In the Journals

In the Journals January 2015 – Part I

Welcome to 2015 in reading! Below are interesting abstracts from current issues of medical anthropology journals.

Critical Public Health

The pedagogy of disgust: the ethical, moral and political implications of using disgust in public health campaigns

Deborah Lupton

The developers of public health campaigns have often attempted to elicit disgust to persuade members of their target audiences to change their behaviour in the interests of their health. In this critical essay, I seek to problematise this taken-for-granted and unquestioned tactic. I assert that the pedagogy of disgust in public health campaigns has significant ethical, moral and political implications. In outlining my argument, the literature on the social, cultural and political elements of disgust is drawn upon. I also draw more specifically on scholarship demonstrating the ways in which disgust has operated in relation to health and medical issues to reinforce stigmatisation and discrimination against individuals and groups who are positioned as disgusting. It is concluded that advocates of using such tactics should be aware of the challenge they pose to human dignity and their perpetuation of the Self and Other binary opposition that reinforces negative attitudes towards already disadvantaged and marginalised individuals and social groups.


You can’t walk or bike yourself out of the health effects of poverty: active school transport, child obesity, and blind spots in the public health literature

Claudia Chaufan, Jarmin Yeh, Leslie Ross and Patrick Fox

Mainstream public health theories of obesity attribute current, unprecedented numbers of obese youth to changes in eating practices and levels of physical activity, in turn leading to greater energy consumption and lesser energy expenditure. While substantial research has examined energy consumption among school-age children, key modes of energy expenditure such as active school transport (AST) remain underexplored. Using AST data obtained from the California Safe Routes to Schools program and child health data from the California Physical Fitness Test, we examined the association between AST and child obesity among school-age children and disambiguated this relationship introducing the variable poverty. We found that greater AST correlated with higher rates of child obesity and higher rates of child poverty, which in turn correlated with worse child health and obesity rates. Our findings suggest that child poverty explains the positive relationship between AST and child obesity that has puzzled investigators. Our analysis also reveals recurring blind spots in the public health literature, which often acknowledges that poverty begets poor health yet calls for environmental changes while rarely calling for eliminating poverty, one critical social determinant of health, even as these determinants have become legitimate objects of scientific inquiry. We propose that while environmental changes may improve the health of the poor, the only effective way to improve child health and reduce child obesity is to eliminate or dramatically reduce child poverty, a sociopolitical issue. This study is part of a larger project evaluating socio-political determinants of child health.


‘It puts life in us and we feel big’: shifts in the local health care system during the introduction of rapid diagnostic tests for malaria into drug shops in Uganda

Eleanor Hutchinson, Clare Chandler, Siân Clarke, Sham Lal, Pascal Magnussen, Miriam Kayendeke, Christine Nabirye, James Kizito and Anthony Mbonye

This paper is an analysis of the social interaction between drug sellers, their clients and local health care workers within a medical trial that introduced rapid diagnostic tests for malaria into private sector drug shops in Mukono District, Uganda. It locates the introduction of a new technology to test blood and a system of referral within the context of local concerns about the choice and evaluation of treatment; and the socially legitimated statuses, roles and hierarchies within the local health care system. Based on the multi-layered interpretation of 21 focus group discussions, we describe three key aspects of the trial central to local interpretation: openly testing blood, supervisory visits to drug shops and a new referral form. Each had the potential to shift drug shop vendors from outsider to insider of the formal health service. The responses of the different groups of participants reflect their situation within the health care system. The clients and patients welcomed the local availability of new diagnostic technology and the apparent involvement of the government in securing good quality health services for them from providers with often uncertain credentials. The drug shop vendors welcomed the authorization to openly test blood, enabling the demonstration of a new skill and newfound legitimacy as a health worker rather than simple drug seller. Formal sector health workers were less enthusiastic about the trial, raising concerns about professional hierarchies and the maintenance of a boundary around the formal health service to ensure the exclusion of those they considered untrained, unprofessional and untrustworthy personnel.


