This article is part of the following series: Working Definitions: Making and Unmaking “Medical Anthropology” around the World
The American Anthropological Association website identifies four subfields of anthropology (archaeology, biological, cultural, linguistic) and reserves a separate section for “applied and practicing anthropology.” In our collective experience, we have found this division between ostensibly “academic” and “applied” anthropology problematic, as it limits the possibilities of a broadly conceptualized and enacted medical anthropology that is more continuous than categorical. We firmly believe that working in an applied context is not giving up on anthropology, but rather doubling down and fully embracing our anthropological worldview.
Although we all started with different training – in cultural anthropology, classical art and archaeology, physical anthropology, organizational ethnography, and the history of science and medicine – we found common ground in the ways we have developed our own emergent medical anthropologies.
Our practices have altered how we establish and manage relationships in the field, how we carve out the scope of anthropology in concert with non-anthropologists and health professionals, and how we share our findings with research team members and key stakeholders. Like any traditional anthropological approach, these practices still leverage long-term, meaningful engagement with our respective communities to inform our broader understanding of human behavior. They also involve multifaceted relationships with theory – as material to think with and question with, and arising from our fieldwork.
We therefore turned an anthropological lens on our own field experiences and asked ourselves what it means to generate theory in applied medical anthropology. We examined theory production in its relation to fieldwork, considering in particular the meaningful engagement of stakeholders and the production of shared knowledge disseminated among those stakeholders, not just among other anthropologists.
We use the term “stakeholder” because it is ubiquitous in areas where expert knowledge is used to formulate institutional interventions that involve non-experts (such as “lay people,” “communities,” or other groups) – essentially, most forms of administration, management, or governance where some kind of justification is expected for the exercise of power (especially in health care, with its attention to shifting the power imbalance between patients and practitioners). It is, in other words, an emic term among our practitioner collaborators. While said practitioners are not naïve to the power relations signaled by the term “stakeholder,” they are also invested in designing practical interventions that can effect change. Furthermore, they (like anthropologists) continue to theorize about the best ways to design interventions that identify and incorporate relevant people or groups both effectively and equitably.
In what follows, we focus on the interplay of theory and fieldwork in highlighting three research-related areas that demonstrate what applied medical anthropology looks like in practice. Although it is not without its challenges, applied work has enabled us to do things we never imagined possible with our doctoral degrees. Our goal is to broaden the paradigm of medical anthropology by demonstrating just how many ways there are of being an anthropologist both in and out of the academy.
1. Developing Research Questions in Concert with Others
Definitions of applied anthropology emphasize the use of anthropological knowledge to effect practical change. This desired effect is the distinguishing feature between applied and academic anthropology, with the attendant assumption that applied anthropologists do not contribute to the advancement of theory. However, theoretical engagement and ethnographic attunement are ever-present across our work.
Dahlberg’s experience as a National Network for Environmental Management Studies (NNEMS) Fellow with the Environmental Protection Agency (EPA) during her doctoral dissertation research provides one example of how theory and practice converge:
I was studying how different people make sense of environmental risk in the same landscape through ethnographic research that encompassed a Superfund Site and surrounding neighborhoods in Pennsylvania, and places where that site was studied and managed (primarily government health agencies like the EPA).
EPA officials participated in a Community Involvement Process at the site and hosted monthly public meetings. They mentioned a concern that the people “most affected” by the site seemed “least interested.” They figured I could do research by interviewing residents to find out why they weren’t coming. They said Black residents, in particular, in the neighborhood bordering the site tended to come to one or two meetings and then stop.
I had noticed this issue, too. And in fact, residents with whom I spoke described their concerns that decisions were being made about their neighborhood without them. They talked of being systematically excluded from decision making.
In the end, I gave a presentation to EPA officials in a meeting that brought together on-site staff, their managers, and the national directors. I used findings from both the site and from archives and interviews with government officials to open a discussion about how “community” and “participation” were defined by implicit agency practices. I fielded questions from directors and highlighted the complexities that needed to be addressed to problem-solve collectively.
