Doing and living medical anthropology
Personal reflections
Rebekah Park & Sjaak van der Geest (editors)
AMB Diemen 2010
(isbn 97890-79700-25-7, 156 pp., paperback, € 25,00)
The essays in this volume consider what medical anthropology means in the academy and outside of it. Written by a diverse group of anthropologists, some of whom also work as doctors, public health workers, and NGO staff members, the essays share personal insights on how they used anthropology to solve health problems and improve interventions.
Several of the contributors draw on their own illness experiences to reconsider the health challenges they have previously sought to understand, analyse, and document. Other essays come from authors who have struggled to incorporate anthropological methodologies and perspectives in multi-disciplinary research and medical relief work. Also included are essays from professional anthropologists who reflect on the value of their discipline’s mission and methodology.
This collection demonstrates how anthropology is used in policy and health interventions and attempts to bridge the gaps between policymakers, clinicians, NGO workers, doctors, and academic researchers.
Rebekah Park is a PhD candidate at the University of California, Los Angeles in the Department of Anthropology. She is currently writing her dissertation based on her work with the Association of Former Political Prisoners of Córdoba, Argentina.
Sjaak van der Geest is emeritus professor of Medical Anthropology at the University of Amsterdam. He carried out fieldwork in Ghana and Cameroon on a variety of topics in medical anthropology, including social meanings of medicines, growing old, and culture & hygiene.
Table of Contents
Preface - Sjaak Van Der Geest & RebekahPark
Chapter 1- Doing and living medical anthropology: An introduction
RebekahPark & Sjaak Van Der Geest
Chapter 2 - Staking a middle ground between public health and medical anthropology to reduce health disparities in the USA
Emily Bhargava
Chapter 3 - A medical anthropology contribution: Participatory research with young people in Uganda
Paul Bukuluki
Chapter 4 - From revelation to reality: The struggle of a doctor trained in medical anthropology
Laura Ciaffi
Chapter 5 - Medical anthropology and hiv prevention: Analyzing the use of condoms among gay men in Chile
Carla Donoso Orellana
Chapter 6 - A bump in the neck: From doctor to patient to doctor
Michael Golinko
Chapter 7 - From participant observation to reflection: Notes on returning from the field
RebekahPark
Chapter 8 - Thick and thinned description: How useful can medical anthropology be?
Sjaak Van Der Geest
Chapter 9 Saving my soul
Els Van Dongen
Chapter 10 - We came, we saw, we misdiagnosed: How medical anthropology can enhance emergency medical relief programmes
Vanessa Van Schoor
Chapter 11 - Why medical anthropology matters: Looking back on a career
Corlien Varkevisser
Chapter 12 - Journeying with medical anthropology
Shahaduz Zaman
Index
PREFACE
In May 2007 the Amsterdam Master’s of Medical Anthropology (AMMA) of the University of Amsterdam celebrated its tenth anniversary with a conference about “Teaching and Applying Medical Anthropology.” This volume contains nine selected essays from this conference and two additional ones since the conference. AMMA graduates wrote seven of the chapters and faculty members penned the remaining four. The contributions feature autobiographical accounts on applying medical anthropology in diverse professional positions and in personal lives, contextualised within the broader history and theoretical development of the discipline. The authors engage in reflexive anthropology, delving into the role medical anthropology plays both in and outside of academia. Several essays recommend medical anthropological pedagogies and applications in settings of both theory and work.
The AMMA programme opened its doors in 1997 with eleven students. By 2010, 159 students had graduated from AMMA. From the start, the student body has always been, and remains, global. Each year, the classes are filled with extremely diverse individuals, of varying ages, professions, and cultural backgrounds. The vast majority of the students already possess an advanced graduate degree and work in various health-related fields. Students are often doctors, public health officials, social science researchers, and ngo workers who are looking to improve their existing professions with a medical anthropology perspective. They have encountered obstacles in their work, such as failing interventions due to lack of cultural knowledge, and desire knowledge on qualitative methodologies. They also look for a richer theoretical understanding of culture, particularly in terms of health, illness and medicine.
In many ways, the personal identities of the students create an ideal environment to learn anthropology because each class discussion is a practice for cultural brokering. Speaking about ‘genital mutilation’ with students who have undergone circumcision rituals, or classic early anthropological works conducted in ‘primitive cultures’ where many of the students are from, creates an entirely different experience than if taught to a homogenous student body.
