UNC - ANTH 147 Final

militarization of medicine (CIA vaccination campaign in Pakistan)

- seen as a benevolent use, but medical humanitarianism used to justify political campaigns

- vaccination campaigns as espionage feed the mistrust of medical humanitarian: HEP b Campaign used by CIA to locate Osama bin Laden - vaccine resistance and attacks on healthcare workers

- weaponization of biomedicine is in the use of medicine to harm/subdue populations (against the assumption that medicine is about healing)

plurality of biomedicine

- there are multiple traditions/professions within biomedicine

-evolved from different lineages

- EX: cancer treatment doesn't work in Botswana like it does in the US

humanitarian biomedicine

- targets infectious diseases

- diagnostic and pharmaceutical intervention ("stove piping")

- only focuses on one disease

- doesn't address overall picture, doesn't address underlying issues that lead to health issues in the first place

- where public health infrastructure is nonexistent/poor

- values the individual life

global health security

- targets emerging infectious diseases seen to threaten wealthy nations

- anything that could undermine the global economy

- systems of surveillance (CDC)

- early outbreak warnings

- large amount of money invested in to it

-predicated on fear of pandemic outbreaks

- focused more on self-protection and on national public health infrastructures and common humanity

indonesian avian bird flu case

- stopped sharing virulent with WHO (said they didnt need to relinquish their property to international agencies

- claimed to have viral sovereignty

- didn't want to share because other nations would produce vaccines and patent them to make them too expensive for their populations to afford

- WHO argued that it was for the good of global health, "globally shared health risks require health transparency"

Doctors Without Borders (MSF)

Background:

- Emergency Med; develops out of military med, triage becomes a norm in WW1, resuscitation/life saving, post WW2 ER's become a norm

- Rise of NGOs; post WW2 UN team, decolonization and new world orders, way for former colonizers to maintain control over other countries

- perform humanitarian biomedicine

- developed out of emergency medicine in the world wars

- focus mostly on rapid therapeutic responses

Example:

- cholera: simple emergency in theory (access to clean water and rehydration) but rapid infection requires rapid response, morality might fall but the ROOT cause is not being addresses (caused by structural issues like clean water access)

"Stratified livability" (Wahlberg, Burke, and Manderson)

- refers to unequal access to life sustaining resources, highlighted by pandemics like COVID-19

--- 'strata = layers hierarchy of power ability to live/stay alive I the first few months after the COVID lockdown SES influences COVID 19 disease and lockdown

- deep inequalities already existed, diseases amplified disadvantage

Social Darwinism

- natural selection: best-adapted organisms survive to pass on genetic traits

- wasn't supposed to be projected on to humans

- worked to justify colonialism

- control resources and people seen as part of "natural" struggle for survival

Symbolic relationship between biomedicine and colonialism

- spread of medicine was key to how colonizers justified colonial rule as a "civilizing" mission

- disease control and experimentation implemented under the guise of practicing medicine

- assumed native populations were unclean or diseased

- biomedicine could advance because it could use indigenous people as experiments to further medicine

Tuskegee Syphilis Study (1932-1972)

- history of medical mistrust from deceitful US public health experiment in which black men thought they were being treated, but researchers actually studying what happens when not (even thought there was penicillin available at the time) NAACP files a lawsuit

- TODAY:

- black Americans less likely to utilize services

- saying they are "misinformed" is not a useful approach]

- calling it "vaccine hesitant" can mask structural access to problems/frame it as an attribute of a group (not enough sites lack transportation, internet access/literacy, childcare) need a multifaceted approach

global vaccine inequity and the COVID-19 pandemic

- operation warp speed by US army general "shots in arms in 24 hours"

- COVID vaccine was already being developed before $ sped up the process and it was the main focus

- point is that vaccine developments only speed up when they start to effect wealthy countries and there is global interest ('global' interest = '$ country' interest)

COVAX

- global initiative that worked toward global equitable access to COVID 19 vaccines

- "insurance policy" for wealthiest self-financing countries to negotiate prices with vaccine developers to adjust pricers for poorer countries

- argue that vaccinating all countries equally will ensure that the other 'less developed' countries do not "restart" the epidemic

- BUT... "Me First Approach" emerged where $$$ continued to hoard by paying in advance which crated funding shortfalls

improvisation of medicine at PMH

- the same kind of cancer treatment is not practiced in the US and Botswana

- Global health has an infectious disease model of public health in Africa and this doesn't work with cancer

