In the Journals

In the Journals, September 2015 (Part 1)

Here is the first round of “In the Journals” for September. Happy autumn reading!

American Anthropologist

Commitments of Debt: Temporality and the Meanings of Aid Work in a Japanese NGO in Myanmar
Chika Watanabe

The rise of debt as a mechanism of development troubles many scholars and aid practitioners. Contrary to these concerns, however, ethnographic research at a Japanese NGO in Myanmar showed that Japanese and Burmese aid workers found value in moral and monetary debt relations. In this article, I argue that these aid workers viewed indebtedness as a precondition for the making of voluntary actors, willing and committed to aid work. What they problematized was not indebtedness but, rather, competing understandings of the appropriate temporality of a debt’s repayment. The fault lines did not appear along cultural or moral-monetary boundaries; they existed in the ways that people conceptualized voluntary actors as emerging from either long-term forms of indebted gratitude or sequences of short-term contractual agreements. While the entrapment of the poor in cycles of debt remains an increasing concern in the world, I here ask how we might understand local aid workers’ professional commitments when they do not question indebtedness as a moral framework.

Rich Sentiments and the Cultural Politics of Emotion in Postreform Ho Chi Minh City, Vietnam
Allen L. Tran

Linking socioeconomic and personal transformations, recent scholarship on neoliberalism in East and Southeast Asia has examined the role of various emotional experiences in reconfiguring selfhood toward values of personal responsibility and self-care. However, studies rarely focus on how such experiences come to be understood as specifically emotional themselves. In this article, I examine the growing use of emotion (cảm xúc) as a conceptual category to define the self and everyday life in a psychologistic idiom among middle-class residents of Ho Chi Minh City, Vietnam. While more established discourses of sentiment (tình cảm) define selfhood in relation to notions of obligation and care, the emerging model of emotion emphasizes individuated self-knowledge. However, instead of replacing sentiment, newer understandings of emotion have developed alongside and in relation to sentiment. In categorizing various feelings as explicitly “emotional” in nature, people participate in a self-fashioning project that cultivates an emotionally aware and expressive self that is informed by neoliberal sensibilities yet does not supplant socialist or Confucian models of selfhood. I argue that emotions are not only central to the subjective experience of the transition to a market-oriented economy but also that emotion as a category itself is a medium through which economic transformations reorganize selfhood more generally.


Pheromones, feminism and the many lives of menstrual synchrony
Michael Pettit and Jana Vigor

Since first proposed in 1971, the theory of menstrual synchrony has been haunted by doubt while gaining greater public visibility. Based on a study of women living in a dormitory, biopsychologist Martha McClintock found that there was a greater synchronization in the date for the onset of menstruation among close friends and roommates. An analysis of newspapers, magazines and textbooks alongside the scientific literature suggests that the tenacity of menstrual synchrony is because of its circulation within many heterogeneous communities where the ambiguous phenomenon acquired multiple meanings. It was simultaneously heralded as offering the first evidence of human pheromones and demonstrating how behavior regulates biological processes. This history offers an untapped lens to explore the fraught relationship between sociobiology and feminism. This relationship has primarily been understood in terms of opposition, but menstrual synchrony’s reception reveals a more complicated and intertwined story about the simultaneous growth of evolutionary and feminist psychology. The history of menstrual synchrony illustrates late twentieth-century debates over ‘the social,’ when it could entail both the influence of affect-laden friendships and the biochemicals secreted from the body.

Healthy citizenship beyond autonomy and discipline: Tactical engagements with genetic testing
Tamar Sharon

In recent decades a model of healthy citizenship has emerged, which construes citizens as autonomous, responsible and active participants in the management of their health. While proponents view this as an empowering discourse, critics claim that it creates new forms of discipline and social control. This article argues that there is a need for a shift in the conceptual framework surrounding this discussion – beyond autonomy versus discipline understood as heteronomy – because it obscures the many ways in which individuals engage with healthy citizenship discourse that are not governed by principles of autonomous choice and that do not corroborate fears of normalization and discipline. Michel de Certeau’s theory of the creative tactics of everyday life is offered as a useful alternative framework, insofar as it is concerned less with individual autonomy than with the rendering ‘habitable’ of a given space. Drawing on existing empirical research on people’s engagements with genetic risk information, four tactics are identified that escape both healthy citizenship discourse and its critique: translation; selective mobilization; non-disclosure; and a refusal to engage. Thinking in terms of tactics and habitability, it is argued, provides a vocabulary with which to articulate other modes of reasoning, action and moral conduct that are at work.