Biopedagogy digitalized: ‘educational’ relations among participants on an online weight loss surgery forum

Matthew D. Ferrya and Centáe Richards

Foucault uses the term ‘biopower’ to describe the totalizing effects of regulation of life through the manipulation of political messages, such as those in the obesity debate. This paper attempts to uncover ways in which these flows are made manifest among members of a public online weight loss surgery (WLS) discussion forum. Drawing from Foucauldian scholarship, we spent two-and-a-half years conducting a critical discourse analysis of over 2000 conversational threads on one US-based public discussion forum devoted to providing a support community to those who were considering WLS. Our intent is to analyze how ‘truths’ about the surgery are constructed among and between the community participants at different stages of the surgery to identify how they engage with ideologies associated with contemporary obesity and healthism.


‘Sex’ – it’s not only women’s work: a case for refocusing on the functional role that sex plays in work for both women and men

Elanah Uretsky

Mention of the term sex work often invokes images of marginalized women at risk for HIV infection. Such images, however, are counterintuitive to the functional role intended by the movement that spawned use of the terms ‘sex work’ and ‘sex worker.’ This article looks at the sexual practices of men in urban China to argue for a return to a functional definition of ‘sex work’, which was originally meant to legitimize the role sex plays in work. The progenitors of this movement intended to use ‘sex work’ as a means to legitimize sex as an income-generating activity for women involved in prostitution. I show that sex can also serve a functional role in the work-related duties of men seeking economic and political success in contemporary urban China. Men in China utilize sex as one way for demonstrating the loyalty necessary to access state-owned and controlled resources in a market economy governed under a Leninist system. Overall, the article demonstrates that reclaiming perception of sex work as a functional rather than behavioral category can expand its use for preventing HIV among the broad subset of people who engage in sex as part of their work.


Leaving the stethoscope behind: public health doctors and identity work

Lee Thompson

Public health medicine is distinct in two ways from most other forms of medical specialisation; firstly, it is predominantly non-clinical and secondly, its concern is with populations, rather than the more common individual physician–patient encounter. In spite of recent attempts to ‘mainstream’ public health approaches into medical training and practice, it remains a relatively low prestige medical specialty. In the face of the centrality of all things clinical in medical training, the identity work needed to think beyond this and into population health approaches is significant. In the face of public health physicians’ subaltern position within medicine, this research investigates the identity work doctors did as they made the transition into public health medicine and how they understood their positioning once they were within the specialty. The inductive thematic analysis conducted on the qualitative interview data generated for this research elicited three key themes of relevance for the 19 public health physicians in New Zealand who were interviewed. The calling into question of biomedical identities was evident and concomitant with this was a sense of loss of the satisfactions of clinical medicine including contact with patients and the ability to solve discrete clinical problems. The final theme revolved around how public health physician identities were felt by the participants to be discredited. Lack of attention to the identity work required to think beyond the individual in health terms may contribute to a slow pace of change.


‘You don’t ditch your girls’: young Māori and Pacific women and the culture of intoxication

Fiona Hutton and Sarah Wright

Māori and Pacific Peoples experience a disproportionate burden of alcohol-related harm relative to other ethnic groups, yet little is known about the context in which this drinking occurs. Few studies have explored how and why young Māori and Pacific women drink. Therefore, this article aims to develop a more nuanced and detailed account of Māori and Pacific young women’s drinking practices. The following article reports on an ethnographic study of young Māori and Pacific women aged 18–30. Five Māori participants and six Pacific participants were selected and asked to become researchers within their social groups. Nine female researchers also became participants in the study, accompanying recruited participants to drinking occasions and events. Participants were each given a ‘drinking diary’ to document drinking occasions, which formed the data-set for the project. Three levels of thematic analysis were undertaken. The first noted broad themes with the second and third levels exploring more nuanced themes and identifying intersections across themes. The study demonstrated that Māori and Pacific young women’s engagement with New Zealand’s culture of intoxication is complex: Māori and Pacific women drink for pleasure or to achieve a ‘buzz’ and to be social. Drinking practices are deeply affected by ethnic and peer group collectives (‘the girls’), traditions and expectations. Harm reduction initiatives need to take account of the many pathways specific to how Māori and Pacific young women engage with alcohol use. Additionally, the wider context in which alcohol-related harm occurs needs to be considered in policy and harm reduction debates.