In AMMA, students are engaging with others who can draw from their personal and professional experiences, particularly since AMMA students are what the tradition has often defined as the ‘other.’ Thus, this programme not only trains a diverse generation of anthropologists, but it also teaches anthropology through its peers.
The student profile is also reflected in the main purpose of AMMA, which is to enable its graduates to help solve health problems with anthropological theories, concepts and methodologies. Faculty members take pride in showing how anthropology can be used to improve existing health efforts. While the length of time limits the breadth of knowledge that can be conveyed within a year, the programme still endows its students with core concepts that enable them to better champion an anthropological perspective in multi-disciplinary teams. In other cases, AMMA strives to equip the individual with the tools to consider cultural, political, and economic factors in the process of creating and implementing health interventions.
On the occasion of its jubilee conference, the AMMA department invited all its alumni to submit a paper on their lives after AMMA. The invitation posed the following questions as possible themes for their contribution:
– What kind of work did you engage in after graduating from AMMA?
– How did you use the skills and knowledge gained from AMMA in your current work?
– Can you present and discuss concrete cases and/or projects in which medical anthropology made a difference?
– Can you present and discuss concrete cases and/or projects where the opposite happened?
– Are there case studies in which the integration of medical anthropology improved past failures in health-related initiatives?
– Could you, on the basis of your (and others’) experiences draw wider theoretical, methodological, ethical or policy-related conclusions (or raise questions of more general importance)?
In total 33 abstracts were submitted for the conference, and 19 of those abstracts were chosen to be presented and discussed at the conference. As mentioned before, nine of the conference papers were eventually selected for this book, which were peer-reviewed and went through substantial revisions.
We encouraged the writers to personally reflect on the intertwinement of medical anthropology in work and life. Both the personal reflection and the emphasis on research outside academia follow the ‘culture’ of AMMA’s teaching and organization. Applied medical anthropology is for many of the students a crucial objective, especially those who have previous training in medical and related professions to which they return to upon graduation.
We hope that this collection of essays will not only serve as a – perhaps nostalgic – memory of a successful conference and ten years of AMMA life, but will also inspire present-day colleagues and future generations of the professional and existential potentials of medical anthropology.
And finally, we want to thank all who contributed to the success of the conference in 2007 and the production of this book, in particular Trudy Kanis, Peter Mesker, Janus Oomen and Chris Aldenhuijsen, the authors and their discussants during the conference, Susan R. Whyte, Michael L. Tan, Sera Young and Ria Reis who advised us in the selection of the conference papers, the anonymous peer reviewers, Anthony Holslag, and the other AMMA colleagues.
We dedicate this book to Els van Dongen, an original anthropologist and gifted teacher who taught eight generations of AMMA students. She passed away in 2009, at the age of 62. We are grateful that we have been able to include her last publication, a reflection on her final year, as patient and medical anthropologist.
Sjaak van der Geest
Rebekah Park
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Chapter 1
Doing and Living Medical Anthropology
An introduction
rebekah park & sjaak van der geest
This volume brings together essays written by people of extremely diverse backgrounds on how their study of medical anthropology has impacted their work and life – primarily outside of academia. It is our intention to shed light on how anthropology is practiced in non-academic settings through the eyes of those who are both within and outside of the university. Academics generally tend to regard applied anthropology as superficial, lacking theory and ‘thin’ in its efforts to gain attention from non-anthropologists working in public policy and clinical practice. Non-academics, in contrast, often regard the anthropology being practiced and taught in universities as slow, jargon-filled, and overly theoretical. These views underestimate the complexities of making research findings work beyond hypothetical scenarios, as well as the feasibilities of adopting an anthropological approach without working under the label of ‘medical anthropologist.’
By and large, the authors have avoided the tired debate between theory and practice. The essays address three themes: methodology, personal experience, and anthropological thinking. This volume is less engaged with academic texts as it is with the actual work and life experiences of those trained in anthropology. For this reason, the majority of the chapters deal with methodological challenges within multi- or interdisciplinary projects. Other contributors ruminate on how their anthropological training has impacted their personal lives as they recover from or succumb to illnesses. Others describe ways that people have integrated an anthropological view into jobs, which are not anthropological, and how they are still able to utilize their training regardless of limitations. In our contributions to this volume, we reaffirm the strengths of anthropological methodology.
The idea that applied research is theoretically thin is a misunderstanding (Bailey & Van der Geest 2009). Adding practical consequences to ethnographic data rather requires complex theoretical reasoning on agency, situationality and political leverage (see Bailey 2009, Oosterhoff 2009). It also requires cultural translation, one of the main ambitions of anthropology.