The decision: Relations to oneself, authority and vulnerability in the field of selective abortion (open access) 
Sølvi Marie Risøy, Thorvald Sirnes

This article is about selective abortion. It concentrates on the existential, moral and social conditions that arise when pregnant women, using prenatal diagnosis (PND), are told that there is something seriously wrong with the foetuses that they are carrying. This is characterised as a micro state of emergency, where both normal cognitive categories and normative orders are dissolved. The analyses are anchored in the womens’ own presentations and understandings of the processes and dilemmas related to the abortion decisions, and our most important empirical materials are interviews with women who have experienced them. Our main ambition is to show the relation between some important dimensions of the situation in which the abortion decision has to be made, and the special kind of authority on behalf of the women that presents itself. Of equal importance is the vulnerability of the pregnant women, resulting in a co-production of the women as both Sovereigns and Homo Sacer in the decision situation. We also analyse some of the experienced relations between the women and the foetuses, and how the women constitute themselves as moral subjects, with a particular emphasis on the motifs of sacrifice and self-sacrifice. It is a central argument in the article that we have to understand the specificity of the decision situation, without reducing it either to other phases (before or after) of the total processes of PND and selective abortion, or to general discourses of disability or normality. The specificity of the situation in which the abortion decision is made is a pivotal point in society’s regulation (in a broad sense) of the field and in the constitution of the regime of selective abortion.

Genetic services and birth defect intervention in China
Suli Sui

This article discusses birth defect intervention and genetic services as measures of intervention in China. Based on the practical application of a three-level intervention model, it analyses the important roles played by genetic services in the areas of premarital, pregestational and prenatal genetic screening, genetic counselling, and testing in the prevention of birth defects in China. It demonstrates that since there is imbalanced development in different areas of China, genetic services are underutilised. In practice, the intervention model has problems and is facing difficulties and challenges. And, given the national desire to reduce birth defects, nondirectiveness is not getting the attention deserved in genetic counselling. An insufficiency of psychological support and humanistic care in genetic services, and lack of social and financial support for the children with birth defects and their families still exists widely in China.

The resilient child, human development and the “postdemocracy”
Jennifer Henderson, Keith Denny

Resilience is the popular term for a capacity to ‘bounce back’ from adversity. It is also a scientific concept informing an influential bio-psychological approach to contemporary inequality. This article recalls the origins of the term in developmental psychopathology and suggests that the project of cultivating resilient selves is an aspect of the broader depoliticization characterizing “post-democracies” today. The scientific object of resilience is produced through the study of the interplay of risky and protective variables in the individual life course. Resilience is present when developmental resources in and around the self help to combat threats to ‘adaptation’. The project of resilience is to know how to cultivate individual robustness in the face of immutable threats – including poverty, grasped as a developmental risk factor. In this way of knowing the world, structured inequality is seen to be relatively unchangeable compared to the powers of resilience. Resilience has been taken up by neoliberal governments as the model of evidence-based ‘actionable knowledge’ for population interventions. But its influence extends further, to institutions of global governance, where resilience’s central object of enquiry and intervention – the child – has been projected onto humanity as a whole. The appeal of resilience as a practical and optimistic science is undeniable but we suggest that it is time to take account of its implications for political contestation. Resilience provides positive psychology’s contribution to the narrowing of justice- and equity-seeking projects in the current moment, reducing their horizons to the care for ‘human capital’ under conditions of socioeconomic precarity.

Culture, Medicine and Psychiatry

Rethinking ‘Efficacy’: Ritual Healing and Trance in the Mahanubhav Shrines in India
Shubha Ranganathan

Ritual healing has been one of the core topics in anthropology and, to a lesser extent, in psychology as well. Much of the research on ritual healing has focused on how healing works, and what factors constitute the efficacy of healing. In answering this question, scholars have focused primarily on two main factors—the symbolic significance of rituals, and the relationship between the healer and the patient. This paper explores understandings about efficacy in a context where elaborate rituals do not occur, the role of the healer is minimal, and the sufferers do not have expectations of complete wellness. In the Mahanubhav temples in India, healing is not understood as the removal of symptoms. The healing process involves amplifying unpleasant and painful symptoms, thereby ‘drawing out’ the illness from the body. Moreover, the temple narratives emphasize the transient nature of temple healing, where people rarely become completely well. They therefore frequently return to stay in the temple as and when their symptoms recur, thus forging long-term bond with the temple community and sect. These findings suggest that temple healing is powerful not so much for the practice of specific exorcist rituals, but for providing a refuge and a community for suffering individuals.