The development of the specialism of emergency medicine: Media and cultural influences

Stephen Timmons and Stuart Nairn

In this article we analyse, via a critical review of the literature, the development of a relatively new medical specialism in the United Kingdom, that of emergency medicine. Despite the high media profile of emergency care, it is a low-status specialism within UK medicine. The creation of a specialist College in 2008 means that, symbolically, recognition as a full specialism has now been achieved. In this article, we will show, using a sociology of professions approach, how emergency medicine defined itself as a specialism, and sought to carve out a distinctive jurisdiction. While, in the context of the UK National Health Service, the state was clearly an important factor in the development of this profession, we wish to develop the analysis further than is usual in the sociology of professions. We will analyse the wider cultural context for the development of this specialism, which has benefited from its high profile in the media, through both fictional and documentary sources.


The social negotiation of fitness for work: Tensions in doctor–patient relationships over medical certification of chronic pain

Elaine Wainwright, David Wainwright, Edmund Keogh and Christopher Eccleston

The UK government is promoting the health benefits of work, in order to change doctors’ and patients’ behaviour and reduce sickness absence. The rationale is that many people ‘off sick’ would have better outcomes by staying at work; but reducing the costs of health care and benefits is also an imperative. Replacement of the ‘sick note’ with the ‘fit note’ and a national educational programme are intended to reduce sickness-certification rates, but how will these initiatives impact on doctor–patient relationships and the existing tension between the doctor as patient advocate and gate-keeper to services and benefits? This tension is particularly acute for problems like chronic pain where diagnosis, prognosis and work capacity can be unclear. We interviewed 13 doctors and 30 chronic pain patients about their experiences of negotiating medical certification for work absence and their views of the new policies. Our findings highlight the limitations of naïve rationalist approaches to judgements of work absence and fitness for work for people with chronic pain. Moral, socio-cultural and practical factors are invoked by doctors and patients to contest decisions, and although both groups support the fit note’s focus on capacity, they doubt it will overcome tensions in the consultation. Doctors value tacit skills of persuasion and negotiation that can change how patients conceptualise their illness and respond to it. Policy-makers increasingly recognise the role of this tacit knowledge and we conclude that sick-listing can be improved by further developing these skills and acknowledging the structural context within which protagonists negotiate sick-listing.


Performing ‘pragmatic holism’: Professionalisation and the holistic discourse of non-medically qualified acupuncturists and homeopaths in the United Kingdom

Assaf Givati

Complementary and alternative medicine practitioners have often utilised ‘holism’ as a key identification mark of their practice, distancing themselves from ‘the reductionist biomedicine’. However, the past couple of decades have witnessed increased engagement of several complementary and alternative medicines in professionalisation, which includes a degree of biomedical alignment while ‘reducing’ holistic claims in order to provide practice with a ‘credible outlook’ and move closer to the mainstream, a development which challenges the role of holism in complementary and alternative medicine practices. This article explores the strategies by which two groups of complementary and alternative medicine practitioners, namely, non-medically qualified acupuncturists and homeopaths in the United Kingdom, pragmatically accommodateholistic notions as a professional resource, a process of negotiation between maintaining their holistic premise, on the one hand, and the drive to professionalise and enhance their societal status, on the other. Based on in-depth interviews with non-medically qualified acupuncture and homeopathy practitioners and school principals, textual analysis of practitioners’ web sites and observation of practice, the findings demonstrate the dynamic approach to ‘holism’ in complementary and alternative medicine practice. This discourse, through which practitioners use a range of strategies in order to ‘narrow’ or ‘expand’ their holistic expression, can be described as ‘pragmatic holism’, by which they try to make gains from the formalisation/standardisation processes, without losing the therapies’ holistic outlook and appeal.