It seems that anthropologists struggle more with bridging the cultural gap between policymakers and health practitioners than they do between themselves and their research participants – even when they do not speak the same language. Anthropologists are more eager to capture the ‘villagers’ point of view than to delve into the culture of policymakers. Their unwillingness to transition into the world of policy may have to do with academic ethnocentrism (Van der Geest 1985), lack of accountability (Glasser 1988), and romanticization of the exotic (Hemmings 2005), or its corollary, what Blok (2001) calls “the narcissism of minor differences.” For Blok, narcissism hinges on the “idea that identity lies in difference, and difference is asserted, reinforced and defended against what is closest and represents the greatest threat” (Blok 2001: 123).
Thus, we present essays in which academic anthropologists reflect upon the utility and meaningfulness of their research findings to policymakers and clinicians, as well as writings by clinicians, public health workers, and policymakers who incorporate anthropological methods in their work despite financial, temporal, and ideological restraints.
The struggle to show that medical anthropology ‘matters’ is well described by veteran Dutch anthropologist Corlien Varkevisser who, in her retrospective essay, believes in the value of anthropology in the world of public health. She has continuously sought to share ownership of research projects with the people for whom the findings mattered, in hopes of ensuring that health interventions actually succeed in solving the problems at hand. Paul Bukuluki writes from Uganda about his work on a multidisciplinary team that initially rebuffed his efforts to incorporate anthropology into the research design. In the end, however, the team benefits from the nuanced insights gained from Bukuluki’s anthropological approach, which reveals that the concerns of their young subjects about teenage pregnancy took precedence over their feelings about hiv/aids – a discovery that contradicts the assumptions about risk, fear, and stigma. Vanessa Van Schoor, raised in South Africa and Canada, reflects on her experience as newly trained medical anthropologist and emergency aid worker in Côte d’Ivoire. A long-time worker with Médecins Sans Frontières, Van Schoor credits her anthropological gaze as having helped her to take some distance from the hectic work in which she was involved, and thus identify her organization’s misdiagnosis of the situation.
Emily Bhargava, an American public health worker, discusses the role that anthropology played in a public health programme aimed at the elimination of health inequality in the Boston area of the United States. Anthropology, she asserts, provides a language and a framework for thinking about culture and difference in a neutral way that can help make conversations about disparities and cross-cultural partnerships more productive. Carla Donoso Orellana reports on the benefits and limitations of an anthropological approach to researching condom use among homosexual men in her home country, Chile. While her research uncovers important themes of love, pleasure and sexual experience in regards to condom use in homosexual relationships, she also finds herself limited by the epistemological gap that exists between her and her medical colleagues.
The uneasy relationship between theoretical and applied medical anthropology is the main issue in the essay by Dutch anthropologist Sjaak van der Geest. He argues for a rapprochement between both, and for a productive combination of qualitative and quantitative approaches in medical anthropology methodology. Reflecting upon his own past research, however, he admits rarely succeeding in ‘selling’ his results to policymakers or health practitioners (Shahaduz Zaman draws a similar conclusion in his essay.) Van der Geest’s main audience is overwhelmingly anthropology students and colleagues.
Laura Ciaffi, a physician from Italy, writes about her decision to study medical anthropology to better prepare for emergency relief work in various cultural contexts. Now, several years later, she is ambivalent about her decision. On the one hand, she experiences a kind of ‘revelation’, now viewing her clinical work from a broader perspective and seriously considering what is at stake for the people she works with in the field. On the other hand, she realises (like Orellana) that the gulf between the medical and the anthropological gaze remains wide. As a doctor in the field, Ciaffi uses anthropological insights when working in different cultural settings. She goes beyond what is spoken and considers her patients within their context. What is more difficult, however, is actually making use of an anthropological approach – even applied medical anthropology – in her clinical work.
Rebekah Park, who is in the early stages of her academic career in the United States, rediscovers an appreciation for participant observation, one of anthropology’s strongest methodologies in understanding the contradictions between what subjects say and do. Conducting research over a long period of time enhances an anthropologist’s relationships in the field, and also the quality of her data. Park suggests that anthropological methodology is not only limited to the way we conduct research, but also includes the writing process. Choosing how and what to write entails balancing the priorities of the local communities in which we conduct our research with those of the academic community that shapes our theoretical approaches.