Thwarting the Diseased Will: Ulysses Contracts, the Self and Addiction
Kirsten Bell

Ulysses contracts are a particular type of advance directive that has been advocated for use in mental health settings and addictions treatment. Taking their name from the legend of Ulysses, such contracts are distinctive insofar as they are designed to thwart certain anticipated future wishes rather than realize them. In this paper, I consider what Ulysses contracts reveal about contemporary conceptions of addiction and the self. Drawing on discussions of Ulysses contracts in the psychiatric and addictions literature, as well as historical and contemporary examples of such, I show that Ulysses contracts are premised on a split between the present ‘rational’ self and the future ‘irrational’ self, thereby reproducing a very particular notion of addiction—one that serves to naturalize certain ways of thinking about freedom, choice, coercion, and the self.

Writing Prozāk Diaries in Tehran: Generational Anomie and Psychiatric Subjectivities
Orkideh Behrouzan

I explore the historical and cultural shifts that underlie the normalization of the term dépréshen and the emergence of public psychiatric discourses in 1990s Iran. I do this by investigating the cultural sensibilities of a particular generation, the self-identified 1980s generation, and the ways they situate what is perceived as dépréshen in social anomie and the memories of the Iran–Iraq war. I argue that psychiatrization of psychological distress in Iran was not simply a de-politicizing hegemonic biomedical discourse, but that the contemporary Iranian discourses of psychological pathology and social loss evolved in public, hand-in-hand, through the medicalization of post-war loss. Psychiatric subjectivity describes conditions where individuals internalize psychiatry as a mode of thinking, and performatively articulate not only their desires, hopes, and anxieties, but also historical losses as embodied in individual and collective brains. I underscore my interlocutors’ simultaneous historicization and medicalization of their dépréshen, arguing that psychiatrically medicalized individuals are performative actors in the discursive formation of both biomedical and social truth. Dépréshen, in the larger sense of the word, has become one way to navigate ruptured pasts, slippery presents, and uncertain futures.

On the Social Constructionist Approach to Traumatized Selves in Post-disaster Settings: State-Induced Violence in Nandigram, India
Kumar Ravi Priya

Through the use of concepts such as traumatization and posttraumatic stress disorder (PTSD), the distressing experiences of survivors are understood in psychology and psychiatry primarily as the behavioural symptoms resulting supposedly from an incomplete emotional and cognitive processing of traumatic events. Due to such an exclusive focus on the intra-psychic processes, besides the survivors’ healing facilitated by cultural beliefs and symbols, their trauma-related distress associated with the cultural interpretation of loss is also generally ignored. This paper illustrates the utility of the social constructionist paradigm in understanding the survivors’ experiences of suffering and healing within the cultural and socio-political context of violence through an ethnographic study among the poor farmers of Nandigram, India, inflicted by violence from the state government as it tried to forcibly acquire their land to build a chemical factory. How the traumatized selves experience intense distress resulting from disruptions to a sense of wholeness and how this wholeness may be reformulated through culturally valued beliefs are highlighted in the themes of suffering (‘experience of PTSD symptoms’, ‘betrayed self’, ‘overwhelmed by loss’, and ‘biographical disruption’) and healing (‘moral re-affirmation’, ‘sense of togetherness’, ‘sense of security due to change in political environment’) presented in the vignettes.

Narrative Structures of Maya Mental Disorders
Andrew R. Hatala, James B. Waldram, Tomas Caal

Several Indigenous communities around the globe maintain unique conceptions of mental illness and disorder. The Q’eqchi’ Maya of southern Belize represent one Indigenous community that has maintained, due to highly “traditional” ways of life and the strong presence of many active localized healers or bush doctors, distinct conceptions of mental disorders as compared to Western psychiatric nosology. The purpose of this ethnographic study was to understand and interpret Q’eqchi’ nosological systems of mental disorders involving the factors—spiritual, cultural, social, historical, cosmological, or otherwise—implicated in their articulation and construction. Over a period of 9 months, and with the help of cultural advisors from several Q’eqchi’ communities, 94 interviews with five different traditional Q’eqchi’ healers were conducted. This paper demonstrates that the mental illnesses recognized by the Q’eqchi’ healers involved narrative structures with recognizable variations unfolding over time. What we present in this paper are 17 recognizable illnesses of the mind grouped within one of four broad “narrative genres.” Each genre involves a discernible plot structure, casts of characters, themes, motifs, and a recognizable teleology or “directedness.” In narrative terms, the healer’s diagnostic and therapeutic work can be understood as an ability to discern plot, to understand and interpret a specific case within the board, empirically based structure of Q’eqchi’ medical epistemology.