Counterpublic health and the design of drug services for methamphetamine consumers in Melbourne

Cameron Duff and David Moore

This article is interested in how notions of the ‘public’ are conceived, marshalled and enacted in drug-treatment responses to methamphetamine use in Melbourne, Australia. After reviewing qualitative data collected among health-care providers and methamphetamine consumers, we draw on the work of Michael Warner to argue that services for methamphetamine consumers in Melbourne betray ongoing tensions between ‘public’ and ‘counterpublic’ constituencies. Our analysis indicates that these tensions manifest in two ways: in the management of ‘street business’ in the delivery of services and in negotiating the meaning of health and the terms of its restoration or promotion. Reflecting these tensions, while the design of services for methamphetamine consumers is largely modelled on public health principles, the everyday experience of these services may be more accurately characterised in terms of what Kane Race has called ‘counterpublic health’. Extending Race’s analysis, we conclude that more explicit focus on the idea of counterpublic health may help local services engage with methamphetamine consumers in new ways, providing grounds for novel outreach, harm-reduction and treatment strategies.


Impact of age at onset for children with renal failure on education and employment transitions

Helen Lewis and Sara Arber

Previous medical research has shown that children with end-stage renal failure experience delay or underachievement of key markers of transition to adulthood. This article analyses 35 qualitative interviews with end-stage renal failure patients, aged 20–30 years, first diagnosed at 0–19 years of age, to explore how far delayed or underachievement in education and employment is related to their age at onset of end-stage renal failure. This study shows how unpredictable failures of renal replacement therapies, comorbidities and/or side effects of treatment in the early life course often coincided with critical moments for education and employment. Entering school, college, work-related training or employment, and disclosing health status or educational underachievement to an employer, were particularly critical, and those who were ill before puberty became progressively more disadvantaged in terms of successful transition into full-time employment, compared with those first diagnosed after puberty.


The effect of strategies of personal resilience on depression recovery in an Australian cohort: A mixed methods study

Frances E Griffiths, Felicity K Boardman, Patty Chondros, Christopher F Dowrick, Konstancja Densley, Kelsey L Hegarty and Jane Gunn

Strategies of personal resilience enable successful adaptation in adversity. Among patients experiencing depression symptoms, we explored which personal resilience strategies they find most helpful and tested the hypothesis that use of these strategies improves depression recovery. We used interview and survey data from the Diagnosis, Management and Outcomes of Depression in Primary Care 2005 cohort of patients experiencing depression symptoms in Victoria, Australia. A total of 564 participants answered a computer-assisted telephone interview question at 12 months follow-up, about what they found most helpful for their depression, stress or worries. Depressive disorder and severity were measured at annual follow-up using the Composite International Diagnostic Interview and the Patient Health Questionnaire self-rating questionnaire. Using interview responses, we categorised participants as users or not of strategies of personal resilience, specifically, drawing primarily on expanding their own inner resources or pre-existing relationships: 316 (56%) were categorised as primarily users of personal resilience strategies. Of these, 193 (61%) reported expanding inner resources, 79 (25%) drawing on relationships and 44 (14%) reported both. There was no association between drawing on relationships and depression outcome. There was evidence supporting an association between expanding inner resources and depression outcome: 25 per cent of users having major depressive disorder 1 year later compared to 38 per cent of non-users (adjusted odds ratio: 0.59, confidence interval: 0.36–0.97). This is the first study to show improved outcome for depression for those who identify as most helpful the use of personal resilience strategies. The difference in outcome is important as expanding inner resources includes a range of low intensity, yet commonly available strategies.


