In the Journals, June (Part II)

Abstract: This article interrogates the modes by which cultural constructions of male contraceptive use emerge in Costa Rica by analyzing men’s narratives of vasectomy. Drawing on ethnographic research data, I examine men’s contraceptive decision making and perspectives on vasectomy and specify the ways they work through their vasectomy to rearticulate the relationship between masculinity and contraceptive responsibility and tensions in an emerging Costa Rican social modernity. Following Oudshoorn’s (2003) analysis on male contraceptive research, this article highlights contraceptive technologies and men’s narratives of these technologies as key sites for examining gender politics in contemporary societies and the materialization of new social orders. In the discussion, I argue that the men’s narratives examined here potentiate creation of an “alternative technosociality” (Oudshoorn 2003) in Costa Rica, in which men taking contraceptive responsibility does not constitute performing a subordinate masculinity, but simply another way of acting as men (23).

“Plot and Irony in Childbirth Narratives of Middle-Class Brazilian Women” (Maureen O’Dougherty)

Abstract: Brazil’s rate of cesarean deliveries is among the highest in the world and constitutes the majority of childbirths in private hospitals. This study examines ways middle-class Brazilian women are exercising agency in this context. It draws from sociolinguistics to examine narrative structure and dramatic properties of 120 childbirth narratives of 68 low- to high-income women. Surgical delivery constituted 62% of the total. I focus on 20 young middle-class women, of whom 17 had C-sections. Doctors determined mode of childbirth pre-emptively or appeared to accommodate women’s wishes, while framing the scenario as necessitating surgical delivery. The women strove to imbue C-section deliveries with value and meaning through staging, filming, familial presence, attempting induced labor, or humanized childbirth. Their stories indicate that class privilege does not lead to choice over childbirth mode. The women nonetheless struggle over the significance of their agency in childbirth (43).

“The Weight on Our Shoulders is Too Much, and We Are Falling”: Suicide among Inuit Male Youth in Nunavut, Canada” (Michael J. Kral)

Abstract: Inuit youth suicide is at an epidemic level in the circumpolar north. Rapid culture change has left Inuit in a state of coloniality that destabilized their kin-based social organization, and in spite of advances in self-governance social problems such as suicide continue. Drawing on ethnographic fieldwork I carried out in Nunavut, Canada (2004–2005), including 27 interviews with Inuit between the ages of 17 and 61, I examine male youth in particular in the context of recent colonial change, gender ideologies and behavior, youth autonomy, and the family. Anger is common among Inuit male youth, often directed toward girlfriends and parents, and suicide is embedded in some of these relationships. Many Inuit male youth are struggling with a new cultural model of love and sexuality. Inuit speak about a need for more responsible parenting. Evidence is beginning to show, however, that local, community-based suicide prevention may be working (63).

“‘Love Isn’t There in Your Stomach’: A Moral Economy of Medical Citizenship among Nicaraguan Community Health Workers” (Alex M. Nading)

Abstract: Drawing on participant-observation in Nicaraguan dengue prevention campaigns and a series of semistructured interviews with Nicaraguan health ministry personnel, this article shows how community health workers (CHWs) balanced two kinds of “medical citizenship.” In some situations, CHWs acted as professional monitors and models of hygienic behavior. At other times, CHWs acted as compassionate advocates for their poor neighbors. In 2008, Nicaragua’s Sandinista government moved to end a long-standing policy of paying CHWs, recasting them as citizen–volunteers in a “popular struggle” against dengue. Although CHWs approved of the revival of grassroots advocacy, they were hostile to the elimination of compensation. Framing this ambivalence as part of CHWs’ desire to serve as “brokers” between the poor and the state, I suggest that attention to medical citizenship provides insight into the sometimes contradictory ways in which CHWs engage the participatory health policies now taking hold in Latin America and elsewhere (84).