Open Mind, Open Heart: An Anthropological Study of the Therapeutics of Meditation Practice in the US
Neely Myers, Sara Lewis, Mary Ann Dutton

Based on ethnographic fieldwork and interviews collected with meditation teachers and students in the United States, this article will argue that active training in meditation-based practices occasions the opportunity for people with traumatic stress to develop a stronger mind–body connection through heightened somatic awareness and a focus on the present moment that they find to be therapeutic. Three important themes related to healing through meditation for trauma emerged from the data and centered around the ways our interlocutors attempted to realign their sense of self, mind and body, after a traumatic experience. The themes helped explain why US women perceive meditation as therapeutic for trauma, namely that the practice of meditation enables one to focus on the lived present rather than traumatic memories, to accept pain and “open” one’s heart, and to make use of silence instead of speech as a healing modality. As meditation practices increasingly enter global popular culture, promoted for postulated health benefits, the driving question of this research—how meditation may perpetuate human resilience for women who have experienced trauma based on their own perspectives of meditation practices—is a critical addition to the literature.

To Forgive and Discredit: Bipolar Identities and Medicated Selves Among Female Youth in Residential Treatment
Leah Gogel Pope

Based on 11 months of ethnographic fieldwork at a residential treatment center in the United States, this article explores the varied meanings that female youth attribute to behavior and the strategic (mis)use of knowledge about psychiatric diagnosis and medication at a time when the scope of behaviors pathologized in young people continues to expand. Drawing upon psychological and critically applied medical anthropology, as well as contributions from philosophy on how classifications of people come into being and circulate, attention is paid to the multiple contradictions at work in diagnosing young people with mental disorders. A detailed examination of an exchange that occurred during one particular group therapy session is presented to demonstrate how psychiatric selves emerge in this environment when conventional labeling practices no longer suffice as an explanation of behavior. This turn to psychiatry reveals both the salience of and confusion around mental health treatment and diagnosis among adolescents, opens up the distinctions young people make between “real selves” and “medicated selves,” and invokes the possibility of psychiatric disorder as a means to both forgive and discredit.

Music as Illness; Music as Healing
Maureen Pritchard

Throughout the Soviet Union, the arts became tied to ethnicity through the project of Socialist Realism. When, in 1991, the Kyrgyz Republic became independent from the Soviet Union, its national narrative continued to be built upon tropes of Kyrgyz ethnicity. Through their engagement with images of the ethno-national self, the arts provide a great source of beauty. Defining beauty as a representation of the self that is pure whole, and stable, Julia Kristeva asserts that beauty and suffering are part of the same phenomena. Arthur Kleinman argues that suffering is best understood as existing within the triangulated relationship of cultural representation, collective experience, and subjectivity. Music too is part of this triangulated relationship, and therefore, a part of suffering. Drawing upon ten months of ethnographic fieldwork in Kyrgyzstan, this article explores the illness experience of a single Kyrgyz musician. In doing so, it illustrates music’s role in self-formation and the development of social, economic, and political ties and the shifts that occur in these during illness. In drawing forth the role of music in the construction of racialized ethnicities, this article demonstrates how the experience of transformative beauty can coexist with turmoil, marginalization, and violence.

Suicide in Three East African Pastoralist Communities and the Role of Researcher Outsiders for Positive Transformation: A Case Study
Bilinda Straight, Ivy Pike, Charles Hilton, Matthias Oesterle

We examine cultural understandings and practices surrounding suicide in Pokot, Samburu, and Turkana pastoralists in north-central Kenya—three geographically overlapping and mutually interacting pastoralist communities. We collected our data in the context of a study of poverty, violence, and distress. In all three communities, stigma associated with suicide circumscribed individual responses to the World Health Organization’s Self-Report Questionnaire, which led to an ethnographic sub-study of suicide building upon our long-standing research in East Africa on distress, violence, and death. As is true for most of sub-Saharan Africa, reliable statistical data are non-existent for these communities. Thus, we deliberately avoid making assertions about generalizable statistical trends. Rather, we take the position that ethnographically nuanced studies like the one we offer here provide a necessary basis for the respectful collection of accurate quantitative data on this important and troubling practice. Moreover, our central point in this paper is that positive transformational work relating to suicide is most likely when researcher outsiders practice ‘deep engagement’ while respectfully restricting their role to (1) iterative, community-driven approaches that contextualize suicide; and (2) sharing contextualized analyses with other practitioners. We contend that situating suicide within a broader cultural framework that includes attitudes and practices surrounding other forms of death is essential to both aspects of anthropological-outsiders’ role.