Health and Place

Community influences on contraceptive use in Mozambique

Boaventura Manuel Cau

Fertility in sub-Saharan Africa remains the highest in the world. Yet, the average contraceptive prevalence in Africa is the lowest in major world regions and there is limited understanding of the mechanisms through which community context shapes contraceptive use in the region. Using data from the 2011 Mozambique Demographic and Health Survey, we examine the mechanisms through which community context influences women’s use of modern methods of contraception in Mozambique. We find that community context influences the use of modern methods of contraception by shaping the environment in which women live.


Alcohol outlet density and related use in an urban Black population in Philadelphia public housing communities

Julie A. Cederbaum, Robin Petering, M. Katherine Hutchinson, Amy S. He, John P. Wilson, John B. Jemmott III and Loretta Sweet Jemmott

Adolescent alcohol use behaviors are influenced by familial patterns and neighborhood factors. This work explored the influence of individual, family, and environment on alcohol use. Baseline data from a randomized controlled trial with Black mothers son dyads (n=382) were paired with census tract and alcohol control board data. Among mothers, younger age, along with neighborhood factors of alcohol outlet density, race, and education were significantly associated with use. Among sons, older age and alcohol outlet density in the neighborhood predicted use. Findings highlight neighborhood influence, beyond family qualities, as a significant determinant of disadvantaged Black mothers’ alcohol use. Implications for public health policy are discussed.


The meaning of ‘place’ in families’ lived experiences of paediatric outpatient care in different settings: A descriptive phenomenological study

Gemma Heath, Sheila Greenfield and Sabi Redwood

Health service reforms in the United Kingdom have sought to ensure that children and young people who are ill receive timely, high quality and effective care as close to home as possible. Using phenomenological methods, this study examined the experience and impact of introducing new, community-based paediatric outpatient clinics from the perspective of NHS service-users. Findings reveal that paediatric outpatient ‘care closer to home’ is experienced in ways that go beyond concerns about location and proximity. For families it means care that ‘fits into their lives’ spatially, temporally and emotionally; facilitating a sense of ‘at-homeness’ within the self and within the place, through the creation of a warm and welcoming environment, and by providing timely consultations which attend to aspects of the families’ lifeworld.


Re-thinking children׳s agency in extreme hardship: Zimbabwean children׳s draw-and-write about their HIV-affected peers

Catherine Campbell, Louise Andersen, Alice Mutsikiwa, Claudius Madanhire, Morten Skovdal, Constance Nyamukapa and Simon Gregson

We compare two analyses of the same ‘draw-and-write’ exercises in which 128 Zimbabwean children represented their HIV-affected peers. The first, informed by the ‘New Social Studies of Childhood’, easily identified examples of independent reflection and action by children. The second, informed by Sen׳s understandings of agency, drew attention to the negative consequences of many of the choices available to children, and the contextual limits on outcomes children themselves would value: the support of caring adults, adequate food, and opportunities to advance their health and safety. Conceptualisations of agency need to take greater account of children׳s own accounts of outcomes they value, rather than identifying agency in any form of independent reflection and action per se.


Conceptualizations of pluralistic medical fields: exploring the therapeutic landscapes of Nepal

Rikke Stamp Thorsen

Using the concept of ‘therapeutic landscapes’ this study explores how people in Nepal conceptualize their health care opportunities and how health care seeking practices are interpreted and experienced differently among people in their everyday contexts. Relational therapeutic landscapes were experienced through notions related to time and place as treatments were positioned along spectrums ranging from home to city and past to present. Conceptualizations of treatments were influenced by accessibility, lack of knowledge and uncertainties related to getting diagnosis as well as structural constraints beyond the health care system.


