UNC ANTH 270 review

Autonomy

free will, and respecting the free will of others

Allied Health Professionals

Provide additional care alongside another/multiple practitioners (Ex. therapists, dental hygienist, and radiographers)

Beneficence

duty of the physician to always do things that are for the benefit of the patient

Bioethics

concerned with the moral implications and controversies of medical research and procedures/applications

4 pillars of bioethics

1. autonomy

2. beneficence

3. non-maleficence

4. justice

The Belmont Report

first nationally organized statement on the treatment of human subjects with core principles of autonomy, beneficence, justice

Caring and competence

our biomedical system juxtaposes caring and competence. Caring is just being willing to care for others versus competence is actually having the capacity and capital to do so.

Conferred Status

Deals with medical professional capital will confer on someones prestige/ respect in a society. Particularly when the individual grows capital in all 3 areas

Clinical Hierarchy

The hierarchy that is established in a clinical environment that is usually dictated by social and cultural hierarchy.

Good reasons for hierarchy:

1. clear chain of demand

2. helps prevent people from doing things that they cannot or should not do

3. decreases liability

4. delegating

Negative outcomes of hierarchy:

1. most doctors are specialists

2. fosters cowboys and not pit crews

Medical Error; Causes

1. Healthcare complexity (drug interaction)

2. System design

(inadequate communication between healthcare providers, or between providers and the patients has root cause of over 50% the serious adverse events in hospitals)

3. Training and supervision

(the July Effect)

4. Fatigue

(sleep depravation, overwork, and burnout)

Medical Error; Reporting and prevention

1. Self-reporting and review

2. Admitting mistakes to patients

3. Reporting the mistakes of other physicians

4. mortality and morbidity conferences

Cultural Capital

the knowledge, habits, and tastes learned from parents and family that individuals can use to gain access to scarce and valuable resources in society

(this includes the school a physician went to, whether their parents are also physicians)

Social Capital

the networks of relationships among people who live and work in a particular society, enabling that society to function effectively.

Institutional Review Board (IRB)

Committee designated to approve, monitor, and review biomedical, clinical, and behavioral research

The July Effect

in July when interns and how residents start, and it puts patients at risk and would have a greater risk of medical error

(Only real dip is in prescribing errors)

Medical Residency

-graduate medical training

-provides in depth training within specific branch of medicine

Medical Pluralism

the intersection of multiple cultural approaches to healing

-Using multiple medical healing systems to appeal to cultural and religious beliefs

M&M Conferences

Mortality and Morbidity Conferences

-Special conferences where physicians (especially in teaching hospitals) meet and go over the cases of medical error that occurred over a set period of time

Mid-Level Provider

-More narrow scope of practice than physicians

-Advanced Practice nurses (Masters-level minimum and some move to doctoral-level schooling)

-Physicians assistants (2-3 years of specialized program, post-bacc and some can move on to specialize in a residency

Non-maleficence

duty to do no harm

Paternalism

decisions are taken by a health care professional in order to benefit the patient or society as a whole; can sidestep a patient's autonomy

-They will always have the patient's best interest in mind and can even make consentual decisions on the patient's behalf based off their own training/practice.

Risk/Benefit

Understanding the cost and what can be taken from certain research studies and medical practices

(EX: The Belmont Report and Informed Consent)

Surgical Checklist

A set checklists for procedures for a surgeon to follow. Believed to help decrease medical error. Not widely implemented

Critical Medical Anthropology

Theoretical approach in anthropology

-often applied toward social change

Tuskegee Experiment

-Goal was to track the natural progression of untreated syphilis

-about 600 participants

-was stopped after a press release that exposed the wrong things about the experiment

Meaningful Work

Physicians doing work thats meaningful to them

ex. potential for a physician to make financial or career sacrifices

ex. error prevention through checklist, "stepping out the box" or ideas to improve care

Kleinman's Approach

Approach to clinical care

-alternate approach to cultural competency model

-ideal approach but difficult to alter clinical encounter

-one of the ways to tailor care in a way that will help individuals better with attention to cultural issues and issues of respect, patient dignity, and power in clinical interactions

Patient Centered Models

3 Types

1. Informative (doctors tell patients of treatment options and relevant medical information but patients select their own treatment)

2. Interpretive (doctors helps patients explore their health-related values, presents options, and patients selects the treatment that best fits their values)

3. Deliberate (doctor helps patients explore health related values, doctors share their own morals and medical views with the patients in the discussion process)

Cultural Competency Model

-federal mandates and recommendations

-required to adhere if receive any federal funding

-learned in training and workshop settings but also used in medical schools as they are moving to the clinical space. Also found in publications to boil down a race or religious group.