- research it out of reach of the type of cancer they treat in Africa (often coupled with co-infections due to high rated of HIV-AIDS)

-limited on resources so doctors have to improvise and decide who does and does not get treatment

invisibility of cancer in Africa

- infectious disease model of public health in Africa

- high degree of pharmaceuticalization of cancer puts it out of reach of doctors in Africa with limited resources

- seen as a "modern" disease in the west, which could possibly happen in Africa

HIV and cancer in Botswana (Livingston)

- high rated of HIV AIDS in Africa, cancer that were HIV infection related

- people used to die with cancer because of AIDS but now with ARVs live longer and die of cancer

- infect with underlying HIV caused "troubling synergy" created KS, lymphomas, sarcomas, etc.

illness and disease experience of cancer in Botswana (Livingston)

- fuzzier = less screening/testing

- more direct = late stages

- less medicated

- not only is the illness experience different (knowledge around being a cancer vs HIV patient, type of care team, family role) disease is also different (late stage is a every different treatment and HIV also complicated pathology itself)

autonomy

- "it's the patient's choice"

- based on the patient's choices and values

-patient can choose what treatment they want

- practiced in the US

paternalism

- the doctor knows best

- implies authoritarian relationship

- doctor acts in your best interest

- practiced in Botswana

rationing

- result of lack of resources in cancer ward in Botswana

- doctors have to ration out medicines and beds - must decide who has best chance of survival with treatment and turn away those who do not

open triage

- Botswana

- stems from paternalism practiced in Botswana

- doctor must assess if patient is well enough to be able to withstand treatment and send away those who would not make it though treatment

- also stems from involvement of relatives in selecting who gets treatment

hidden triage

- USA

- hidden triage by cost

- people only get the healthcare they can afford since we have to pay for everything

- not everyone gets the same healthcare since not everyone can afford the same amount

fee-for-service system and the US healthcare system

US spends the most of healthcare, but private, and has lowest developed life expectancy

- more care does not mean better care

- too many specialists and not enough PCPs

- cancer overall is declining, but certain group's risk is increasing (tied to structural problems and fee-for-service model)

example: increase in preventable cancers in Appalachia due to access barrier, poverty/unemployment, literacy rates, discrimination, low quality care

medical pluralism

- the coexistence of more than one healing system in a given cultural context (increased with globalization)

- plurality can also exist within one healing system

Hierarchy of the resort (Romanucci-Ross)

- theory for understanding how individuals make decisions in the presence of medical pluralism

- found biomedicine was uses as a last resort

- people go to what is familiar and cheap first

- exceptions: time sensitive, presumes biomedicine always remains unfamiliar, economic factors, risk/benefit calculations

maruka vs cure

- maruka: to change, not about getting back to a baseline health, but to an elevated level of health, not only dictated by ill health (can be healthy and still achieve higher health), view health ad having ups and downs and is not static

- cure: return to a baseline health, focused more on the removal of a pathogen than improvement of overall experience

talapodichil (Halliburton)

- Ayurvedic headmask treatment

-example of how healing can be focused on aesthetics and can be pleasing for the patient

- cooling feeling and is more pleasant than taking biomedical treatments

phenomenology (Halliburton)

- lived, sensory experience

- captured through phenomenological ethnography

- focused on what healing feels like

- attention to local metaphors to illness and experience

-foregroudns individual stories and experiences, theory in the background

Indian Psychiatry

- prescribe alot of medications in one meeting since they dont have alot of time with the patient; want the patient to feel like the meeting was successful

- heavy involvement of the family in treatment; often the family brings the patient in and are the ones who talk for the patient with the doctor

- patient is often hid away in the home and cut off from social ties, unable to access their usual social supports

gender and family dynamics in the psychiatric encounter in Kerala

- family involved in identification and decision to seek treatment

- talk to the doctor for the patient

- involved in treatment delivery at home

- this sometimes means patient isn't removed from potential family problems, sometimes justifies the lack of development of mental healthcare sector

- can be beneficial - shared decision making, better information about patient, more interaction and social support for the patient

race and ethnic based health and healthcare disparities

- differences in diagnostic work up, treatment, and outcome present even when influencing factors are controlled for