Disability Studies Quarterly (open access) 

Beyond A Beautiful Mind: Schizophrenia and Bioethics in the Classroom (open access) 
Elizabeth J. Donaldson

This essay focuses on specific teaching assignments, strategies, and resources designed to help undergraduate students think critically about key concepts in bioethics—such as autonomy, paternalism, informed consent, and competency—using examples and case studies involving people diagnosed with schizophrenia. The assignments described below are disability-rights inspired interventions into the students’ career-focused mindsets and training; one of my main strategies is social decentering, or having students examine a situation from a variety of theoretical and subjective perspectives. Exposing students to online talks by people diagnosed with schizophrenia and similar primary sources helps those students without first-hand experience to better understand these different points of view. While these assignments are primarily geared toward bioethics classes, they include resources and ideas for class activities that might be useful in other courses within disability studies, mad studies, psychiatry, literature, or film.

Teaching with Trauma: Disability Pedagogy, Feminism, and the Trigger Warnings Debate (open access) 
Angela M. Carter

Recently, a heated debate has risen in Academia following numerous student initiatives petitions for the formal incorporation of rigger warnings in course syllabi. When contextualized within the intersecting politics of disability and feminist pedagogies, a number of fundamental contentions within this debate become apparent. First, grave misunderstandings remain regarding about practices of accommodation and the possibility of establishing the classroom as a “safe space.” Second, resistance within the academy to understand trauma as a pedagogical issue illustrate a failure to consider experiences of and responses to trauma as issues of disability (in)justice. Through an exploration of these issues, it becomes evident that the conflicting approaches to trauma in the classroom demand the more integrated, collaborative praxis of a “Feminist Disability Studies Pedagogy” (FDSP). When approached through this hybrid pedagogy, the conversation shifts from whether we should use trigger warnings, to why trauma itself is an imperative social justice issue within our classrooms.

East Asian Science, Technology, & Society

Diagnosing “Collaborative Culture” of Biomedical Science in South Korea: Misoriented Knowledge, Competition, and Failing Collaboration
Leo Kim and Han Woo Park

In this article, the authors review collaborations in the emerging biomedical sciences in South Korea. At the global level, several studies have made substantial contributions to the understanding of the underlying structure of collaboration networks across countries. Despite the increase in international collaborations, researchers have rarely paid attention to the structural pattern of internal collaboration among individual actors that reflects culturally embedded characteristics in East Asia. To fill this gap, this study explores research collaboration in South Korea. In this study, the “collaborative culture” is interpreted and assessed through collaborative patterns in the network of important scientific actors and their conduct subject to reproduction. By applying a social network analysis approach, the authors visualize such attributes of network relations and discuss how to deal with ethical issues that are vital to sustainable scientific collaboration.


The Morality of Performance: HIV Disclosure in Speech and Song in South Africa
Steven P. Black

This article synthesizes anthropological research on morality and performance, drawing from ethnographic fieldwork with a Zulu choir that was an HIV support group and AIDS activist organization. The article responds to an increasing level of anthropological interest in the topic of morality and contributes to an emerging body of literature on language and experience. The concept of moral assemblages is used to examine the embodied communicative dispositions of choir members amid two overlapping and sometimes conflicting public discourses about HIV disclosure. Building on previous research on how performance makes it possible to address topics otherwise outside cultural boundaries of acceptable speech, the article explores how framing HIV disclosure as performance allowed some South Africans living with HIV to embody the conflicting prescriptions of two distinct public discourses about disclosure.