-Long definition: Cultural and linguistic competence in a set of congruent behaviors, attitudes, and policies that come together in a system.

Science and Technology Studies

-science as a social act

-interdisciplinary study of science and technology as socially embedded processes

Informed Consent

an ethical principle that research participants be told enough to enable them to choose whether they wish to participate

Scientific-Medical Habitus

Talks about how people take their cultures medical preferences as their own

*can be see in the US bc we view birth as a medical occurrence, thus causing Most women to see hospital births as the only plausible method

Political Economy of Health Care

*Ch 7 of A Heart for the Work

- Ways in which health service is allocated based off of wealth and class & the ways policies have an impact on health and delivery of healthcare services

*Brings the connection between the legal, economic, social, and cultural health

- Critical Medical Anthropology is what studies this

* Ex. Why does this individual live in a place with no access to health care so that they are dying from the flu

Kleinman's approach

Is contrasted to the cultural competence model and will help to ask what people should do to better methodize and understand the combination of health/culture/science

• Attention to cultural issues = necessary for medical practice to be effective

• Attention to issues of respect, patient dignity, and power in clinical interactions = inseparable from fulfilling the humanitarian goals of medicine

• Both illness and disease needed to be addressed

- An operationalized method to getting at a the social construction of health

*How are illness experiences given meaning?

-Illness Narratives:

- Story telling and accounting practices that occur in the face of illness

- Bring suffering under meaningful control

- Culturally available repertoires of narrative

* This creates a personal, individual narrative

- Asks questions to help understand their own ideas about ones body and health

* Could be with an unbalance in chi (china)

- Shows that health is constructed based off of culture and their beliefs

- Possible Solution: Train doctors in Cultural Competence

Cowboys vs Pit Crews

*Gwandes Ted Talk

- Talks about the culture of being a physician and how it has developed over the past hundred years

- They have become more of cowboys bc they are at the top of the hierarchy and can come into a patients room and manage/have left word

- Then they "ride out to the next patient"

- Doctors cant afford to keep doing this because of the complexity of medicine

**Instead doctors should be trained to work as pit crews

- This would allow someone to be able to apply better quality care because medicine has become too advanced over time

- This would also prevent careless human error from occurring

- He believes that checklists should be used in OR

Local Biology

- Theoretical idea that people are more than just biological function

- Culture

- Environment

* "Coproduction of biologies and cultures contributes to embodied experience, which, in turn, shapes discourse about the body"

iii. Bodies are not only products of local histories, knowledge, and politics but also local biologies - can not assume universality of "body"

Moral Order of Medicine

How it becomes trained into students

* 4 categories of importance

- Shared set of values that guides its members and allows you to judge values

○ Reductionist Rationality

○ Authority over Nature in the Body

○ Individualism - patients are seen as people

○ Technological orientation - people feel compelled to use technology even when it is not warranted

- Allows medicine and physician to be judged as good or bad

- Moral Economy - can be brought in the context of thinking about critical medical anthropology

*LOOK AT PAGE 195

Explanatory Models

- Tools that Anthropologists use to make sense of the culture and way a group of people might understand a disease

*Think of the strep throat model

○ Signs and symptoms by which it is recognized

○ Presumed Causes

○ Recommended therapies

○ Pathophysiology

○ Prognosis

Ethnomedicine

is healing contextualized in culture and healing invokes social and sometimes spiritual relationships

Applied Medical Anthropology

*is analyzing and improving real human health problems whether it be political campaigns or through efficacy

Focuses in analyzing and improving real human health problems

-Case studies in explanatory models

-Defining the culture of biomedicine

-Ethnicity and health care

-Stigma and coping with chronic illness

-Gender and health

-Culture and nutrition

-Global health issues and programs

*Think of more public health and community health outreaches

Medicalization (of Birth)

Medicalizing Birth

- Seeks to Control and Mechanize the process

1) Disable the machine

- They used to use chloroform as anesthesia - this was stopped bc it posed many health threats to the mother and led to traumatic births