In several of the contributions, personal life experiences intertwine with the professional sphere and anthropological research. Reflection on how medical anthropology affects personal lives is one of the major themes in this volume. The emphasis on the personal may be related to the pedagogy of University of Amsterdam’s Applied Master’s in Medical Anthropology program – where all of the authors have either graduated from or taught. Students from very different professional, national and cultural backgrounds are assembled together within an intensive course that forces them to be in each other’s company continuously for a full year. This diversity is, in fact, an important element of the course; cultural differences among the students are openly discussed and demonstrate the ever present but elusive concept of culture. Cultural sensitivity, therefore, is practically required and enhanced by frequent reflection on personal biography and experience among people of varying backgrounds.
We chose the overlap of research and work with personal life because we believe it to be a crucial but under-exposed space where medical anthropology is done. In their collection of essays, Athena McLean and Annette Leibing (2007) speak of the ‘shadow side’ of fieldwork, or how the unacknowledged – hence shadowy – combination of autobiography and personal experiences directs research and analysis. McLean and Leibing draw their inspiration from Michel Foucault who observes the following about his own analytic process:
Every time I have tried to do a piece of theoretical work it has been on the elements of my own experience: always in connection with processes I saw unfolding around me. It was always because I thought I identified cracks, silent tremors, and dysfunctions in things I saw, institutions I was dealing with, of my relations with others, that I set out to do a piece of work, and each time was partly a fragment of autobiography (cited in McLean & Leibing 2007: 6).
In this volume, we compare Foucault’s observation with our own experiences on the intersection of autobiography and fieldwork. Personal reflections on the mundane become a part of the analytic framework, yet how and to what extent they do often goes undefined. In this volume, we seek to capture this interaction.
In his book on the production of ethnographic knowledge in Papua New Guinea, Crook (2007) argues that the personal life experiences of anthropologists like Margaret Mead, Reo Fortune, Gregory Bateson, Fredrik Barth and Annette Weiner influenced their theoretical and methodological approaches in their ethnographic work. For example, the “temperamental ménage à trois” of Mead, Fortune and Bateson in the field informed their ethnographic choices and analytical perspectives. Mead was then drifting towards Bateson, away from her husband Fortune. In her autobiography Blackberry Winter Mead wrote:
Reo [Fortune] was both repelled and fascinated by the Mundugumor. They struck some note in him that was thoroughly alien to me, and working with them emphasized aspects of his personality with which I could not empathize (quoted in Crook 2007: 138).
This is a prime example of ‘Sex and Temperament’ in statu nascendi. Somewhat hyperbolically one could perhaps say that the three were channelling their emotional states into anthropology.
Anja Krumeich’s ethnography Blessings of Motherhood: Health, Pregnancy and Child Care in Dominica is another illustration of how personal life and research converged in the field. Krumeich conducted research on mothers’ ideas and practices during pregnancy and their care for young children in the Caribbean island of Dominica. At first, the mothers were friendly and helpful but reserved. They viewed Krumeich’s questioning as a cross-examination and did their best to give the ‘right’ answers. However, when one of them discovered that Krumeich got pregnant with a Dominican man, everything changed. From that moment onwards the all-knowing anthropologist turned into a helpless young woman who, far from home, had become pregnant by ‘one of those men’ and needed the mothers’ help and advise.
All of a sudden people understood my presence and my silly questionnaires. They forgot I had asked them as a researcher, and interpreted them as a testimony of my helplessness. I instantly had a number of ‘mothers’ who felt responsible for teaching me the meaning of being a woman and preparing me for motherhood (Krumeich 1994: 138).
Unprompted the mothers started to tell Krumeich what she should do to protect her pregnancy and have a safe delivery. When her son was born – in a local hospital – they instructed her on how to raise a newborn child healthily and properly. The information she had tried to acquire as an anthropologist – with limited success – was suddenly given to her in abundance (Krumeich 1994).
Moreover, it was not only ‘information’ that was offered to Krumeich. Getting pregnant, having a baby, looking after her son, and arguing with the child’s father enabled Krumeich to experience the range of emotions that are seen to be integral parts of the motherhood experience in Dominica. At one point, when the child’s father had beaten Krumeich, the mothers (who by now had become her friends), offered their comfort. Participant observation was no longer just a methodological tool; it had become her personal reality as well.
