In the Journals

In The Journals – September 2017, part II

Hi folks! Without further ado, the second half of September’s installment:

Medical Anthropology Quarterly

Normal, Regular, and Standard: Scaling the Body through Fecal Microbial Transplants

Matthew J. Wolf‐Meyer

In 2013, the National Institutes of Health (NIH) and the Food and Drug Administration (FDA) held a workshop to determine the risks and benefits associated with the experimental use of fecal microbial transplants to treat Clostridium difficile and other gastroenterological disorders. By focusing on the proceedings of the NIH–FDA workshop on the treatment of the human microbiome, the question of how medicine colonizes human bodies through microbial transplants raises questions about what an individual body is, how determinative of human health the microbiome is, and what the limits of molecular biomedicine are when the microbiome is taken into consideration. In the workshop presentations and discussion of this emerging treatment, experts used ideas about the normal, regular, and standard to move between scales of bodily analysis, from the microbial to the body politic, demonstrating how the individual and society are deeply influenced by the unruly community of microbial symbiotes that humans host.

Bioseguridad in Mexico: Pursuing Security between Local and Global Biologies

Emily Mannix Wanderer

In the aftermath of the 2009 outbreak of H1N1 influenza, scientists in Mexico sought to develop bioseguridad, that is, to protect biological life in Mexico by safely conducting research on infectious disease. Drawing on ethnographic research in laboratories and with scientists in Mexico, I look at how scientists make claims about local differences in regulations, infrastructure, bodies, and culture. The scientists working with infectious microbes sought to establish how different microbial ecologies, human immune systems, and political and regulatory systems made the risks of research different in Mexico from other countries. In developing bioseguridad, the idea of globalized biology that animates many public health projects was undermined as scientists attended to the elements of place that affected human health and safety. Scientists argued for the importance of local biologies, generating tension with global public health projects and regulations premised on the universality of biology.

Mohit’s Pharmakon: Symptom, Rotational Bodies, and Pharmaceuticals in Rural Rajasthan

Andrew McDowell

This article reexamines medical anthropology theories of symptom, illness, and disease to consider unregulated medical care in India. It builds on clinical observations, an inventory of the pharmaceuticals used by men who call themselves “Bengali doctors,” and their patients to understand medical care in a context that privileges symptom not disease. It draws on Derrida’s use of pharmakon to outline the complexities of care and embodiment and helps locate local and medical anthropology theories of symptom and pharmaceuticals within theories of the experiential body. It asks two key questions: What is medical care without disease and what are its implications on a local biology in which disease-based biomedicine is modified? Searching for a tentative answer, it works to bring medical anthropology’s interest in symptom back to the body without losing symptoms’ connection to political economies, individual experience, and localized biomedicine.

Shifting Gears: Triage and Traffic in Urban India

Harris Solomon

While studies of triage in clinical medical literature tend to focus on the knowledge required to carry out sorting, this article details the spatial features of triage. It is based on participation observation of traffic-related injuries in a Mumbai hospital casualty ward. It pays close attention to movement, specifically to adjustments, which include moving bodies, changes in treatment priority, and interruptions in care. The article draws on several ethnographic cases of injury and its aftermath that gather and separate patients, kin, and bystanders, all while a triage medical authority is charged with sorting them out. I argue that attention must be paid to differences in movement, which can be overlooked if medical decision-making is taken to be a static verdict. The explanatory significance of this distinction between adjustment and adjudication is a more nuanced understanding of triage as an iterative, spatial process.

Ethical Gifts?: An Analysis of Soap‐for‐data Transactions in Malawian Survey Research Worlds

Crystal Biruk

In 2008, thousands of Malawians received soap from an American research project as a gift for survey participation. Soap was deemed an ethical, non-coercive gift by researchers and ethics boards, but took on meanings that expressed recipients’ grievances and aspirations. Research participants reframed soap and research benefits as “rights” they are entitled to, wages for “work,” and a symbol of exploitation. Enlisting the perspectives of Malawi’s ethics board, demographers, Malawian fieldworkers, and research participants, I describe how soap is spoken about and operates in research worlds. I suggest that neither a prescriptive nor a situated frame for ethics—with their investments in standardization and attention to context, respectively—provides answers about how to compensate Malawian research participants. The conclusion gestures toward a reparative framework for thinking ethics that is responsive not just to project-based parameters but also to the histories and political economy in which projects (and ethics) are situated.

Ethics in Numbers: Auditing Cleft Treatment in Mexico and Beyond

Samuel Taylor‐Alexander

Plastic surgeons around the globe are implementing projects that mix audit with medical research to ensure and improve the level of care offered to patients with cleft lip and palate. Drawing on recent literature on “audit culture” and the global growth of “performance indicators” as a form of governance, I demonstrate the conjugation of ethics and the production of numerical indicators in cleft treatment. By standardizing documentation, cleft treatment audit programs facilitate evidence-based medicine and a form of reflexive self-governance. However, the abstraction that accompanies standardization is amplified as corollary data practices travel. In emerging as the answer to improving treatment, these projects lock out the politico–economic factors that mediate medical care in resource poor settings. This danger is compounded by the tendency of numerical governance to replace political conversation with technocratic expertise.