Dahlberg’s experience helped her reframe her role as an anthropologist. She came to see part of her work as shifting the scope and frame of research with her collaborators, helping them name a different – and often more nuanced – question behind their question.
Taber had a similar realization in his role as an anthropologist at the U.S. Department of Veterans Affairs (VA):
One methodological forte of the VA research center where I have worked for the last few years is health informatics, typically focused on designing provider-facing digital tools or epidemiological and public health interventions. A recent QI (quality improvement) project was framed as an attempt to improve “information sharing” in this informatics-focused center. Researchers recruited my help interviewing center employees (principal investigators, research support, data managers, and administrative staff). One of my opening questions was how they defined “information” in the context of their work.
When I reported this back to the project’s other investigators, laughter exploded in the conference room: “What did they say?”
Unsurprisingly, the people I interviewed did not share a coherent description of “information.” I briefly managed to make a very familiar term slightly “strange” for my collaborators. At a strictly practical level, it was clear to all of us that the question, “How can we improve information sharing?” was going to mean something different to different people.
It was also clear to me that understanding the role played by the idea of “information” would require both firsthand observation and concept work, and that it might lend itself to working out an enriched perspective on the social life of the research center – a more typically “academic” orientation.
2. Contributing to Collaborative Knowledge Production
The anthropological model of the solo ethnographer exists in contrast to the laboratory model of the hard sciences, in which everyone who is part of the lab becomes a co-author, with each discipline having its own politics of author ordering.
Our applied medical anthropology work has most often resembled something closer to the laboratory model, with a principal investigator (PI) at the top of the hierarchy who is responsible for designing the study and securing the funding. At times, for some of us, this has meant we have no longer “owned” our own data; data belong to the lab or to the institution.
But the solitary ownership model of “my” research in which many of us were socialized during graduate school is not the only way to have intellectual control over a project or to manage its ethics. Dahlberg’s role as a public scholar and project director at a non-profit organization enabled her to work on creating an “our” model of research that included research participants and local residents, staff and postdoctoral fellows.
Even as some projects are initiated by other team members, they still leave open the possibility of pursuing new avenues of inquiry emergent throughout the course of research. This possibility derives in part from the ongoing lack of clarity regarding what anthropologists actually do. Every time we join a new research team, both we and our respective team members must figure out our role. This can sometimes be frustrating, but it can also be freeing because it gives us space to follow the threads that pique our curiosity.
Fix speaks to this freedom as an anthropologist at the VA:
I was part of a research study examining HIV care across the VA. As part of the sampling strategy, we visited “high” and “low” performing HIV clinics. During an interview, an HIV provider made a disparaging comment about patients at risk for HIV, calling them an expletive and remarking on their promiscuous behavior (Fix et al. 2018). That interview sparked an anthropologically informed curiosity about how providers think about their patients.
As an anthropologist, I wondered how providers’ thinking might be informed by their own context. An anthropologist colleague and I undertook an in-depth examination across the eight HIV clinics. Through this theory-building analysis, we identified a relationship between the composition of HIV care teams and how these teams thought about and planned care for their patients.
In addition, being a team member does not mean losing one’s autonomy or reflexive capabilities. All of us have had experiences in which we have stepped back, out of our role as “employees,” to reflect on and even critique our own working conditions.
In Faro’s dual role as assistant professor and associate director of quality at an academic medical center, she was able to turn a critical gaze on her employer:
One area of particular interest to hospital leadership was the emergency department (ED). Things weren’t going well down there. I thought that maybe I could be helpful, so I spent six months doing ethnographic “fieldwork” down in the ED. What emerged wasn’t necessarily what leadership was expecting – a deep look into the tribalism within the unit (Faro and Bauman 2020) – but I hoped that a nuanced understanding of the culture would inform future work and improvement efforts.
One thing that did emerge from my deep engagement with this context and its people was the dysfunction of the error reporting system that was used by hospitals, an internally-developed system but a process mandated across all hospitals in the U.S. All providers (clinicians, nurses, residents, etc.) were educated about the system and encouraged to report medical errors and unsafe conditions. The idea behind this reporting was that data could then be aggregated centrally and mined for patterns to identify areas for improvement.
