires the transformation of moral values around life.
Chronic conditions associated with lifestyle and modifiable behaviors are the leading causes of morbidity and mortality in the United States. The implementation of the Affordable Care Act offers an historic opportunity to consider novel approaches to addressing the nation’s public health concerns. We adopt an anticipatory anthropological perspective to consider lifestyle behavior change as common ground shared by practitioners of both biomedicine and common forms of complementary and alternative medicine (CAM). At issue is whether CAM practitioners might play a more proactive and publicly endorsed role in delivering preventive and promotive health services to address these needs. Recognizing that this is a contentious issue, we consider two constructive roles for engaged medical anthropologists: (1) as culture brokers helping to facilitate interprofessional communities of preventive and promotive health practice and (2) in collaboration with health service researchers developing patient-near evaluations of preventive and promotive health services on patient well-being and behavior change.
Gendering the Burden of Care: Health Reform and the Paradox of Community Participation in Western Belize
Beth A. Uzwiak & Siobhan Curran
Belizean health policy supports a primary health care (PHC) strategy of universal access, community participation, and multisectoral collaboration. The principals of PHC were a key part of Belize’s emergent national identity and built on existing community-based health strategies. Ethnographic research in western Belize, however, reveals that ongoing health reform is removing providers from participatory arenas. In this article, we foreground a particular moment in Belizean health history—the rise and demise of multisectoral collaboration—to question what can constitute meaningful community participation in the midst of health reform. Many allied health providers continue to believe in the potential of PHC to alleviate the structural causations of poor health and to invest in PHC despite a lack of state support. This means that providers, the majority women, are palliating the consequences of neoliberal reform; it also means that they provide spaces of contestation to the consumer “logic” of this reform.
The following article identifies new areas for engaged medical anthropological research on health insurance in low- and middle-income countries (LMICs). Based on a review of the literature and pilot research, we identify gaps in how insurance is understood, administered, used, and abused. We provide a historical overview of insurance as an emerging global health panacea and then offer brief assessments of three high-profile attempts to provide universal health coverage. Considerable research on health insurance in LMICs has been quantitative and focused on a limited set of outcomes. To advance the field, we identify eight productive areas for future ethnographic research that will add depth to our understanding of the social life and impact of health insurance in LMICs. Anthropologists can provide unique insights into shifting health and financial practices that accompany insurance coverage, while documenting insurance programs as they evolve and respond to contingencies.
Society for Medical Anthropology Council on Anthropology and Reproduction (CAR) Policy Statement: The Council on Anthropology and Reproduction (CAR) Opposes Legislation that Creates Barriers to Safe Abortion Care (open access)
This special issue on Digitised Health, Medicine and Risk, edited by Deborah Lupton, has three sections: 1) Risk in the design and development of apps; 2) Individual users and the construction of risk; 3) Citizens’ understanding of the impact of digital technology on risk.
The gamification of risk: how health apps foster self-confidence and why this is not enough
Antonio Maturo & Francesca Setiffi
Weight loss apps enable users to quantify many aspects of food consumption, beginning with calories intake. Users of weight loss apps can also participate in online forums that act as digital self-help groups. These apps also include several features related to game playing or gamification such as avatars, points and virtual awards. Gamification has the aim of strengthening motivation to carry out a (boring) task. We downloaded the 20 most popular free weight loss apps in Google Play. We analysed app descriptions provided by developers, comments about the selected apps in online forums and user reviews. We focused on four of these apps, since they had some special functions. We found that users’ risk management was based on a mixed method that combined quantification and gamification, that is, rationality and emotions. Quantification, which includes self-tracking, data analysis and graphic layout, provides the ‘rational’ basis for dietary regimes, while gamification provides the emotional support needed to maintain motivation and continue with the diet. Our analysis provides support for the emotion–risk assemblage theory and the in-between strategy. Our analysis reinforces the importance of emotions in risk management. However, these dieting apps are based on a reductionist approach to obesity and weight loss, as obesity is framed as an individual problem, while weight loss is seen as dependent on individual motivation. Such framing tends to conceal the social determinant of health and the social and political causes of obesity.