Putting the party down on paper: A novel method for mapping youth drug use in private settings

Signe Ravna and Cameron Duff

This article proposes a novel method for generating context-rich knowledge about ‘hard-to-access’ places. We ground our discussion in a recent qualitative study of social settings of youth drug use in Denmark. The study confirmed that private house parties are common sites of youth drug use, although these parties presented limited opportunities for fieldwork. In response, a ‘map-task’ was introduced to the study to complement fieldwork and interviews. We assess the most significant methodological and epistemological features of this map-task, and explore how it may to used to conduct observations ‘from a distance’ in hard-to-access places. Further, we argue that the map-task has a number of analytical and logistical advantages for scholars interested in the health and social aspects of ‘hidden’ phenomena, such as youth drug use.


Dreaming of toilets: Using photovoice to explore knowledge, attitudes and practices around water–health linkages in rural Kenya

Elijah Bisung, Susan J. Elliott, Bernard Abudho, Corinne J. Schuster-Wallace  and Diana M. Karanja

As part of a knowledge, attitudes, practices and empowerment (KAPE) project implemented by the United Nations University Institute for Water, Environment and Health (UNU-INWEH) in the Lake Victoria Basin, this paper reports findings from a photovoice study with women in Usoma, a lakeshore community in Western Kenya. Drawing on ecosocial and political ecology theory, findings reveal that access to water, perceptions and practices were shaped by ecological and broader structural factors. Further, collective actions to improve access were constrained by institutional and economic structures, thus (re)enforcing inequalities.


International Journal of Social Psychiatry

Hearing their voices: The lived experience of recovery from first-episode psychosis in schizophrenia in South Africa

Anneliese de Wet, Leslie Swartz and Bonginkosi Chiliza

Background: Recovery was previously regarded as a somewhat unattainable goal, and the subjective experience was de-emphasised. Lately, the person and his or her experiences are emphasised.

Material: Seven participants were interviewed regarding their experience of recovery from first-episode psychosis in schizophrenia. Data were analysed using interpretative phenomenological analysis (IPA).

Discussion: Support and having to care for another are possibly the greatest contributors to their recovery. Spirituality plays an important role. Stigma, found to be ingrained and pervasive, could be a barrier to recovery. The rediscovery by the participants of their abilities (re)introduced a sense of agency.

Conclusion: The narrative in the process of recovery is crucial.


War traumas in the Mediterranean area

Mauro Giovanni Carta, Maria Francesca Moro and Judith Bass

Introduction: The purpose is to explore the consequences of war and its impact on mental health with attention to the Mediterranean area.

Methods: Narrative review of consequences of war on mental health and on the mental health of the communities in the current crises in the Mediterranean region.

Results: A series of outbreaks of war are still raging in the Mediterranean region and producing horrible effects with a considerable number of refugees with unsatisfied needs. Studies relating to conflicts of the past suggest that the mental health consequences of these wars may affect future generations for many years. While violations of human rights are not new, what is new are attacks on medical institutions perceived to be traditionally Western.

Conclusion: The scientific community has to fight violence through mediation of conflicts. The idea that science can improve lives is a concept that is found in the history of all Mediterranean cultures. The Greek and Roman medical tradition was saved thanks to doctors of the Arab courts when Christian fundamentalism fought science in the Middle Ages. Health institutions are the product of the great Islamic medical tradition as well as Western culture.


Identification of the hikikomori syndrome of social withdrawal: Psychosocial features and treatment preferences in four countries

Alan R Teo, Michael D Fetters, Kyle Stufflebam, Masaru Tateno, Yatan Balhara, Tae Young Choi, Shigenobu Kanba, Carol A Mathews and Takahiro A Kato

Background: Hikikomori, a form of social withdrawal first reported in Japan, may exist globally but cross-national studies of cases of hikikomori are lacking.

Aims: To identify individuals with hikikomori in multiple countries and describe features of the condition.

Method: Participants were recruited from sites in India, Japan, Korea and the United States. Hikikomori was defined as a 6-month or longer period of spending almost all time at home and avoiding social situations and social relationships, associated with significant distress/impairment. Additional measures included the University of California, Los Angeles (UCLA) Loneliness Scale, Lubben Social Network Scale (LSNS-6), Sheehan Disability Scale (SDS) and modified Cornell Treatment Preferences Index.