“Malicious Whites, Greedy Women, and Virtuous Volunteers: Negotiating Social Relations through Clinical Trial Narratives in South Africa” (Eirik Saethre and Jonathan Stadler)

Abstract: As clinical trial research increasingly permeates sub-Saharan Africa, tales of purposeful HIV infection, blood theft, and other harmful outcomes are widely reported by participants and community members. Examining responses to the Microbicide Development Programme 301—a randomized, double-blind, placebo-controlled microbicide trial—we investigate the ways in which these accounts embed medical research within postcolonial contexts. We explore three popular narratives circulating around the Johannesburg trial site: malicious whites killing participants and selling their blood, greedy women enrolling in the trial solely for financial gain, and virtuous volunteers attempting to ensure their health and aid others through trial participation. We argue that trial participants and community members transform medical research into a meaningful tool that alternately affirms, debates, and challenges contemporary social relations (103).

 “Somos Muchos (We Are So Many): Population Politics and ‘Reproductive Othering’ in Mexican Fertility Clinics”  (Lara Braff)

Abstract: Although Mexican state officials have long attributed Mexico’s “overpopulation problem” to its “high” fertility rate, that rate is almost at replacement level today. Nevertheless, anxieties about overpopulation rooted in reproduction persist. Based on my ethnographic fieldwork in Mexico City fertility clinics, this article examines how overpopulation anxieties affect infertile women as they use assisted reproductive technologies (ARTs) to try to conceive children. I examine how these women attempt to justify their seemingly out-of-place use of ARTs in this “overpopulated” context by evoking discourses of “reproductive othering.” Through these discourses they lay claim to a whiter, worthier status than racialized Others on the basis of their purported reproductive practices. I contend that their discourses reveal that infertility and its care are potent sites for the local production and reproduction of personhood, parenthood, and citizenship (121).

Abstract: In this paper I will show how the medical image, presented to the patient by the physician, participates in medicine’s cold culture of abstraction, objectification and mandated normativity. I begin by giving a brief account of the use of anatomical imaging since the Renaissance to show how images have historically functioned in contrast to how they are currently used in medical practice. Next, I examine how contemporary medical imaging techniques participate in a kind of knowledge production that objectifies the human body. Finally, I elucidate how physicians ought to place the medical image within the context of the lived body so as to create a healing relationship with the patient. In all this I hope to show that the medical image, far from a piece of objective data, testifies to the interplay of particular beliefs, practices and doctrines contemporary medicine holds dear. To best treat her patient, the physician must appreciate the influence of these images and appropriately place them within the context of the patient’s lived experience (53).

This month, guest editors Steve Woolgar and Javier Lezaun put together a special issue of Social Studies of Science  entitled “A Turn to Ontology in Science and Technology Studies?”  The issue included the following articles:

“The Wrong Bin Bag: A Turn to Ontology in Science and Technology Studies?” (Steve Woolgar and Javier Lezaun)

Abstract: There is in science and technology studies a perceptible new interest in matters of ‘ontology’. Until recently, the term ‘ontology’ had been sparingly used in the field. Now it appears to have acquired a new theoretical significance and lies at the centre of many programmes of empirical investigation. The special issue to which this essay is a contribution gathers a series of enquiries into the ontological and reflects, collectively, on the value of the analytical and methodological sensibilities that underpin this new approach to the make-up of the world. To what extent and in what sense can we speak of a ‘turn to ontology’ in science and technology studies? What should we make of, and with, this renewed interest in matters of ontology? This essay offers some preliminary responses to these questions. First, we examine claims of a shift from epistemology to ontology and explore in particular the implications of the notion of ‘enactment’. This leads to a consideration of the normative implications of approaches that bring ‘ontological politics’ to centre stage. We then illustrate and pursue these questions by using an example – the case of the ‘wrong bin bag’. We conclude with a tentative assessment of the prospects for ontologically sensitive science and technology studies (321).