Making Selves and Meeting Others in Neo-Shamanic Healing
Nofit Itzhak

Anthropological accounts of healing tend to draw, either explicitly or implicitly, on the notion of “symbolic” healing initially developed in Lévi-Strauss’s seminal article, “The Effectiveness of Symbols.” Within this framework, therapeutic efficacy is understood as the result of a transformation of meaning or the manipulation of symbols. This article seeks to challenge and refine this approach by suggesting that the transformative potential of the healing ritual may be located prior to the establishment of symbolic meaning and manipulation in the course of the healing ritual. Through an experientially specific analysis of soul retrieval, a neo-shamanic healing ritual practiced by contemporary Euro-Americans in the United States, I demonstrate that the healing process begins with, and hinges on, a successful encounter with alterity or otherness, which is established in the course of the ritual but extends beyond it. Serving as a counterweight to accounts of ritual healing that emphasize processes of meaning making as anchored in the creation of coherence, the article argues that a fuller understanding of therapeutic or healing processes must also include an appreciation for the transformative effects that discontinuities or disruptions to one’s implicitly coherent sense of self can have.


A ‘new normal’: Exploring the disruption of a poor prognostic cancer diagnosis using interviews and participant-produced photographs
Claire BalmerFrances GriffithsJanet Dunn

Cancer survival is increasing, and many people are living years after cancer treatment. For example, it is predicted that 46 per cent of men and 56 per cent of women diagnosed in 2007 in England and Wales will survive their cancer for 5 years or more. However, ‘survivors’ may be living with significant physical, psychological and social disruption caused by their illness. Furthermore, huge disparities exist in the outcomes for different cancer ‘types’, and there has been little investigation of those living with ‘poor prognostic’ cancers. Our aim was to explore the experience of living after the diagnosis of a poor prognostic cancer. Data were gathered from 30 people via interviews and participants’ own photographs. Our findings suggest that a full ‘recovery’ may be impossible after a cancer diagnosis. Such diagnoses will continue to threaten biographical trajectory and self-identity forever. ‘Returning to normal’ was considered highly important for participants, but a changed normality had to be accepted in which lives were managed carefully and a constant fear of recurrence created liminality and made ‘survivorship’ ambiguous. Experience was often complicated by the social response associated with cancer that hindered communication and increased isolation. Participant-produced photographs, used here for the first time specifically by a sample of people with poor prognosis cancer, proved to be an acceptable data collection method and have added a poignancy and ‘completeness’ to the data that have arguably led to a more comprehensive understanding.

Resolute efforts to cure hepatitis C: Understanding patients’ reasons for completing antiviral treatment
Jack A ClarkAllen L Gifford

Antiviral treatment for hepatitis C is usually difficult, demanding, and debilitating and has long offered modest prospects of successful cure. Most people who may need treatment have faced stigma of an illness associated with drug and alcohol misuse and thus may be deemed poor candidates for treatment, while completing a course of treatment typically calls for resolve and responsibility. Patients’ efforts and their reasons for completing treatment have received scant attention in hepatitis C clinical policy discourse that instead focuses on problems of adherence and patients’ expected failures. Thus, we conducted qualitative interviews with patients who had recently undertaken treatment to explore their reasons for completing antiviral treatment. Analysis of their narrative accounts identified four principal reasons: cure the infection, avoid a bad end, demonstrate the virtue of perseverance through a personal trial, and achieve personal rehabilitation. Their reasons reflect moral rationales that mark the social discredit ascribed to the infection and may represent efforts to restore creditable social membership. Their reasons may also reflect the selection processes that render some of the infected as good candidates for treatment, while excluding others. Explication of the moral context of treatment may identify opportunities to support patients’ efforts in completing treatment, as well as illuminate the choices people with hepatitis C make about engaging in care.

Tainted blood: Probing safety practices in the Danish blood system
Ida Deleuran, Zainab Afshan SheikhKlaus Hoeyer

The existing literature on donor screening in transfusion medicine tends to distinguish between social concerns about discrimination and medical concerns about safety. In this article, we argue that the bifurcation into social and medical concerns is problematic. We build our case on a qualitative study of the historical rise and current workings of safety practices in the Danish blood system. Here, we identify a strong focus on contamination in order to avoid ‘tainted blood’, at the expense of working with risks that could be avoided through enhanced blood monitoring practices. Of further significance to this focus are the social dynamics found at the heart of safety practices aimed at avoiding contamination. We argue that such dynamics need more attention, in order to achieve good health outcomes in transfusion medicine. Thus, we conclude that, to ensure continuously safe blood systems, we need to move beyond the bifurcation of the social and medical aspects of blood supply as two separate issues and approach social dynamics as key medical safety questions.