Electronic Health Records and the Disappearing Patient

Linda M. Hunt, Hannah S. Bell, Allison M. Baker, Heather A. Howard

With rapid consolidation of American medicine into large-scale corporations, corporate strategies are coming to the forefront in health care delivery, requiring a dramatic increase in the amount and detail of documentation, implemented through use of electronic health records (EHRs). EHRs are structured to prioritize the interests of a myriad of political and corporate stakeholders, resulting in a complex, multi-layered, and cumbersome health records system, largely not directly relevant to clinical care. Drawing on observations conducted in outpatient specialty clinics, we consider how EHRs prioritize institutional needs manifested as a long list of requisites that must be documented with each consultation. We argue that the EHR enforces the centrality of market principles in clinical medicine, redefining the clinician’s role to be less of a medical expert and more of an administrative bureaucrat, and transforming the patient into a digital entity with standardized conditions, treatments, and goals, without a personal narrative.

Neocolonialism and Health Care Access among Marshall Islanders in the United States

Michael R. Duke

In the Marshall Islands, a history of extensive nuclear weapons testing and covert biomedical research, coupled with the U.S.’s ongoing military presence in the country, has severely compromised the health of the local population. Despite the U.S.’s culpability in producing ill health along with high rates of emigration from the islands to the mainland United States, the large portion of Marshallese who reside in the United States face substantial barriers to accessing health care. Drawing from ongoing field research with a Marshallese community in Arkansas, this article explores the multifaceted impediments that U.S.-based Marshall Islanders face in receiving medical treatment. Calling on an expansive and inclusive notion of neocolonialism, I argue that Marshallese structural vulnerability with regard to health and health care treatment derives from their status as neocolonial subjects and from their limited claims to health-related deservingness associated with this status. [Marshall Islanders, health care access, neocolonialism, radiation exposure, immigrant health]

Science as Culture

Folded Futurity: Epigenetic Plasticity, Temporality, and New Thresholds of Fetal Life

Becky Mansfield

The life sciences are generating a transformative view of the biological body not as fixed and innate but as permeable to its environment and, therefore, plastic: development is open and malleable. Emblematic of these new sciences is environmental epigenetics, which investigates environmental factors that come into the body to shape expression of genes across the life course; prominent are environmental exposures during fetal development, which epigeneticists propose influence not only birth outcomes but also lifelong health. How does this new emphasis on permeability and plasticity during fetal development change how the fetus and fetal vulnerability are understood in the current scientific literature? Perspectives on genomic and reproductive temporality help conceptualize environmental epigenetics as a dynamic relationship between plasticity and determinism. This epigenetic temporality links past, present, and future in way that gives the fetus a keystone role as the vulnerable space-time of environmental epigenetics. Epigenetic temporality produces a new, folded futurity that brings multiple, future generations into the present, influenced by current environmental conditions. In doing this, epigenetics shifts thresholds of fetal vulnerability and intervention to incorporate other entities, including reproductive cells (gametes and primordial germ cells) and very young children. Epigenetic temporality folds in on itself, producing new versions of vulnerable, plastic life that require protection now, in the enduring present, even as the future toward which epigenetics is oriented constantly recedes.

Science, Technology, and Human Values

Synchronicity: Time, Technicians, Instruments, and Invisible Repair

Joeri Bruyninckx

Sociological studies of work and time have argued that academic temporalities are increasingly rationalized and rendered accountable, resulting in a divergence of planned and experienced time in academic work. Shared research facilities that provide platform technologies to large user pools are no exception to this, as its administrations seek to increase the profitability of limited instrument time. Based on an ethnographic study of three facilities at an American university, this article examines how diverging rhythms are enacted in organizational schedules and instrument work and kept aligned on the laboratory floor. Drawing insights from time studies and repair sociology, I argue that although technologies of time accounting provide powerful templates for action, they become effective only through ongoing “synchronization” work. Synchronization calls attention to discrete techniques and work practices, such as the adjustment of users’ bodies, user expectations, or work processes, that technical staff draw upon to resolve slippages between organizational rhythms and the temporal realities of data collection. This analysis suggests that technicians’ local and embodied (but also invisible) practices not only affect their own professional roles but also organizational stability and productivity in time-sensitive environments.