“Turning to Ontology in STS? Turning to STS through ‘Ontology’?” (Bas van Heur, Loet Leydesdorff, and Sally Wyatt)

Abstract: We examine the evidence for the claim of an ‘ontological turn’ in science and technology studies (STS). Despite an increase in references to ‘ontology’ in STS since 1989, we show that there has not so much been an ontological turn as multiple discussions deploying the language of ontology, consisting of many small movements that have changed the landscape within STS and beyond. These movements do not point to a shared STS-wide understanding of ontology, although it can be seen that they do open up STS to neighbouring disciplines. Three main thematic complexes are identified in this literature: constructivism and realism; instruments and classification; and the social sciences and the humanities. The introduction of ontology into the long-running constructivism-realism debate can be considered as an acknowledgement on both sides that objects are real (i.e. pre-existing the situation) and constructed at the same time. The second thematic complex focuses on the role of instruments and classification in establishing not only relations of heterogeneity, but also of stability. The third thematic complex broadens the debate and actively seeks to promote an STS-driven ontological turn for research concerned with the humanities and the social sciences more generally. This study is based on both quantitative and qualitative interpretations of the literature (341).

“Slippery: Field Notes in Empirical Ontology” (John Law and Marianne Elisabeth Lien)

Abstract: This paper explores empirical ontology by arguing that realities are enacted in practices. Using the case of Atlantic salmon, it describes a series of scientific and fish-farming practices. Since these practices differ, the paper also argues that different salmon are being enacted within those different practices. The paper explores the precarious choreographies of those practices, considers the ways in which they enact agency and also work to generate Otherness. Finally it emphasises the productivity of practices and notes that they generate not simply particular realities (for instance particular salmon), but also enact a penumbra of not quite realised realities: animals that were almost but not quite created (363).

“Mind your Plate! The Ontonorms of Dutch Dieting” (Annemarie Mol)

Abstract: In the Netherlands as elsewhere, the overriding message of most dieting advice is that a person who wants to lose weight needs to overrule the desires of her craving body. Her mind has to put itself in a sovereign position and make ‘good choices’ about what to eat. But there are many ways of doing so. Linking up with different traditions within nutrition science, different dieting techniques enact different versions of food and concern themselves with different bodies. The ideals they strive after and the dangers they warn against are different, too. In short, they incorporate different ontonorms. At the same time, in all the ‘mind your plate’ advice, however varied, bodies figure as endowed with a nature that is problematic under the present cultural circumstances. This is in contrast with advice to ‘enjoy your food’, that targets a body that is not naturally given, but deserves to be cultivated. As I bring out the details of the discrepancies between the ontonorms embedded in different kinds of dieting advice, the term ‘ontonorms’ serves as a methodological tool. It helps to focus the analysis. But this article does not provide a ‘theory of ontonorms’, instead it argues for theoretical fluidity and specificity (379).

“Identifying Ontologies in a Clinical Trial” (Charlotte Brives)

Abstract: For a number of years, clinical trials have been the focus of a growing body of social science research and have come to represent the gold standard of evidence-based medicine. While a considerable and wide-ranging body of research has been devoted to trial participants, the approach is partial in that the participants’ reality tends to be cut loose from the very practices that constitute the beating heart of the trials. The practices of clinical research tend to be accepted as an unquestioned premise from which myriad actions and consequences emerge. Following the praxiological turn initiated by Mol and basing my analysis on my fieldwork and an ethnographic account of the running of a clinical trial, I hope to propose a new reading of trial participation. Indeed, whatever their form or their objectives, trials are essentially scientific experiments and are invariably grounded in a clinical design. The individuals who take part in trials must also contend with these two types of practices – the clinical and the scientific – yet in terms of their significance for participants, the latter are often obscured by or reduced to the former. Using my account of a routine visit in a trial conducted in Burkina Faso, I would like to examine the specific nature of these research practices, and in doing so, identify the ontologies they involve. How do these practices do the body? And what might the consequences be? (397)