- have wore physical exams, history-taking, medications, and lab tests

- differences in likelihood of treatments and diagnoses

- often have misdiagnoses because of preconceived notions about what diseases people pf certain race should have

preference hypothesis

- reason for disparities has to do with patient choice

- choices are based on personal preference and cultural values

- doesn't explain all disparities - unlikely that cultural differences are the sole causes of health disparities

bias hypothesis

-attributes disparities to doctors

-doctors' racial and/or ethnic stereotypes and biases affect healthcare provision

- oversimplifies how bias works - it is shaped by many social cues (education, social class)

- important to be aware of in discussing racial disparities in healthcare

communication hypothesis

- focuses on quality of interactions between doctors and patient, and how power shaped those interactions

- important concepts:

1) language or dialect discordance between doctor and patient

2) communication style of patients

3) discourse differences between doctor and patient (medical jargon, conflicting agenda)

4) power relations in communications (authority of biomedicine and doctors; gender, age, race pf patient and doctor shapes power in the relationship)

5) How context (institutions, sociopolitical, historical) shapes communication (medical mistrust)

Schuman et all 1999 study

- showed simulated videos of patients with exact same symptoms but altered race and gender

- doctors had differences in referral rated based on race and gender

- black patients referred less than white; women less than men; black women fared the worst

- important study in revealing biases in healthcare an dhow it affects treatment

cultural competence (categorical approach)

- understanding the importance of social and cultural influences on patient health beliefs and behaviors

- goal is to address structural barriers to access and care (physical, affordability, language, etc.)

- categorical: teaches information about cultures, increased knowledge about different forms of healing; relies on provider doing profiling (rote memorization)

discontents with cultural competence

- doesn't address healthcare providers own biases and emotional reactions

- doesn't recognize that patient behavior is shaped by more than belief and choice

- doesn't;t develop a more complex understanding of culture as dynamic; assumes it is finite and a skill a doctor can acquire through studying

- diverts attention away from socioeconomic factors that shape illness and access to care

- requires doctors to do some initial profiling based on patient phenotype (can reinforce stereotypes)

cultural humility

- defined not by a given endpoint but as a commitment and active engagement in a lifelong process that individuals enter in to an ongoing basis with patients communities, colleagues, and themselves

- Goal: views culture as a life long difference

- Difference between humility and competence: humility is about maintaining an attitude of openness and recognizing one's limitations in understanding while competence emphasized acquiring specific knowledge about other cultures to inform better practices.

patient-centered interviews

- less authoritative

- finding out what is at stake for the patient (what are their priorities, what matters)

- demonstrates that the provider values the patients perspective and agenda

-explanatory model of illness (ged rid of compliance which places blame on ten the patient; mediation not coercion

structural competence

- "structure" as an organizing principle in inequality and illness, and a unit of intervention

- focuses on the bigger picture outside of the clinic, health impacts of the social contexts in which people live and work

- work on providers recognizing and responding to the ways in which broad social, political and economic structures contribute to the vulnerability and ill health of the individuals

- to provide care:

1) co-locate health and social/legal services

2) train providers to know what resources exist

3) work together in health teams in collaboration

kleinman's 3 suggestions to Fadiman

1. get rid of 'compliance'

2. mediation instead of coercion

3. recognize BM also has a culture and need to find a middle ground

- First get rid of the term compliance. It's a lousy term. It implies moral hegemony. You don't want a command from a general, you want a colloquy.

- Second, instead of looking at a model of coercion, look at a model of mediation rather than a model of coercion. Cultural humility vs. Cultural competence

- Third, you need to understand that as powerful and influential as the culture of the Hmong patient and her family is in this case, the culture of biomedicine is equally powerful. If you can't see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal with someone else's culture?

How is Halliburtons phenomenological approach expressed in his ethnography? How does the way he writes or what he writes about illustrate this phenomenological approach?

In Mudpacks and Prozac, Murphy Halliburton employs a phenomenological approach to vividly depict the lived experiences of individuals in Kerala, India, as they navigate different medical systems. Through detailed descriptions, personal narratives, and local terminology, he brings readers into the sensory and emotional realities of treatments like Ayurveda. His writing foregrounds individual stories and critiques the simplistic view that patients follow a strict "hierarchy of resort." Instead, he emphasizes how people blend and choose therapies based on their beliefs, availability, and practical considerations, giving a nuanced understanding of health and healing in Kerala.

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