Contingencies of the will: Uses of harm reduction and the disease model of addiction among health care practitioners
Kelly Szott

The concept of addiction as a disease is becoming firmly established in medical knowledge and practice at the same time as the logics of the harm reduction approach are gaining broader acceptance. How health care practitioners understand and intervene upon drug use among their patients is complicated by these two models. While harm reduction can be understood as a form of governmentality wherein drug-taking individuals express their regulated autonomy through self-governance, the notion of addiction as a disease removes the option of self-governance through negating the will of the individual. Through analysis of qualitative interviews conducted with 13 health care practitioners who provide care for economically marginalized people who use drugs in New York City, it was found that the absence of will articulated in constructions of addiction as disease offered a gateway through which health care practitioners could bring in ideological commitments associated with harm reduction, such as the de-stigmatization of drug use. Despite differences in the attribution of agency, sewing together these two approaches allowed health care practitioners to work with drug-using patients in practical and compassionate ways. This resembles the strategic deployment of diverse subjectivities found in feminist, post-structural liberatory projects wherein differential subjectification proves tactical and productive. Although drug-using patients may enjoy the benefits of practical and compassionate health care, the conjoint facilitation and denouncement of their will occasioned by the use of both harm reduction and the disease model of addiction imply their management by both pastoral and disciplinary technologies of power.

Prising open the ‘black box’: An epistemological critique of discursive constructions of scaling up the provision of mental health care in Africa
Sara Cooper

Global mental health research is increasingly highlighting the high levels of untreated mental illness in Africa and calling for the scaling-up of services in order to redress this situation. A particular model of care is being strongly advocated for such scale-up, and a recent explosion of research is providing guidelines for its implementation. This article seeks to open up the ‘black box’ of international research on scaling up the provision of mental health care in Africa, unearthing the hidden assumptions and power dynamics underpinning the knowledge produced. It insists that gaining a better understanding of care provision demands that we not only fill the gaps in knowledge but also problematize the assumptions upon which existing knowledge is based. This article demonstrates how two interrelated paradigms are strongly mediating research in this area – those of ‘scientific evidence’ and ‘human rights’. Drawing on recent research within the sociology of scientific knowledge, and strands of postcolonial thought, it demonstrates how these paradigms are both underpinned by several contentious epistemological assumptions, assumptions which are deeply inserted within the epistemological order of Western modernity. The main argument is that through their shared ideological undertones of ‘objectivity’, ‘universalism’ and ‘rationalism’, these paradigms are potentially marginalizing other possibly important ways of thinking about care in Africa, ways which might not originate from modernist forms of consciousness. This article makes a plea for a more inclusive and plural archive of knowledge on scaling up mental health care in Africa, one which is more hospitable to diverse epistemological politics and moral landscapes.

Adolescents’ sense-making of alcohol-related risks: The role of drinking situations and social settings
Anu Katainen, Anna-Sofia Lehto, Antti Maunu

The article explores how young people understand the risks of alcohol use and how these understandings are associated with differing drinking situations and social settings. By taking account of situational factors, the aim is to demonstrate how young people have highly nuanced notions of drinking styles that suit different drinking situations and of associated risks. The data for the research were gathered in 18 group interviews with Finnish ninth graders aged 14–15 years. Short film clips portraying young people in different drinking situations were used as stimulus material for the interviews. Data analysis focussed on the risk factors related to the social situations illustrated in the film clips. The results show that young people’s risk assessments are not based on alcohol itself, but the magnitude of risk is estimated in relation to the social setting of the drinking situation. What is relevant for young people is whether the social situation allows them to make choices with which they feel comfortable. At the opposite pole of problem drinking was social drinking for the purpose of having fun together with other people in such a way that one remains in control of the drinking situation. From a prevention point of view, a key implication is that awareness of the risks is closely associated with situational and social factors. However, the awareness of those risks does not necessarily prevent young people from drinking because they may be accepted as part of the drinking experience.