Results: A total of 36 participants with hikikomori were identified, with cases detected in all four countries. These individuals had high levels of loneliness (UCLA Loneliness Scale M = 55.4, SD = 10.5), limited social networks (LSNS-6 M = 9.7, SD = 5.5) and moderate functional impairment (SDS M = 16.5, SD = 7.9). Of them 28 (78%) desired treatment for their social withdrawal, with a significantly higher preference for psychotherapy over pharmacotherapy, in-person over telepsychiatry treatment and mental health specialists over primary care providers. Across countries, participants with hikikomori had similar generally treatment preferences and psychosocial features.

Conclusion: Hikikomori exists cross-nationally and can be assessed with a standardized assessment tool. Individuals with hikikomori have substantial psychosocial impairment and disability, and some may desire treatment.


Beliefs about the causes of schizophrenia among Aymara and non-Aymara patients and their primary caregivers in the Central–Southern Andes

Alejandra Caqueo-Urízar, Joshua Breslau and Stephen E Gilman

Aim: The aim of this study is to investigate differences in the beliefs about the causes of schizophrenia between Aymara and non-Aymara patients with schizophrenia and their primary caregivers. Ethnic background plays an important role in the formation of beliefs regarding the causes of schizophrenia, and there have been no prior studies on such beliefs among the Aymara, an indigenous community with a population of about 2 million people living in the Andes. We focused on three systems of beliefs distinguished in the literature: biological, psychosocial and magical–religious.

Methods: The sample comprised 253 patients (n = 117 Aymara, and n = 136 non-Aymara) of public mental health centers in Chile (33.6%), Peru (33.6%) and Bolivia (32.8%) with a diagnosis of schizophrenia, and each patient’s primary caregiver. We administered to patients and caregivers a questionnaire with scales assessing the perceived causes of schizophrenia. Linear regression models were fitted to compare differences in the levels of causal beliefs between Aymara and non-Aymara patients and caregivers, and to identify socio-demographic and clinical predictors of different types of beliefs about the causes of schizophrenia.

Results: Adjusted for socio-demographic and clinical covariates, levels of psychosocial beliefs were significantly higher for Aymara caregivers (0.33, 95% confidence interval (CI) = 0.05, 0.62) than non-Aymara caregivers.

Conclusions: Contrary to expectations, beliefs about the causes of schizophrenia among Aymara are not more magical–religious than those of their non-Aymara counterparts. It may be necessary for mental health staff members to evaluate beliefs about the disorder, especially in ethnic minorities, before applying a standard model of treatment.


Journal of the History of Medicine and Allied Sciences

Diabetes and “Defective” Genes in the Twentieth-Century United States

Arleen Marcia Tuchman

In the decades following the discovery of insulin, eugenicists grew concerned that more diabetics would survive into their reproductive years and contribute “defective” genes to the gene pool. Insulin thus came to be seen as both a blessing for the individual and a problem for the future of humankind. Nevertheless, diabetics in the United States were neither prevented nor discouraged from reproducing. I argue that this stemmed from the widespread belief that diabetes was a disease primarily of middle-class whites, who possessed positive traits that outweighed their particular genetic defect. Historians of eugenics have demonstrated convincingly that race and class stereotypes made some populations more vulnerable to coercive eugenic practices. The case of diabetes demonstrates that race and class stereotypes could also confer protection. In the end, possession of a defective gene mattered less than the perception of one’s contribution to society.