“Ontography: Investigating the Production of Things, Deflating Ontology” (Michael Lynch)

Abstract: In this postscript to the special issue of Social Studies of Science on the ‘turn to ontology’ in science and technology studies, I discuss a tension that runs through many of the articles in the issue. This is a tension between adopting a general philosophical ontology and pursuing empirical studies of particular historical and contemporary practices. The general ontology highlights multiplicity and difference and rejects the idea that, for example, an identical disease entity underlies different practical enactments of that disease in different clinical and research circumstances. The empirical approach investigates how particular identities and differences are negotiated and instantiated in specific circumstances. The two approaches are not necessarily incompatible, but the first settles questions of identity and difference through a ‘pre-theoretical decision’, while the second remains open to distinct resolutions of what counts as identity and difference in the practical settings studied. In this postscript, I argue that a commitment to a general philosophical ontology confuses investigations of specific practical ontologies. To avoid such confusion, I recommend ‘ontography’: historical and ethnographic investigations of particular world-making and world-sustaining practices that do not begin by assuming a general picture of the world. Such investigations avoid making sharp distinctions between epistemology and ontology and take a symmetrical approach to concerns about identity and difference (444).

The June issue of Social Science & Medicine also has several pieces relevant to Somatosphere readers:

“‘Eyes that Don’t See, Heart that Doesn’t Feel’: Coping With Sex Work in Intimate Relationships and its Implications for HIV/STI Prevention” (Jennifer L. Syversten, Angela M. Robertson, Maria Luisa Rolon, Lawrence A. Palinkas, Gustavo Martinez, M. Gudelia Rangel, Steffanie A. Strathdee)

Abstract: Partner communication about HIV sexual risk behaviors represents a key area of epidemiologic and social importance in terms of infection acquisition and potential for tailored interventions. Nevertheless, disclosing sexual risk behaviors often presents myriad challenges for marginalized couples who engage in stigmatized behaviors. Using qualitative data from a social epidemiology study of risk for HIV and other sexually transmitted infections (STIs) among female sex workers and their intimate, non-commercial male partners along the Mexico–U.S. border, we examined both partners’ perspectives on sex work and the ways in which couples discussed associated HIV/STI risks in their relationship. Our thematic analysis of individual and joint interviews conducted in 2010 and 2011 with 44 couples suggested that broader contexts of social and economic inequalities profoundly shaped partner perspectives of sex work. Although couples accepted sex work as an economic contribution to the relationship in light of limited alternatives and drug addiction, it exacted an emotional toll on both partners. Couples employed multiple strategies to cope with sex work, including psychologically disconnecting from their situation, telling “little lies,” avoiding the topic, and to a lesser extent, superficially discussing their risks. While such strategies served to protect both partners’ emotional health by upholding illusions of fidelity and avoiding potential conflict, non-disclosure of risk behaviors may exacerbate the potential for HIV/STI acquisition. Our work has direct implications for designing multi-level, couple-based health interventions (1).

“Standards and Classification: A Perspective on the Obesity Epidemic” (Stuart G. Nicholls)

Abstract: In this paper I critique the increasing standardization of obesity. Specifically, I consider two ‘definitional turns’: the way language has been standardized to such an extent that it obscures uncertainty and variation, and the appearance of objectivity through quantification and standardized measurement. These, I suggest, have fostered a simplified picture of obesity, promoting the classification of weight and thereby facilitating the emergence of the ‘obesity epidemic’. These definitional turns fail to acknowledge the distinctions between fat and mass and intraclass variation within weight categories. A consequence of this process of simplification has been the erroneous application of population level information to individuals in a clinical context, with potentially harmful results (9).