Gerhard Nijhof, a sociologist, who after being diagnosed with colon cancer and undergoing extensive treatment, wrote about how his cancer changed not only his life but also his sociology. Nijhof spent an anxious period in the hospital and had to learn how to live with his disease. He later published Ziekenwerk (Sick work), where he attempted to forge a new kind of medical sociology from an insider’s perspective (Nijhof 2001). For most medical sociologists, however, serious illness is not a personal experience. They conduct surveys or hold interviews and return to their universities to analyse and write their findings. The concepts they use reveal their provenance: the minds of healthy sociologists.
Nijhof became acutely aware of this when he became sick, encountering completely different perspectives. One of these was the unspoken word. For years, analysing texts had been his main occupation, but he suddenly realised that people may remain silent about certain experiences. “Yet, we continue to pay attention only to their speaking… The things about which they don’t speak escape us.” That is the reason that “interrogating sociologists miss so much of what sickness means to sick people.” Serious illnesses like cancer are often surrounded by silence.
Sociologist Ian Craib’s own experience with cancer, which he ultimately died of, led him to reconsider what his colleagues called a ‘good death.’ Using this concept, he wrote that sociologists produce, “a sanitized version of dying, hiding the powerful feelings, contradictions and horrors” (Craib 2003: 292).
Other examples of researchers who were affected by serious sicknesses and used their experiences to write more analytically about illness are Robert Murphy and Arthur Frank. Murphy (1998) began writing about his illness from the moment the first symptoms of his spinal cord tumour presented themselves, and continued to write to the point at which he became restricted to his wheelchair and dependent on others, eighteen years later. This ethnography of one person demonstrated how illness could shape social identity. Frank (1995, 2001) has written extensively about his own illness experiences, using them as ‘data’ to provide in-depth insights on sickness and suffering. Arthur Kleinman (2006) reflected on his life as a psychiatrist and anthropologist and realised that he did not really understand the pain of those who approached him for help. Experiences of pain and misfortune in his own life have since opened the world of others to him (see also Van der Geest 2007). Three authors in this volume use their personal experiences as starting points for reflections on medical anthropology. They focus less on experience as a way to do better anthropology and more on how they used their anthropological ‘worldview’ to interpret their own lives.
Shahaduz Zaman, a physician from Bangladesh, considers his own journey with medical anthropology. He began his career as a ‘reluctant doctor’, who was instead interested in becoming a writer, and eventually escaped clinical life by devoting himself to public health. Then, by a twist of fate, he was given a chance to study medical anthropology in Amsterdam. Anthropology provided him with the ability to blend together his interests in medicine, culture, and literature. Medical anthropology enriched him both as a doctor and as a writer. These three ‘souls’ constituted a type of internal ‘triangulation’. Medical anthropology, Zaman concludes, has helped him to discover himself.
In his essay, Michael Golinko, a physician from the United States, discovers the value of medical anthropology through the experience of becoming a cancer patient. While he did gain new insights into the practice of medicine by using an anthropological perspective, he did not apply those lessons to his clinical practice until he experienced cancer. Golinko realizes that doctors – actually his colleagues – treated him differently from other patients because of his medical degree, even though he harboured as many doubts as other patients did. Golinko embarked on a personal journey that taught him empathy – a quality he had not fully realized in his previous attempts to assuage his patients’ fears before having had cancer himself.
Els van Dongen, a long-term faculty member at University of Amsterdam who passed away in 2009, writes about her experience living with cancer both as a patient and as a medical anthropologist. For the better part of her career, Van Dongen devoted her writings to narratives on social suffering. She finds herself battling the tension between her intellectual acknowledgment of maintaining oral practices while being sick, and the desire to reject the social obligations of putting on a strong face to lessen the burden of her death for others.
Her conviviality and willingness to present a stronger self-image enables others to offer their comfort and to be comforted themselves. She wants to care for her husband and children as much as they care for her. Likening her experience to Job’s trials and the tests of his faith, Van Dongen finds herself continually facing gruelling and frightening treatments, and yet remaining optimistic. In the end, she discovers that “being ill is trying to remain a social being.” This volume strives to show what medical anthropology means to scholars not only in their work and scholarship, but also in their personal lives. Several of the contributors draw from their own experiences with illness, which offer the most direct knowledge of the kinds of challenges they seek to understand, analyse, and document. For others, struggling to apply the new insights of medical anthropological theory and methodology in their non-anthropological jobs becomes almost a personal cause. As a whole, the volume brings together the views of anthropologists who are both in and outside of the university as a way to bridge the gap between policymakers, clinicians, ngo workers, and academics.
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