One «Both» Sex«es»: Observations, Suppositions, and Airy Speculations on Fetal Sex Anatomy in British Scientific Literature, 1794–1871

Ross Brooks

The hegemony of the two-sex paradigm in the European scientific imagination and wider culture did not automatically equate to the hegemony of two discrete genders. In fact, two sexes facilitated a variety of gender choices: two singular and a number of double or otherwise intersexed (most commonly referred to as “hermaphrodite” or “bisexual” in its anatomical sense). This article explores some key British medical and allied scientific texts, with reference to associated Continental literature, as a means of illustrating the complexity of the two-sex paradigm and the unexpected transformation of gender possibilities that it helped produce through the early and middle decades of the nineteenth century. Discourses surrounding the first direct observations of the earliest development of fetal urinogenital anatomy were pivotal. The prevailing view that the incipient embryo was sexually undifferentiated (a paragon of the one-sex paradigm) was challenged by the Edinburgh anatomist Robert Knox, initially as he sought to bolster his professional reputation at the height of the Burke and Hare “body-snatching” scandal. Knox suggested that every embryo began life in an essentially dual-sexed state, an individual’s sex anatomy depending on the greater or lesser development of component female and male structures. Greater clarification on the contested status of the homology—hermaphrodite distinction was achieved with the discovery of the early co-existence of the excretory duct of the Wolffian body (mesonephric duct) and the Müllerian duct (paramesonephric duct), an observation that made anatomical bisexuality difficult to ignore. The nineteenth-century’s greatest champion of primordial hermaphroditism was Charles Darwin who was pivotal in phylogenizing the principle and establishing the premise that (in his own words) “Every man & woman is hermaphrodite,” a foundation stone of late-nineteenth-century sexology.


Alfred Russel Wallace’s Medical Libertarianism: State Medicine, Human Progress, and Evolutionary Purpose

Michael A. Flannery

Alfred Russel Wallace (1823–1913), naturalist and explorer of South America and the Malay Archipelago, secured his place in history by independently discovering the theory of natural selection. His letter outlining the theory was sent from Ternate in eastern Indonesia and received at Down House, according to Charles Darwin (1809–82), on June 18, 1858, prompting the now-famed evolutionist to rush his languishing manuscript to press. Wallace’s contributions to evolutionary biology, biogeography, and anthropology are well known, but his medical views have received far less attention. Within the context of a strident populist antivaccination movement and an ominous elitist eugenics campaign, Wallace took his stand, which revealed itself in a libertarianism that defended traditional socialist constituencies (the working poor, the lumpenproletariat, and feminist reformers) against state-mandated medical interventions. Rather than viewing Wallace as a heterodox contrarian, this article argues that his positions were logical outgrowths of his medical libertarianism and evolutionary and social theories.


Investigating “Mass Hysteria” in Early Postcolonial Uganda: Benjamin H. Kagwa, East African Psychiatry, and the Gisu

 Yolana Pringle

In the early 1960s, medical officers and administrators began to receive reports of what was being described as “mass madness” and “mass hysteria” in Tanganyika (now Tanzania) and Uganda. Each epidemic reportedly affected between three hundred and six hundred people and, coming in the wake of independence from colonial rule, caused considerable concern. One of the practitioners sent to investigate was Benjamin H. Kagwa, a Ugandan-born psychiatrist whose report represents the first investigation by an African psychiatrist in East Africa. This article uses Kagwa’s investigation to explore some of the difficulties facing East Africa’s first generation of psychiatrists as they took over responsibility for psychiatry. During this period, psychiatrists worked in an intellectual climate that was both attempting to deal with the legacy of colonial racism, and which placed faith in African psychiatrists to reveal more culturally sensitive insights into African psychopathology. The epidemics were the first major challenge for psychiatrists such as Kagwa precisely because they appeared to confirm what colonial psychiatrists had been warning for years—that westernization would eventually result in mass mental instability. As this article argues, however, Kagwa was never fully able to free himself from the practices and assumptions that had pervaded his discipline under colonial rule. His analysis of the epidemics as a “mental conflict” fit into a much longer tradition of psychiatry in East Africa, and stood starkly against the explanations of the local community.

By Melanie Boeckmann

aiming for a PhD in Public Health, currently working in health policy and research.

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