Threats and thrills: pregnancy apps, risk and consumption
Gareth M. Thomas & Deborah Lupton
In this article, we draw on the findings of a critical discourse analysis of pregnancy-related mobile software applications designed for smartphones (‘apps’) to examine how such apps configure pregnant embodiment. Drawing on a detailed analysis of all such apps available in June 2015 in the two major global app stores Google Play and Apple App Store, we discuss how such technologies (the ‘threats’ mode of representation) portray the pregnant body as a site of risk requiring careful self-surveillance using apps to reduce potential harm to women and particularly their foetuses. We show that the second dominant mode of representation (‘thrills’) constructs the pregnant body and self-tracking in more playful terms. App developers use ludification strategies and encourage the social sharing of pregnancy-related details as part of emphasising the enjoyable aspects of pregnancy. We found that both types of pregnancy-related apps endorse expectations around pregnancy behaviour that reproduce heteronormative and gendered ideals around sexuality, parenthood and consumption. These apps are sociocultural artefacts enacting pregnant bodies as sites of both risk and pleasure. In both cases, users of the apps are encouraged to view pregnancy as an embodied mode of close monitoring and surveillance, display and performance.
Mobile health apps have emerged as a technological fix promising to improve asthma management. In the United States, treatment non-adherence has become the most pressing asthma risk; as such, emphasis has increasingly focused on getting asthmatics to take medications as prescribed. In this article I examine how mobile Asthma (mAsthma) apps operate as part of digital risk society, where mobile apps create new modes of risk identification and management; promise to control messy and undisciplined subjects and care practices; use algorithms to generate new risk calculations; and make risk livelier through digital assemblages. Drawing on ethnographic fieldwork, content analysis of mAsthma app design, as well as interviews with app developers, in this article I argue that these digital care technologies strip disease and risk of biographical, ecological and affective detail in ways that largely reinforce biomedical paradigms. Yet some apps offer new insight into the place-based dynamics of environmental health, a view made possible with digitised personal tracking, visual analytics and crowdsourced data. mAsthma apps are caught in the tension between the biopolitics of existing chronic care infrastructure, which reinforce a strict neoliberalised patient responsibility, and the promise of collective, place-based approaches to global environmental health problems.
In this article, we critically interrogate the discourses used during the development of eCoaches. We draw on data from a four-phase qualitative study about the ethical, legal and social aspects of using digital technologies to encourage lifestyle changes that was conducted in the Netherlands between March 2014 and May 2015. The four phases of this study included interviews, document analysis, participant observation, interventionist workshops on legal issues and a forward-looking techno-ethical scenarios workshop. We use data from the first three phases to identify how both health-related and technology-related risks for individuals and society were constructed. There were multiple, concurrent references to risk in the programme and project documents, as well as in the various discussions we observed among designers. We discuss three major constructions of risk found in these discourses: risks to the health system, risks of developing an ineffective eCoach and new risks to the individual user. We argue that these three constructions feed particular norms and values into the design of the resultant eCoaches, whereby notions such as effectiveness, social solidarity, responsibility for health and individual autonomy (and thus, our understanding of what constitutes ‘risk’) are redefined. Understandings of risk may shift once users begin engaging with these eCoaches in practice. Future research should therefore also examine (discursive) constructions and understandings of digital risk from the perspective of the users of such technologies.
In 2013, the ‘right to baby formula’ movement supported by educated, middle-class Chinese families in Hong Kong was launched online challenging the dominant message that ‘breast is best’. In this article, I focus on links between mediatisation, globalisation of formula milk and motherhood in post-colonial Hong Kong. Although previous research has examined ideologies of motherhood and mothers’ infant feeding decisions, little research has focused on the impact of digital media within post-colonial societies undergoing rapid social change. Drawing on data from a study of mothers living in Hong Kong that I conducted during 2010–2011 and 2013–2014, I show how digital media contribute to changes in individuals’ experiences with breastfeeding, perceptions of risk and health, as well as social relations, norms, values and identities in contemporary Hong Kong. I explore how and with what consequences the family, especially as it relates to motherhood and childhood, and the practices of infant feeding are intertwined with digital media and the body politic in neoliberal, post-colonial Hong Kong. I argue that although digital media have globalised the biomedical discourse that ‘breast is best’, mothers in Hong Kong have, through digital storytelling and virtual interaction, generated alternative interpretations of science, health and their embodied illness experience that serve to counterbalance the cultural contradictions of motherhood. I show that through social networking, parents have not only gained sufficient political power to secure formula milk, they are also simultaneously subsumed to consumer desire created by the marketing of international pharmaceutical companies.