2 ) Position the machine

- However, it is much more difficult for a woman to give birth on her back - but because it is common most physicians never question

*An epidural is often overused and while it can decrease the amount of pain it can cause the rate of birth to be slowed which increases the potential for a complication

Greatly improved the Medicalization of Child birthing

○ Antibiotics

○ Infection Control

○ Sterilization

Biomedicine

applies biology to clinical practice

Cartesian Dualism

1. Descartes most clearly formulated ideas that there is a Separation of mind and body

Stigma

*Stigma as a "spoiled identity"

- Concept of stigma seems to be universal, referents are culturally constructed

- Creating medical classification for illness or condition - provides a neutral medical label

- Moral definition/illness career may create or encourage stigma, thus "spoiling the identity" of those suffering

- The Cultural Construction of Illness and Care: The Illness Experience

*The over-medicalization of disease has caused there to be more stigma around health related diagnosis

-However, there can be some positive there because it can create a form of a support group that will make people feel better about themselves and their condition

ex. Breast cancer vs leprosy

Moral Definition of Disease

Talks about illness career and what society expects of people who have a disease

*Think about the Leprosy article: even though the disease is curable, it is culturally/socially feared and therefore people are still stigmatized and shunned

Brain Drain

• Movement of educated individuals from their native homes to more lucrative areas

• This decreases the amount of educated individuals in a country and prevent it from developing and progressing

*Country will spend a lot on training doctors and then the doctors will leave - causing a deficit

-This creates an increase in foreign trained doctors and saves the rich countries money

*Ex. a heart for the work

***Critiques of Cultural Competence Models

- Doesn't go far enough in transforming medicine and incorporating alternative healing systems, religious practices, ways of life

○ Culture described as the problem *There is an issue with people speaking another language not being able to understand English - this causes an increase in health care costs for translators

- This places the problem back on the patient

- Doctors rarely seen as "having culture"

- Translation and its variations are not critically examined

- The physician/nurse has to make a split decision based off of whether or not they need a translator

*Considerations of paternalism and "right to know"

- Physicians will take means and actions without checking with the culture and rights of the patient

○ Potential for Stereotyping

- There is little nuance: cultural knowledge gets abbreviated into he X group and the Y group

- Some groups are other and some are not. Who is it that requires cultural competency?

* Example: Do white Europeans familiar with biomedicine require a cultural competency approach?

- Excludes other disparities

- Being from a minority background (of any kind) = statistically poorer health outcomes

* Cultural competency often excludes history as a component

- When culture is reduced to only race/religion/language and excludes the history or the collective memory of history and social determinants of health

* This is a concern bc it is not fully culturally competent

Normal Body

Healthy/Normal = Average & Morally Right

i. Illness Careers / Moral Definition of disease

ii. Stigma

iii. Medicalization

1) Ex. An infants growth chart- provides averages but just cause you aren't average doesnt mean you are ill

iv. The Biomedical perspective is that the mind and the body are two separate entities

Rene Descartes proposed this

iii. Dualism --> Reality is composed of two substances (mind & body)

1) This is due to the fact that the mind is indivisible - whereas the body can be altered

Holistic Model of Birth

*FOCUSES ON EMPOWERING THE WOMAN - OFTEN HOME BIRTHS AND MIDWIFES

- Sees the Female body: powerful, intentional

* Can bridge nature and technology & the pregnant body is considered a standard bodily state that humans are prepared to experience.

Technocratic Model of Birth

Prerequisite for the technocratic model

- Cartesian Dualism

1) Mind/Body

2) Body as a machine

- Technocratic Model

* A system-centered approach:

1) Technology being best

2) Pregnancy - medical "state" that needs assistance

3) Uniform Production

4) Hierarchical Power of Drs

** Technocratic

-Sees the Normal human body: male

- Female body: deviant and unpredictable

- Closer to nature and further from technology

* Needs regulation

- The normal body Is not pregnant. Therefore the pregnant body is a medicalized state that has been thrown into a pathological state

- Pregnancy symptoms - which must be managed and treated carefully in order to eventually bring it back to normal