Identifying and addressing problems with an internal technological system that was purely clinical might not seem like a very theoretical or even anthropological research question. But my hypothesis for why the system wasn’t working involved questions of power; the hierarchical dynamics of medicine; information sharing; trust; and the production of knowledge.
It seemed that these questions could only be answered by engaging with these theoretical concepts and that our findings would contribute to theory through their unique combination and their application to a previously unconsidered question. Additionally, the only way to develop a comprehensive understanding of the system was through a mixed methods approach, which felt inherently anthropological.
What we find compelling about anthropology is using theoretical and methodological approaches to answer questions that are not only embedded in our working conditions, but also meaningful to stakeholders. If those stakeholders are practitioners rather than scholars, does that make their engagement any less meaningful?
3. Communicating Research Findings to Diverse Audiences
The publication requirements for advancement in a traditional academic department are extraordinarily narrow: peer-reviewed articles and ethnographic monographs published by university presses. Work done to educate the broader public through films, websites, podcasts, or other media generally do not count.
The requirements are slightly different for applied medical anthropologists who do health services research. Books do not count for career advancement; they are something you write on your own time. Typically, only articles in PubMed-indexed, peer-reviewed journals count toward tenure (when it’s available) for those in schools of medicine or public health.
Questions of where we write and publish are paramount in applied work because communicating our research findings is part of building the relationships that enable our continued research. As anthropologists, we create materials with people’s stories – working hard to access that “emic” perspective – but as academics we often disseminate these materials in a format that is wholly “etic” and therefore inaccessible to them. We end up excluding the very people with whom we work.
Applied work allows us the opportunity to reimagine the types of relationships we want to have with our interlocutors. Writing jargon-heavy texts does not foster relationships; engaging in interactive work and publishing in multiple venues does. Rubinstein’s contrasting experiences as a graduate researcher in anthropology and as a postdoctoral fellow at a medical school speak to this difference:
During my fieldwork in Japan, I spent about nine months making weekly visits to an outpatient mental health clinic, where I hung out with clients and joined them in their therapy groups. When a commentary I’d written on anthropology in psychiatry came out in Japanese, I was excited to have a document explaining my research in their native language. I thought they would finally understand why I was at the clinic.
But none of the clients wanted to read it. Here I was with something that proved (to me, at least) that I was a legitimate researcher, and no one was interested. It was too hard, they said. It was in academic Japanese. Only one woman, who had taken an anthropology course in college, politely folded the paper in half and tucked it into her purse to read later.
My experience was completely different during my postdoctoral fellowship at a medical school. I visited primary care clinics all over the country for only a week or two at a time – practically nothing compared to the 14 months I spent in Japan. Although I was only briefly at these clinics, my relationships with many people have continued beyond the research. It is much easier to maintain contact with them. I publish in their journals and in their language – not just English, but also their professional language – and I address issues that are directly relevant to their lives.
Dahlberg, in her work on environmental risk, has had opportunities to create both an oral history collection that is housed in a local historical society and a series of short plays at an area theater:
These became places to gather to talk about science, research, and risk in historical, social, economic, and political contexts. I have felt such spaciousness to explore: What forms are called for here? What do the “findings” point toward, not only in terms of research “results,” but also in terms of creative practices and events? Asking this was new, especially when I was in a setting where it was obvious what kinds of work (i.e., writing) mattered, and it was deeply energizing and satisfying.
The current practice in academia is for scholarly “experts” to extract and disseminate data rather than involving stakeholders in interpretation and reflection. If we want anthropological insights to effect change in the world – whether that is the world writ large or the microcosm in which our research and teaching occurs – we need to start thinking beyond solo-authored, peer-reviewed journal articles or monographs as the only modes of dissemination.
We also need to think beyond individually owned and controlled forms of research, reflection, and creation – in short, to begin recognizing the benefits of collaborative knowledge production. We need to provide tools to create spaces of joint inquiry where different kinds of people can reflect together on local issues. Such spaces, in turn, can give rise to anthropologically informed understandings that effect change beyond words on a page. This is how research can truly “give back” to those who create it.