Health and Place

Making unhealthy places: The built environment and non-communicable diseases in Khayelitsha, Cape Town
Warren Smit, Ariane de Lannoy, Robert V.H. Dover, Estelle V. Lambert, Naomi Levitt, Vanessa Watson

In this paper, we examine how economic, social and political forces impact on NCDs in Khayelitsha (a predominantly low income area in Cape Town, South Africa) through their shaping of the built environment. The paper draws on literature reviews and ethnographic fieldwork undertaken in Khayelitsha. The three main pathways through which the built environment of the area impacts on NCDs are through a complex food environment in which it is difficult to achieve food security, an environment that is not conducive to safe physical activity, and high levels of depression and stress (linked to, amongst other factors, poverty, crime and fear of crime). All of these factors are at least partially linked to the isolated, segregated and monofunctional nature of Khayelitsha. The paper highlights that in order to effectively address urban health challenges, we need to understand how economic, social and political forces impact on NCDs through the way they shape built environments.

Divided and disconnected — An examination of youths’ experiences with emotional distress within the context of their everyday lives
Emily K. Jenkins, Joy L. Johnson, Vicky Bungay, Anita Kothari, Elizabeth M. Saewyc

This paper is based on a qualitative study conducted in a rural community in British Columbia, Canada. Ethnographic methods were used to: (1) to bring youth voice to the literature on emotional distress; and (2) to capture the ways in which context shapes young peoples’ experiences of emotional distress within their everyday lives. Our findings demonstrate how socio-structural contextual factors such as the local economy, geographical segregation, racism, ageism, and cutbacks in health and social service programming operate to create various forms of disconnection, and intersect in young peoples’ lives to shape their experiences of emotional distress.

Ethics of care in medical tourism: Informal caregivers’ narratives of responsibility, vulnerability and mutuality
Rebecca Whitmore, Valorie A. Crooks, Jeremy Snyder

This study examines the experiences of informal caregivers in medical tourism through an ethics of care lens. We conducted semi-structured interviews with 20 Canadians who had accompanied their friends or family members abroad for surgery, asking questions that dealt with their experiences prior to, during and after travel. Thematic analysis revealed three themes central to an ethics of care: responsibility, vulnerability and mutuality. Ethics of care theorists have highlighted how care has been historically devalued. We posit that medical tourism reproduces dominant narratives about care in a novel care landscape. Informal care goes unaccounted for by the industry, as it occurs in largely private spaces at a geographic distance from the home countries of medical tourists.

International Journal of Social Psychiatry

Transatlantic variation in the attributed etiology of psychosis
G Eric Jarvis, Venkat Bhat, Tomas Jurcik, Vincenzo Spigonardo, Rob Whitley

Background: Differences in transatlantic perception of psychosis have been reported in the historical psychiatric literature.
Aims: This study aims to determine if articles in the American Journal of Psychiatry (AJP) are more likely to attribute biological factors to the etiology of psychosis than those of the British Journal of Psychiatry (BJP).
Methods: A systematic MEDLINE search for articles in the AJP and BJP from 2005 to 2007 identified 360 abstracts with psychosis and etiology-related words. Chi-square analyses were used to test differences in the proportion of attributed biological or psychosocial etiology of psychosis in each journal.
Results: A greater proportion of abstracts (83/87) in the AJP attributed biological etiology of psychosis (χ2 = 12.33, df = 1, p < 0.001), while a greater proportion in the BJP (16/44 abstracts) attributed psychosocial etiology (χ2 = 19.76, df = 1, p < 0.001).
Conclusions: The AJP tends to publish biomedical explanations of psychosis, while the BJP shows a relative preference for psychosocial theories.

Role of traditional healers in the pathway to care of patients with bipolar disorder in Egypt
Tarek Assad, Tarek Okasha, Hisham Ramy, Tamer Goueli, et al.

Background: A large number of mentally ill patients prefer to visit non-medical practitioners such as traditional healers because of the confidence in the system, affordability and accessibility of the service. This may lead to delay in seeking psychiatric services and has prognostic impact.
Aim: To assess the rate of bipolar affective disorder (BAD) patients seeking traditional healers, the sociodemographic and clinical correlates of those patients.
Methods: We assessed 350 patients with BAD after confirmation of diagnosis with Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I) research version and assessment of functioning with Global Assessment of Functioning scale. They were assessed for percent, rate and timing of seeking traditional healers.
Results: In all, 40.8% sought traditional healers, with 34.9% more than four times. Of those, 62.2% were before seeking psychiatric services and 37.8% after. Lower educational level, less impairment of functioning and presence of hallucinations were significant correlates.
Conclusion: This study shows that most of the patients suffering from mental illness prefer to approach faith healers first, which may delay entry to psychiatric care and thereby negatively impact the prognosis of BAD. This highlights the importance of mental health education and developing a positive collaborative relationship with traditional healers.

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