○ To being holistic

*FOCUSES ON OBSTETRICS - OFTEN IS VERY MEDICAL AND PROCEDURAL, SOMETIMES CAN BE DEMORALIZING FOR THE WOMAN

Disease vs Illness

Disease - is the abnormal condition constructed by biomedical practice

Illness- is the experience of the altered physical state

Birthing Models

1) Historical moments

- Cultural understandings (past and present)

- Political Economies (past and present)

2) Technocratic Model of Birth

- Extremely medical - the traditional hospital birth

3) Holistic Model of Birth - alternative birth methods

Birth and Anthropology

- Birth Models: Spectrum of Care

- Medicalization of birthing in biomedicine

- Political economies of birth - how economic and socioeconomic status effects how one has a child

Globalization of Biomedicine

Elements of Globalized (Bio)medicine

-Medical tourism

*Types of care abroad

- Biomedical care elsewhere

- Pluralistic Care

- Alternative Care

*Ex. Amish

Some other causes:

○ International aid

○ Brain drain

Globalization

• Globalization: The expansion of global linkages via the flows of information, materials, and people; the organization of social life on global scale, and growth of global consciousness

○ Integration of markets, capitalism

○ Circulation of ideas

○ Relaxation of boundaries

○ Worldwide dissemination of practices

○ Loss of local power

Critical Medical Anthropology

A theoretical Approach in anthropology Foci:

○ Political Anthropology of health and healthcare - ways in which health services allocated based on wealth/class, and ways in which policy impacts health and delivery of health service

○ Often applied, looking towards social change

• Key figures (all doing applied work)

○ "system-challenging praxis"

○ "the body is more than a symbol"

"worldwide inequality of biomedical care"

* is a branch of medical anthropology that blends critical theory and consideration of the political economy of health, and the effect of social inequality on people's health. It puts emphasis on the structure of social relationships, rather than purely biomedical factors in analyzing health and accounting for its determinants.

Expose "unhealthy"Health policies

Unmask the political-economic processes perpetuating inequality & poor health

****Medical globalization

-Benefits

○ Increased availability of care

○ Lower costs

○ Anonymity

- You can go abroad and get an operation without having to explain to their boss why they had to take leave

*Instead it merely looks like a vacation

• Critiques

- Disruption of local population

- People who are in positions of poverty are in a position of vulnerability

- This is because someone might be forced to sell their organs in order to prevent bankruptcy

* There is also a shortage of Drs in the countries offering medical tourism

-This leaves the citizens of the country without access to care bc Drs are willing to service medical tourists and not citizens

- Explanation of the vulnerable

- The black market is known for selling organs to people illegally

* This can be an issue because they are not always taken willingly

Obstetric Dilemma

The Obstetric Dilemma: Bipedalism

*Bipedalism

- Narrow Pelvis

- Slight slant in birth canal

- Therefore there is a curve that a baby must pass through in order to escape the human birthing canal

- Increased Cephalization

- Neonate head to pelvic inlet ratios are bigger than cervical dilatation

Most other species have:

- A much smaller dilatation needed to reach

- A much smaller head size of the baby (therefore the baby's head is smaller than the standard dilatation)

*This leads to a longer labor and therefore more potential for complications

Bipedalism

The evolutionary mechanism of humans moving to walking on 2 feet. This evolutionary advancement has caused the pelvis to tilt, making birth much more difficult. This is why women have such a difficult time in labor.

- Problem: Pelvic inlet small and birth passage the bent

* One solution: Babies naturally turn during descent

-This is qued by gravity

- The plates in the head can also overlap under pressure to help make the skull smaller

- Soft spots in the skull

Increased Encephalization

As bipedalism occurred, humans evolved to also have increased encephalization

*This made birthing harder

- Humans have much narrower birthing canals, due to bipedalism

- Female Cervix is much smaller than other animals

- The human head is among the largest of other species

- The cervix must dilate much larger than is normal, for this reason there is among the most complications among human birth

*This is what has lead to the need for the medicalization of human birth

Illness Narratives

*Individual subjective stories of experiences in the face of illness that bring disturbance and suffering under some form of meaningful control

- Typically reflective of culturally available repertoire of narrative types

*More personal accounts

- Illness Careers → culturally - influenced path that individuals move along in association with an illness