“The World as the New Local Clinic: A Critical Analysis of Three Discourses of Global Medical Competency” (Maria Athina Martimianakis and Frederic W. Hafferty)

Abstract: The effects of globalization on health are the focus of administrators, educators, policy makers and researchers as they work to consider how best to train and regulate health professionals to practice in a globalized world. This study explores what happens to constructs such as medical competence when the context of medical practice is discursively expanded to include the whole world. An archive of texts was assembled (1970–2011) totaling 1100 items and analyzed using a governmentality approach. Texts were included that articulated rationales for pursuing global education activities, and/or that implicitly or explicitly took a position on medical competencies in relation to practicing medicine in international or culturally diverse contexts, or in dealing with health issues as global concerns. The analysis revealed three distinct visions, representative of a primarily western mentality, for preparing physicians to practice in a globalized world: the universal global physician, the culturally versed global physician and the global physician advocate. Each has its own epistemological relationship to globalization and is supported by an evidence base. All three discourses are active and productive, sometimes within the same context. However, the discourse of the universal global physician is currently the most established. The challenge to policy makers and educators in evolving regulatory frameworks and curricula that are current and relevant necessitates a better understanding of the socio-political effects of globalization on medical education, and the ethical, political, cultural and scientific issues underlying efforts to prepare students to practice competently in a globalized world (31).

“Becoming and Remaining Community Health Workers: Perspectives from Ethiopia and Mozambique” (Kenneth Maes and Ippolytos Kalofonos)

Abstract: Many global health practitioners are currently reaffirming the importance of recruiting and retaining effective community health workers (CHWs) in order to achieve major public health goals. This raises policy-relevant questions about why people become and remain CHWs. This paper addresses these questions, drawing on ethnographic work in Addis Ababa, the capital of Ethiopia, between 2006 and 2009, and in Chimoio, a provincial town in central Mozambique, between 2003 and 2010. Participant observation and in-depth interviews were used to understand the life histories that lead people to become CHWs, their relationships with intended beneficiaries after becoming CHWs, and their social and economic aspirations. People in Ethiopia and Mozambique have faced similar political and economic challenges in the last few decades, involving war, structural adjustment, and food price inflation. Results suggest that these challenges, as well as the socio-moral values that people come to uphold through the example of parents and religious communities, influence why and how men and women become CHWs. Relationships with intended beneficiaries strongly influence why people remain CHWs, and why some may come to experience frustration and distress. There are complex reasons why CHWs come to seek greater compensation, including desires to escape poverty and to materially support families and other community members, a sense of deservingness given the emotional and social work involved in maintaining relationships with beneficiaries, and inequity vis-à-vis higher-salaried elites. Ethnographic work is needed to engage CHWs in the policy process, help shape new standards for CHW programs based on rooting out social and economic inequities, and develop appropriate solutions to complex CHW policy problems (52).

“Resisting the Colonization of the Lifeworld?  Immigrant Patients’ Experiences with Co-Ethnic Healthcare Workers” (Ming-Cheng Miriam Lo and Roxana Bahar)

Abstract: This article analyzes how “ethnic concordance” (i.e., matching the ethnicity of patients and healthcare workers) shapes patients’ experiences of clinical interaction. Adopting the Habermasian framework of lifeworld-medicine contention, we inductively analyze 60 in-depth interviews with low-income LEP (limited English proficiency) Vietnamese and Mexican immigrants, which were conducted in a metropolitan area in Northern California between January 2006 and April 2007. Our findings indicate that, net of linguistic concordance, ethnic concordance appeared to exacerbate rather than alleviate the problem of “the colonization of the lifeworld.” Patients often felt that co-ethnic healthcare workers introduced additional power struggles from other systems, such as boundary work among co-ethnic immigrants, into the institution of healthcare. Likewise, immigrant patients sometimes racialized the professional competence and virtues of healthcare providers, ranking co-ethnic doctors below white doctors. While these two general themes characterize the experiences of ethnic concordance among both Mexican and Vietnamese patients, the comparison between the two groups also highlights some differences. Existing research has documented the impacts of ethnic concordance, but little is known about patients’ subjective experiences of these interactions. Our findings address this empirical gap. Drawing heavily on the Habermasian theoretical framework, our research in turn broadens this framework by showing how both lifeworld and medicine can become distorted by strategic actions in other systems, such as class and immigration, in which the American healthcare system has become deeply imbedded (68).