‘Holy shit, didn’t realise my drinking was high risk’: an analysis of the way risk is enacted through an online alcohol and drug screening intervention
Michael Savic, S. Fiona Barker, Barbara Hunter & Dan I. Lubman
Commentators view online screening and automated feedback interventions as low-cost ways of addressing alcohol and other drug-related harms. These interventions place people into categories of risk based upon scores from standardised screens and provide automated feedback about a person’s level of risk of developing alcohol and other drug ‘problems’. In this article, we examine how one particular alcohol and other drug online screening and feedback intervention enacts risky alcohol and other drug use and users, and explore how these enactments compare to alcohol and other drug users’ own accounts of risk. In order to do this, we undertook a qualitative analysis of intervention content and intervention recipients’ responses (n = 489) to an open-ended question about their experience of the online screening and feedback intervention. Our analysis highlights how the online screening and feedback intervention draws on prevention science to cultivate a sense of expertness and objectivity. Intervention recipients’ accounts of risk were either overshadowed by the ‘expert’ risk account provided by the intervention, ‘validated’ by the intervention or were not accurately reflected by the intervention. In the latter case, intervention recipient comments draw attention to the way in which the intervention enacts alcohol and other drug use as inherently risky without accounting for the context and purpose of use. While the online screening and feedback intervention assumes that people are capable of self-monitoring and managing their alcohol and other drug use and risk, recommendations for help provided enact intervention recipients as fragile and in need of professional help. We suggest that there is a need for the development of interventions that are better equipped to take account of the complexity of alcohol and other drug use and risk experiences and subjectivities.
Stem cell miracles or Russian roulette?: patients’ use of digital media to campaign for access to clinically unproven treatments
Alan Petersen, Casimir MacGregor & Megan Munsie
In this article, we examine how patients use digital media to gain access to treatments that have yet to be clinically proven as safe and effective. Making reference to the case of an Australian patient who achieved notoriety following a 60 Minutes television programme in 2014 following her travel to Russia to undertake stem cell treatment, in the article we discuss the dynamic interplay of discourses of hope, risk and trust in this digitally mediated context. As we argue, Web 2.0 digital media provides patient activists with a powerful means to generate their own framings of the significance of treatments especially when linked with more traditional media such as television. Our findings underline how citizens may use digital media to create ‘communities of hope’ that sustain optimistic portrayals of treatments that may be resistant to official, regulatory discourses of risk-benefit and trust. Patients’ growing use of digital media, we conclude, necessitates a reconceptualisation of ‘health’ and ‘risk’ and approaches to regulating treatments that are unproven and hence deemed ‘risky’.
Biosensing: how citizens’ views illuminate emerging health and social risks
Maggie Mort, Celia Mary Roberts, Mette Kragh Furbo, Joann Wilkinson & Adrian Mackenzie
This article explores material from a citizen’s inquiry into the social and ethical implications of health biosensors. In ‘Our Bodies, Our Data’ a space was afforded for members of the public to examine two forms of health biosensing, and for the authors to research what happens when such examination shifts from the domain of experts to that of citizens. Drawing on data from this inquiry, which form part of a wider research project, ‘Living Data: making sense of health biosensors’, we open up conceptual and methodological questions about how to study innovative health technologies and contribute to debates about the direction of health biosensing by bringing forward the views of a group rarely heard in this domain: the public. The panel of 15 participants was shown examples, handled devices and heard evidence about the development of home ovulation monitoring and direct-to-consumer genetic testing. Citizens identified key areas of concern around the development, design and marketing of these devices, implicating technology companies, public bodies and civil society organisations. The panel articulated serious concerns relating to ethics, trust, accountability, quality and governance of health biosensors that operate ‘outside the clinic’. Their deliberations reflect concern for what kind of society is being made when genetic testing and home reproductive technologies are promoted and sold directly to the public. The panel process allowed us to re-imagine biosensors, wresting their narratives from the individualising discourses of self-optimisation and responsibilisation which have dominated their introduction in Euro-US markets.