Air Pollution in the Making: Multiplicity and Difference in Interdisciplinary Data Practices

Emma Garnett

This article traces an emergent tension in an interdisciplinary public health project called Weather Health and Air Pollution (WHAP). The tension centered on two different kinds of data of air pollution: monitored and modeled data. Starting out with monitoring and modeling practices, the different ways in which they enacted air pollution are detailed. This multiplicity was problematic for the WHAP scientists, who were intent on working across disciplines, an initiative driven primarily by the epidemiologists who imbued the project with meaning and value as the protagonists of “health.” To work collaboratively implies a stable, singular, and shared research object, however: one kind of data, one version of air pollution. In detailing two attempts by researchers to address the inadequacies of modeled and monitored data, this article explores the ways in which difference and multiplicity were negotiated and transformed. In doing so, this article suggests that it is the mobility and instability of data that are particularly fruitful for exploring the facilitation and enactment of new realities, while also making explicit the emergent problematics and partialities which inevitably result.

Social Science & Medicine

Same medicine, different reasons: Comparing women’s bodily experiences of producing eggs for pregnancy or for profit

Rene Almeling, Iris L. Willey

 Women doing in vitro fertilization (IVF) to have a child describe it as painful and emotionally draining. Egg donors undergo the same medical regimen for a different reason – to produce eggs for another woman in exchange for thousands of dollars – and describe it as quick and relatively painless. Medical researchers typically compare bodily responses by variables such as gender, age, and health status. We use the case of “egg production” to propose a new factor that may be an important source of variation in bodily experience: an individual’s reason for undergoing the medical intervention in the first place. Using cluster analysis to analyze an original survey of 50 IVF patients and 62 egg donors from the United States, we find two distinct kinds of bodily experiences – “less intense” and “more intense” – and the intensity of one’s experience is associated with one’s reason for producing eggs: either to become pregnant or to donate them for money.

Medication takeovers: Covert druggings and behavioral control in Alzheimer’s

Brandon Berry, Ester Carolina Apesoa-Varano

Older adults consume the most prescription medication in the U.S. For those who develop Alzheimer’s disease, risk of medication misuse increases with the progression of the disease. Family members commonly intervene to lessen risks by taking over the management and administering of a medication regimen. Despite the potential for grave harm around the misuse of powerful drugs, few studies provide insight into the household social context of medication use for this disease. Drawing on 60 in-depth interviews conducted in four waves over 2.5 years, this study investigates how family members administered prescription and over-the-counter medications to elders with Alzheimer’s. The findings detail how family members initially created and enacted the role of proxy-administrator to avoid self-administration errors and then expanded the role to manage disruptive behaviors. During this process, family members perceived themselves as working in partnership with doctors, especially in the effort to craft a regimen that controlled the affected individual’s mood and sleep/wake cycle. The paper concludes by discussing the implications that family members used medications to improve conformity to a preferred household social order. The study offers conceptual advances in understanding 1) the process of proxy-administration in Alzheimer’s care and 2) the role of proxy-administrators in the medicalization of deviant behavior.

Sociology of Health and Illness

Engaging conceptions of identity in a context of medical pluralism: explaining treatment choices for everyday illness in Niger

Kelley Sams

This article uses ethnographic research to reflect upon how the treatment of ‘everyday’ illnesses in Niger engages concepts of social identity. Inspired by Bourdieu’s concept of social distinction, as well as Appadurai’s edited volume on the ‘social lives’ of ‘things’, I present an analysis of how medications are understood by their users in terms of social and ideological meaning in one rural Hausa village. Decisions about medication choice were framed by three main themes: belonging to the ‘modern’ world, ‘traditional’ Hausa culture, and religious identity. This article does not argue that these notions of identity fully explain medication use, nor necessarily predict treatment choices. The purpose of this paper is to reflect on the dynamic meanings given to treatment decisions after they have been made, attributed to the medications themselves and negotiated through their circulation in a context where multiple medical systems are drawn from to manage illness. Producers and sellers of medication also engage these meaning-centred concepts, which have theoretical and practical interest for the social sciences and public health.

Keeping out and getting in: reframing emergency department gatekeeping as structural competence

Mara Buchbinder

Sociologists have tended to frame medical gatekeeping as an exclusionary social practice, delineating how practitioners and clerical staff police the moral boundaries of medicine by keeping out patients who are categorised as ‘bad’, ‘deviant’, or otherwise problematic. Yet medical gatekeeping, understood more broadly, can include not only keeping patients out of particular clinical settings, but also redirecting them to alternative sources of care. In this article, I draw on qualitative analysis of audio-recorded patient-provider interactions in a United States emergency department (ED) to illustrate medical gatekeeping as a two-step process of, first, categorising certain patient complaints as unsuitable for treatment within a particular setting, and second, diverting patients to alternative sites for care. I refer to these as the restrictive and facilitative components of medical gatekeeping to denote how each relates to patients’ access to care, recognising that both components of medical gatekeeping are part of a coordinated organisational strategy for managing resource scarcity. By illustrating how ED providers reveal intimate knowledge of structural vulnerabilities in diverting socioeconomically disadvantaged patients with chronic back pain to clinical sites that are better equipped to provide care, I suggest that we rethink the emphasis on restrictive practices in sociological accounts of medical gatekeeping.