“The Uses of Ultrasonography in Relation to Foetal Malformation in Rio de Janeiro, Brazil” (Véronique Mirlesse and Isabelle Ville)

Abstract: The world-wide diffusion of prenatal ultrasound has encountered local historical, cultural and political particularities. The purpose of this article is to study the varied uses of this technology in cases of detection of a foetal anomaly, in Rio de Janeiro, in a context of generalized access to ultrasound, restrictive legislation on abortion and major social inequalities. An ethnographic approach was chosen combining from 2009 to 2011, observations of prenatal consultations and interviews with specialist physicians and pregnant women, in both public and private sector institutions. Analysis of the data allowed us to identify three ideal-typical moments in the trajectory of the pregnant women when a foetal malformation was detected. The first moment occurs before the detection of the anomaly, when an initial ultrasound is carried out, essentially in private centres. The standardized actions of pregnancy monitoring are performed in the background while practitioners use the technology to support the local culture of praise to motherhood and the family. The second ideal-typical moment shows how detection of an anomaly leads to fragmentation of the foetus at the public referral centre for foetal malformations. But far from depersonalizing the consultation, the formalism of the diagnostic procedure is considered by some professionals as a political lever to empower women from poor neighbourhoods as they acquire knowledge and comprehension of the situation despite their lack of decisional autonomy. During the third ideal-typical moment, professionals put the data produced by the image into the larger perspective of the logic of care: the focus is no longer on access to knowledge and autonomy, but on the joint collaboration of women and professionals towards solving the problems of everyday life. The combination of these three moments in time illustrates a process whereby the malformed foetus is humanised, dehumanised and re-humanised with respect to the technological tool (168).

Finally, the June issue of Sociology of Health & Illness includes the following articles, which will be of interest to scholars of medical anthropology, pain, biomedicine, and the body:

“Inviting Pain?  Pain, Dualism and Embodiment in Narratives of Self-Injury” (Amy Chandler)

Abstract: The role of pain in the practice of self-injury is not straightforward. Existing accounts suggest that self-injury does not cause ‘physical’ pain, however self-injury is also said to alleviate ‘emotional’ pain by inflicting ‘physical’ pain. This article explores these tensions using sociological theories regarding the socio-cultural and subjective nature of pain. Analysis derives from in-depth, life-story interviews carried out in the UK with people who had self-injured. Findings contribute to on-going debates within social science regarding the nature of pain. Participants’ narratives about pain and self-injury both drew on and challenged dualistic models of embodiment. I suggest that self-injury offers a unique case on which to extend existing theoretical work, which has tended to focus on pain as an unwanted and uninvited entity. In contrast, accounts of self-injury can feature pain as a central aspect of the practice, voluntarily invited into lived experience (716).

“The Craft of Intensive Care Medicine” (Simon Carmel)

Abstract: The practice of medicine is often represented as a dualism: is medicine a ‘science’ or an ‘art’? This dualism has been long-lasting, with evident appeal for the medical profession. It also appears to have been rhetorically powerful, for example in enabling clinicians to resist the encroachment of ‘scientific’ evidence-based medicine into core areas of medical work such as individual clinical judgement. In this article I want to make the case for a more valid conceptualisation of medical practice: that it is a ‘craft’ activity. The case I make is founded on a theoretical synthesis of the concept of craft, combined with an analysis of ethnographic observations of routine medical practice in intensive care. For this context the craft aspects of medical work can be seen in how biomedical and other types of knowledge are used in practice, the embodied skills and practical judgement of practitioners and the technological and material environment. These aspects are brought together in two conceptual dimensions for ‘craft’: first, the application of knowledge; second, interaction with the material world. Some practical and political implications of a ‘craft’ metaphor for medical practice are noted (731).