Some Final Thoughts
What became clear from our conversations was our enduring interest in the role of theory, the ostensible hallmark of academic anthropology, and our own assumptions that theory separated “academic” anthropology from “applied.” This made us reflect upon theory not just as an inherited artifact of anthropology, but to explore the ties between research inquiry and theory-building in our applied work.
All of us have been confronted with ambivalence at our career choices from those in the so-called “academic” anthropology world – from scholars who wondered why we would bother showing up to the American Anthropological Association meetings when we were so obviously “applied” anthropologists; from grant reviewers who doubted our ability to produce sufficiently theoretical findings because we did not work in an academic department; from editors who expressed skepticism at publishing our work once our job titles deviated from the familiar academic path. Many of us graduated from our doctoral programs believing that the only legitimate job was one on the tenure track, even as those opportunities continued to decline.
But we have also encountered people who embrace our desire and ability to think beyond the academy. We have been invited to talk to far more varied audiences: practitioners, clinicians, scientists, medical and public health students – and yes, even “academic” anthropologists. It is crucial that academic anthropologists expand their horizons to engage with their applied colleagues outside of the academy, especially given the uncertainties in higher education today.
Current practices in the academy emphasize “theoretical” work over applied, which neither serves students whose paths will likely diverge from academia, nor exposes students to alternative careers. The traditional focus on classical and contemporary social theory, as well as reading and writing assignments that promote academic jargon over clear writing, prevents students from finding novel ways to put their anthropological training to use.
We envision a healthy, supportive relationship between the academic and applied workforce that opens new opportunities to grow the field. Only by increasing the depth and breadth of communication between these two alleged poles can we begin to expand the vision of what medical anthropology can and should be. Only then can we begin to create a new, emergent medical anthropology in conversation with the multiple worlds around us.
Ellen B. Rubinstein, Ph.D., is Assistant Professor of Anthropology at North Dakota State University and an associate member of the University of Michigan Mixed Methods Program. Her research interests include mental health, disability, family, and care in the U.S. and Japan.
Britt Dahlberg, PhD, is Director of Research of the Center for Humanism at Cooper Medical School, and Affiliated Faculty at Johns Hopkins University and the University of Pennsylvania. Her research interests include environmental risk, climate change, diagnosis, chronicity, and compassionate patient care. Her work builds spaces of dialogue, reflection, and intervention through critical public medical humanities. https://www.beyondbetter.org/
Elissa Z. Faro, Ph.D., is Research Assistant Professor in the Department of Internal Medicine at the University of Iowa’s Carver College of Medicine. Her research focuses on using implementation science approaches to improve care delivery and health outcomes for underserved and minority populations, both in the U.S. and globally.
Peter Taber, Ph.D., is a National Library of Medicine Postdoctoral Fellow in the University of Utah’s Department of Biomedical Informatics. His current work focuses on the interface between healthcare and public health in the context of programs to manage antimicrobial resistance.
Gemmae M. Fix, Ph.D., is a Research Health Scientist with the U.S. Department of Veteran Affairs Center for Healthcare, Organization & Implementation Research, as well as Research Assistant Professor at Boston University’s School of Medicine. She uses anthropological approaches to understand patient and provider behaviors. Much of her work has focused on using these insights to advance “patient-centered care,” a biomedical movement to better align healthcare with patients’ daily lives.
Faro, E. Z., and L. J. Bauman. 2020. “Tribalism in a Pediatric Emergency Department.” Human
Organization 79(1):24-32. https://doi.org/10.17730/0018-72184.108.40.206
Fix, G. M., J. K. Hyde, R. E. Bolton, V. A. Parker, K. Dvorin, J. Wu, A. A. Skolnik, D. K. McInnes, A.
M. Midboe, S. M. Asch, A. L. Gifford, and B. G. Bokhour. 2018. “The moral discourse of HIV providers within their organizational context: An ethnographic case study.” Patient Education and Counseling 101(12):2226-32. http://doi.org/10.1016/j.pec.2018.08.018
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