International Healthcare Aid

-Governmental, NGO non-profit financial aid

1) Dedicated Aid Work

- Long term commitment with a NGO, foreign hospital, or government organization

2)Supplementary Aid Work

- Short/Medium term commitments as supplementary work

*Religious medical missions, student trips

International Aid Money

○ Health related aid programs growing - particularly since 2000

○ Aid accounts for 25-30% of healthcare spending in some countries

○ During the decade from 2000-2010

§ 34% reduction in under-5 mortality in countries receiving the most aid, 26% in countries receiving the least

○ Aid continued to improve numbers up to 5 years after distribution

Mechanical Metaphor

Body as machine, body as factory, body as war zone - think about the Exploring Medical Anthropology article (Joralemon) with the car parts

*This is what then led to the scientific exploration of the body

Cultural Competency

Cultural and linguistic competence Is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations ... "competence" implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities

**Social Determinants of Health

All of the other aspects of health

○ Environment

○ Race

○ Income

Would take things into account such as - lives in a food desert/is able afford fresh food

This type of care is more geared towards the Malawian doctor

In Class Film

• Pakistan realized that there was a deficit of physicians and a lack of healthcare

○ In order to be able to combat this the government decided to train women to be community health care workers

- This would allow women to come out of poverty, increase health, increase womens rights, and save money for the gov

- This would also be beneficial because these women are less likely to leave the country or even their community

- This has also decreased the IMR

- Women are leaving for the UK because there were better salaries and they were treated better

The UK subsidized the Pakistan government in order to equalize this

***Medicalization

*Something in the human body needs intervention

- The thyroid can be different sizes due to diet

- In the US we medicalize this as a precursor to disease whereas in other cultures this is seen as normal

- This is due to the fact that we are trying to make a standard "normal"

- Thus assigning medical terms to anything that creates a slight deviation

- Though this is an issue because most people do not fit the standard association of normal

**Critiques of Medicalization

*In some cases it can add stigma

ex. Shyness as a personality disorder

- Positive: The person finds value in the explanation for their shyness

* they begin to feel better about themselves and not as ostracized

- Negative: People feel ashamed about the fact that they are so shy that they have a personality condition

* This causes them to revert into themselves more and worsen their condition/feel bad about themselves

May also reframe "syndromes" as in need expertise

- Premenstrual Dysphoric Disorder is Premenstrual Syndrome

• Medicalization often attached to medical industries

- The growth of big pharmacy

* If people are not careful then drug companies will attempt to over medicate the public in order to make money

• Perspective Reporting --> you are required to keep a log of your symptoms every day

**Benefits of Medicalization

Brings attention to some conditions that can be treated

- Allows for the ability to achieve a treatment, while also being able to progress research

• Creates shared identity around illness experience

- Can give people an explanation for why the people are going through what they are going through

- Helps to create a standard of normal & Inherent social safety net and support group

- For once people who have a disease can feel as thought they are truly being apart of a group

- However one must be careful not to overly medicalize the human experience

*Reading: The Normal Body

Goes over what the expectations of having a normal/healthy body are

- Normal as average concept

- Normal as morally right concept

*Medical modality starts to reclassify the experience as a medical phenomenon it makes something appear to be outside the realms of normal

***Types of Approaches to Medical Anthropology

1. Biosocial

* Focused on health

-Evolution, health, medical use, population health

-Human biological variation

-Bioarcheology and the history of health

2. Cultural

* Cultural and political ecologies of disease

-Ethnomedicine and its healers or practitioners

-Belief and healing

-The meaning and experience of illness

-Biomedicine, technology, and their body

-Culture, illness, and mental health

3. Applied Medical Anthropology

*Focuses in analyzing and improving real human health problems

-Case studies in explanatory models

-Defining the culture of biomedicine

-Ethnicity and health care

-Stigma and coping with chronic illness

-Gender and health

-Culture and nutrition

-Global health issues and programs

4. Linguistic

* Focuses on the language of medicine

- Illness Narratives

- Language Barriers

- The way people talk about health

Medical Pluralism

Pluralism → when two different methods go hand in hand

a. other, indigenous, folk, or "alternative" medical systems (Herbal med, homeopathy, humoral med, Ayurveda, Traditional Chinese med, Western/Eastern adaptations)

Medical Tourism

-Medical tourism

* Why travel for treatment?

- Lower cost of care

- Higher quality of care

- Better access to care

- Different care than available at home